IDEAS home Printed from https://ideas.repec.org/a/plo/pone00/0234041.html
   My bibliography  Save this article

Disentangling the contribution of hospitals and municipalities for understanding patient level differences in one-year mortality risk after hip-fracture: A cross-classified multilevel analysis in Sweden

Author

Listed:
  • Pia Kjær Kristensen
  • Raquel Perez-Vicente
  • George Leckie
  • Søren Paaske Johnsen
  • Juan Merlo

Abstract

Background: One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variation in patient outcomes in isolation rather than as a component of the underlying patient variation. We therefore aimed to extend the traditional approach to simultaneously estimate both case-mix adjusted hospital and municipality comparisons in order to disentangle the amount of the total patient variation in clinical outcomes that was attributable to the hospital and municipality level, respectively. Methods: We determined 1-year mortality risk in patients aged 65 or above with hip fractures registered in Sweden between 2011 and 2014. We performed cross-classified multilevel analysis with 54,999 patients nested within 54 hospitals and 290 municipalities. We adjusted for individual demographic, socioeconomic and clinical characteristics. To quantify the size of the hospital and municipality variation we calculated the variance partition coefficient (VPC) and the area under the receiver operator characteristic curve (AUC). Results: The overall 1-year mortality rate was 25.1%. The case-mix adjusted rates varied from 21.7% to 26.5% for the 54 hospitals, and from 18.9% to 29.5% for the 290 municipalities. The VPC was just 0.2% for the hospital and just 0.1% for the municipality level. Patient sociodemographic and clinical characteristics were strong predictors of 1-year mortality (AUC = 0.716), but adding the hospital and municipality levels in the cross-classified model had a minor influence (AUC = 0.718). Conclusions: Overall in Sweden, one-year mortality after hip-fracture is rather high. However, only a minor part of the patient variation is explained by the hospital and municipality levels. Therefore, a possible intervention should be nation-wide rather than directed to specific hospitals or municipalities.

Suggested Citation

  • Pia Kjær Kristensen & Raquel Perez-Vicente & George Leckie & Søren Paaske Johnsen & Juan Merlo, 2020. "Disentangling the contribution of hospitals and municipalities for understanding patient level differences in one-year mortality risk after hip-fracture: A cross-classified multilevel analysis in Swed," PLOS ONE, Public Library of Science, vol. 15(6), pages 1-14, June.
    • Handle: RePEc:plo:pone00:0234041
    DOI: 10.1371/journal.pone.0234041
    as

    Download full text from publisher

    File URL: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0234041
    Download Restriction: no
    File URL: https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0234041&type=printable
    Download Restriction: no
    File URL: https://libkey.io/10.1371/journal.pone.0234041?utm_source=ideas
    LibKey link: if access is restricted and if your library uses this service, LibKey will redirect you to where you can use your library subscription to access this item
    ---><---

    References listed on IDEAS

    as
    1. Juan Merlo & Philippe Wagner & Nermin Ghith & George Leckie, 2016. "An Original Stepwise Multilevel Logistic Regression Analysis of Discriminatory Accuracy: The Case of Neighbourhoods and Health," PLOS ONE, Public Library of Science, vol. 11(4), pages 1-31, April.
    2. Margaret Pepe & Holly Janes & Gary Longton & Wendy Leisenring & Polly Newcomb, 2004. "Limitations of the Odds Ratio in Gauging the Performance of a Diagnostic or Prognostic Marker," UW Biostatistics Working Paper Series 1035, Berkeley Electronic Press.
    3. Nermin Ghith & Philippe Wagner & Anne Frølich & Juan Merlo, 2016. "Short Term Survival after Admission for Heart Failure in Sweden: Applying Multilevel Analyses of Discriminatory Accuracy to Evaluate Institutional Performance," PLOS ONE, Public Library of Science, vol. 11(2), pages 1-20, February.
    4. Corallo, Ashley N. & Croxford, Ruth & Goodman, David C. & Bryan, Elisabeth L. & Srivastava, Divya & Stukel, Therese A., 2014. "A systematic review of medical practice variation in OECD countries," Health Policy, Elsevier, vol. 114(1), pages 5-14.
    5. Harvey Goldstein & David J. Spiegelhalter, 1996. "League Tables and Their Limitations: Statistical Issues in Comparisons of Institutional Performance," Journal of the Royal Statistical Society Series A, Royal Statistical Society, vol. 159(3), pages 385-409, May.
    6. Nermin Ghith & Anne Frølich & Juan Merlo, 2017. "The role of the clinical departments for understanding patient heterogeneity in one-year mortality after a diagnosis of heart failure: A multilevel analysis of individual heterogeneity for profiling p," PLOS ONE, Public Library of Science, vol. 12(12), pages 1-18, December.
    7. Emma Medin & Fanny Goude & Hans Olav Melberg & Fabrizio Tediosi & Eva Belicza & Mikko Peltola, 2015. "European Regional Differences in All‐Cause Mortality and Length of Stay for Patients with Hip Fracture," Health Economics, John Wiley & Sons, Ltd., vol. 24, pages 53-64, December.
    Full references (including those not matched with items on IDEAS)

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. Anna Persmark & Maria Wemrell & Sofia Zettermark & George Leckie & S V Subramanian & Juan Merlo, 2019. "Precision public health: Mapping socioeconomic disparities in opioid dispensations at Swedish pharmacies by Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA)," PLOS ONE, Public Library of Science, vol. 14(8), pages 1-21, August.
    2. Richard Heijink & Peter Engelfriet & Clas Rehnberg & Sverre A. C. Kittelsen & Unto Häkkinen & on behalf of the EuroHOPE study group, 2015. "A Window on Geographic Variation in Health Care: Insights from EuroHOPE," Health Economics, John Wiley & Sons, Ltd., vol. 24(S2), pages 164-177, December.
    3. Unto Häkkinen & Tor Iversen & Mikko Peltola & Clas Rehnberg & Timo T. Seppälä & on behalf of the EuroHOPE study group, 2015. "Towards Explaining International Differences in Health Care Performance: Results of the EuroHOPE Project," Health Economics, John Wiley & Sons, Ltd., vol. 24(S2), pages 1-4, December.
    4. Paul Hewson & Keming Yu, 2008. "Quantile regression for binary performance indicators," Applied Stochastic Models in Business and Industry, John Wiley & Sons, vol. 24(5), pages 401-418, September.
    5. Debashis Ghosh & Michael S. Sabel, 2022. "A Weighted Sample Framework to Incorporate External Calculators for Risk Modeling," Statistics in Biosciences, Springer;International Chinese Statistical Association, vol. 14(3), pages 363-379, December.
    6. Bolte, Gabriele, 2018. "Epidemiologische Methoden und Erkenntnisse als eine Grundlage für Stadtplanung und gesundheitsfördernde Stadtentwicklung," Forschungsberichte der ARL: Aufsätze, in: Baumgart, Sabine & Köckler, Heike & Ritzinger, Anne & Rüdiger, Andrea (ed.), Planung für gesundheitsfördernde Städte, volume 8, pages 118-134, ARL – Akademie für Raumentwicklung in der Leibniz-Gemeinschaft.
    7. Sophie Massin & Antoine Nebout & Bruno Ventelou, 2018. "Predicting medical practices using various risk attitude measures," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 19(6), pages 843-860, July.
    8. Bornmann, Lutz & Leydesdorff, Loet & Wang, Jian, 2014. "How to improve the prediction based on citation impact percentiles for years shortly after the publication date?," Journal of Informetrics, Elsevier, vol. 8(1), pages 175-180.
    9. Huhr, Scott & Wulczyn, Fred, 2022. "Do intensive in-home services prevent placement?: A case study of Youth Villages’ Intercept® program," Children and Youth Services Review, Elsevier, vol. 132(C).
    10. Aljoscha Benjamin Hwang & Guido Schuepfer & Mario Pietrini & Stefan Boes, 2021. "External validation of EPIC’s Risk of Unplanned Readmission model, the LACE+ index and SQLape as predictors of unplanned hospital readmissions: A monocentric, retrospective, diagnostic cohort study in," PLOS ONE, Public Library of Science, vol. 16(11), pages 1-33, November.
    11. Anna-Karin Ivert & Marie Torstensson Levander & Juan Merlo, 2013. "Adolescents' Utilisation of Psychiatric Care, Neighbourhoods and Neighbourhood Socioeconomic Deprivation: A Multilevel Analysis," PLOS ONE, Public Library of Science, vol. 8(11), pages 1-1, November.
    12. Arpino, Bruno & Varriale, Roberta, 2009. "Assessing the quality of institutions’ rankings obtained through multilevel linear regression models," MPRA Paper 19873, University Library of Munich, Germany.
    13. Mutz, Rüdiger & Daniel, Hans-Dieter, 2018. "The bibliometric quotient (BQ), or how to measure a researcher’s performance capacity: A Bayesian Poisson Rasch model," Journal of Informetrics, Elsevier, vol. 12(4), pages 1282-1295.
    14. Margaret Sullivan Pepe & Tianxi Cai & Gary Longton, 2006. "Combining Predictors for Classification Using the Area under the Receiver Operating Characteristic Curve," Biometrics, The International Biometric Society, vol. 62(1), pages 221-229, March.
    15. Magne Mogstad & Joseph P Romano & Azeem M Shaikh & Daniel Wilhelm, 2024. "Inference for Ranks with Applications to Mobility across Neighbourhoods and Academic Achievement across Countries," The Review of Economic Studies, Review of Economic Studies Ltd, vol. 91(1), pages 476-518.
    16. Daraio, Cinzia & Bonaccorsi, Andrea & Simar, Léopold, 2015. "Rankings and university performance: A conditional multidimensional approach," European Journal of Operational Research, Elsevier, vol. 244(3), pages 918-930.
    17. Noémie Malléjac & Zeynep Or, 2019. "évaluation d’impact d’une nouvelle organisation en chirurgie orthopédique sur les parcours de soins," Working Papers DT79, IRDES institut for research and information in health economics, revised Jun 2019.
    18. David A Cook & Laurie J Pencille & Denise M Dupras & Jane A Linderbaum & V Shane Pankratz & John M Wilkinson, 2018. "Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants," PLOS ONE, Public Library of Science, vol. 13(1), pages 1-12, January.
    19. Holly Janes & Margaret S. Pepe, 2008. "Matching in Studies of Classification Accuracy: Implications for Analysis, Efficiency, and Assessment of Incremental Value," Biometrics, The International Biometric Society, vol. 64(1), pages 1-9, March.
    20. repec:lan:wpaper:991 is not listed on IDEAS
    21. Kollerup, Anna & Wadmann, Sarah & Bek, Toke & Kjellberg, Jakob, 2022. "National clinical guidelines and treatment centralization do not guarantee consistency in healthcare delivery. A mixed-methods study of wet age-related macular degeneration treatment in Denmark," Health Policy, Elsevier, vol. 126(12), pages 1291-1302.

    More about this item

    Statistics

    Access and download statistics

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:plo:pone00:0234041. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: plosone (email available below). General contact details of provider: https://journals.plos.org/plosone/ .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.