Textbook process as a composite quality indicator for in-hospital hip fracture care

Stijn C Voeten,Michel W J M Wouters,E J Verleisdonk,C Stevens,J H Hegeman,A H P Niggebrugge,D Van Der Velde,Franka S Würdemann,Pieta Krijnen,The Dhfa Indicator Task Force ,G De Klerk,Inger B Schipper,O Geragthy,J Snoek,H A F Luning,M Regtuijt

doi:10.1007/s11657-021-00909-6

Abstract

SummaryIndividual process indicators often do not enable the benchmarking of hospitals and often lack an association with outcomes of care. The composite hip fracture process indicator, textbook process, might be a tool to detect hospital variation and is associated with better outcomes during hospital stay.PurposeThe aim of this study was to determine hospital variation in quality of hip fracture care using a composite process indicator (textbook process) and to evaluate at patient level whether fulfilment of the textbook process indicator was associated with better outcomes during hospital stay.MethodsHip fracture patients aged 70 and older operated in five hospitals between 1 January 2018 and 31 December 2018 were included. Textbook process for hip fracture care was defined as follows: (1) assessment of malnutrition (2) surgery within 24 h, (3) orthogeriatric management during admission and (4) operation by an orthopaedic trauma certified surgeon. Hospital variation analysis was done by computing an observed/expected ratio (O/E ratio) for textbook process at hospital level. The expected ratios were derived from a multivariable logistic regression analysis including all relevant case-mix variables. The association between textbook process compliance and in-hospital complications and prolonged hospital stay was determined at patient level in a multivariable logistic regression model, with correction for patient, treatment and hospital characteristics. In-hospital complications were anaemia, delirium, pneumonia, urinary tract infection, in-hospital fall, heart failure, renal insufficiency, pulmonary embolism, wound infection and pressure ulcer.ResultsOf the 1371 included patients, 753 (55%) received care according to textbook process. At hospital level, the textbook compliance rates ranged from 38 to 76%. At patient level, textbook process compliance was significantly associated with fewer complications (38% versus 46%) (OR 0.66, 95% CI 0.52–0.84), but not with hospital stay (median length of hospital stay was 5 days in both groups) (OR 1.01, 95% CI 0.78–1.30).ConclusionThe textbook process indicator for hip fracture care might be a tool to detect hospital variation. At patient level, this quality indicator is associated with fewer complications during hospital stay.

Highlights

Leeuwenhoek Hospital, Amsterdam, The Netherlands 4 Department of Trauma Surgery, Ziekenhuisgroep Twente, Almelo-Hengelo, The NetherlandsSociety increasingly demands insight into the quality of care
In the American Society of Anesthesiologists (ASA) 1-2 group and in the ASA 3-4 group, 62% and 52% of the patients, respectively, received care according to the textbook process definition
Our study only focused on the in-hospital part of hip fracture care and validated the textbook process indicator against

Summary

Introduction

Society increasingly demands insight into the quality of care. To provide this insight, quality indicators are useful instruments [1]. In the Donabedian framework, quality indicators are categorized into structure, process and outcome indicators [2]. Structure and process indicators reflect the care a patient receives, the assumption being that good structures and processes will lead to good end results of care [3]. Outcome indicators are expected to reflect the end result of care. A quality indicator can be qualified as adequate if it meets the following four criteria: clinically relevant, scientifically acceptable (valid and reliable), feasible and usable [1, 4, 5]

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