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Objective: To estimate the potential influence of pre-operative patient condition on the benefit of earlier hip fracture surgery for elderly patients.Background: Many studies emphasize the benefit of earlier hip fracture surgery for patient survival. However less is known regarding how this relationship is influenced by clinical factors which could serve as potential contra-indicators for earlier surgery. Rushed surgery of patients with contra-indications may even compromise their survival.Methods: A retrospective study of patients aged 65 and above with an isolated hip fracture following trauma, based on data from 19 hospitals of the national trauma registry available for the years 2015-2016. Registry data was crossed with data on co-morbidities and medication intake from the biggest health insurance agency in the country, serving more than 50% of the country's population. Mediation analysis was performed on a wide list of co-morbidities, medications and clinical test results in order to establish the mediation of their relationship with inhospital mortality by earlier hip fracture surgery. Factors found significant in the mediation analysis were utilized to adjust a logistic regression for predicting inhospital mortality by function of waiting time to surgery and patient's sex and age.Results: Anti-coagulant and anti-platelet intake; test results pointing to decreased kidney function and being diagnosed with diabetes or Ischemic Heart Disease were found to be significantly mediated in their influence on inhospital mortality by hip fracture surgery. Despite anti-platelet intake and kidney function having a significant impact on mortality in the multi-variate analysis, the positive effect of earlier hip surgery on survival remained unchanged after adjustment.Conclusions: Earlier hip fracture surgery was found to be beneficial for elderly patients even when their co-morbidities and medication intake are taken into account. [ABSTRACT FROM AUTHOR]

Background In patients with obstructive hypertrophic cardiomyopathy, surgical myectomy (SM) is indicated for severe symptoms. We sought to compare long‐term outcomes of patients with obstructive hypertrophic cardiomyopathy where SM was based on guideline‐recommended Class I indication (Functional Class or FC ≥3 or angina/exertional syncope despite maximal medical therapy) versus earlier (FC 2 and/or impaired exercise capacity on exercise echocardiography with severe obstruction). Methods and Results We studied 2268 consecutive patients (excluding

Abstract Quality measures are widely used globally in order to measure clinical performance and organizational efficiency of the healthcare systems. However, in a race to achieve certain numerically defined goal, the more important purpose of any organizational step being aimed at improving clinical outcomes could be overshadowed. The introduction of the requirement to perform most hip fracture surgeries in the first 48 h of hospitalization by the Israeli Ministry of Health (IMOH) provides an interesting example of the complexity of this phenomenon. In 2004, the IMOH decided that hospitals would receive the full DRG payment for hip fractures operations only in cases in which the operation is performed within 48 h of hospitalization. In 2013, the IMOH proceeded to designate the proportion of less than 48 h surgeries as an official quality parameter for comparing hospital performance. Despite the widely acknowledged and proven clinical benefit of earlier surgery for hip fracture patients, the desired proportion of such surgeries in a given population is not easily defined for a given population, as a significant number of patients may be unsuited for immediate surgery due to medical instability, having a serious co-morbidity or receiving anticoagulant treatment. Rushing these patients to surgery can be therefore expected to have a negative effect on their outcomes, and the subsequent increase in hip fracture mortality recorded in Israel after 2013 may be a result of that. This example suggests that designating an organizational quality measure without adjusting it for the patient’s medical condition may make it too inaccurate to guide healthcare policy.

Abstract: Background: In April 2004 the Israeli Ministry of Health decided to condition DRG payment for hip surgery by time between hospitalisation and operation, giving a fine for every day's delay beyond 48h. An evaluation study performed 2 years after the reform has shown the positive influence of the reform on patient's survival in the hospital. This study evaluates the impact of the reform on the longer-term mortality of patients. Methods: A retrospective study based on data from nine hospitals of the national trauma registry available for the years 2001–2007, with surveillance on 2-year survival through data of Ministry of the Interior. The study population includes patients aged 65 and above with an isolated hip fracture following trauma. Mortality curves and Cox regression were utilised to compare the influence of different parameters on long-term mortality. Results: Earlier surgery had a significant positive impact on survival through the whole length of the study period. In the period after the introduction of the new reimbursement system for hip fracture surgeries, a significant decrease in the longer-term mortality was observed up to 6 months of follow-up, even when adjusted by patients’ age, gender and the receiving hospital. After 6 months there was no further decrease in relative risk, though the survival advantage remained with patients hospitalised after the reform. Conclusions: The reform appears successful in decreasing the longer-term patient mortality after hip fracture through influencing surgical practice. [Copyright &y& Elsevier]

Background In patients with obstructive hypertrophic cardiomyopathy, surgical myectomy (SM) is indicated for severe symptoms. We sought to compare long-term outcomes of patients with obstructive hypertrophic cardiomyopathy where SM was based on guideline-recommended Class I indication (Functional Class or FC ≥3 or angina/exertional syncope despite maximal medical therapy) versus earlier (FC 2 and/or impaired exercise capacity on exercise echocardiography with severe obstruction). Methods and Results We studied 2268 consecutive patients (excluding <18 years, ≥ moderate aortic stenosis and subaortic membrane, 56±14 years, 55% men), who underwent SM at our center between June 2002 and March 2018. Clinical data, including left ventricular outflow tract gradient, were recorded. Death and/or appropriate internal defibrillator discharge were primary composite end points. One thousand three hundred eighteen (58%) patients met Class I indication and 950 (42%) underwent earlier surgery; 222 (10%) had a history of obstructive coronary artery disease. Basal septal thickness, and resting and maximal left ventricular outflow tract gradient were 2.0±0.3 cm, 61±44 mm Hg, and 100±31 mm Hg, respectively. At 6.2±4 years after SM, 248 (11%) had composite events (13 [0.6%] in-hospital deaths). Age (hazard ratio [HR], 1.61; 95% CI, 1.26-1.91), obstructive coronary artery disease (HR, 1.46; 95% CI, 1.06-1.91), and Class I versus earlier SM (HR, 1.61; 95% CI, 1.14-2.12) were associated with higher primary composite events (all P <0.001). Earlier surgery had better longer-term survival (similar to age-sex-matched normal population) versus surgery for Class I indication (76 [8%] versus 193 [15%], P <0.001). Conclusions In patients with obstructive hypertrophic cardiomyopathy, earlier versus surgery for Class I indication had a better long-term survival, similar to the age-sex-matched US population.

Quality measures are widely used globally in order to measure clinical performance and organizational efficiency of the healthcare systems. However, in a race to achieve certain numerically defined goal, the more important purpose of any organizational step being aimed at improving clinical outcomes could be overshadowed.The introduction of the requirement to perform most hip fracture surgeries in the first 48 h of hospitalization by the Israeli Ministry of Health (IMOH) provides an interesting example of the complexity of this phenomenon. In 2004, the IMOH decided that hospitals would receive the full DRG payment for hip fractures operations only in cases in which the operation is performed within 48 h of hospitalization. In 2013, the IMOH proceeded to designate the proportion of less than 48 h surgeries as an official quality parameter for comparing hospital performance.Despite the widely acknowledged and proven clinical benefit of earlier surgery for hip fracture patients, the desired proportion of such surgeries in a given population is not easily defined for a given population, as a significant number of patients may be unsuited for immediate surgery due to medical instability, having a serious co-morbidity or receiving anticoagulant treatment. Rushing these patients to surgery can be therefore expected to have a negative effect on their outcomes, and the subsequent increase in hip fracture mortality recorded in Israel after 2013 may be a result of that.This example suggests that designating an organizational quality measure without adjusting it for the patient's medical condition may make it too inaccurate to guide healthcare policy.