BETWEEN-HOSPITAL VARIABILITY IN THE MANAGEMENT AND OUTCOMES OF POSTOPERATIVE PERIPROSTHETIC FEMORAL FRACTURES

Post-operative periprosthetic femoral fractures (POPFFs) following joint replacement surgery 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 for POPFF. Administrative data from all 177 NHS hospital Trusts in England were analysed for patients aged 18 and over with a primary diagnosis of POPFF between April 2016 and December 2022. Patient demographics, comorbidities, procedures, in-hospital mortality, length of stay (LOS, dichotomised at the upper quartile, <23 days and ≥23 days), and emergency 30-day all-cause readmissions were extracted. Procedures were classified as revision with or without fixation, fixation alone, and neither procedure. Multilevel models with random intercepts for hospitals and funnel plots assessed the non-random variations between hospitals in procedures and outcomes. Variation was assessed before and after adjusting for patient age, sex and number of comorbidities. Among 39,035 hospitalised patients, 66% were female, with a median age of 82 years. Common comorbidities included hypertension (51.7%), arrhythmias (24.3%), and chronic pulmonary disease (18.2%). Hospital variation existed in treatment, with adjusted intraclass correlation coefficients for fixation without revision, revision, and no surgical procedure at 4%, 3.8%, and 2.4%, respectively. Funnel plots revealed many outliers for procedure choice and outcomes, though the numbers fell appreciably after adjustment. Among 177 hospitals after adjustment, nine (5.1%) exceeded the upper 95% control limit for fixation and 17 (9.6%) did so for revision, and LOS (n=25, 14.1%) and emergency 30-day readmission (n=7, 3.9%) but fewer for mortality (n=2, 1.1%). Between-hospital variation exists for the management of, and some short-term outcomes following, POPFFs in England. This warrants further explanation to better understand the reasons for this and how these may be overcome.