The Effect of Care Pathways for Hip Fractures: A Systematic Review

Leigheb, Fabrizio; Vanhaecht, Kris; Sermeus, Walter; Lodewijckx, Cathy; Deneckere, Svin; Boonen, Steven; Boto, Paulo; Mendes, Rita; Panella, Massimiliano

doi:10.1007/s00223-012-9589-2

Cited by 42 publications

(42 citation statements)

References 52 publications

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“…A recent review by Leigheb et al showed similar reductions in the hospital length of stay in eight out of 12 studies [6]. Three studies reported a longer hospital stay [14][15][16] and one did not find any difference after implementing a clinical pathway [17].…”

Section: Discussionmentioning

confidence: 99%

“…Implementing multidisciplinary clinical pathways may improve the logistic management of the growing population of elderly patients with a hip fracture. This tends to have positive effects on mortality, postoperative complications, and in-hospital stay, consequently leading to reduced costs [5,6]. The aim of this study was to compare the treatment-related hospital length of stay before and after implementing a clinical pathway for all patients undergoing hip fracture surgery.…”

Section: Introductionmentioning

confidence: 99%

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Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients

Burgers

Lieshout

Verhelst

et al. 2013

International Orthopaedics (SICOT)

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Purpose Modern management of the elderly with a hip fracture is complex and costly. The aim of this study was to compare the treatment-related hospital length of stay (HLOS) before and after implementing a clinical pathway for patients undergoing hip fracture surgery. Methods This was a retrospective, before-and-after study. The first period ranged from June 21, 2008 to November 1, 2009 (N =212), and the second was from January 7, 2010 to July 7, 2011 (N =314). The electronic hospital system and patients records were reviewed for demographics, HLOS, mortality, complications and readmissions. Results In the first period 53 % had a femoral neck fracture, of which 57 % were treated with hemiarthroplasty. In the second period this was 46 % and 71 %. Pertrochanteric fractures were treated with a Gamma nail in 85 % in the first period, and in 92 % in the second period. The median HLOS decreased from nine to six days (p <0.001). For the hemiarthroplasty group HLOS decreased from nine to seven days (p <0.001); for internal fixation there was no significant difference (five versus six days, p =0.557) and after Gamma nailing it decreased from ten to six days (p <0.001). For mortality no statistically significant difference was found (6 % versus 5 %, p =0.698). Complications decreased for the Gamma nail group (44 % versus 31 %, p =0.049). Readmissions for the total group were not different (16 % versus 17 %, p =0.720).Conclusions Implementing a clinical pathway for hip fractures is a safe way to reduce the HLOS and it improves the quality of care.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients

Burgers

Lieshout

Verhelst

et al. 2013

International Orthopaedics (SICOT)

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“…The reviews identified 3,5,9,10,14,17,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60] and their reference lists were the starting point for identifying both…”

Section: Scoping the Literaturementioning

confidence: 99%

“…This was recognised as a limitation of traditional review methods, as were the myriad of treatment strategies used and inconsistent reporting, 9,10,23,24,47,50 which made comparisons across studies difficult and led to inconclusive results. 3,[8][9][10]21,[23][24][25]28,29,47,49,50,240,241 These issues also led to difficulties in replicating intervention designs in different health-care systems as well as in drawing evidence-based conclusions about best practice. 10,24 Successfully combining a few commonly reported outcomes to estimate the long-term health outcomes of rehabilitation programmes 10 could help to more accurately estimate the comorbid disease burden, which may benefit from longer-term rehabilitation and falls prevention programmes, leading to health gains and reduced costs in the long term.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

“…Previous systematic reviews 3,9,10,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] have found insufficient evidence for the overall effectiveness or cost-effectiveness of multidisciplinary rehabilitation programmes following proximal femoral fracture. However, the recommendations made by such reviews, as well as existing guidelines, suggest that individual components show promise but it needs to be determined which components work for which patient groups in which circumstances.…”

Section: Introductionmentioning

confidence: 99%

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Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

Williams

Roberts

Din

et al. 2017

Health Technol Assess

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BackgroundProximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.ObjectivesTo develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.DesignPhase I – realist review, survey and focus groups to develop the rehabilitation package. Phase II – parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.SettingRecruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.ParticipantsOlder adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.InterventionsParticipants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients’ self-efficacy and increasing the amount and quality of patients’ practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.Main outcome measuresThe primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale – International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.ResultsSixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control,n = 32; intervention,n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen’sd = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen’sd = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen’sd = 0.31) and 1.3 (Cohen’sd = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.ConclusionsTrial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.Trial registrationCurrent Controlled Trials ISRCTN22464643.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

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