VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California.
Duke University School of Medicine, Durham, North Carolina.
JAMA Netw Open. 2023 Dec 1;6(12):e2347834. doi: 10.1001/jamanetworkopen.2023.47834.
Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions.
To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022.
Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds).
A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work.
In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.
髋部骨折后 24 小时内进行手术可改善患者的发病率和死亡率，这促使一些医院启动质量改进计划（例如，针对性资源管理、有记录的协议）以解决延迟问题。然而，这些计划在缩短手术时间（TTS）方面的效果各不相同，这表明有机会提高干预措施的效果。
确定不同医院髋部骨折患者 TTS 的背景决定因素（特定于地点的障碍和促进因素）。
设计、设置和参与者：这是一项采用探索性序贯设计的定性混合方法研究，包括 2 个阶段。在第 1 阶段，对参与髋部骨折护理的利益相关者（骨科医生或住院医师、急诊医生、医院医生、麻醉师、护士以及临床或支持人员）进行了半结构化访谈，这些利益相关者来自 4 家具有不同财务、运营和教育结构的医院。访谈于 2021 年 5 月至 7 月进行。在第 2 阶段，2022 年 5 月至 7 月，代表美国 23 家不同医院的骨科医生领导完成了一项评估成人髋部骨折患者 24 小时内 TTS 的背景决定因素的定量调查。数据分析于 2022 年 8 月进行。
对访谈的主题分析确定了髋部骨折患者 24 小时内 TTS 的背景决定因素。然后在多个医院中测量了新出现的背景决定因素，并使用频率和分布来评估决定因素与各种医院特征（例如，设置、床位数）之间的关联。
第 1 阶段共访谈了 34 名利益相关者，第 2 阶段完成了 23 份调查。两个阶段的受访者中均有一半以上是男性（分别为 19 名[56%]和 18 名[78%]）。确定了以下 4 个与 24 小时内 TTS 相关的背景决定因素主题：可用性、护理协调、改进氛围和激励结构。在这些主题中，不同医院最常涉及的决定因素包括手术室可用性、骨科和内科或老年病学之间的正式共同管理系统、专注于及时手术的医生冠军的存在以及促进改进工作的计划。
在这项研究中，髋部骨折患者 24 小时内 TTS 的背景决定因素因医院地点而异，由于没有两个地点具有相同的特征，因此无法在不同的医院环境中进行概括。因此，这些发现表明，改善 TTS 的策略指导应该基于每个医院特有的背景决定因素。
