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Disentangling the contribution of hospitals and municipalities for understanding patient level differences in one-year mortality risk after hip-fracture : A cross-classified multilevel analysis in Sweden

Kristensen, Pia Kjær ; Perez-Vicente, Raquel LU ; Leckie, George LU ; Johnsen, Søren Paaske and Merlo, Juan LU orcid (2020) In PLoS ONE 15(6).
Abstract

BACKGROUND: One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variation in patient outcomes in isolation rather than as a component of the underlying patient variation. We therefore aimed to extend the traditional approach to simultaneously estimate both case-mix adjusted hospital and municipality comparisons in order to disentangle the amount of the total patient variation in clinical outcomes that was attributable to the hospital and municipality level,... (More)

BACKGROUND: One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variation in patient outcomes in isolation rather than as a component of the underlying patient variation. We therefore aimed to extend the traditional approach to simultaneously estimate both case-mix adjusted hospital and municipality comparisons in order to disentangle the amount of the total patient variation in clinical outcomes that was attributable to the hospital and municipality level, respectively.

METHODS: We determined 1-year mortality risk in patients aged 65 or above with hip fractures registered in Sweden between 2011 and 2014. We performed cross-classified multilevel analysis with 54,999 patients nested within 54 hospitals and 290 municipalities. We adjusted for individual demographic, socioeconomic and clinical characteristics. To quantify the size of the hospital and municipality variation we calculated the variance partition coefficient (VPC) and the area under the receiver operator characteristic curve (AUC).

RESULTS: The overall 1-year mortality rate was 25.1%. The case-mix adjusted rates varied from 21.7% to 26.5% for the 54 hospitals, and from 18.9% to 29.5% for the 290 municipalities. The VPC was just 0.2% for the hospital and just 0.1% for the municipality level. Patient sociodemographic and clinical characteristics were strong predictors of 1-year mortality (AUC = 0.716), but adding the hospital and municipality levels in the cross-classified model had a minor influence (AUC = 0.718).

CONCLUSIONS: Overall in Sweden, one-year mortality after hip-fracture is rather high. However, only a minor part of the patient variation is explained by the hospital and municipality levels. Therefore, a possible intervention should be nation-wide rather than directed to specific hospitals or municipalities.

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author
; ; ; and
organization
publishing date
type
Contribution to journal
publication status
published
subject
in
PLoS ONE
volume
15
issue
6
article number
e0234041
publisher
Public Library of Science (PLoS)
external identifiers
  • scopus:85086008214
  • pmid:32492053
ISSN
1932-6203
DOI
10.1371/journal.pone.0234041
language
English
LU publication?
yes
id
0315ee9b-cbbb-45fa-b695-3328786a7c63
date added to LUP
2020-06-06 09:02:24
date last changed
2024-04-03 07:49:26
@article{0315ee9b-cbbb-45fa-b695-3328786a7c63,
  abstract     = {{<p>BACKGROUND: One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variation in patient outcomes in isolation rather than as a component of the underlying patient variation. We therefore aimed to extend the traditional approach to simultaneously estimate both case-mix adjusted hospital and municipality comparisons in order to disentangle the amount of the total patient variation in clinical outcomes that was attributable to the hospital and municipality level, respectively.</p><p>METHODS: We determined 1-year mortality risk in patients aged 65 or above with hip fractures registered in Sweden between 2011 and 2014. We performed cross-classified multilevel analysis with 54,999 patients nested within 54 hospitals and 290 municipalities. We adjusted for individual demographic, socioeconomic and clinical characteristics. To quantify the size of the hospital and municipality variation we calculated the variance partition coefficient (VPC) and the area under the receiver operator characteristic curve (AUC).</p><p>RESULTS: The overall 1-year mortality rate was 25.1%. The case-mix adjusted rates varied from 21.7% to 26.5% for the 54 hospitals, and from 18.9% to 29.5% for the 290 municipalities. The VPC was just 0.2% for the hospital and just 0.1% for the municipality level. Patient sociodemographic and clinical characteristics were strong predictors of 1-year mortality (AUC = 0.716), but adding the hospital and municipality levels in the cross-classified model had a minor influence (AUC = 0.718).</p><p>CONCLUSIONS: Overall in Sweden, one-year mortality after hip-fracture is rather high. However, only a minor part of the patient variation is explained by the hospital and municipality levels. Therefore, a possible intervention should be nation-wide rather than directed to specific hospitals or municipalities.</p>}},
  author       = {{Kristensen, Pia Kjær and Perez-Vicente, Raquel and Leckie, George and Johnsen, Søren Paaske and Merlo, Juan}},
  issn         = {{1932-6203}},
  language     = {{eng}},
  month        = {{06}},
  number       = {{6}},
  publisher    = {{Public Library of Science (PLoS)}},
  series       = {{PLoS ONE}},
  title        = {{Disentangling the contribution of hospitals and municipalities for understanding patient level differences in one-year mortality risk after hip-fracture : A cross-classified multilevel analysis in Sweden}},
  url          = {{http://dx.doi.org/10.1371/journal.pone.0234041}},
  doi          = {{10.1371/journal.pone.0234041}},
  volume       = {{15}},
  year         = {{2020}},
}