Hospitals´ Discharge Tendency and Risk of Death - An Analysis of 60,000 Norwegian Hip Fracture Patients

Sara Marie Nilsen, 1,* Johan Håkon Bjørngaard, 2, 3,* Fredrik Carlsen, 4 Kjartan Sarheim Anthun, 2, 5 Lars Gunnar Johnsen, 6, 7 Lars Johan Vatten, 2 Andreas Asheim 1, 8 1Center for Health Care Improvement, Trondheim University Hospital, Trondheim, Norway; 2Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway; 3Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway; 4Department of Economics, Norwegian University of Science and Technology, Trondheim, Norway; 5Department of Health Research, SINTEF Digital, Trondheim, Norway; 6Department of Orthopaedic Surgery, Trondheim University Hospital, Trondheim, Norway; 7Department of Neuromedicine, Norwegian University of Science and Technology, Trondheim, Norway; 8Department of Mathematical Sciences, Norwegian University of Science and Technology, Trondheim, Norway*These authors contributed equally to this workCorrespondence: Johan Håkon BjørngaardNTNU, Institutt for samfunnsmedisin og sykepleie, Postboks 8905, Trondheim 7491, NorwayTel +47 92242734Fax +47 73597577Email johan.h.bjorngaard@ntnu.noPurpose: A reduction in the length of hospital stay may threaten patient safety. This study aimed to estimate the effect of organizational pressure to discharge on 60-day mortality among hip fracture patients.Patients and Methods: In this cohort study, hip fracture patients were analyzed as if they were enrolled in a sequence of trials for discharge. A hospital’s discharge tendency was defined as the proportion of patients with other acute conditions who were discharged on a given day. Because the hospital’s tendency to discharge would affect hip fracture patients in an essentially random manner, this exposure could be regarded as analogous to being randomized to treatment in a clinical trial. The study population consisted of 59,971 Norwegian patients with hip fractures, hospitalized between 2008 and 2016, aged 70 years and older. To calculate the hospital discharge tendency for a given day, we used data from all 5,013,773 other acute hospitalizations in the study period.Results: The probability of discharge among hip fracture patients increased by 5.5 percentage points (95% confidence interval (CI)=5.3– 5.7) per 10 percentage points increase in hospital discharges of patients with other acute conditions. The increased risk of death that could be attributed to a discharge from organizational causes was estimated to 3.7 percentage points (95% CI=1.4– 6.0). The results remained stable under different time adjustments, follow-up periods, and age cut-offs.Conclusion: This study showed that discharges from organizational causes may increase the risk of death among hip fracture patients.Keywords: length of stay, causality, bed occupancy, quality of healthcare, mortality, orthopedic procedures