Between-hospital variability in the management and outcomes of postoperative periprosthetic femoral fractures.

Aims: Postoperative periprosthetic femoral fractures (POPFFs) following hip arthroplasty pose complex challenges, with differences in management and outcomes across healthcare facilities. However, there is limited published literature on such variability to inform improvement initiatives. This study aims to quantify the between-hospital variations in surgical management and short-term outcomes.

Methods: Administrative hospitalizations data from all 177 NHS hospital Trusts in England were analyzed for patients aged 18 years and above with a primary diagnosis of POPFF between April 2016 and December 2022. Patient demographic characteristics, comorbidities, procedures, length of stay, in-hospital mortality, 30-day total mortality (in or out of hospital), and emergency 30-day all-cause readmissions were extracted. Multilevel models with random intercepts for hospitals and funnel plots assessed the non-random variations between hospitals in procedures and outcomes.

Results: Among 39,035 hospitalized patients, 66% were female (n = 25,720), with a median age of 82 years (IQR 73 to 88). Hospital variation existed in treatment outcomes, with adjusted intraclass correlation coefficients for fixation without revision, revision, and no surgical procedure of 4.0%, 3.8%, and 2.4%, respectively. Funnel plots revealed hospital outliers for procedure choice after adjusting for age, sex, and number of comorbidities - among 177 hospitals, nine (5.1%) exceeded the upper 95% control limit for fixation and 17 (9.6%) did so for revision; outlier proportions were 14.1% for length of stay, 3.9% for emergency 30-day readmission, and 1.1% for mortality.

Conclusion: Inter-hospital variation exists for the management and short-term outcomes following POPFFs in England. This warrants further explanation to better understand the reasons for this.