Brad Petrisor

Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis

Objective To compare quality of care in for-profit and not-for-profit nursing homes. Design Systematic review and meta-analysis of observational studies and randomised controlled trials investigating quality of care in for-profit versus not-for-profit nursing homes. Results A comprehensive search yielded 8827 citations, of which 956 were judged appropriate for full text review. Study characteristics and results of 82 articles that met inclusion criteria were summarised, and results for the four most frequently reported quality measures were pooled. Included studies reported results dating from 1965 to 2003. In 40 studies, all statistically significant comparisons (P<0.05) favoured not-for-profit facilities; in three studies, all statistically significant comparisons favoured for-profit facilities, and the remaining studies had less consistent findings. Meta-analyses suggested that not-for-profit facilities delivered higher quality care than did for-profit facilities for two of the four most frequently reported quality measures: more or higher quality staffing (ratio of effect 1.11, 95% confidence interval 1.07 to 1.14, P<0.001) and lower pressure ulcer prevalence (odds ratio 0.91, 95% confidence interval 0.83 to 0.98, P=0.02). Non-significant results favouring not-for-profit homes were found for the two other most frequently used measures: physical restraint use (odds ratio 0.93, 0.82 to 1.05, P=0.25) and fewer deficiencies in governmental regulatory assessments (ratio of effect 0.90, 0.78 to 1.04, P=0.17). Conclusions This systematic review and meta-analysis of the evidence suggests that, on average, not-for-profit nursing homes deliver higher quality care than do for-profit nursing homes. Many factors may, however, influence this relation in the case of individual institutions.

Predictors of reoperation following operative management of fractures of the tibial shaft.

Background Accurate prediction of likelihood of reoperation in patients with tibial shaft fractures would facilitate optimal management. Previous studies were limited by small sample sizes and noncomprehensive examination of possible risk factors. Objective We conducted an observational study to determine which prognostic factors were associated with an increased risk of reoperation following operative treatment in a heterogeneous population of patients with tibial shaft fractures. Design Retrospective observational study. Setting Level 1 trauma center. Methods We identified 200 patients with tibial shaft fractures from two university-affiliated centers. Two reviewers independently abstracted data regarding 20 possible prognostic variables, reviewed preoperative and postoperative radiographs, and documented reoperations (defined as any surgical procedure ≤1 year after the initial surgery that was aimed specifically at achieving bony union of the fracture, including bone grafts, implant exchanges, or débridement for infections). We chose a Cox proportion hazards model to conduct a survival analysis for time to reoperation and constructed a multivariable model to estimate the relative risk of reoperation and associated 95%confidence interval (CI) for each predictor variable. Main Outcome Measures Time to reoperation following the initial surgery. Results Complete follow-up information was available for 192 of 200 (96%) patients. Three variables predicted reoperation: the presence of an open fracture wound (relative risk 4.32, 95% CI 1.76 to 11.26), lack of cortical continuity between the fracture ends following fixation (relative risk 8.33, 95% CI 3.03 to 25.0), and the presence of a transverse fracture (relative risk 20.0, 95% CI 4.34 to 142.86). Conclusions We identified a set of three simple prognostic variables (open fracture, transverse fracture, and postoperative fracture gap) that can assist surgeons in predicting reoperation following operative treatment of tibial shaft fractures.

Femoral Neck Shortening After Fracture Fixation With Multiple Cancellous Screws : Incidence and Effect on Function

BACKGROUND Shortening of the femoral neck after fracture fixation with multiple parallel screws decreases the moment arm for the abductor muscles of the hip. This study aimed to assess the incidence of femoral neck shortening quantitatively and qualitatively in patients with femoral neck fractures treated with multiple cannulated screws, and to investigate its influence on functional outcome. METHODS We conducted an observational study in a consecutive series of 56 patients with united fractures of the femoral neck treated with multiple cancellous screws. The latest anterior-posterior radiograph of the fractured hip was compared with that of the contralateral uninjured hip. After scanning and electronically overlapping those radiographs, femoral neck shortening was assessed. All identified patients were contacted and the Short Form-36 (SF-36) functional outcome questionnaire was administered. RESULTS The shortening rate was 31% for undisplaced (14 of 45) and 27% for displaced fractures (3 of 11). The average abductor moment arm shortening was 10 +/- 4 mm. The average femur length decrease was 8 +/- 5 mm. In all other patients, abductor moment arm as well as femur length measurements were within 3 mm of the contralateral side and considered not to be shortened. Thirteen patients completed the SF-36 questionnaire (12 of 13 undisplaced fractures; all 13 with good fracture reduction). Patients with shortened fractures (8 of 13) had significantly lower Physical Functioning (p = 0.01) and Role Physical (p = 0.04) SF-36 subscores. CONCLUSIONS Femoral neck shortening after femoral neck fracture fixation with multiple cancellous screws is common and it has a significant negative impact on physical functioning.

The Epidemiology of Metatarsal Fractures

Background: Metatarsal fractures are common injuries; however little has been written regarding their epidemiology in an adult population. Methods: All patients with metatarsal fractures during a 1-year time period were included in the study. Demographic information, grade, and mechanism of injury, associated injuries, and fracture location and type were recorded. Results: Three hundred and fifty-five patients with 411 metatarsal fractures were identified. The average age of the patients was 42 years. There was a higher proportion of women in the higher age groups, and the most common fracture was that of the fifth metatarsal. Multiple metatarsal fractures occurred in contiguous metatarsals, and 63% of third metatarsal fractures were associated with a fracture of either the second or fourth metatarsal. Conclusion: Knowledge of the epidemiology and injury patterns of metatarsal fractures can aid in the accurate identification and subsequent treatment of fractures of the metatarsals.

Bone stimulation for fracture healing: What's all the fuss?

Approximately 10% of the 7.9 million annual fracture patients in the United States experience nonunion and/or delayed unions, which have a substantial economic and quality of life impact. A variety of devices are being marketed under the name of “bone growth stimulators.” This article provides an overview of electrical and electromagnetic stimulation, ultrasound, and extracorporeal shock waves. More research is needed for knowledge of appropriate device configurations, advancement in the field, and encouragement in the initiation of new trials, particularly large multicenter trials and randomized control trials that have standardized device and protocol methods.

Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study

BackgroundTibial shaft fractures are the most common long bone fracture and are prone to complications such as nonunion requiring reoperations to promote fracture healing. We aimed to determine the fracture characteristics associated with tibial fracture nonunion, and their predictive value on the need for reoperation. We further aimed to evaluate the predictive value of a previously-developed prognostic index of three fracture characteristics on nonunion and reoperation rate.MethodsWe conducted an observational study and developed a risk factor list from previous literature and key informants in the field of orthopaedic surgery, as well as via a sample-to-redundancy strategy. We evaluated 22 potential risk factors for the development of tibial fracture nonunion in 200 tibial fractures. We also evaluated the predictive value of a previously-identified prognostic risk index on secondary intervention and/or reoperation rate. Two individuals independently extracted the data from 200 patient electronic medical records. An independent reviewer assessed the initial x-ray, the post-operative x-ray, and all available sequential x-rays. Regression and chi-square analysis was used to evaluate potential associations.ResultsIn our cohort of patients, 37 (18.5%) had a nonunion and 27 (13.5%) underwent a reoperation. Patients with a nonunion were 97 times (95% CI 25.8-366.5) more likely to have a reoperation. Multivariable logistic regression revealed that fractures with less than 25% cortical continuity were predictive of nonunion (odds ratio = 4.72; p = 0.02). Such fractures also accounted for all of the reoperations identified in our sample. Furthermore, our data provided preliminary validation of a previous risk index predictive of reoperation that includes the presence of a fracture gap post-fixation, open fracture, and transverse fracture type as variables, with an aggregate of fracture gap and an open fracture yielding patients with the highest risk of developing a nonunion.ConclusionsWe identified a significant association between degree of cortical continuity and the development of a nonunion and risk for reoperation in tibial shaft fractures. In addition, our study supports the predictive value of a previous prognostic index, which inform discussion of prognosis following operative management of tibial fractures.

Radial head and neck fractures: functional results and predictors of outcome.

BACKGROUND The purpose of this study was to determine the functional outcomes and predictive factors of radial head and neck fractures. METHODS Over an 18-month period, we performed a prospective study of 237 consecutive patients with a radiographically confirmed proximal radial fracture (156 radial head and 81 radial neck). Follow-up was carried out over a 1-year period using clinical and radiologic assessment, including the Mayo Elbow Score (MES). Multivariate regression analysis was used to determine significant predictors of outcome according to the MES. RESULTS Of the 237 patients enrolled in the study, 201 (84.8%) attended for review, with a mean age of 44 years (range, 16-83 years; standard deviation, 17.3). One hundred eighty-seven (93%) patients achieved excellent or good MESs. The mean MES for Mason type-I (n = 103) and type-II (n = 82) fractures was excellent, with only two patients undergoing surgical intervention. For Mason type-III (n = 11) and type-IV (n = 5) fractures, the flexion arc, forearm rotation arc, and MES in the nonoperatively treated patients were not significantly different (all p ≥ 0.05) from those managed operatively. Regression analysis revealed that increasing age, increasing fracture complexity according to the AO-OTA classification, increasing radiographic comminution, and operative treatment choice were independently significant predictors of a poorer outcome (all p < 0.05). CONCLUSIONS A majority of radial head and neck fractures can be treated nonoperatively, achieving excellent or good results. Age, fracture classification, radiographic comminution, and treatment choice are important factors that determine recovery.

Selection of outcome measures for patients with hip fracture.

In designing a study protocol relating to hip fracture treatment and outcomes, it is important to select appropriate outcome instruments. Before beginning the process of instrument selection, investigators must gain a comprehensive understanding of the condition of interest and have a thorough knowledge of the expected benefits and harms of the proposed intervention. Adequate evidence of an interventions effectiveness includes indication of impact on the patients health. We provide a brief discussion about different ways that health and health measurement have been defined, including the International Classification of Function, Disability and Health (ICF), health-related quality of life (HRQOL), and cost-to-benefit analyses. We outline important properties (reliability, validity, sensitivity to change, and responsiveness) that a measurement instrument must demonstrate before being considered an acceptable means to measure outcome. Potential outcome measures relevant to patients with hip fracture are summarized, and important points to consider in the selection of outcome measures for a hypothetical research question in a hip fracture population are discussed.

Improving reliability in the classification of fractures of the acetabulum

Background. Plain radiographs of the pelvis are routinely used in the initial assessment of patients with suspected fractures of the acetabulum. It is necessary for orthopaedic resident trainees, emergency physicians as well as orthopaedic surgeons who infrequently treat trauma patients to be able to describe these fracture patterns reliably to traumatologist orthopaedic surgeons who ultimately take over the patient care. Our purpose was two-fold: (1) to determine the reliability of the component parts of the Letournel classification of acetabular fractures involving six anteroposterior (AP) radiographic lines, and (2) to examine whether the addition of oblique radiograph views (Judet views) would improve the reliability. Methods. Thirty sets of AP and oblique radiographs (Judet views) of the pelvis were selected from a hospital database to represent various types of acetabular fractures. Six reviewers (three orthopaedic trainees and three community orthopaedic surgeons) independently reviewed the radiographs. For each radiograph, the reviewer classified the acetabular fracture according to the Letournel classification. In addition, each reviewer utilized a simplified classification scheme using six radiographic lines on the AP pelvic radiograph. Interobserver reliabilities among reviewers were reported along with the intraclass correlation coefficient (ICC) and kappa values. Results. Agreement for the Letournel classification increased with increasing physician experience (trainees ICC=−0.14 and community surgeons ICC=0.56). Interobserver reliability between trainees and community surgeons improved when the six radiographic lines were used (range kappa=0.09–0.89). The oblique pelvic radiographs (Judet views) did not significantly improve reliability among physicians. Conclusions. In this study we report the following: (1) the reliability of the Letournel classification improves with level of training, (2) physicians with less experience with acetabular fractures have significantly better agreement in identifying fractures using the six radiographic lines on the AP film than the Letournel classification, and (3) agreement among the reviewers for the AP pelvic radiograph is not improved with additional oblique (Judet) views.

Infection after reamed intramedullary nailing of the tibia: a case series review.

Objective: We reviewed those patients who developed a postoperative infection after reamed intramedullary nailing of tibial shaft fractures to investigate the possible causes of infection, its effect on union time, and the requirement for reconstructive surgery. Design: Retrospective review of patients who developed deep infection after reamed tibial nailing during a 15-year period. Setting: University Level II Trauma Center. Patients: Thirty-five with tibial diaphyseal fractures. Intervention: All patients were treated with reamed intramedullary nailing. Outcome measures: Union, union time, compartment syndrome, requirement for reconstructive procedures, and development of deep infection. Results: In the closed-fracture group, 43.8% of patients were considered to have developed infection because of inappropriate fasciotomy closure, exchange nailing, and thermal necrosis. In the open-fracture group, 62.5% were considered to have developed infection attributable to late complications of plastic surgery. The most significant problem was marginal necrosis after flap cover. Conclusions: A number of deep infections after reamed intramedullary tibial nailing are avoidable. Particular attention must be paid to correct reaming, exchange nailing, and fasciotomy closure in closed fractures. In open fractures, marginal flap necrosis should be actively treated and not left to granulate.