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

Abstract

Individual 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.

Purpose: The 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.

Methods: Hip 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.

Results: Of 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).

Conclusion: The 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.

Keywords: Audit; Hip fracture; Quality of care; Textbook process.

Fig. 1

Textbook process: a composite measurement of four individual indicators. Each bar depicts the overall fulfilment of each quality indicator. The lines represent the hospitals, and the intersection with the bars (indicators) show the percentage of patients treated according to the textbook process definition in each hospital. If an indicator was not met, the patient could not receive care according to the textbook process definition anymore and was excluded from the next bar (indicator) leading to a cumulative effect

Fig. 2

Per hospital, the textbook process rate is shown for both outcome measures: complication rate and length of hospital stay. The hospital with the largest textbook process group (hospital 2 – 75.6%) had the lowest complication rate (23.4%) and the lowest prolonged length of hospital stay (35.6%)