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The proportion of Australians aged 65 and over is projected to
continue increasing for the next 50 years.1 Fractures of the neck of
femur are common in this age group and are associated with increased
risk of morbidity and mortality, long-term institutionalisation
and costly management. Their impact on a public healthcare system
funded by an ever-diminishing number of tax-paying workers is a major
concern.
Increasing attention is being given to improving management of these
fractures and rehabilitation of patients.2-5 Morbidity and mortality
rates have been reduced through increased surveillance for and
treatment of complications, such as wound and other infections,
pressure sores and deep venous thrombosis. Early involvement of
multidisciplinary teams in patient rehabilitation and early
mobilisation have been used in large hospitals to reduce delays and
optimise treatment for previously ambulatory patients. These
programs result in fewer perioperative complications and enable
patients to return home and resume functional independence earlier,
reducing the number who need long term residential aged
care.2,3
However, these improvements come at a cost -- direct costs, such as
salaries of additional staff for multidisciplinary
teams,6 and indirect costs, such as
when patients are sent home early, and postdischarge care is assumed
by family and community.7 Pressure on hospital
administrations to contain or reduce costs may result in outcomes of
little, if any, benefit to the patient, but which may have a
substantial impact on others living with or looking after the
patient. Little is known about the nature and extent of this potential
impact. Implementation of these efforts needs to be both preceded and
accompanied by careful evaluation and assessment.
Among strategies that attempt to achieve savings is the development
and use of clinical pathways, as outlined by Choong and
colleagues8 in this issue of the Journal. A clinical pathway is a type of management plan
formulated for a specified condition, which defines expected daily
activities, identifies lines of responsibility for those
activities, and indicates goals for the patient to achieve along the
way.9
These pathways are based on a multidisciplinary perspective and
collaboration. Introduction of a clinical pathway requires
considerable commitment and investment of time from many
departments within the hospital, as well as substantial changes to
the medical record. It also raises concerns about the medicolegal
implications of non-compliance with the pathway in the event of an
adverse outcome. All these issues require further study.10,11
Clinical pathways have been successfully implemented for a variety
of conditions and settings, overseas and in Australia. However,
patient groups have been relatively homogeneous, such as those
having elective hip, knee or other surgery. In contrast,
hip-fracture patients are very heterogeneous, ranging from the fit,
active (albeit osteoporotic) "young" elderly, to the very frail,
bedridden 90-years-plus residents of nursing homes. A clinical
pathway developed from evidence-based practices may be the most
efficient way to restore the mobility of elderly patients and ensure
their discharge back to their pre-admission residence. However,
because of the high level of comorbidities in these patients, the
potential for variation from the pathway is high.2
Choong and colleagues describe a controlled trial of a clinical
pathway for patients with proximal femoral fracture in a major
teaching hospital.8 Modest benefits were found
for the hospital budget, and clinical outcomes for patients on the
pathway appeared no worse than for patients who received standard
hospital treatment. Use of the pathway seemed to have little real
effect on shortening stay in comparison with the control group; the
major difference in stay was found for patients who required review by
the Aged Care Assessment Team and were therefore likely to be frailer.
The frail elderly have not usually been seen as a target group for
clinical pathways, but future studies of this group may show that they
benefit from this approach without adverse outcomes on
complications or discharge destinations.
This study illustrates the problems of assessing the usefulness of
clinical pathways, which should be addressed in the design of future
studies. The clinical relevance of short reductions in length of
hospital stay (1.4 days in this instance) is open to question.
Economic aspects need to be documented as part of study design to allow
analysis of cost effectiveness. The real effectiveness of the
pathway for the community, rather than just the hospital, remains
unclear, and future studies need to include strategies to assess that
effect. The overall economic benefit to the community should take
into account the increased use of community services, use of interim
or permanent residential care, and extra costs and stress for
families who provide a large proportion of the care after discharge
from hospital.3
Clinical pathways have developed primarily in large metropolitan
hospitals with resources to research and implement the process,
while proximal femoral fractures are treated in a wide range of
hospitals with varying levels of funding and allied health support.
These pathways may have the potential to improve clinical outcomes
and costs in hospitals where the number of femoral fracture patients
is too small to warrant an orthogeriatric unit or where there is no
access to a designated rehabilitation unit. Ultimately, the
generalisability of this approach will become evident as more
research in this area is reported.
Recent reports in the Journal highlight the difficulties in
transforming evidence into practice.12,13 Despite these
difficulties, compliance with evidence-based best practice in the
management of fractured neck of femur, together with preventive
measures such as early management of osteoporosis and falls
prevention programs, should help lessen the current and future
economic and personal burden of hip fracture in Australia.
Cheryl E Swanson
Research Scientist, Division of Orthopaedic Surgery
Catherine E Yelland
Director, Geriatric Assessment and Rehabilitation Unit
Gregory A Day
Senior Lecturer, Division of Orthopaedic Surgery
University of
Queensland and Royal Brisbane Hospital Brisbane, QLD
- Cooper C, Campion G, Melton IJ III. Hip fractures in the elderly: a
world-wide projection. Osteoporosis Int 1992; 2: 285-289.
-
March LM, Chamberlain AC, Cameron ID, et al. How best to fix a broken
hip. Med J Aust 1999; 170: 489-494.
-
Swanson CE, Day GA, Yelland CE, et al. The management of elderly
patients with femoral fractures. A randomized controlled trial of
early intervention versus standard care. Med J Aust 1998;
169: 515-518.
-
Dowsey M, Kilgour M, Santamaria N, Choong PFM. A prospective study
of clinical pathways in hip and knee arthroplasty. Med J Aust
1999; 170: 59-62.
-
Sanders KM, Nicholson GC, Ugoni AM, et al. Health burden of hip and
other fractures in Australia beyond 2000. Med J Aust 1999;
170: 467-470.
-
Farnsworth MG, Kenny P, Shiell A. The costs and effects of early
discharge in the management of fractured hip. Age Aging 1994;
23: 190-194.
-
Caplan G, Board N, Paten A, et al. Decreasing lengths of stay: the
cost to the community. Aust N Z J Surg 1998; 68: 433-437.
-
Choong PFM, Langford AK, Dowsey MM, Santamaria NM. Clinical
pathway for fractured neck of femur: a prospective controlled study.
Med J Aust 2000; 172: 423-427.
-
Tallis G, Balla JI. Critical path analysis for the management of
fractured neck of femur. Aust J Pub Heath 1995; 19: 155-159.
-
Kitchiner DJ, Bundred PE. Clinical pathways: a practical tool for
specifying, evaluating and improving the quality of clinical
practice. Med J Aust 1999; 170: 54-55.
-
Dwyer P. Legal implications of clinical practice guidelines.
Med J Aust 1998; 169: 292-293.
-
Doust JA, Silagy CA. Applying the results of a systematic review in
general practice. Med J Aust 2000; 172: 153-156.
-
Rubin GL, Frommer MS, Vincent NC, et al. Getting new evidence into
medicine. Med J Aust 2000; 172: 180-183.
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