Quality indicators for hip fracture patients: a scoping review protocol ...

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Quality indicators for hip fracture patients: A scoping review protocol

Journal:

BMJ Open

rp Fo Manuscript ID: Article Type:

Date Submitted by the Author:

Complete List of Authors:

bmjopen-2014-006543 Protocol 03-Sep-2014

Primary Subject Heading:

Rehabilitation medicine, Evidence based practice Quality Indicators, Hip Fractures, Quality of Healthcare, Outcomes Assessment

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Keywords:

Health services research

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Secondary Subject Heading:

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Pitzul, Kristen; University of Toronto, Institute of Health Policy, Management, and Evaluation Munce, Sarah; Toronto Rehabilitation Institute, Perrier, Laure; University of Toronto, Institute of Health Policy, Management, and Evaluation Beaupre, Lauren; University of Alberta, Physical Therapy; University of Alberta, Surgery Morin, Suzanne; McGill University, Internal Medicine McGlasson, Rhona; Bone and Joint Canada, Jaglal, Susan; Toronto Rehabilitation Institute, ; University of Toronto, Physical Therapy

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on For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Quality indicators for hip fracture patients: A scoping review protocol Kristen B. Pitzul MSc1; Sarah E.P. Munce PhD2; Laure Perrier MLIS Med1; Lauren Beaupre PhD3,4; Suzanne N. Morin MD MSc5; Rhona McGlasson MBA6; Susan B. Jaglal PhD1,2,7

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Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada 2 Toronto Rehabilitation Institute, University Health Network, Toronto, Canada 3 Department of Physical Therapy, University of Alberta, Edmonton, Canada 4 Department of Surgery, University of Alberta, Edmonton, Canada 5 Department of Medicine, McGill University, Montreal, Canada 6 Bone and Joint Canada, Toronto, Canada 7 Department of Physical Therapy, University of Toronto, Toronto, Canada

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Corresponding Author: Susan B. Jaglal, PhD Professor, Department of Physical Therapy, University of Toronto 160-500 University Avenue Toronto, Ontario, M5G 1V7 Email: [email protected] Phone: 1-416-978-0315

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Keywords: Quality Indicators, Hip Fractures, Quality of Healthcare, Outcomes Assessment

Word Count (excluding title page, abstract, and references): 1,444 words

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For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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ABSTRACT Introduction. Hip fractures are a significant cause of morbidity and mortality and care of hip fracture patients places a heavy burden on health care systems due to prolonged recovery time. Measuring quality of care delivered to hip fracture patients is important to help target efforts to improve care for patients and efficiency of the health system. The purpose of this study is to synthesize the evidence surrounding quality of care indicators for patients who have sustained a hip fracture. Using a scoping

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review methodology, the research question that will be addressed is: “What patient, institutional, and system-level indicators are currently in use or proposed for measuring quality of care across the continuum for individuals following a hip fracture?” Methods and analysis. We will employ the

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methodological frameworks used by Arksey and O’Malley (2005) and Levac et al (2010). The synthesis will be limited to quality of care indicators for individuals who suffered low trauma hip fracture. All

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English peer-reviewed studies published from the year 2000-most recent will be included. Literature

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search strategies will be developed using medical subject headings and text words related to hip fracture quality indicators and the search will be peer-reviewed. Numerous electronic databases will be

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searched. Two reviewers will independently screen titles and abstracts for inclusion, followed by

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screening of the full text of potentially relevant articles to determine final inclusion. Abstracted data will include study characteristics and indicator definitions. Dissemination. To improve quality of care for

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patients and create a more efficient healthcare system, mechanisms for the measurement of quality of

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care are required. The implementation of quality of care indicators enables stakeholders to target areas for improvement in service delivery. Knowledge translation activities will occur throughout the review with dissemination of the project goals and findings to local, national, and international stakeholders.

STRENGTHS AND LIMITATIONS Strengths • Guided by validated methodological frameworks, has a peer-reviewed search strategy, and follows a systematic approach to data analysis.

1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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This review will include quality of care indicators for hip fracture patients across the entire continuum of care, and not just within the acute care setting. Both validated and potential quality of care indicators for hip fracture patients will be included, which will provide insight into which potential indicators require further validation research.

Limitations • The review will be limited to English-language studies only • The quality of the evidence will not be evaluated (as this is a scoping, not systematic, review)

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INTRODUCTION

In 2000, there were approximately 1.6 million hip fractures worldwide1. By 2050, this number is projected to increase to 6.26 million primarily due to the aging population2-5. Hip fractures are a significant cause of increased morbidity and mortality, and are most prevalent in elderly women with

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low bone strength1,6-12. These hip fractures, also known as fragility fractures, are most often associated with osteoporosis, clinically defined by low bone mineral density12. Fragility hip fractures occur

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spontaneously or from minimal trauma (e.g., a fall from standing height or less)13.

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The high prevalence of hip fractures is concerning because hip fractures are both a cause and

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consequence of increased frailty: Persons who sustain a hip fracture are significantly frailer, meaning they have an increased vulnerability to adverse outcomes compared to their age-matched peers11,14,15.

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Evidence suggests that the extensive morbidity resulting from these hip fractures results in 30-50% of

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hip fracture patients not returning to their pre-morbid function, even 1-2 years post-fracture16-18. Furthermore, a 2010 meta-analysis concluded that the all-cause mortality risk for older adults is 5 to 8

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fold higher 3 months post-hip fracture compared to age-matched controls19.

Personal and societal costs of hip fractures are high. Stukel et al 2012 determined that approximately 14% of hip fracture patients are either readmitted to acute care or die within 30 days post-discharge from the initial acute care admission20. Readmissions to hospital and subsequent fractures after a hip fracture have serious consequences for both patients (e.g., increased morbidity)


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and the health care system (increased utilization)21,22. Furthermore, post-acute health care utilization in hip fracture patients is also substantial as these persons require rehabilitation23,24. In an effort to improve quality of care for patients and create a more efficient healthcare system, mechanisms for the measurement of quality of care should be in place. The implementation quality of care indicators enables stakeholders to target areas for improvement in service delivery to improve patient outcomes and ultimately save costs25,26. The purpose of this study is to synthesize the

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evidence surrounding current quality of care indicators for patients following a hip fracture. Using a scoping review methodology, the specific research question to be address is: “What patient, institutional, and system-level indicators are currently in use or proposed for measuring quality of care

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across the continuum for individuals following a hip fracture?”

METHODS AND ANALYSIS

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We will employ the methodological frameworks used by Arksey and O’Malley (2005) as well as Levac et al (2010) for the current scoping review27,28. The research team has expertise in both the

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content area and methodological approach. For the purpose of this review, quality of care indicators are

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defined as validated quality of care measures and potential quality of care measures that have a

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descriptive statement26. Care continuum includes any interaction with the healthcare system from the acute-care to post-acute care period. Eligibility Criteria

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This synthesis is limited to quality of care indicators for individuals with hip fracture caused by low trauma (e.g., a fall from standing height or less). Indicators for individuals with hip fractures caused by high levels of trauma (i.e., motor vehicle collisions) malignant neoplasms, and Paget’s disease will be excluded. These exclusion criteria will be applied as these patients are considered to be a different population and will have different care pathways and require different measures of quality. 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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All study designs will be included (e.g., observational studies, randomized controlled trials, and qualitative studies). Quality indicators targeted at patients, institutions, or the healthcare system for hip fracture care will be included. Indicators developed or proposed for either the acute care and post-acute care setting will be included. Only studies or abstracts published from the year 2000-onwards, or in English or French will be included to ensure relevance to the current healthcare context.

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Search Strategy and Information Sources Literature search strategies will be developed using medical subject headings (MeSH) and text words related to hip fracture quality indicators. Studies will be identified by searching Medline (OVID interface), CINAHL (EBSCO interface), EMBASE (OVID interface), AgeLine (EBSCO interface), Cochrane

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Central Register Controlled Trials (Cochrane Library), and PEDro (physiotherapy evidence database). A

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hand search of the reference lists from reviews and selected articles from Osteoporosis International, a highly relevant journal, will be made to ensure literature saturation. Finally, experts in the field of

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osteoporosis and hip fracture will be contacted and consulted in order to ensure that all relevant data is obtained. An experienced information specialist (LP) will conduct all of the literature searches. The

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search strategy will be peer reviewed by another information specialist using the Peer Review of

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Electronic Search Strategies (PRESS)29. This will be done to clarify the boundaries of the questions and to identify other key search terms.

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Study Selection

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To increase the reliability of screening by the two reviewers, a pilot test of the level 1 screening form based on the eligibility criteria described above will be performed on a random sample of 50 articles. The kappa statistic will then be calculated to determine the inter-rater agreement for study inclusion30. If necessary, the inclusion and exclusion criteria will be clarified to promote the consistent application of the selection criteria. Two reviewers will independently screen the titles and abstracts


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identified by the literature search for inclusion using the screening form (level 1 screening). The full text of potentially relevant articles will then be obtained and screened to determine final inclusion (level 2 screening). A pilot test of the level 2 screening form will be performed on approximately 1% of the articles and the inter-rater agreement for study inclusion will also be calculated30. Discussion or the involvement of a third reviewer who is knowledgeable in the research area will be available to resolve discrepancies. Studies excluded during the screening phases will be recorded along with the reason(s) for exclusion.

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Data Items and Data Collection Process Abstracted data will include study characteristics (e.g., year of publication, country of study),

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indicator definitions (e.g., length of stay defined as the number of total days stayed at institution

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without interruption), numerator and denominator definitions when applicable (e.g., per 1000 hip fractures). The main focus of the studies will be categorized or ‘charted’ by target of interest (either

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individual, institution, or system-level) as well as the indicator’s place within the continuum of care (e.g., acute care setting). We will examine the purpose and components of the indicators as well as the

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reported measurement properties if available/applicable (e.g., sensitivity and specificity). Further

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categories may be identified through the completion of the search and via discussion with the study

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team. As in the study selection process, a data abstraction form will be pilot tested, standardized, and modified if poor agreement is observed.

For example, any wording on the form that may be

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contributing to poor agreement will be reviewed and modified as necessary. Two reviewers will independently abstract all of the data, and a discussion or the involvement or a third reviewer will resolve discrepancies. Study quality will not be assessed during the scoping review as the objective of the review is to identify gaps in the literature and highlight future areas for systematic review27,28. Synthesis


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The results of this scoping review will be summarized quantitatively using numerical counts and qualitatively using thematic analysis (i.e., using a qualitative descriptive approach). Specifically, the results of this review will determine what individual, institutional, and system-level quality of care indicators are currently in use for individuals with hip fractures. This review will identify gaps in the literature as well as future areas for study either via primary research or systematic review.

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ETHICS AND DISSEMINATION

Knowledge translation (KT) activities will take place at the beginning of the review and continue throughout with dissemination of the project goals to members of Bone and Joint Canada (BJC) and Osteoporosis Canada (OC) to create awareness of the project. End-of-grant KT will also occur through

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these agencies and their venues (e.g., print and online newsletters) as well as through conventional KT

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mechanisms (e.g., conferences and peer-reviewed journals). For example, the results of the scoping will be presented at relevant meetings locally, nationally, and internationally (e.g., the Technology

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Evaluation in the Elderly Network Conference, the Fragility Fracture Network’s International Hip Fracture Registries group, Health Quality Ontario,) and published in a peer-reviewed journal so that

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results are available to the appropriate academic and clinical audiences. Lastly, partnerships with local

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clinical programs and/or research initiatives (for example, Toronto Rehabilitation Institute) will be made to give timely and effective application of the research results.

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This scoping review will summarize the body of evidence of established and potential quality

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indicators for hip fracture patients across the continuum of care, thereby summarizing performance measures that can be used to determine the quality of care delivery for these patients. REFERENCE LIST 1. 2.

Johnell O, Kanis JA. An estimate of the worldwide prevalence of disability associated with osteoporotic fractures. Osteoporos Int. 2006;17:1726-1733. Papadimitropoulos EA, Coyte PC, Josse RG, et al. Current and projected rates of hip fracture in Canada. CMAJ. 1997;157(10):1357-1363. 6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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3. 4. 5. 6. 7. 8. 9. 10. 11.

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16.

21.

22. 23. 24.

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17.

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15.

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14.

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12.

Cooper C, Campion G, Melton, LJ3rd. Hip fractures in the elderly: A world-wide projection. Osteoporos Int. 1992;2(6):285-289. Schneider EL, Guralnik JM. the aging of America: impact on health care costs. JAMA. 1990;263:235-250. Dhanwal DK, Dennison EM, Harvey NC, et al. epidemiology of hip fracture: Worldwide geographic variation. Ind J Ortho. 2011;45(1):15-22. Rosell PAE, Parker MJ. Functional outcome after hip fracture: A 1-year prospective outcome study of 275 patients. Injury, Int. J. Care Injured. 2003;34:529-532. Nikitovic M, Wodchis WP, Krahn MD, et al. direct health-care costs attributed to hip fractures among seniors: A matched cohort study. Osteoporos Int. 2013;24:659-669. Heikkinen T, Parker MJ, Jalovaara P. hip fractures in finland and great britain- a comparison of patient characteristics and outcomes. Int Orthop. 2001;25:349-354. Davidson CW, Merrilees MJ, Wilkinson TJ, et al. Hip fracture mortality and morbidity-can we do better? N Z Med J. 2001;114(1136):329-332. Haleem S, Lutchman L, Mayahi R, et al. Mortality following hip fracture: Trends and geographical variations over the last 40 years. Injury. 2008;39(10):1157-1163. Magaziner J, Hawkes W, Hebel JR, et al. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci. 2000;55(9):M498-507. Kanis JA, Delmas P, Burckhardt P, et al. Guidelines for diagnosis and management of osteoporosis. Osteoporos Int. 1997;7:390. Brown JP, Josse RG, The-Scientific-Advisory-Council-of-OSC. Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002;167(10):S1-S34. Magaziner J, Lydick E, Hawkes W, et al. Excess mortality attributable to hip fracture in white women aged 70 years and older. Am J Public Health. 1997;87(10):1630-1636. McMillan GJ, Hubbard RE. Frailty in older inpatients: What physicians need to know. QJM. 2012;105:1059-1065. Bertram M, Norman R, Kemp L, et al. Review of the long-term disability associated with hip fractures. Inj Prev. 2011;17(6):365-370. Magaziner J, Fredman L, Hawkes W, et al. Changes in functional status attributable to hip fracture: A comparison of hip fracture patients to community-dwelling aged. Am J Epidemiol. 2003;157(11):1023-1031. Norton R, Butler M, Robinson E, et al. Declines in physical functioning attributable to hip fracture among older people: A follow-up study of case control participants. Disabil Rehabil. 2000;22(8):345-351. Haentjens P, Magaziner J, Colon-Emeric CS, et al. Excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-390. Stukel TA, Fisher ES, Alter DA, et al. association of hospital spending intensity with mortality and readmission rates in Ontario hospitals. JAMA. 2012;10:1037-1045. Boockvar KS, Halm EA, Litke A, et al. Hospital readmissions after hospital discharge for hip fracture: Surgical and nonsurgical causes and effect on outcomes. J Am Geriatr Soc. 2003;51(3):399-403. Egan M, Jaglal S, Byrne K, et al. Factors associated with a second hip fracture: A systematic review. Clin Rehabil. 2008;22(3):272-282. Dai K, Zhang W, Fan T, et al. Estimation of resource utilization associated with osteoporotic hip fracture and level of post-acute care in China. Curr Med Res Opin. 2007;23(12):2937-2943. Pasco JA, Sanders KM, Hoekstra FM, et al. The human cost of fracture. Osteoporos Int. 2005;16(12):2046-2052.

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25. 26. 27. 28. 29. 30.

Gunasekera N, Boulton C, Morris C, et al. Hip fracture audit: The Nottingham experience. Osteoporos Int. 2010;21(4):S647-653. Stelfox HT, Bobranska-Artiuch B, Nathens A, et al. Quality Indicators for Evaluating Trauma Care: A Scoping Review. Arch Surg. 2010;145(3):286-295. Arksey H, O'Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. Levac DC, Colquhoun H, O'Brien KK. Scoping studies: Advancing the methodology. Implement Sci. 2010;5. Sampson M, McGowan J, Cogo E, et al. An evidence-based practice guideline for the peer review of electronic search strategies. J Clin Epidemiol. 2009;62(9):944-952. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159-174.

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AUTHORS CONTRIBUTIONS

Pitzul: Writing protocol, preliminary literature review, project coordinator Munce: Editing of protocol, scoping review frameworks, analysis Perrier: Editing of protocol, search strategy Beaupre: Editing of protocol, content expert input (rehabilitation) Morin: Editing of protocol, content expert input (clinical) McGlasson: Editing of protocol, stakeholder input (BJC) Jaglal: Project conception, editing of protocol, senior responsible investigator

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FUNDING STATEMENT This work was supported by a Technology Evaluation in the Elderly Network Knowledge Synthesis Grant # 2013-07. KB Pitzul is supported by the Women’s College Research Institute through the Enid Walker Estate. LA Beaupre receives salary support from the Canadian Institute of Health Research as a New Investigator and from Alberta Innovates Health Solutions as a Population Health Investigator.

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COMPETING INTERESTS STATEMENT The authors have no conflicts of interest to report.

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BMJ Open

Quality indicators for hip fracture patients: A scoping review protocol

Journal:

BMJ Open

rp Fo Manuscript ID: Article Type:

Date Submitted by the Author:

Complete List of Authors:

bmjopen-2014-006543.R1 Protocol 26-Sep-2014

Primary Subject Heading:

Rehabilitation medicine, Evidence based practice Quality Indicators, Hip Fractures, Quality of Healthcare, Outcomes Assessment

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Keywords:

Health services research

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Secondary Subject Heading:

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Pitzul, Kristen; University of Toronto, Institute of Health Policy, Management, and Evaluation Munce, Sarah; Toronto Rehabilitation Institute, Perrier, Laure; University of Toronto, Institute of Health Policy, Management, and Evaluation Beaupre, Lauren; University of Alberta, Physical Therapy; University of Alberta, Surgery Morin, Suzanne; McGill University, Internal Medicine McGlasson, Rhona; Bone and Joint Canada, Jaglal, Susan; Toronto Rehabilitation Institute, ; University of Toronto, Physical Therapy

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on For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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ABSTRACT Introduction. Hip fractures are a significant cause of morbidity and mortality and care of hip fracture patients places a heavy burden on health care systems due to prolonged recovery time. Measuring quality of care delivered to hip fracture patients is important to help target efforts to improve care for patients and efficiency of the health system. The purpose of this study is to synthesize the evidence surrounding quality of care indicators for patients who have sustained a hip fracture. Using a scoping

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review methodology, the research question that will be addressed is: “What patient, institutional, and system-level indicators are currently in use or proposed for measuring quality of care across the continuum for individuals following a hip fracture?” Methods and analysis. We will employ the

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searched. Two reviewers will independently screen titles and abstracts for inclusion, followed by

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screening of the full text of potentially relevant articles to determine final inclusion. Abstracted data will include study characteristics and indicator definitions. Dissemination. To improve quality of care for

on

patients and create a more efficient healthcare system, mechanisms for the measurement of quality of

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care are required. The implementation of quality of care indicators enables stakeholders to target areas for improvement in service delivery. Knowledge translation activities will occur throughout the review with dissemination of the project goals and findings to local, national, and international stakeholders.



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INTRODUCTION

In 2000, there were approximately 1.6 million hip fractures worldwide1. By 2050, this number is projected to increase to 6.26 million primarily due to the aging population2-5. Hip fractures are a significant cause of increased morbidity and mortality, and are most prevalent in elderly women with

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low bone strength1,6-12. These hip fractures, also known as fragility fractures, are most often associated with osteoporosis, clinically defined by low bone mineral density12. Fragility hip fractures occur

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spontaneously or from minimal trauma (e.g., a fall from standing height or less)13.

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The high prevalence of hip fractures is concerning because hip fractures are both a cause and

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consequence of increased frailty: Persons who sustain a hip fracture are significantly frailer, meaning they have an increased vulnerability to adverse outcomes compared to their age-matched peers11,14,15.

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Evidence suggests that the extensive morbidity resulting from these hip fractures results in 30-50% of

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hip fracture patients not returning to their pre-morbid function, even 1-2 years post-fracture16-18. Furthermore, a 2010 meta-analysis concluded that the all-cause mortality risk for older adults is 5 to 8

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fold higher 3 months post-hip fracture compared to age-matched controls19.

Personal and societal costs of hip fractures are high. Stukel et al 2012 determined that approximately 14% of hip fracture patients are either readmitted to acute care or die within 30 days post-discharge from the initial acute care admission20. Readmissions to hospital and subsequent fractures after a hip fracture have serious consequences for both patients (e.g., increased morbidity)


BMJ Open

and the health care system (increased utilization)21,22. Furthermore, post-acute health care utilization in hip fracture patients is also substantial as these persons require rehabilitation23,24. In an effort to improve quality of care for patients and create a more efficient healthcare system, mechanisms for the measurement of quality of care should be in place Quality of care indicators are a widely accepted performance measure used to determine the deviation in actual performance from ideal performance (i.e., actual care delivery versus best practice care delivery)25,26.

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implementation quality of care indicators enables stakeholders to target areas for improvement in service delivery to improve patient outcomes and ultimately save costs27,28. Examples of positive change resulting from the implementation of quality of care indicator(s) include hip fracture quality of care

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indicators in the United Kingdom, the World Health Organization’s surgical safety checklist29,30. The

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development of quality of care indicators may occur from a deductive approach (i.e., indicators are derived from scientific evidence, followed by expert opinion if required) or an inductive approach (i.e.,

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existing quality of care data is used to develop indicators)31. Although there is no gold standard to guide quality of care indicator development, Stelfox and Straus 2014 suggest the approach depends on the

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strength of evidence for a given indicator as well as its potential impact on patient health32,33.

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A national pre-consensus meeting was held in June 2013 to garner experts’ opinions on possible

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(i.e., feasible) quality of care indicators for hip fracture patients (i.e., inductive approach). However, experts felt their suggested indicators were insufficient to appropriately measure the quality of care

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delivery, particularly across the entire continuum of care. More information with respect to the strength and breadth of scientific evidence, particularly for potential quality of care indicators was requested. Therefore, the purpose of this study is to synthesize the evidence surrounding current quality of care indicators for patients following a hip fracture. Using a scoping review methodology, the specific research question to be address is: “What patient, institutional, and system-level indicators are currently


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in use or proposed for measuring quality of care across the continuum for individuals following a hip fracture?”

METHODS AND ANALYSIS We will employ the methodological frameworks used by Arksey and O’Malley (2005) as well as Levac et al (2010) for the current scoping review34,35. The research team has expertise in both the

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content area and methodological approach. For the purpose of this review, quality of care indicators are defined as validated quality of care measures and potential quality of care measures that have a descriptive statement28. Care continuum includes any interaction with the healthcare system from the

ee

acute-care to post-acute care period. Eligibility Criteria

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This synthesis is limited to quality of care indicators for individuals with hip fracture caused by

ev

low trauma (e.g., a fall from standing height or less). Indicators for individuals with hip fractures caused by high levels of trauma (i.e., motor vehicle collisions) malignant neoplasms, and Paget’s disease will be

ie

excluded. These exclusion criteria will be applied as these patients are considered to be a different

w

population and will have different care pathways and require different measures of quality.

on

All study designs will be included (e.g., observational studies, randomized controlled trials, and qualitative studies). Quality indicators targeted at patients, institutions, or the healthcare system for hip

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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fracture care will be included. Indicators developed or proposed for either the acute care and post-acute care setting will be included. Only studies or abstracts published from the year 2000-onwards, or in English will be included to ensure relevance to the current healthcare context and feasibility. Limiting the search to English-language only may result in bias in results towards English-language speaking countries.


BMJ Open

Search Strategy and Information Sources Literature search strategies will be developed using medical subject headings (MeSH) and text words related to hip fracture quality indicators. Studies will be identified by searching Medline (OVID interface), CINAHL (EBSCO interface), EMBASE (OVID interface), AgeLine (EBSCO interface), Cochrane Central Register Controlled Trials (Cochrane Library), and PEDro (physiotherapy evidence database). A hand search of the reference lists from reviews and selected articles from Osteoporosis International, a

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highly relevant journal, will be made to ensure literature saturation. Finally, experts in the field of osteoporosis and hip fracture will be contacted and consulted in order to ensure that all relevant data is obtained. An experienced information specialist (LP) will conduct all of the literature searches. The

ee

search strategy will be peer reviewed by another information specialist using the Peer Review of Electronic Search Strategies (PRESS)36. This will be done to clarify the boundaries of the questions and to identify other key search terms.

ev

Study Selection

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To increase the reliability of screening by the two reviewers, a pilot test of the level 1 screening

ie

form based on the eligibility criteria described above will be performed on a random sample of 50

w

articles. The kappa statistic will then be calculated to determine the inter-rater agreement for study

on

inclusion37. If necessary, the inclusion and exclusion criteria will be clarified to promote the consistent application of the selection criteria. Two reviewers will independently screen the titles and abstracts

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Page 6 of 22

identified by the literature search for inclusion using the screening form (level 1 screening). The full text of potentially relevant articles will then be obtained and screened to determine final inclusion (level 2 screening). A pilot test of the level 2 screening form will be performed on approximately 1% of the articles and the inter-rater agreement for study inclusion will also be calculated37. Discussion or the involvement of a third reviewer who is knowledgeable in the research area will be available to resolve


Page 7 of 22

discrepancies. Studies excluded during the screening phases will be recorded along with the reason(s) for exclusion. Data Items and Data Collection Process Abstracted data will include study characteristics (e.g., year of publication, country of study), indicator definitions (e.g., length of stay defined as the number of total days stayed at institution

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without interruption), numerator and denominator definitions when applicable (e.g., per 1000 hip fractures). The main focus of the studies will be categorized or ‘charted’ by target of interest (either individual, institution, or system-level) as well as the indicator’s place within the continuum of care (e.g., acute care setting). We will examine the purpose and components of the indicators as well as the

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reported measurement properties if available/applicable (e.g., sensitivity and specificity). Further

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categories may be identified through the completion of the search and via discussion with the study team. As in the study selection process, a data abstraction form will be pilot tested, standardized, and modified if poor agreement is observed.

ev


contributing to poor agreement will be reviewed and modified as necessary. Two reviewers will

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independently abstract all of the data, and a discussion or the involvement or a third reviewer will

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resolve discrepancies. Study quality will not be assessed during the scoping review as the objective of

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the review is to identify gaps in the literature and highlight future areas for systematic review34,35. This means that results from poor quality studies may be inaccurate and therefore have the potential to bias study findings.

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Synthesis The results of this scoping review will be summarized quantitatively using numerical counts and qualitatively using thematic analysis (i.e., using a qualitative descriptive approach). Specifically, the results of this review will determine what individual, institutional, and system-level quality of care


BMJ Open

indicators are currently in use for individuals with hip fractures. Due to the anticipated breadth of evidence that will arise from this scoping review, there is a likelihood that a given quality of care indicator, or potential quality of care indicator, is measured in a number of different ways, is contextdependent, and its applicability may change over the study time period (i.e., within the past 14 years) due to changes in best practice.

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The synthesis of results will ensure these differences in measurement are highlighted in order to determine potential areas of discussion amongst international experts (e.g., discussion of why certain measures are used, and the pros and cons of each measure). Although different healthcare contexts likely require different quality of care indicators (due to, for example, different funding policies), this

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synthesis enables discussion of the role of context, as well as any potential areas for international

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synergy, or at the very least international learnings (i.e., informs a consensus meeting). Trends in quality of care delivery for hip fracture patients have changed over the course of the study inclusion years (i.e.,

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within the past 14 years). These changes will be discussed in brief within our synthesis, however priority will be given to results that are most recent as they are more consistent with the current healthcare This review will identify gaps in the literature as well as future areas for study either via

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context.

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primary research, consensus meeting, or systematic review. ETHICS AND DISSEMINATION

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Knowledge translation (KT) activities will take place at the beginning of the review and continue

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Page 8 of 22

throughout with dissemination of the project goals to members of Bone and Joint Canada (BJC) and Osteoporosis Canada (OC) to create awareness of the project. End-of-grant KT will also occur through these agencies and their venues (e.g., print and online newsletters) as well as through conventional KT mechanisms (e.g., conferences and peer-reviewed journals). For example, the results of the scoping will be presented at relevant meetings locally, nationally, and internationally (e.g., the Technology


Page 9 of 22

Evaluation in the Elderly Network Conference, the Fragility Fracture Network’s International Hip Fracture Registries group, Health Quality Ontario,) and published in a peer-reviewed journal so that results are available to the appropriate academic and clinical audiences. Lastly, partnerships with local clinical programs and/or research initiatives (for example, Toronto Rehabilitation Institute) will be made to give timely and effective application of the research results.

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This scoping review will summarize the body of evidence of established and potential quality indicators for hip fracture patients across the continuum of care, thereby summarizing performance measures that can be used to determine the quality of care delivery for these patients. REFERENCE LIST 1.

4.

7.

10. 11. 12. 13. 14.

ly

9.

on

8.

w

6.

ie

5.

ev

3.

Johnell O, Kanis JA. An estimate of the worldwide prevalence of disability associated with osteoporotic fractures. Osteoporos Int. 2006;17:1726-1733. Papadimitropoulos EA, Coyte PC, Josse RG, et al. Current and projected rates of hip fracture in Canada. CMAJ. 1997;157(10):1357-1363. Cooper C, Campion G, Melton, LJ3rd. Hip fractures in the elderly: A world-wide projection. Osteoporos Int. 1992;2(6):285-289. Schneider EL, Guralnik JM. the aging of America: impact on health care costs. JAMA. 1990;263:235-250. Dhanwal DK, Dennison EM, Harvey NC, et al. epidemiology of hip fracture: Worldwide geographic variation. Ind J Ortho. 2011;45(1):15-22. Rosell PAE, Parker MJ. Functional outcome after hip fracture: A 1-year prospective outcome study of 275 patients. Injury, Int. J. Care Injured. 2003;34:529-532. Nikitovic M, Wodchis WP, Krahn MD, et al. direct health-care costs attributed to hip fractures among seniors: A matched cohort study. Osteoporos Int. 2013;24:659-669. Heikkinen T, Parker MJ, Jalovaara P. hip fractures in finland and great britain- a comparison of patient characteristics and outcomes. Int Orthop. 2001;25:349-354. Davidson CW, Merrilees MJ, Wilkinson TJ, et al. Hip fracture mortality and morbidity-can we do better? N Z Med J. 2001;114(1136):329-332. Haleem S, Lutchman L, Mayahi R, et al. Mortality following hip fracture: Trends and geographical variations over the last 40 years. Injury. 2008;39(10):1157-1163. Magaziner J, Hawkes W, Hebel JR, et al. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci. 2000;55(9):M498-507. Kanis JA, Delmas P, Burckhardt P, et al. Guidelines for diagnosis and management of osteoporosis. Osteoporos Int. 1997;7:390. Brown JP, Josse RG, The-Scientific-Advisory-Council-of-OSC. Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002;167(10):S1-S34. Magaziner J, Lydick E, Hawkes W, et al. Excess mortality attributable to hip fracture in white women aged 70 years and older. Am J Public Health. 1997;87(10):1630-1636.

rr

2.

ee

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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BMJ Open

15. 16. 17.

18.

19. 20. 21.

23.

26

31 32.

33.

ly

30.

on

29.

w

28.

ie

27.

ev

25.

rr

24.

ee

22.

McMillan GJ, Hubbard RE. Frailty in older inpatients: What physicians need to know. QJM. 2012;105:1059-1065. Bertram M, Norman R, Kemp L, et al. Review of the long-term disability associated with hip fractures. Inj Prev. 2011;17(6):365-370. Magaziner J, Fredman L, Hawkes W, et al. Changes in functional status attributable to hip fracture: A comparison of hip fracture patients to community-dwelling aged. Am J Epidemiol. 2003;157(11):1023-1031. Norton R, Butler M, Robinson E, et al. Declines in physical functioning attributable to hip fracture among older people: A follow-up study of case control participants. Disabil Rehabil. 2000;22(8):345-351. Haentjens P, Magaziner J, Colon-Emeric CS, et al. Excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-390. Stukel TA, Fisher ES, Alter DA, et al. association of hospital spending intensity with mortality and readmission rates in Ontario hospitals. JAMA. 2012;10:1037-1045. Boockvar KS, Halm EA, Litke A, et al. Hospital readmissions after hospital discharge for hip fracture: Surgical and nonsurgical causes and effect on outcomes. J Am Geriatr Soc. 2003;51(3):399-403. Egan M, Jaglal S, Byrne K, et al. Factors associated with a second hip fracture: A systematic review. Clin Rehabil. 2008;22(3):272-282. Dai K, Zhang W, Fan T, et al. Estimation of resource utilization associated with osteoporotic hip fracture and level of post-acute care in China. Curr Med Res Opin. 2007;23(12):2937-2943. Pasco JA, Sanders KM, Hoekstra FM, et al. The human cost of fracture. Osteoporos Int. 2005;16(12):2046-2052. Agency for Healthcare Research and Quality. AHRQ Quality Indicators. U.S. Department of Health and Human Services. Accessed at www.qualityindicators.ahrq.gov/. Accessed on September 23rd 2014. Berg K, Fries B, Jones R, et al. Identification and evaluation of existing quality indicators that are appropriate for use in long-term care settings. Centers for Medicare and Medicaid Sedrvices, Office Clinical Standards and Quality. Contract No.: 500-95-0062/T.O.#4 Gunasekera N, Boulton C, Morris C, et al. Hip fracture audit: The Nottingham experience. Osteoporos Int. 2010;21(4):S647-653. Stelfox HT, Bobranska-Artiuch B, Nathens A, et al. Quality Indicators for Evaluating Trauma Care: A Scoping Review. Arch Surg. 2010;145(3):286-295. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Eng J Med. 2009;360:491-499. Royal College of Physicians and the Falls and Fragility Fracture Audit Programme. National Hip Fracture Database (NHFD) extended report. Accessed at http://www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2014-15/NHFD-extended-report2014-FINAL.pdf. Accessed on September 23rd 2014. Stelfox HT, Straus SE. Measuring quality of care: considering conceptual approaches to quality indicator development and evaluation. J Clin Epidemiol. 2013:66(12):1328-1337. Stelfox HT, Straus SE. Letter reply to Kris Doggen et al.: The right indicator for the job: different levels of rigor may be appropriate for the development of quality indicators. J Clin Epidemiol. 2014:67(9):964-965. Doggen K, Lavens A, Van Casteren VV. The righ indicator for the job: different levels of rigor may be appropriate for the development of quality indicator. Comment on Stelfox and Strau. J Clin Epidemiol. 67(9):963-964.

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Page 11 of 22

34. 35. 36. 37.

Arksey H, O'Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. Levac DC, Colquhoun H, O'Brien KK. Scoping studies: Advancing the methodology. Implement Sci. 2010;5. Sampson M, McGowan J, Cogo E, et al. An evidence-based practice guideline for the peer review of electronic search strategies. J Clin Epidemiol. 2009;62(9):944-952. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159-174.


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FUNDING STATEMENT This work was supported by a Technology Evaluation in the Elderly Network Knowledge Synthesis Grant # 2013-07. KB Pitzul is supported by the Women’s College Research Institute through the Enid Walker Estate. LA Beaupre receives salary support from the Canadian Institute of Health Research as a New Investigator and from Alberta Innovates Health Solutions as a Population Health Investigator. COMPETING INTERESTS STATEMENT The authors have no conflicts of interest to report.

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BMJ Open


1


ee

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Page 12 of 22


Page 13 of 22

ABSTRACT Introduction. Hip fractures are a significant cause of morbidity and mortality and care of hip fracture patients places a heavy burden on health care systems due to prolonged recovery time. Measuring quality of care delivered to hip fracture patients is important to help target efforts to improve care for

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patients and efficiency of the health system. The purpose of this study is to synthesize the evidence surrounding quality of care indicators for patients who have sustained a hip fracture. Using a scoping review methodology, the research question that will be addressed is: “What patient, institutional, and system-level indicators are currently in use or proposed for measuring quality of care across the continuum for individuals following a hip fracture?” Methods and analysis. We will employ the

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searched. Two reviewers will independently screen titles and abstracts for inclusion, followed by screening of the full text of potentially relevant articles to determine final inclusion. Abstracted data will

w

include study characteristics and indicator definitions. Dissemination. To improve quality of care for patients and create a more efficient healthcare system, mechanisms for the measurement of quality of

on

care are required. The implementation of quality of care indicators enables stakeholders to target areas for improvement in service delivery. Knowledge translation activities will occur throughout the review

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with dissemination of the project goals and findings to local, national, and international stakeholders.


1


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• •



INTRODUCTION

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In 2000, there were approximately 1.6 million hip fractures worldwide1. By 2050, this number is projected to increase to 6.26 million primarily due to the aging population2-5. Hip fractures are a

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significant cause of increased morbidity and mortality, and are most prevalent in elderly women with low bone strength1,6-12. These hip fractures, also known as fragility fractures, are most often associated

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with osteoporosis, clinically defined by low bone mineral density12. Fragility hip fractures occur spontaneously or from minimal trauma (e.g., a fall from standing height or less)13.

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The high prevalence of hip fractures is concerning because hip fractures are both a cause and consequence of increased frailty: Persons who sustain a hip fracture are significantly frailer, meaning

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they have an increased vulnerability to adverse outcomes compared to their age-matched peers11,14,15.

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Evidence suggests that the extensive morbidity resulting from these hip fractures results in 30-50% of hip fracture patients not returning to their pre-morbid function, even 1-2 years post-fracture16-18.

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Furthermore, a 2010 meta-analysis concluded that the all-cause mortality risk for older adults is 5 to 8 fold higher 3 months post-hip fracture compared to age-matched controls19.

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Page 14 of 22

Personal and societal costs of hip fractures are high. Stukel et al 2012 determined that

approximately 14% of hip fracture patients are either readmitted to acute care or die within 30 days post-discharge from the initial acute care admission20. Readmissions to hospital and subsequent fractures after a hip fracture have serious consequences for both patients (e.g., increased morbidity)

2


Page 15 of 22

and the health care system (increased utilization)21,22. Furthermore, post-acute health care utilization in hip fracture patients is also substantial as these persons require rehabilitation23,24. In an effort to improve quality of care for patients and create a more efficient healthcare system, mechanisms for the measurement of quality of care should be in place. Quality of care

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indicators are a widely accepted performance measure used to determine the deviation in actual performance from ideal performance (i.e., actual care delivery versus best practice care delivery)(25,26).

Formatted: Superscript

The implementation quality of care indicators enables stakeholders to target areas for improvement in service delivery to improve patient outcomes and ultimately save costs(27,28)265,276. Examples of positive

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change resulting from the implementation of quality of care indicator(s) include hip fracture quality of care indicators in the United Kingdom, the World Health Organization’s surgical safety checklist(29,30).

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Comment [KP1]: Addresses concern#3 Formatted: Superscript

The development of quality of care indicators may occur from a deductive approach (i.e., indicators are derived from scientific evidence, followed by expert opinion if required) or an inductive approach (i.e.,

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existing quality of care data is used to develop indicators)(31). Although there is no gold standard to guide

Formatted: Superscript Formatted: Superscript

quality of care indicator development, Stelfox and Straus 2014 suggest the approach depends on the

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strength of evidence for a given indicator as well as its potential impact on patient health(32,33).


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A national pre-consensus meeting was held in June 2013 to garner experts’ opinions on possible (i.e., feasible) quality of care indicators for hip fracture patients (i.e., inductive approach). However,

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experts felt their suggested indicators were insufficient to appropriately measure the quality of care delivery, particularly across the entire continuum of care. More information with respect to the strength

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and breadth of scientific evidence, particularly for potential quality of care indicators was requested.

Therefore, tThe purpose of this study is to synthesize the evidence surrounding current quality of care

Comment [KP2]: Addresses concern#2

indicators for patients following a hip fracture. Using a scoping review methodology, the specific research question to be address is: “What patient, institutional, and system-level indicators are currently

3


BMJ Open

in use or proposed for measuring quality of care across the continuum for individuals following a hip fracture?”

METHODS AND ANALYSIS

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We will employ the methodological frameworks used by Arksey and O’Malley (2005) as well as Levac et al (2010) for the current scoping review(34,35)27,28. The research team has expertise in both the content area and methodological approach. For the purpose of this review, quality of care indicators are defined as validated quality of care measures and potential quality of care measures that have a descriptive statement286. Care continuum includes any interaction with the healthcare system from the acute-care to post-acute care period.

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Eligibility Criteria

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This synthesis is limited to quality of care indicators for individuals with hip fracture caused by

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low trauma (e.g., a fall from standing height or less). Indicators for individuals with hip fractures caused by high levels of trauma (i.e., motor vehicle collisions) malignant neoplasms, and Paget’s disease will be

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excluded. These exclusion criteria will be applied as these patients are considered to be a different

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population and will have different care pathways and require different measures of quality. All study designs will be included (e.g., observational studies, randomized controlled trials, and

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qualitative studies). Quality indicators targeted at patients, institutions, or the healthcare system for hip fracture care will be included. Indicators developed or proposed for either the acute care and post-acute

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Page 16 of 22

care setting will be included. Only studies or abstracts published from the year 2000-onwards, or in English or French will be included to ensure relevance to the current healthcare context and feasibility.

Limiting the search to English-language only may result in bias in results towards English-language speaking countries.


4


Page 17 of 22

Search Strategy and Information Sources Literature search strategies will be developed using medical subject headings (MeSH) and text words related to hip fracture quality indicators. Studies will be identified by searching Medline (OVID interface), CINAHL (EBSCO interface), EMBASE (OVID interface), AgeLine (EBSCO interface), Cochrane

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Central Register Controlled Trials (Cochrane Library), and PEDro (physiotherapy evidence database). A hand search of the reference lists from reviews and selected articles from Osteoporosis International, a highly relevant journal, will be made to ensure literature saturation. Finally, experts in the field of osteoporosis and hip fracture will be contacted and consulted in order to ensure that all relevant data is obtained. An experienced information specialist (LP) will conduct all of the literature searches. The

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search strategy will be peer reviewed by another information specialist using the Peer Review of Electronic Search Strategies (PRESS)(36)29. This will be done to clarify the boundaries of the questions and to identify other key search terms.

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Study Selection

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To increase the reliability of screening by the two reviewers, a pilot test of the level 1 screening

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form based on the eligibility criteria described above will be performed on a random sample of 50

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articles. The kappa statistic will then be calculated to determine the inter-rater agreement for study inclusion(37)0. If necessary, the inclusion and exclusion criteria will be clarified to promote the consistent

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application of the selection criteria. Two reviewers will independently screen the titles and abstracts identified by the literature search for inclusion using the screening form (level 1 screening). The full text

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of potentially relevant articles will then be obtained and screened to determine final inclusion (level 2 screening). A pilot test of the level 2 screening form will be performed on approximately 1% of the articles and the inter-rater agreement for study inclusion will also be calculated(37)0. Discussion or the


involvement of a third reviewer who is knowledgeable in the research area will be available to resolve

5


BMJ Open

discrepancies. Studies excluded during the screening phases will be recorded along with the reason(s) for exclusion. Data Items and Data Collection Process Abstracted data will include study characteristics (e.g., year of publication, country of study),

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indicator definitions (e.g., length of stay defined as the number of total days stayed at institution without interruption), numerator and denominator definitions when applicable (e.g., per 1000 hip fractures). The main focus of the studies will be categorized or ‘charted’ by target of interest (either individual, institution, or system-level) as well as the indicator’s place within the continuum of care (e.g.,

ee

acute care setting). We will examine the purpose and components of the indicators as well as the reported measurement properties if available/applicable (e.g., sensitivity and specificity). Further

rr

categories may be identified through the completion of the search and via discussion with the study team. As in the study selection process, a data abstraction form will be pilot tested, standardized, and modified if poor agreement is observed.

ev


contributing to poor agreement will be reviewed and modified as necessary. Two reviewers will

ie

independently abstract all of the data, and a discussion or the involvement or a third reviewer will

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resolve discrepancies. Study quality will not be assessed during the scoping review as the objective of the review is to identify gaps in the literature and highlight future areas for systematic review(34,35)27,28.


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This means that results from poor quality studies may be inaccurate and therefore have the potential to


bias study findings.


Synthesis

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Page 18 of 22

The results of this scoping review will be summarized quantitatively using numerical counts and qualitatively using thematic analysis (i.e., using a qualitative descriptive approach). Specifically, the results of this review will determine what individual, institutional, and system-level quality of care

6


Page 19 of 22

indicators are currently in use for individuals with hip fractures. Due to the anticipated breadth of evidence that will arise from this scoping review, there is a likelihood that a given quality of care indicator, or potential quality of care indicator, is measured in a number of different ways, is contextdependent, and its applicability may change over the study time period (i.e., within the past 14 years)

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due to changes in best practice.

The synthesis of results will ensure these differences in measurement are highlighted in order to

Formatted: Indent: First line: 0.5"

determine potential areas of discussion amongst international experts (e.g., discussion of why certain measures are used, and the pros and cons of each measure). Although different healthcare contexts

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likely require different quality of care indicators (due to, for example, different funding policies), this synthesis enables discussion of the role of context, as well as any potential areas for international

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synergy, or at the very least international learnings (i.e., informs a consensus meeting). Trends in quality of care delivery for hip fracture patients have changed over the course of the study inclusion years (i.e.,

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within the past 14 years). These changes will be discussed in brief within our synthesis, however priority will be given to results that are most recent as they are more consistent with the current healthcare context.

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This review will identify gaps in the literature as well as future areas for study either via

primary research, consensus meeting, or systematic review.

Comment [KP5]: Addresses concerns 4-6

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ETHICS AND DISSEMINATION

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Knowledge translation (KT) activities will take place at the beginning of the review and continue throughout with dissemination of the project goals to members of Bone and Joint Canada (BJC) and

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Osteoporosis Canada (OC) to create awareness of the project. End-of-grant KT will also occur through

these agencies and their venues (e.g., print and online newsletters) as well as through conventional KT mechanisms (e.g., conferences and peer-reviewed journals). For example, the results of the scoping will be presented at relevant meetings locally, nationally, and internationally (e.g., the Technology

7


BMJ Open

Evaluation in the Elderly Network Conference, the Fragility Fracture Network’s International Hip Fracture Registries group, Health Quality Ontario,) and published in a peer-reviewed journal so that results are available to the appropriate academic and clinical audiences. Lastly, partnerships with local clinical programs and/or research initiatives (for example, Toronto Rehabilitation Institute) will be made

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to give timely and effective application of the research results. This scoping review will summarize the body of evidence of established and potential quality indicators for hip fracture patients across the continuum of care, thereby summarizing performance measures that can be used to determine the quality of care delivery for these patients. REFERENCE LIST

2.

4.

6.

8.

10.

12. 13. 14.

ly

11.

on

9.

w

7.

ie

5.

ev

3.

Johnell O, Kanis JA. An estimate of the worldwide prevalence of disability associated with osteoporotic fractures. Osteoporos Int. 2006;17:1726-1733. Papadimitropoulos EA, Coyte PC, Josse RG, et al. Current and projected rates of hip fracture in Canada. CMAJ. 1997;157(10):1357-1363. Cooper C, Campion G, Melton, LJ3rd. Hip fractures in the elderly: A world-wide projection. Osteoporos Int. 1992;2(6):285-289. Schneider EL, Guralnik JM. the aging of America: impact on health care costs. JAMA. 1990;263:235-250. Dhanwal DK, Dennison EM, Harvey NC, et al. epidemiology of hip fracture: Worldwide geographic variation. Ind J Ortho. 2011;45(1):15-22. Rosell PAE, Parker MJ. Functional outcome after hip fracture: A 1-year prospective outcome study of 275 patients. Injury, Int. J. Care Injured. 2003;34:529-532. Nikitovic M, Wodchis WP, Krahn MD, et al. direct health-care costs attributed to hip fractures among seniors: A matched cohort study. Osteoporos Int. 2013;24:659-669. Heikkinen T, Parker MJ, Jalovaara P. hip fractures in finland and great britain- a comparison of patient characteristics and outcomes. Int Orthop. 2001;25:349-354. Davidson CW, Merrilees MJ, Wilkinson TJ, et al. Hip fracture mortality and morbidity-can we do better? N Z Med J. 2001;114(1136):329-332. Haleem S, Lutchman L, Mayahi R, et al. Mortality following hip fracture: Trends and geographical variations over the last 40 years. Injury. 2008;39(10):1157-1163. Magaziner J, Hawkes W, Hebel JR, et al. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci. 2000;55(9):M498-507. Kanis JA, Delmas P, Burckhardt P, et al. Guidelines for diagnosis and management of osteoporosis. Osteoporos Int. 1997;7:390. Brown JP, Josse RG, The-Scientific-Advisory-Council-of-OSC. Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002;167(10):S1-S34. Magaziner J, Lydick E, Hawkes W, et al. Excess mortality attributable to hip fracture in white women aged 70 years and older. Am J Public Health. 1997;87(10):1630-1636.

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Page 20 of 22

8


Page 21 of 22

15. 16. 17.

18.

19. 20. 21.

23.

26

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FUNDING STATEMENT This work was supported by a Technology Evaluation in the Elderly Network Knowledge Synthesis Grant # 2013-07. KB Pitzul is supported by the Women’s College Research Institute through the Enid Walker Estate. LA Beaupre receives salary support from the Canadian Institute of Health Research as a New Investigator and from Alberta Innovates Health Solutions as a Population Health Investigator.

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COMPETING INTERESTS STATEMENT The authors have no conflicts of interest to report.

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