Duke University School of Medicine, Durham, North Carolina.
Duke University School of Medicine, Department of Orthopaedic Surgery, Durham, North Carolina.
JAMA Netw Open. 2024 Aug 1;7(8):e2429691. doi: 10.1001/jamanetworkopen.2024.29691.
Institutions have adopted protocol-driven standardized hip fracture programs (SHFPs). However, concerns persist regarding bias in adherence to guideline-concordant care leading to disparities in implementing high-quality care for patients recovering from surgery for hip fracture.
To assess disparities in the implementation of guideline-concordant care for patients after hip fracture surgery in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Hip Fracture (THF) Database.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted using the ACS-NSQIP THF database from 2016 to 2021 for patients aged 65 years and older with hip fractures undergoing surgical fixation. Care outcomes of racial and ethnic minority patients (including American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, or multiple races and Hispanic ethnicity) were compared with non-Hispanic White patients via risk difference, stratified by care institution SHFP status. Modified Poisson regression was used to measure interactions. Statistical analysis was performed from November 2022 to June 2024.
The primary outcomes of interest encompassed weight-bearing as tolerated (WBAT) on postoperative day 1 (POD1), venous thromboembolism (VTE) prophylaxis, bone-protective medication, and the presence of SHFP at the institution.
Among 62 194 patients (mean [SD] age, 82.4 [7.3] years; 43 356 [69.7%] female) who met inclusion criteria and after multiple imputation, 11.2% (95% CI, 10.8%-11.5%) were racial and ethnic minority patients, 3.3% (95% CI, 3.1%-3.4%) were Hispanic patients, and 92.0% (95% CI, 91.7%-92.2%) were White. Receiving care at an institution with an SHFP was associated with improved likelihood of receiving guideline-concordant care for all patients to varying degrees across care outcomes. SHFP was associated with higher probability of being WBAT-POD1 (risk difference for racial and ethnic minority patients, 0.030 [95% CI, 0.004-0.056]; risk difference for non-Hispanic White patients, 0.037 [95% CI, 0.029-0.45]) and being prescribed VTE prophylaxis (risk difference for racial and ethnic minority patients, 0.066 [95% CI, 0.040-0.093]; risk difference for non-Hispanic White patients, 0.080 [95% CI, 0.071-0.089]), but SHFP was associated with the largest improvements in receipt of bone-protective medications (risk difference for racial and ethnic minority patients, 0.149 [95% CI, 0.121-0.178]; risk difference for non-Hispanic White patients, 0.181 [95% CI, 0.173-0.190]). While receiving care at an SHFP was associated with improved probability of receiving guideline-concordant care in both race and ethnicity groups, greater improvements were seen among non-Hispanic White patients compared with racial and ethnic minority patients.
Older adults who received care at an institution with an SHFP were more likely to receive guideline-concordant care (bone-protective medication, WBAT-POD1, and VTE prophylaxis), regardless of race and ethnicity. However, the probability of receiving guideline-concordant care at an institution with an SHFP increased more for non-Hispanic White patients than racial and ethnic minority patients.
重要性：医疗机构已经采用了基于协议的标准化髋部骨折方案（SHFP）。然而，人们仍然担心在遵循指南一致的护理方面存在偏见，这导致接受髋关节骨折手术后康复的患者在实施高质量护理方面存在差异。
目的：评估美国外科医师学会国家手术质量改进计划（ACS-NSQIP）靶向髋部骨折（THF）数据库中患者髋关节骨折手术后接受指南一致护理的差异。
设计、地点和参与者：这是一项使用 ACS-NSQIP THF 数据库进行的横断面研究，纳入了 2016 年至 2021 年期间接受手术固定的年龄在 65 岁及以上的髋部骨折患者。通过风险差异比较种族和民族少数群体患者（包括美洲印第安人或阿拉斯加原住民、亚洲人、黑人和非裔美国人、夏威夷原住民或太平洋岛民或多种族裔和西班牙裔）与非西班牙裔白人患者的护理结果，通过 care 机构 SHFP 状态分层。使用修正泊松回归测量交互作用。统计分析于 2022 年 11 月至 2024 年 6 月进行。
主要结果和措施：主要研究结果包括术后第 1 天（POD1）能够负重（WBAT）、静脉血栓栓塞（VTE）预防、骨保护药物以及机构是否存在 SHFP。
结果：在纳入标准并经过多次插补的 62194 名患者中（平均[SD]年龄，82.4[7.3]岁；43356[69.7%]为女性），11.2%（95%CI，10.8%-11.5%）为种族和民族少数群体患者，3.3%（95%CI，3.1%-3.4%）为西班牙裔患者，92.0%（95%CI，91.7%-92.2%）为白人。在接受有 SHFP 的医疗机构的护理与所有患者接受指南一致的护理的可能性增加有关，在不同的护理结果方面存在差异。SHFP 与更高的 WBAT-POD1 概率相关（种族和民族少数群体患者的风险差异为 0.030[95%CI，0.004-0.056]；非西班牙裔白人患者的风险差异为 0.037[95%CI，0.029-0.045]）和接受 VTE 预防的概率相关（种族和民族少数群体患者的风险差异为 0.066[95%CI，0.040-0.093]；非西班牙裔白人患者的风险差异为 0.080[95%CI，0.071-0.089]），但 SHFP 与骨保护药物的接受率改善最大（种族和民族少数群体患者的风险差异为 0.149[95%CI，0.121-0.178]；非西班牙裔白人患者的风险差异为 0.181[95%CI，0.173-0.190]）。虽然在 SHFP 医疗机构接受护理与提高种族和民族群体接受指南一致护理的可能性相关，但与非西班牙裔白人患者相比，种族和民族少数群体患者的改善幅度更大。
结论和相关性：无论种族和民族如何，在有 SHFP 的医疗机构接受护理的老年患者更有可能接受指南一致的护理（骨保护药物、POD1 时的 WBAT 和 VTE 预防）。然而，在有 SHFP 的医疗机构接受护理的非西班牙裔白人患者接受指南一致护理的可能性增加幅度大于种族和民族少数群体患者。
