OUTCOME FOLLOWING FRACTURED NECK OF FEMUR - VARIATION IN ACUTE HOSPITAL-CARE OR CASE-MIX

Background This study examined the quality of care given to patients a dmitted to hospital with a fractured neck of femur by assessing the li nk between outcome, case severity and resource use. Fractured neck of femur was chosen for this study as it is a common condition amongst el derly people which causes considerable morbidity and mortality, uses a high proportion of acute hospital resources and is a condition where virtually all new cases will come under the care of the hospital servi ce. Methods Three hospitals which had different case fatality rates an d costs were included in the study. These were an inner-city teaching hospital (Hospital 1), an inner-city associated teaching hospital (Hos pital 2) and an associated teaching hospital in an urban location (Hos pital 3). Patients were recruited for this study over a 12-month perio d. Details on case severity and basic demographic data were collected on admission, and information on the process of care was collected dur ing the hospital slay. Four outcome measures were assessed: activities of daily living (ADL) before discharge and at three months post-fract ure: mortality up to 12 months post-fracture; complications occurring after admission to hospital; and destination on discharge. Results A t otal of 492 patients were recruited into the study, with a male to fem ale ratio of 1:4 and an age range of 60-101 years. Patients admitted t o the three hospitals showed no difference with respect to the presenc e of co-morbidities, medication, pre-fracture ADL, mental state, age a nd sex. There were some differences observed in pre-fracture place of residence. Hospital 1 had the highest proportion of patients admitted from sheltered housing and other hospitals, Hospital 2 the highest pro portion from residential homes, and Hospital 3 the highest proportion admitted from their own homes. Hospital 3 discharged patients at an ea rlier stage of recovery in that a higher proportion were discharged wi th a poor ADL index. This hospital also had more orthopaedic complicat ions but fewer medical com plications; however, the outcome in terms o f ADL at three months post-fracture and mortality at 12 months was sim ilar in all three hospitals. The severity variables which predicted po or outcome were co-morbidities, impaired mental state, impaired ADL pr e-fracture, increasing age and an extracapsular fracture. After contro lling for severity variables, the resource variables had no further im pact on mortality, either in hospital or within one year. An epidural anaesthetic was related to a poor ADL at three months and more orthopa edic complications but fewer medical complications. There was also a h ospital effect in that Hospital 3, which performed the most epidurals, had the highest proportion of orthopaedic complications but the lowes t proportion of medical complications. When the operating surgeon was a consultant, there were more orthopaedic complications, but this was not related to these patients having a worse case severity on admissio n. However, among the cases operated on by consultants, there were no hospital deaths. No other resource variables were related to ADL at th ree months, or orthopaedic or medical complications. Conclusion The re sults show that a poor outcome following a fractured neck of femur was related to increased case severity at the rime of fracture. The resou rce variables had very little further impact on the outcome.