Bigger is not always better

For several years the Danish health service has been moving towards increased centralisation and specialisation in large hospital departments based on the thesis that this provides better results for patients. A new study involving more than 12,000 Danish patients with hip fractures presents a different picture, however:

"Our study shows that the mortality rate for this group of patients is lower in the smaller hospital departments compared to the larger departments. We can also see that the length of stay in hospital is shorter and the quality of care is generally better, says PhD student Pia Kjær Kristensen from the Department of Clinical Epidemiology at Aarhus University and Aarhus University Hospital and Regional Hospital Horsens, who is behind the study together with a number of colleagues.

Each year seven thousand elderly people suffer a hip fracture that requires surgery. Despite a successful operation, eleven per cent of all elderly hip fracture patients die within 30 days.

Correlation between quality and mortality

In the study the researchers studied mortality after 30 days, the quality of care, time for surgery  and the length of stay in hospital. Patients were classified according to whether they had been admitted to a department with less than 151 hip fracture patients annually; with between 152-350 hip fracture patients annually; and with more than 350 hip fracture patients annually.

The quality of treatment was measured according to whether the patient received daily pain assessment  help with physical activity within 24-hours of the operation, an assessment of their functional level, preparation of a rehabilitation plan and the implementation of preventive treatment relating to falls and osteoporosis.

Overall the patients in the smallest departments were in the best position:

“Patients admitted to a high-volume department were to a lesser extent offered physical activity within 24-hours of the operation, their functional level was not assessed as much and they received less of a rehabilitation plan prior to being discharged," says Pia Kjær Kristensen, who emphasises that patients who had been admitted to a high volume department received a greater degree of assessment when it came to the reasons for the original fall, with a view to preventing new falls.

She describes the results as surprising but stresses that the results should be seen in the light of the fact that Denmark does not have very small hospital departments as some centralisation has already taken place. Today, there are 28 departments for hip fracture patients and the small departments in Denmark generally have a high patient volume compared to hospitals abroad. 

Important knowledge

Based on the study, the researchers can see that a significant reason for the higher mortality rate for patients admitted to large departments is the lower quality of treatment. On the other hand, based on the study they are unable to explain why patients admitted to high-volume departments receive poorer quality care.

The results are important for planning the healthcare system of the future:

"The study shows that further centralisation of the current structure does not necessarily give better quality within hip fractures," says Pia Kjær Kristensen.

The study was recently published in the recognised scientific journal Medical Care.

Facts about the study

• 12,065 patients with hip fractures suffered in the period 1 March 2010 to 30 November 2011 were included in the study.
• All of the patients were 65 years old or older.
• For patients admitted to a high-volume department, the thirty-day mortality rate was 13.2 per cent, while the mortality rate was 10.5 per cent for patients admitted to low-volume departments.
• The length of stay in hospital was 1.25 times longer for patients admitted to a high-volume department.
• The study is based on data from the Danish Interdisciplinary Registry for Hip Fractures.

Read more

Download the original article "Is Bigger Always Better? A Nationwide Study of Hip Fracture Unit Volume, 30-Day Mortality, Quality of In-Hospital Care, and Length of Hospital Stay” here: http://www.ncbi.nlm.nih.gov/pubmed/25226544

Further information

PhD student Pia Kjær Kristensen
Aarhus University, Department of Clinical Medicine, Department of Clinical Epidemiology and

The Regional Hospital Horsens, Department of Orthopaedic Surgery

Tel.: +45 6169 1520 

pkkr@clin.au.dk