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Purpose: to examine the association between physiotherapy access after hip fracture and discharge home, readmission, survival, and mobility recovery.Methods: a 2017 Physiotherapy Hip Fracture Sprint Audit was linked to hospital records for 5,383 patients. Logistic regression was used to estimate the association between physiotherapy access in the first postoperative week and discharge home, 30-day readmission post-discharge, 30-day survival and 120-days mobility recovery post-admission adjusted for age, sex, American Society of Anesthesiology grade, Hospital Frailty Risk Score and prefracture mobility/residence.Results: overall, 73% were female and 40% had high frailty risk. Patients who received ≥2 hours of physiotherapy (versus less) had 3% (95% Confidence Interval: 0-6%), 4% (2-6%), and 6% (1-11%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 3% (0-6%) lower adjusted probability of readmission. Recipients of exercise (versus mobilisation alone) had 6% (1-12%), 3% (0-7%), and 11% (3-18%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 6% (2-10%) lower adjusted probability of readmission. Recipients of 6-7 days physiotherapy (versus 0-2 days) had 8% (5-11%) higher adjusted probability of survival. For patients with dementia, improved probability of survival, discharge home, readmission and indoor mobility recovery were observed with greater physiotherapy access.Conclusion: greater access to physiotherapy was associated with a higher probability of positive outcomes. For every 100 patients, greater access could equate to an additional eight patients surviving to 30-days and six avoiding 30-day readmission. The findings suggest a potential benefit in terms of home discharge and outdoor mobility recovery.

The structural and chemical modelling of PmF3.

A universal cluster model applicable to the most common nonstoichiometry in inorganic fluorides with the CaF2 structure.

ObjectivesClinical guidelines favour coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) for patients with stable complex coronary disease. Yet the benefit of CABG as established in trials may not be generalizable to populations in which treatment method determines time to treatment, typically being longer for CABG. For cases in which the cardiac anatomy is suitable for either treatment, it is unclear whether it is appropriate to recommend CABG, which is likely to be delayed, if PCI can be performed sooner. This paper outlines an analytical framework for a policy analysis of the timing of coronary revascularization.MethodsWe constructed a thought experiment to examine whether time to treatment will influence the advantage of CABG. We substantiated the use of mediation analysis to estimate the extent to which differences in outcomes between CABG and PCI would change if times to CABG were the same as times to PCI.ResultsWe designed a study that uses data from a population-based patient registry to obtain effect measures of mediation analysis: the total effect, the natural indirect effect, and the natural direct effect. The partitioning of the total effect will allow us to estimate the proportional reduction in the risk of an outcome if the time to CABG was similar to that of PCI.InterpretationTreatment recommendation, resource allocation and scheduling benchmarks will be guided by understanding the extent to which the time to treatment mediates the relation between revascularization method and outcome.

Summary: Additional physiotherapy in the first postoperative week was associated with fewer days to discharge after hip fracture surgery. A 7-day physiotherapy service in the first postoperative week should be considered as a new key performance indicator in evaluating the quality of care for patients admitted with a hip fracture. Introduction: To examine the association between physiotherapy in the first week after hip fracture surgery and discharge from acute hospital. Methods: We linked data from the UK Physiotherapy Hip Fracture Sprint Audit to hospital records for 5395 patients with hip fracture in May and June 2017. We estimated the association between the number of days patients received physiotherapy in the first postoperative week; its overall duration (< 2 h, ≥ 2 h; 30-min increment) and type (mobilisation alone, mobilisation and exercise) and the cumulative probability of discharge from acute hospital over 30 days, using proportional odds regression adjusted for confounders and the competing risk of death. Results: The crude and adjusted odds ratios of discharge were 1.24 (95% CI 1.19–1.30) and 1.26 (95% CI 1.19–1.33) for an additional day of physiotherapy, 1.34 (95% CI 1.18–1.52) and 1.33 (95% CI 1.12–1.57) for ≥ 2 versus < 2 h physiotherapy, and 1.11 (95% CI 1.08–1.15) and 1.10 (95% CI 1.05–1.15) for an additional 30-min of physiotherapy. Physiotherapy type was not associated with discharge. Conclusion: We report an association between physiotherapy and discharge after hip fracture. An average UK hospital admitting 375 patients annually may save 456 bed-days if current provision increased so all patients with hip fracture received physiotherapy on 6–7 days in the first postoperative week. A 7-day physiotherapy service totalling at least 2 h in the first postoperative week may be considered a key performance indicator of acute care quality after hip fracture.

We conducted a series of simulation experiments to test for differences between three methods of scheduling clinic appointments in a surgical service. The three methods were placing patients on the appointment list of the surgeon named in the referral (the individual list method), placing patients on the appointment list of the surgeon with the fewest patients waiting (the shortest list method), and placing all patients on one appointment list and scheduling appointments with the first available surgeon (the pooled list method). We simulated the entire process of surgical care, beginning with the referral and incorporating appointment scheduling, consultation, registration for surgery, pre-surgical assessment, the operation itself, intensive care treatment and discharge from the hospital, accounting for interactions between the appointment and booking systems. Using the Statecharts specifications for the continuum of clinical and managerial activities, a discreteevent simulation model, and a cluster randomized experimental design, for each scheduling method we generated 36 runs, each representing a surgical service with three surgeons who rotated clinic and operating time. The runs differed in terms of the method of allocating slots between urgent and elective procedures and the initial size of queues for outpatient consultation, elective procedures, and inpatient surgery. The delivery of surgical services was simulated over six cycles of allocation of clinic and operating time, to increase variation in the experimental responses. To estimate the impact of scheduling methods on patient flow, we focused on two common performance measures: clearance time for the appointment list (at the hospital level of analysis) and time to appointment (at the patient level of analysis). Comparisons at the hospital level were used to determine which method of scheduling clinic appointments would reduce the clearance times. Comparisons at the patient level were used to determine which scheduling method would reduce patients’ waiting times. We found that clearance times for appointment lists were more than 1.5 weeks longer for surgical services that used the individual list and shortest list methods than for services that used the pooled list method. After adjustment for hospital and patient factors, the weekly likelihood that patients on an appointment list would have had a consultation with a specialist was 78% lower for services using the individual list and shortest list methods than for those using the pooled list methods. One explanation for these longer clearance times

X-ray and electrophysical investigations of ceramics with a charge composition 95 mol % CeF3 × 5 mol % SrF2 synthesized by hot pressing of CeF3 and SrF2 powders (300 MPa, 900°С, 20 min) in vacuum and the same ceramics annealed in a fluorinating atmosphere (CF4, 1000°С, 180 min) have been carried out. The initial two-phase ceramics consists of the tysonite phase (a = 7.130(1) A, c = 7.295(1) A) and up to 2 wt % of fluorite impurity phase (a = 5.77(1) A). The ionic conductivity of the initial ceramics is σdc = 2.8 × 10–4 S/cm at room temperature. Heat treatment of the ceramics in a fluorinating atmosphere eliminates the fluorite phase. After the annealing, the ceramics becomes single-phase and turns to the Ce1 − ySryF3 − y tysonite solid solution. The σdc value of the annealed ceramics with the nominal composition Ce0.95Sr0.05F2.95 increases by a factor of ∼1.5 and coincides with the σdc value for a single crystal of the same composition.

Background Competing demands for operative resources may affect time to hip fracture surgery. We sought to determine the time to hip fracture surgery by variation in demand in Canadian hospitals. Methods We obtained discharge abstracts of 151,952 patients aged 65 years or older who underwent surgery for a hip fracture between January, 2004 and December, 2012 in nine Canadian provinces. We compared median time to surgery (in days) when demand could be met within a two-day benchmark and when demand required more days, i.e. clearance time, to provide surgery, overall and stratified by presence of medical reasons for delay. Results For persons admitted when demand corresponded to a 2-day clearance time, 68% of patients underwent surgery within the 2-day benchmark. When demand corresponded to a clearance time of one week, 51% of patients underwent surgery within 2 days. Compared to demand that could be served within the two-day benchmark, adjusted median time to surgery was 5.1% (95% confidence interval [CI] 4.1–6.1), 12.2% (95% CI 10.3–14.2), and 22.0% (95% CI 17.7–26.2) longer, when demand required 4, 6, and 7 or more days to clear the backlog, respectively. After adjustment, delays in median time to surgery were similar for those with and without medical reasons for delay. Conclusion Increases in demand for operative resources were associated with dose-response increases in the time needed for half of hip fracture patients to undergo surgery. Such delays may be mitigated through better anticipation of day-to-day supply and demand and increased response capability.

SummaryThe extent of Canadian provincial variation in hip fracture surgical timing is unclear. Provinces performed a similar proportion of surgeries within three inpatient days after adjustment. Time to surgery varied by timing of admission across provinces. This may reflect different approaches to providing access to hip fracture surgery.IntroductionThe aim of this study was to compare whether time to surgery after hip fracture varies across Canadian provinces for surgically fit patients and their subgroups defined by timing of admission.MethodsWe retrieved hospitalization records for 140,235 patients 65 years and older, treated surgically for hip fracture between 2004 and 2012 in Canada (excluding Quebec). We studied the proportion of surgeries on admission day and within 3 inpatient days, and times required for 33%, 66%, and 90% of surgeries across provinces and by subgroups defined by timing of admission. Differences were adjusted for patient, injury, and care characteristics.ResultsOverall, provinces performed similar proportions of surgeries within the recommended three inpatient days, with all provinces requiring one additional day to perform the recommended 90% of surgeries. Prince Edward Island performed 7.0% more surgeries on admission day than Ontario irrespective of timing of admission (difference = 7.0; 95% CI 4.0, 9.9). The proportion of surgeries on admission day was 6.3% lower in Manitoba (difference = − 6.3; 95% CI − 12.1, − 0.6), and 7.7% lower in Saskatchewan (difference = − 7.7; 95% CI − 12.7, − 2.8) compared to Ontario. These differences persisted for late weekday and weekend admissions. The time required for 33%, 66%, and 90% of surgeries ranged from 1 to 2, 2–3, and 3–4 days, respectively, across provinces by timing of admission.ConclusionsProvinces performed similarly with respect to recommended time for hip fracture surgery. The proportion of surgeries on admission day, and time required to complete 33% and 66% of surgeries, varied across provinces and by timing of admission. This may reflect different provincial approaches to providing access to hip fracture surgery.

PurposeTo examine prognostic factors that influence complications after hip fracture surgery. To summarise proposed underlying mechanisms for their influence.MethodsWe reported according to Preferred Reporting Items for Systematic Review and Meta-Analysis Scoping Review extension. We searched MEDLINE, Embase, CINAHL, AgeLine, Cochrane Library, and reference lists of retrieved studies for studies of prognostic factor/s of postoperative in-hospital medical complication/s among patients 50 years and older treated surgically for non-pathological closed hip fracture, published in English January 2008 - January 2018. We excluded studies of surgery type or in-hospital medications. Screening was duplicated by two independent reviewers. One reviewer completed extraction with accuracy checks by a second. We summarised extent, nature, and proposed underlying mechanisms for prognostic factors of complications narratively and in a dependency graph. ResultsWe identified 44 prognostic factors of in-hospital complications after hip fracture surgery from 56 studies. Of these, we identified 7 patient factors– dehydration, anaemia, hypotension, heart rate variability, pressure risk, nutrition, indwelling catheter use; and 7 process factors– time to surgery, anaesthetic type, transfusion strategy, orthopaedic versus geriatric/comanaged care, and multidisciplinary care pathway, potentially modifiable during index hospitalisation. We identified underlying mechanisms for 15 of 44 factors. The reported association between 12 prognostic factors and complications was inconsistent across studies.ConclusionsMost factors were reported by one study with no proposed underlying mechanism for their influence. Where reported by more than one study, there was inconsistency in reported associations and the conceptualisation of complications differed, limiting comparison across studies. It is therefore not possible to be certain whether intervening on these factors would reduce the rate of complications after hip fracture surgery.

ObjectivesTo describe an approach using concomitant medication log records for the construction of treatment episodes. Concomitant medication log records are routinely collected in clinical studies. Unlike prescription and dispensing records, concomitant medication logs collect utilisation data. Logs can provide information about drug safety and drug repurposing.DesignA prospective multicentre, multicohort observational study.SettingTwenty-one clinical sites in the USA, Europe, Israel and Australia.Participants415 subjects from the de novo cohort of the Parkinson’s Progression Markers Initiative.MethodsWe construct treatment episodes of concomitant medication use. The proposed approach treats temporal gaps as a stoppage of medication and temporal overlaps as simultaneous use or changes in dose. Log records with no temporal gaps were combined into a single treatment episode.Results5723 concomitant medication log records were used to construct 3655 treatment episodes for 65 medications. There were 405 temporal gaps representing a stoppage of medication; 985 temporal overlaps representing simultaneous regimens of the same medication and 2696 temporal overlaps representing a change in dose regimen. The median episode duration was 37 months (IQ interval: 11–73 months).ConclusionsThe proposed approach for constructing treatment episodes offers a method of estimating duration and dose of treatment from concomitant medication log records. The accompanying recommendations guide log data collection to improve their quality for drug safety and drug repurposing.

IntroductionThe Canadian Institutes of Health Research (CIHR) and provinces co-fund local Units to increase the quality and quantity of patient-oriented research. These SUPPORT (Support for People and Patient-Oriented Research and Trials) Units include a prominent Data Plan component. The BC Plan is the result of collaboration between many organizational partners. Objectives and ApproachA Data Advisory Committee comprised of eight organizational partners worked together for several months in 2016-2017 to develop BC’s provincial Data Plan. The Data Plan includes seven objectives; in general, the plan seeks to make additional data available for research, increase the speed and transparency of data access, and offer services to enable more efficient data use. The services resulting from the Data Plan are intended to improve support for the entire continuum of a research project, from developing a research question to analyzing the results. Several projects are part of Ministry of Health-led work developing a Health Data Platform. ResultsThe projects initiated so far as part of the Data Plan include: BC Data Scout\textsuperscript{TM}: an online tool that provides aggregate cohort information to inform research question development; REDCap: software to support privacy-sensitive data collection and management; INFORM: software to support data collection for complex clinical research studies and trials; Direct Access: enables Population Data BC to access BC Ministry of Health databases so researchers have access to up-to-date data; Streamlining: making the data request process more efficient; New datasets: several projects that will provide new data sources, including patient experience and outcome measures and secondary use data drawn from electronic medical records; and Inventory: an online catalog for all high-value and linkable data sets available to researchers. Conclusion/ImplicationsThe services and tools included in BC’s Data Plan will help researchers develop and deliver world-class research and inform important health care decisions. The patient-oriented focus of these services help to ensure that research is done in partnership with patients and centered on research questions that matter to them.

Objectivethis systematic review aimed to identify immutable and modifiable prognostic factors of functional outcomes and their proposed mechanism after hip fracture surgery.Designsystematic search of MEDLINE, Embase, CINAHL, PEDRO, OpenGrey and ClinicalTrials.gov for observational studies of prognostic factors of functional outcome after hip fracture among surgically treated adults with mean age of 65 years and older. Study selection, quality assessment, and data extraction were completed independently by two reviewers. The Quality in Prognosis Studies Tool was used for quality assessment and assigning a level of evidence to factors. Proposed mechanisms for reported associations were extracted from discussion sections.Resultsfrom 33 studies of 9,552 patients, we identified 25 prognostic factors of functional outcome after hip fracture surgery. We organised factors into groups: demographics, injury and comorbidities, body composition, complications, and acute care. We assigned two factors a weak evidence level—anaemia and cognition. We assigned Parkinson’s disease an inconclusive evidence level. We could not assign an evidence level to the remaining 22 factors due to the high risk of bias across studies. Frailty was the proposed mechanism for the association between anaemia and functional outcome. Medication management, perceived potential, complications and time to mobility were proposed as mechanisms for the association between cognition and functional outcome.Conclusionwe identified one modifiable and one immutable prognostic factor for functional outcomes after hip fracture surgery. Future research may target patients with anaemia or cognitive impairment by intervening on the prognostic factor or the underlying mechanisms.

BACKGROUND: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay.METHODS: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram.RESULTS: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%).INTERPRETATION: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.In Canada, hospitals admit 30 000 older adults with hip fracture annually.1 These patients face an increased risk of death, with up to 5% of women and 10% of men dying within 30 days.2,3 It is generally accepted that early operative intervention improves survival by reducing patients’ exposure to immobilization and inflammation.4 In 2005, the federal, provincial and territorial governments established a benchmark of 48 hours from admission for 90% of hip fracture surgeries to prevent potentially harmful delays.5 However, delays to hip fracture surgery remain common.6 Patients who are medically stable at presentation may have to wait until a surgeon or an operating room becomes available.7,8There has been considerable debate about the point at which delaying hip fracture surgery for nonmedical reasons worsens mortality.9–25 This uncertainty leads to prioritization without benefit to the patient or underuse of expeditious surgery that could prevent deaths. Some have argued that understanding the effects of policy change should guide reorganization of operating room resources26 and prioritization in the presence of competing demand.7,27–29 In this paper, we offer 2 new estimates: the effect of possible changes in surgical timing policy in the same population of patients, and the proportion of in-hospital deaths attributable to surgical delays.

Episodes of care defined by the event of hip fracture surgery are widely used for the assessment of surgical wait times and outcomes. However, this approach does not consider nonoperative deaths, implying that survival time begins at the time of procedure. This approach makes treatment effect implicitly conditional on surviving to treatment. The purpose of this article is to describe a novel conceptual framework for constructing an episode of hip fracture care to fully evaluate the incidence of adverse events related to time after admission for hip fracture. This admission-based approach enables the assessment of the full harm of delay by including deaths while waiting for surgery, not just deaths after surgery. Some patients wait until their conditions are optimized for surgery, whereas others have to wait until surgical service becomes available. We provide definitions, linkage rules, and algorithms to capture all hip fracture patients and events other than surgery. Finally, we discuss data elements for stratifying patients according to administrative factors for delay to allow researchers and policymakers to determine who will benefit most from expedited access to surgery. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:197–204, 2016.

Adverse drug events are an important cause of emergency department visits, unplanned admissions and prolonged hospital stays. Our objective was to synthesize the evidence on the effect of early in-hospital pharmacist-led medication review on patient-oriented outcomes based on observed data.

Hip fracture increases death risk. Ten percent of survivors have second hip fracture. It is not known if second hip fracture further increases death risk. Here, we report that second hip fracture increases death risk beyond that expected for an increase in age. Secondary prevention after hip fracture could save lives. The purpose of this study is to determine if second hip fracture is associated with an increased death rate. We retrieved 42,435 hospitalization records of patients aged 60 years or older, who were discharged after admission for hip fracture surgery between 1990 and 2005 in British Columbia, Canada. The outcome variable was the time to death. During follow-up, the average monthly death rate was 16.2 (95 % CI 16.0–16.4) per 1000 patient-months for those without second hip fracture and 21.1 (95 % CI 20.2–22.1) per 1000 patient-months for those with second hip fracture. The hazard of death was 55 % higher for patients with second hip fracture compared to those without second hip fracture (HR = 1.55, 95 % CI 1.47–1.63). The hazard of death was 58 % higher for men with second hip fracture than in men without second hip fracture (HR = 1.58, 95 % CI 1.42–1.75). The hazard of death was 54 % higher for women with second hip fracture compared to women without second hip fracture (HR = 1.54, 95 % CI 1.46–1.63). These sex-specific HRs were not statistically different (p = 0.70). Our results are the first to show that second hip fracture increases the risk of death above that anticipated for an increase in age for both men and women. Effective secondary prevention strategies could not only reduce morbidity after hip fracture but could also save lives.

BACKGROUND Adverse drug events are unintended and harmful events related to medication use. They are a leading cause of visits to the emergency department, unplanned admissions to hospital and death. Adverse drug events can be misdiagnosed in the emergency department, resulting in treatment delays. Our objective was to describe a process to evaluate the effect of pharmacist-led medication review in high-risk patients in the emergency department on the number of days these patients subsequently spent in hospital within 30 days of their index visit. METHODS We describe the evaluation of a prospective multicentre quality improvement program. During the evaluation period, triage nurses will flag incoming patients to the emergency department at high risk for adverse drug events by applying a clinical decision rule consisting of 4 variables (comorbid conditions, antibiotic use within 7 days, medication changes within 28 days and age). Consecutive eligible patients will be enrolled in the study and systematically allocated to either a pharmacist-led medication review group or a control group. In the intervention group, pharmacists will collect best-possible medication histories, review the patient's medications for appropriateness and adverse drug events, and communicate the results of their medication review to patients, caregivers and physicians. In the control group, nurses will start medication reconciliation by collecting best-possible medication histories, and physicians will refer patients to onsite pharmacists for specific medication management questions as needed. Health outcomes will be assessed using anonymized data linkage to administrative health databases. The primary outcome will be the percent days spent in hospital over a 30-day period. INTERPRETATION This protocol describes the methods for evaluating the effect of pharmacist-led medication review in high-risk patients in the emergency department on use of health services, and highlights the methodological challenges that will be encountered. We plan to disseminate the results of this evaluation through articles published in peer-reviewed journals, presentations at scientific meetings and briefing notes to institutional, provincial and national stakeholders.

PurposeFailure to account for medically necessary delays may lead to an underestimation of early surgery benefits. This study investigated the feasibility of using administrative data to identify the National Institute for Health and Care Excellence (NICE) 124 guideline list of conditions that appropriately delay hip fracture surgery.MethodsWe assembled a list of diagnosis and procedure codes to reflect the NICE 124 conditions. The list was reviewed and updated by an advanced clinical coder. The list was refined by five clinical experts. We then screened Canadian Institute for Health Information discharge abstracts for 153 918 patients surgically treated for a non-pathological first hip fracture between 1 January 2004 and 31 December 2012 for diagnosis codes present on admission and procedure codes that antedated hip fracture surgery. We classified abstracts as having medical reasons for delaying surgery based on the presence of these codes.ResultsIn total, 10 237 (6.7%; 95% CI 6.5% to 6.8%) patients had diagnostic and procedure codes indicating medical reasons for delay. The most common reasons for medical delay were exacerbation of a chronic chest condition (35.9%) and acute chest infection (23.2%). The proportion of patients with reasons for medical delays increased with time from admission to surgery: 3.9% (95% CI 3.6% to 4.1%) for same day surgery; 4.7% (95% CI 4.5% to 4.8%) for surgery 1 day after admission; 7.1% (95% CI 6.9% to 7.4%) for surgery 2 days after admission; and 15.5% (95% CI 15.1% to 16.0%) for surgery more than 2 days after admission. The trend was seen for admissions on weekday working hours, weekday after hours and on weekends.ConclusionAdministrative data can be considered to identify conditions that appropriately delay hip fracture surgery. Accounting for medically necessary delays can improve estimates of the effectiveness of early surgery.

In hip fracture care, it is disputed whether mortality worsens when surgery is delayed. This knowledge gap matters when hospital managers seek to justify resource allocation for prioritizing access to one procedure over another. Uncertainty over the surgical timing-death association leads to either surgical prioritization without benefit or the underuse of expedited surgery when it could save lives. The discrepancy in previous findings results in part from differences between patients who happened to undergo surgery at different times. Such differences may produce the statistical association between surgical timing and death in the absence of a causal relationship. Previous observational studies attempted to adjust for structure, process, and patient factors that contribute to death, but not for relationships between structure and process factors, or between patient and process factors. In this article, we (1) summarize what is known about the factors that influence, directly or indirectly, both the timing of surgery and the occurrence of death; (2) construct a dependency graph of relationships among these factors based explicitly on the existing literature; (3) consider factors with a potential to induce covariation of time to surgery and the occurrence of death, directly or through the network of relationships, thereby explaining a putative surgical timing-death association; and (4) show how age, sex, dependent living, fracture type, hospital type, surgery type, and calendar period can influence both time to surgery and occurrence of death through chains of dependencies. We conclude by discussing how these results can inform the allocation of surgical capacity to prevent the avoidable adverse consequences of delaying hip fracture surgery.

Background:Hospitalization data underestimate the occurrence of transient ischemic attack (TIA). As TIA is frequently diagnosed in primary care, methodologies for the accurate ascertainment of a TIA from physician claims data are required for surveillance and health systems planning in this population. The present study evaluated the diagnostic accuracy of multiple algorithms for TIA from a longitudinal population-based physician billing database.Methods:Population-based administrative data from the province of British Columbia were used to identify the base population (1992–2007;N=102,492). Using discharge records for hospital admissions for acute ischemic stroke with a recent (Results:Physician billing algorithms showed low to moderate sensitivity, with the algorithm for two consecutive physician visits within 90 days showing the highest sensitivity at 37.7% (CI95%=37.4–38.1). All algorithms demonstrated high specificity and moderate to high overall accuracy, resulting in low positive predictive values (≤5%), low discriminability (0.53–0.57) and high false positive rates (1 – specificity). Population-based estimates of TIA occurrence were comparable to prior studies and declined over time.Conclusions:Physician billing data have insufficient sensitivity to identify TIAs but may be used in combination with hospital discharge data to improve the accuracy of estimating the population-based occurrence of TIAs.

ObjectivesIt is disputed whether the time a patient waits for surgery after hip fracture increases the risk of in-hospital death. This uncertainty matters as access to surgery following hip fracture may be underprioritised due to a lack of definitive evidence. Uncertainty in the available evidence may be due to differences in characteristics of patients, their injury and their care. We summarised the literature on patients and system factors associated with time to surgery, and collated proposed mechanisms for the associations.MethodsWe used the framework developed by Arksey and O’Malley and Levacet alfor synthesis of factors and mechanisms of time to surgery after hip fracture in adults aged >50 years, published in English, between 1 January 2000 and 28 February 2017, and indexed in MEDLINE, EMBASE, CINAHL or Ageline. Proposed mechanisms for reported associations were extracted from discussion sections.ResultsWe summarised evidence from 26 articles that reported on 24 patient and system factors of time to surgery post hip fracture. In total, 16 factors were reported by only one article. For 16 factors we found proposed mechanisms for their association with time to surgery which included surgical readiness, available resources, prioritisation and out-of-hours admission.ConclusionsWe identified patient and system factors associated with time to surgery after hip fracture. This new knowledge will inform evaluation of the putative timing–death association. Future interventions should be designed to influence factors with modifiable mechanisms for delay.

Second hip fractures account for up to 15% of all hip fractures. We sought to determine if the proportion of hip fracture surgeries for second hip fracture changed over time in terms of patient and fracture characteristics.We reviewed the records of patients older than 60 years hospitalized for hip fracture surgery between 1990 and 2005 in British Columbia. We studied the proportion of surgeries for second hip fracture among all hip fracture surgeries. Linear regression tested for trends across fiscal years for women and men.We obtained 46 341 patient records. Second hip fracture accounted for 8.3% of hip fracture surgeries. For women the proportion of second hip fracture surgeries increased linearly from 4% to 13% with each age decade (Second hip fracture surgeries account for an increasing proportion of hip fracture surgeries and may require more health care resources to minimize poorer reported outcomes. Future research should determine whether more health care resources are required to manage these patients and optimize their outcomes.Les secondes fractures de la hanche représentent jusqu'à 15 % de la totalité des fractures de la hanche. Nous avons tenté de déterminer si la proportion de chirurgies de seconde fracture de la hanche avait évolué au fil du temps sur le plan des caractéristiques des patients et des fractures.Nous avons examiné les dossiers des patients de 60 ans et plus qui avaient été hospitalisés pour une chirurgie de fracture de la hanche entre 1990 et 2005, en Colombie-Britannique. De ce total, nous avons ensuite déterminé le nombre de chirurgies de seconde fracture de la hanche. L'analyse de régression linéaire a déterminé les tendances au cours des années financières pour les femmes et les hommes.Nous avons obtenu 46 341 dossiers de patient. Les secondes fractures de la hanche représentaient 8,3 % de la totalité des chirurgies de fracture de la hanche. Chez les femmes, la proportion de seconde fracture de la hanche augmentait de façon linéaire de 4 % à 13 % pour chaque tranche d'âge de 10 ans (Les chirurgies de seconde fracture de la hanche représentent une proportion croissante de la totalité des chirurgies de fracture de la hanche et pourraient nécessiter davantage de ressources en soins de santé pour minimiser les résultats moins bons signalés. Les recherches futures devraient déterminer s'il faut davantage de ressources de soins de santé pour la prise en charge de ces patients et l'optimisation de leurs résultats.

We thank Lardner and colleagues[1][1] for their interest in our article. Our next step is to explore potential mechanisms for our reported associations.[2][2] We agree that factors of care may help to explain the association between treatment setting and mortality after hip fracture. Indeed, we

Background context Waitlists are commonly used in Canada to manage access to surgical procedures such as elective surgical lumbar discectomy (ESLD). The timing of enrollment onto the waitlist is important as this is a proxy measure for the concordance of preferences for surgery between a patient and surgeon. After enrollment, the waiting time to actual surgery extends the duration of preoperative symptoms, which possibly affects the outcome of ESLD. Waiting time also specifically reflects the delay in service delivery imposed by the limited capacity of the health-care system. Purpose To determine if a system-imposed delay in treatment, that is, longer waiting time, for ESLD is associated with a higher odds of experiencing residual postoperative pain. Study design/setting Ambidirectional cohort study with 2-year retrospective and 3-year prospective components, conducted at a major tertiary care center serving a metropolitan area in Canada. Patient sample Patients aged 16 years or older with sciatica because of herniated lumbar disc, confirmed on advanced imaging, were recruited at the time of waitlist enrollment for ESLD. Patients with significant comorbidity or emergency indications for surgery were excluded. Of 391 participants, 291 had complete follow-up information at 6 months postoperatively. Outcome measure Intensity of the predominant symptom (worse of either back or leg pain) was assessed on the 11-point numerical rating scale at waitlist enrollment and 6 months postoperatively. Pain scores were highly skewed and therefore categorized into four ordinal levels defined by quartiles. Methods For the primary analysis, time to surgery from waitlist enrollment was dichotomized based on a predetermined clinically meaningful cut-point of 12 weeks. Ordinal logistic regression was used to compare the odds of experiencing higher pain intensity between wait groups. Control of confounders was achieved using both propensity scores and conventional multivariable modeling. Results In unadjusted analyses, long-wait patients were 80% more likely than short-wait patients to experience higher ordinal pain intensity at 6 months; unadjusted proportional odds ratio (POR)=1.8 (95% confidence interval [CI], 1.2–2.8). The association held after controlling for all imbalances in measured confounders, with long-wait patients still being 70% more likely to report worse pain; adjusted POR=1.7 (95% CI, 1.0–2.8). Conclusions A waiting time of 12 weeks or more after waitlist enrollment for ESLD is associated with a modest likelihood of experiencing worse pain at 6 months postoperatively. This result was not because of differences in measured confounders. Future studies are encouraged to identify other, as-of-yet unmeasured, variables that might be associated with both longer waiting times and worse outcomes among ESLD patients. Until then, in jurisdictions where highly constrained access to ESLD is managed through waitlists, the expected waiting time for the operation could be an informative deciding criterion for patients with otherwise unresolved preferences for operative treatment.

ObjectiveWe describe steps to operationalise a published conceptual framework for a contiguous hospitalisation episode using acute care hospital discharge abstracts. We then quantified the degree of bias induced by a first abstract episode, which does not account for hospital transfers.DesignRetrospective observational study.SettingAll acute care hospitals in nine Canadian provinces.ParticipantsWe retrieved acute hospitalisation discharge abstracts for 189 448 patients aged 65 years and older admitted to acute care with hip fracture between 2003 and 2013.Primary and secondary outcome measuresThe percentage of patients treated surgically, delayed to surgery (defined as two or more days after admission) and dying, between contiguous hospitalisation episodes and the first abstract episodes of care.ResultsUsing contiguous hospitalisation episodes, 91.6% underwent surgery, 35.7% were delayed two or more days after admission and 6.7% died postoperatively, whereas, using the first abstract only, these percentages were 83.7%, 32.5% and 6.5%, respectively.ConclusionWe demonstrate that not accounting for hospital transfers when evaluating the association between surgical timing and death underestimates reporting of the percentage of patients treated surgically and delayed to surgery by 9%, and the percentage who die after surgery by 3%. Researchers must be aware of this potential and avoidable bias as, depending on the purpose of the study, erroneous inferences may be drawn.

Many trauma survivors face challenges of impaired functioning, limited activities and reduced participation. Recovery from injury after acute care, therefore, becomes an important public health issue. This commentary discusses a framework for evaluating outcomes of acute care.

In this study, we assess the accuracy of fertility estimates that stem from the retrospective information that can be derived from an existing cross-sectional population. Swedish population registers contain information on the childbearing of all people ever registered as living in Sweden, and thus allow us to avoid problems of selectivity by the virtue of survival or nonemigration when estimating the fertility measures for previous calendar periods. We calculate two types of fertility rates for each year in 1961–1999: (i) rates that are based on the population that was living in Sweden at the end of 1999, and (ii) rates that also include information on people who had died or emigrated before the turn of the twentieth century. We find that the omission of information on individuals who had emigrated or died, as the situation would be in any demographic survey, most often have negligible effects on fertility measures. However, first-birth rates of immigrants gradually become more biased as we move back in time from 1999 so that they increasingly tend to over-estimate the true fertility of that population.

Background: Where patients with hip fracture undergo treatment may influence their outcome. We compared the risk of in-hospital death after hip fracture by treatment setting in Canada. Methods: We examined all discharge abstracts from the Canadian Institute for Health Information with diagnosis codes for hip fracture involving patients 65 years and older who were admitted to hospital with a nonpathological first hip fracture between Jan. 1, 2004, and Dec. 31, 2012, in Canada (excluding Quebec). We compared the risk of in-hospital death, overall and after surgery, between teaching hospitals and community hospitals of various bed capacities, accounting for variation in length of stay. Results: Compared with the number of deaths per 1000 admissions at teaching hospitals, there were an additional 3 (95% confidence interval [CI] 1-6), 14 (95% CI 10-18) and 43 (95% CI 35-51) deaths per 1000 admissions at large, medium and small community hospitals, respectively. For the risk of in-hospital death overall, the adjusted odds ratios (ORs) were 1.05 (95% CI 0.99-1.11), 1.16 (95% CI 1.09-1.24) and 1.44 (95% CI 1.31-1.57) at large, medium and small community hospitals, respectively, compared with teaching hospitals. For the risk of postsurgical death in hospital, the adjusted ORs were 1.06 (95% CI 1.00-1.13), 1.13 (95% CI 1.04-1.23) and 1.18 (95% CI 0.87-1.60) at large, medium and small community hospitals, respectively. Interpretation: Compared with teaching hospitals, the risk of in-hospital death among patients with hip fracture was higher at medium and small community hospitals, and the risk of in-hospital death after surgery was higher at medium community hospitals. No differences were found between teaching and large community hospitals. Future research should examine the role of volume, demand and bed occupancy for observed differences.

BACKGROUND: Several patient and health system factors were associated with the risk of death among patients with hip fracture. However, without knowledge of underlying mechanisms interventions to improve survival post hip fracture can only be designed on the basis of the found statistical associations.METHODS: We used the framework developed by Arksey and O'Malley and Levac et al. for synthesis of factors and mechanisms of mortality post low energy hip fracture in adults over the age of 50 years, published in English, between September 1, 2009 and October 1, 2014 and indexed in MEDLINE. Proposed mechanisms for reported associations were extracted from the discussion sections.RESULTS: We synthesized the evidence from 56 articles that reported on 35 patient and 9 system factors of mortality post hip fracture. For 21 factors we found proposed biological mechanisms for their association with mortality which included complications, comorbidity, cardiorespiratory function, immune function, bone remodeling and glycemic control.CONCLUSIONS: The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles and with no proposed mechanisms for their effects on mortality. Where reported, underlying mechanisms are often based on a single article and should be confirmed with further study. Therefore, one cannot be certain whether intervening on such factors may produce expected results.