Aims

To determine whether the findings from a landmark Canadian trial assessing the optimal management of acute rupture of the Achilles tendon influenced the practice patterns of orthopaedic surgeons in Ontario, Canada.

Over the last decade, there has been a growing body of level I evidence supporting non-operative management (focused on early range of motion and weight bearing) of acute Achilles tendon ruptures. Despite this emerging evidence, there have been very few studies evaluating its uptake. Our primary objective was to determine whether the findings from a landmark Canadian trial assessing the optimal management strategy for acute Achilles tendon ruptures influenced the practice patterns of orthopaedic surgeons in Ontario, Canada over a 12-year time period. As a second objective we examined whether patient and provider predictors of surgical repair utilisation differed before and after dissemination of the landmark trial results.

Using provincial health administrative databases, we identified Ontario residents 18 years of age and older with an acute Achilles tendon rupture from April 2002 to March 2014. The proportion of surgically repaired ruptures was calculated for each calendar quarter and year. A time-series analysis using an interventional autoregressive integrated moving average (ARIMA) model was used to determine whether changes in the proportion of surgically repaired ruptures were chronologically related to the dissemination of results from a landmark Canadian trial by Willits et al. (first quarter, 2009). Spline regression was then used to independently identify critical time-points of change in the surgical repair rate to confirm our findings. A multivariate logistic regression model was used to assess for differences in patient and provider predictors of surgical repair utilisation before and after the landmark trial.

From the second quarter of 2002 to the first quarter of 2010 the surgical repair rate remained constant at ∼21%, however, by the first quarter of 2014 it fell to 6.5%. A statistically significant decrease in the rate of surgical repair (P<0.001) was observed after the results from a landmark Canadian trial were presented at a major North American conference (February 2009). Both teaching and non-teaching hospitals demonstrated a decline in the surgical repair rate over the study period, however, only the decrease seen at non-teaching hospitals was found to be significantly associated with the dissemination of landmark trial results (P<0.001). All other predictors of surgical repair utilisation remained unchanged in the before-and-after analysis with the exception of patients 30 years of age and younger having a higher odds of undergoing surgical repair after the trial when compared to those 51 years of age and older.

The current study demonstrates that large, well-designed randomised trials, such as the one conducted by Willits et al. can significantly change the practice patterns of orthopaedic surgeons. Moreover, the decline in surgical repair rate observed at both teaching and non-teaching hospitals suggests both academic and non-academic surgeons readily incorporate high quality evidence in to their practice.

Purpose

No knee-specific outcome measures have demonstrated reliability, validity or responsiveness in patients with multiligament knee injuries. Furthermore, the content validity of existing questionnaires has been challenged and remains unknown for patients with concomitant neurovascular injury. As a first step in developing a disease-specific outcome measure, the objective of this study was to identify items from existing knee questionnaires pertinent to patients with multiligament knee injuries using established a priori criteria.

We compared the mortality of hip fracture patients treated in teaching versus community hospitals in Ontario. Hip fracture patients ≥ 50 yrs were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database and linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions. Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals.

The purpose of this study was to compare the mortality of hip fracture patients treated in teaching versus urban and rural community hospitals in Ontario.

Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals.

This finding will have far-reaching implications for health policy in this province. Hip fracture (ICD-9 code 820) patients ≥ 50 yrs treated in Ontario between 1993 and 1999 were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database. These were linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions.

Patients treated in teaching hospitals and rural community hospitals were more likely to have a major complication than those in urban community hospitals, adjusted OR (95% CI) 1.37 (1.29–1.45); 1.28 (1.06–1.55) respectively. Patients in teaching hospitals had more comordities than those in community urban or rural hospitals. Nevertheless, patients treated in teaching hospitals have lower mortality (in hospital, and at three, six and twelve months post-surgery) than those in urban community hospitals, adjusted OR (95% CI) 0.76 (0.60–0.96), 0.90 (0.85–0.96), 0.91 (0.86–0.96), 0.92 (0.88–0.96) respectively. The difference between rural and urban community hospitals was not statistically significant, however there was a trend to higher mortality in rural institutions, adjusted OR (95% CI) 0.79 (0.63–1.00), 1.13 (0.95–1.36), 1.16 (0.98–1.36), 1.13 (0.97–1.32) respectively.

We compared the mortality of hip fracture patients treated in teaching versus community hospitals in Ontario. Hip fracture patients ≥ 50 yrs were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database and linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions. Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals.

To compare the mortality of hip fracture patients treated in teaching versus urban and rural community hospitals in Ontario. Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals. This finding will have far-reaching implications for health policy in this province. Hip fracture (ICD-9 code 820) patients ≥ 50 yrs treated in Ontario between 1993 and 1999 were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database. These were linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions.

Patients treated in teaching hospitals and rural community hospitals were more likely to have a major complication than those in urban community hospitals, adjusted OR (95% CI) 1.37 (1.29–1.45); 1.28 (1.06–1.55) respectively. Patients in teaching hospitals had more comordities than those in community urban or rural hospitals. Nevertheless, patients treated in teaching hospitals have lower mortality (in hospital, and at three, six and twelve months post-surgery) than those in urban community hospitals, adjusted OR (95% CI) 0.76 (0.60–0.96), 0.90 (0.85–0.96), 0.91 (0.86–0.96), 0.92 (0.88–0.96) respectively. The difference between rural and urban community hospitals was not statistically significant, however there was a trend to higher mortality in rural institutions, adjusted OR (95% CI) 0.79 (0.63–1.00), 1.13 (0.95–1.36), 1.16 (0.98–1.36), 1.13 (0.97–1.32) respectively.

Introduction and Aims: There is significant mortality during the first year after hip fracture. US studies indicate that mortality is lower in teaching than non-teaching hospitals for hip fracture patients. Our aim was to compare the mortality of hip fracture patients treated in teaching versus urban and rural community hospitals in Ontario.

Method: Hip fracture (ICD-9 code 820) patients ³ 50 yrs treated in Ontario between 1993 and 1999 were identified from the Canadian Institute for Health Information Hospital Discharge Abstracts Database. These were linked to the Registered Persons Database for death information. Logistic regression analyses were done to assess the relation between hospital type and both mortality and complications after surgery. Covariates examined include sex, age, Charlson-Deyo index, time to surgery and their interactions.

Results: Patients treated in teaching hospitals and rural community hospitals were more likely to have a major complication than those in urban community hospitals, adjusted OR (95% CI) 1.37 (1.29–1.45); 1.28 (1.06–1.55) respectively. Patients in teaching hospitals had more comordities than those in community urban or rural hospitals. Nevertheless, patients treated in teaching hospitals have lower mortality (in hospital, and at three, six and 12 months post-surgery) than those in urban community hospitals, adjusted OR (95% CI) 0.76 (0.60–0.96), 0.90 (0.85–0.96), 0.91 (0.86–0.96), 0.92 (0.88–0.96) respectively. The difference between rural and urban community hospitals was not statistically significant, however there was a trend to higher mortality in rural institutions, adjusted OR (95% CI) 0.79 (0.63–1.00), 1.13 (0.95–1.36), 1.16 (0.98–1.36), 1.13 (0.97–1.32) respectively.

Conclusion: Although patients treated in teaching hospitals have more comorbidities and complications they have lower mortality than those treated in community hospitals. These findings have enormous implications for healthcare providers and health policy-makers.

Death during the first year after hip fracture may be influenced by the type of hospital in which patients are treated as well as the time spent awaiting surgery. We studied 57 315 hip fracture patients who were admitted to hospital in Ontario, Canada. Patients treated in teaching hospitals had a decreased risk of in-hospital mortality (odds ratio (OR) 0.89; 95% confidence interval (CI) 0.83 to 0.97) compared with those treated in urban community institutions. There was a trend toward increased mortality in rural rather than urban community hospitals. In-hospital mortality increased as the surgical delay increased (OR 1.13; 95% CI 1.10 to 1.16) for a one-day delay and higher (OR 1.60; 95% CI 1.42 to 1.80) for delays of more than two days. This relationship was strongest for patients younger than 70 years of age and with no comorbidities but was independent of hospital status. Similar relationships were seen at three months and one year after surgery. This suggests that any delay to surgery for non-medical reasons is detrimental to a patient’s outcome.