Musculoskeletal diseases

Research Health burden of hip and other fractures in Australia beyond 2000 Projections based on the Geelong Osteoporosis Study Kerrie M Sanders, Geoffrey C Nicholson, Antony M Ugoni, Julie A Pasco, Ego Seeman, and Mark A Kotowicz MJA 1999; 170: 467-470 For editorial comment, see Morris et al; see also Pocock et al. Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Author's Detials - - More articles on Public and environmental health Abstract Objective: To calculate the expected increase in the number of fractures in adults attributable to the predicted increase in the number of elderly Australians. Data sources: All fractures in adult residents (> 35 years) of the Barwon Statistical Division (total population, 218 000) were identified from radiological reports from February 1994 to February 1996. The Australian Bureau of Statistics supplied predictions of Australia's population (1996 to 2051). Main outcome measure: The projected annual number of fractures in Australian adults up to 2051 (based on stable rates of fracture in each age group). Results: The number of fractures per year is projected to increase 25% from 1996 to 2006 (from 83 000 fractures to 104 000). Hip fractures are projected to increase 36% (from 15 000 to 21 000) because of a substantial rise in the number of elderly aged 85 years and over. Hip fractures are expected to double by 2026 and increase fourfold by 2051. Conclusions: In contrast to Europe and North America, where numbers of hip fractures are expected to double by 2026 and then stabilise, in Australia hip fractures will continue to place a growing demand on healthcare resources for many decades. These projections can be used for setting goals and evaluating the costs and benefits of interventions in Australia. Introduction Australia's population is ageing. Thus, diseases such as osteoporosis are affecting a greater proportion of the population. Cost-effective prevention and treatment of fractures will become increasingly important, as the proportion of the "prime working" population (aged 15 to 64 years) is expected to decrease by 7% between 1996 and 2051.1 Estimations of the annual number of fractures will facilitate effective allocation of limited healthcare resources. Previously, fracture rates in Australia have been extrapolated from rates in Dubbo and Busselton,2,3 populations that may not be representative of the national population as they are both fairly isolated towns with small numbers of men and women in the oldest age groups. Lord et al investigated changes in hip fracture admissions in New South Wales between 1979 and 1990 using International Classification of Diseases hospital discharge codes.4 Although frequently used for ascertaining hip fractures, the limitations of this method are well documented.5,6 The Geelong Osteoporosis Study is a population-based study of age-, sex- and site-specific fracture rate(s) within a well-defined geographic region sufficiently large to establish reliable rates of fracture. It is the largest Australian epidemiological study of adult fractures, identifying 2184 fractures over two years in people aged 35 years and over. Data from the 1996 national census confirm the findings of an earlier study7 that the regional population is typical of the nation in age distribution and socioeconomic range. The Australian Bureau of Statistics publishes projections of the size, structure and distribution of Australia's population into the next century.1 Assuming stable age- and sex-specific rates of fracture, we have projected annual numbers of fractures by anatomical site in adults over the next 50 years. Methods Population The Barwon Statistical Division is a region of southern Victoria7 defined by the Australian Bureau of Statistics which includes urban, semi-urban and rural residents and has a population of 218 000 (109 923 aged 35 years and over). Fracture ascertainment Using radiological reports from the two medical imaging practices in the region, we identified all fractures in adults (aged 35 years and over) residing within the Barwon Statistical Division over the two-year ascertainment period (17 February 1994 to 16 February 1996). Fractures were identified by a weekly computerised keyword search of all radiological reports. Although radiological services are available at several sites throughout the region, these sites are under the auspices of two medical imaging practices. Only reports of definite fractures were included as "cases". Reports referring to "likely" or "possible" fracture were not included unless radiologically confirmed at a later date. Vertebral fractures were included in the study on the basis of the radiological report, provided there was no previous record of a fracture at that level. The initial x-ray demonstrating each fracture was sought and the date of fracture was the date of the radiological diagnosis. As the region is well provided with medical facilities, few fractures would not have been assessed or followed up by services within the region. The standing orders for the ambulance service are to transport patients from residences within the study region to The Geelong Hospital. The study was well advertised and adults who may have sustained fracture(s) while outside the region were asked to contact study coordinators. Non-residents and patients with pathological fractures (metastatic cancer, Paget's disease and multiple myeloma) were excluded. We have previously reported that the exclusion of high trauma fractures may underestimate the prevalence of bone-fragility fractures in the community,8 so we did not exclude fractures on the basis of trauma classification. The method of fracture ascertainment has been previously described9 and validated, using hip fracture as a model.10 The study was approved by The Geelong Hospital Human Research and Ethics Advisory Committee. Projections We calculated the predicted number of fractures in each five-year age group for men and women as: Predicted number of fractures = Number of fractures in the study region Study region population X Projected Australian population X 0.5 (2 year ascertainment) The study region population was determined from the 1996 Australian Bureau of Statistics census. Annual population projections were also provided by the Australian Bureau of Statistics.1 This method of projection assumes that the fracture rate in each age group will remain unchanged over time. Confidence intervals around the projections were calculated by the bootstrap method.11 Results The number of fractures identified in the study population is shown in Table 1. Projections for all fractures During the ascertainment period, 2184 adults sustained fractures, producing an age- and sex-adjusted incidence of 102 per 10 000 person-years. In 1996, we estimate that about 83 000 Australians aged 35 years and over sustained fractures. We predict that by 2006 the total number of fractures per year will increase by 25%, to 104 000 (Figure 1). Projections for hip fractures Over the two-year ascertainment period, 428 people sustained hip fractures, producing an age- and sex-adjusted incidence in people aged 35 years and over of 17.2. The number of hip fractures in Australian women is projected to increase from 11 300 per year in 1996 to 44 700 in 2051. In men, the number is projected to rise from 4 000 to 15 300. Figure 2 shows the projection for all people aged 35 years or over. The number of Australians sustaining hip fractures each year is projected to increase by 15% every five years until 2036, then by about 10% every five years until 2051. A fourfold increase in hip fractures is expected by 2051, when about 23% of Australia's projected population will be aged 65 years and over (compared with 12% in 1996) and over 8% of the population will be aged 85 years and over (compared with 2% in 1996). Hip fractures are likely to increase more than fractures at other sites because the greatest population growth is expected in the oldest age groups, where the hip is the most common site of fracture.9 Projections for fractures at sites other than the hip During the ascertainment period, 1756 adults aged 35 years and over sustained fractures at sites other than the hip, producing an age- and sex-adjusted incidence of 77 per 10 000 person-years. We estimate that in 1996 about 68 000 Australians aged 35 years and over sustained fractures at sites other than the hip, and that the number of non-hip fractures is likely to increase by 9% every five years until 2036, and then by 4% every five years until 2051 (to 147 645 non-hip fractures per year). Projections for vertebral, Colles, humeral and pelvic fractures (the most common sites of fracture after the hip) are shown in Figure 3. Fractures at these sites are likely to increase more than fractures at other sites where fracture rates do not increase substantially with age.9 Population projections suggest that vertebral, humeral and pelvic fractures will increase by 12% every five years to 2036, then by 6% every five years to 2051. Colles fracture rates increase with age in women, but not in men,8 and the overall number of adults sustaining a Colles fracture will increase by 10% every five years until 2036, then by 5% every five years until 2051. Fractures other than hip, vertebral, Colles, humeral and pelvic fractures are predicted to increase at about half the rate predicted for these sites (6% every five years until 2036, then 3% every five years until 2051). Projection of fracture numbers by age group The number of fractures in adults aged 35 to 59 years is not predicted to change substantially over the projection period, as only a small population increase in this age group is anticipated. By contrast, among those aged 60 years and over, the number of fractures is predicted to increase by at least 10% every five years, and by almost 20% every five years among those aged 85 years and over (Table 2). Figure 4 shows the projected distribution of hip fractures across age groups for selected years from 1996 to 2051. Discussion The ageing of the Australian population is increasing the demand for health resources. Health expenditure per person aged 65 years and over is nearly four times higher than for younger individuals ($4900 v $1300).12It is likely that hip fracture, which becomes increasingly common with advancing age, contributes significantly to this higher expenditure. Almost all people with a fractured hip are hospitalised, with an average length of stay of 13 days.13 Studies in other white populations suggest that 50% of patients who survive hip fracture are discharged to nursing homes, and 25% remain institutionalised one year later.14,15 Comparable Australian data are not available, although the increased mortality after hip fracture has been confirmed.16 We estimate that hip fractures accounted for 0.9% of total government health services expenditure for 1995/96.12 Based on the number of Australian salary earners in 1998 (Australian Bureau of Statistics) and an average cost of $16 000 per hip fracture,17 treatment alone costs salary earners an average of $28 per year. In current dollar terms, this may escalate to $120 per salary earner per year by 2051 if the projected increase is realised. The number of adults sustaining a hip fracture is likely to more than double from 15 000 in 1996 to 34 000 in 2026, then almost double again by 2051. Fractures at other sites are expected to increase by 70% from 1996 to 2026, then by a further 26% to 2051. These rates of increase are far above the expected growth in total healthcare costs due to the ageing of the Australian population, which is estimated to be 4% every five years for the next 30 to 40 years.18 For the number of hip fractures to remain stable, their incidence (per 10 000 population per year) would need to decline from 17.2 in 19969 to 15.6 in 2001, 14.3 in 2006 and 11.3 in 2026. In the United States, an 18% reduction in hip fracture rates between 1988 to 2000 has been targeted by public health strategists.19 Current therapies (such as hormone replacement therapy and bisphosphonates) may reduce fracture rates by 50%, but their cost-effectiveness remains controversial.20,21 In most white populations the number of hip fractures is predicted to double between 1990 and 2025, and then plateau as the growth in the aged population ceases.22 However, in contrast with Europe and North America, the aged population and the number of hip fractures in Australia and New Zealand are likely to continue to increase from 2025 to 2050.22 Current trends suggest that almost three times as many women as men will sustain a hip fracture (Table 1). Largely for this reason, efforts to prevent hip fracture have focused on osteoporosis in women. However, mortality and rate of institutionalisation after hip fracture is higher in men,23 and increasing hip fracture rates among men, but not women, have been reported.24,25 The projected increased longevity in men suggests that osteoporosis will affect a growing number of Australian men, yet there are no data concerning efficacy of any drug treatment to prevent hip or vertebral fractures in men.26 Our projected number of vertebral fractures is likely to be an underestimate because our ascertainment relied on clinical indications for medical imaging. Between 50% and 75% of vertebral fractures do not come to medical attention.27,28 However, our data are likely to include some previously undiagnosed vertebral fractures that occurred before the ascertainment period. Nevertheless, the predicted number of vertebral fractures represents the number likely to come to medical attention each year. Excluding vertebral fractures does not alter the projected rate increase of all fractures. The validity of these projections is dependent upon reliable and stable incidence rates and accurate population projections. The major strength of our study was the comprehensive ascertainment of all fractures among adult residents of a defined region representative of Australia.9 A decline in hip fracture rates has recently been reported,19 but other studies have pointed to stable age-specific rates in women and younger men and increasing rates in older men.24,25,29,30 These projections highlight the need to decrease fracture rates among the elderly and can be used for setting goals and evaluating the costs and benefits of interventions in Australia. Acknowledgements This study was supported by the Victorian Health Promotion Foundation. We acknowledge the invaluable contributions of the radiologists (D Barry, JM Cameron, PJ Carman, WP Holloway, V Mercuri, PM Motterdam and DB Robertson) and staff at the Geelong Radiological Clinic, as well as the radiologists (NJ Ferris, DO Lun, CB Styles) and staff of the Medical Imaging Department at the Geelong and Colac hospitals. We also wish to thank Biljana Skoric and Soheila Panahi. References McLennan W. Projections of the populations of Australia, States and Territories, 1995-2051. Canberra: Australian Bureau of Statistics, 1996: 128. (Catalogue no. 3222.0.) Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA. Symptomatic fracture incidence in elderly men and women: The Dubbo osteoporosis study (DOES). Osteoporos Int 1994; 4: 277-282. Prince RL, Knuiman MW, Gulland L. Fracture prevalence in an Australian population. Aust J Public Health 1993; 17: 124-128. Lord SR. Hip fractures: changing patterns in hospital bed use in NSW between 1979 and 1990. Aust N Z Surg 1993; 63: 352-355. Bacon W, Maggi S, Looker A, et al. International comparison of hip fracture rates in 1988-89. Osteoporos Int 1996; 6: 69-75. Maggi S, Kelsey JL, Litvak J, Heyse SP. Incidence of hip fractures in the elderly: a cross national analysis. Osteoporos Int 1991; 1: 232-241. Ross KN. The development of the 1984 "Indicator of Disadvantage" and its application to resource allocation decisions for the "Disadvantaged Schools Program" in Australia. Geelong: School of Education, Deakin University, 1984. Sanders K, Pasco J, Ugoni A, et al. The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: The Geelong Osteoporosis Study. J Bone Mineral Res 1998; 13: 1337-1342. Sanders K, Seeman E, Ugoni A, et al. The age- and gender-specific rate of fractures in Australia: a population based study. Osteoporos Int 1999. In press. Pasco JA, Henry MJ, Gaudry TM, et al. Identification of incident fractures: Geelong Osteoporosis Study. Aust N Z J Med 1999; 29: 203-206. Efron B, Tibshirani R. The introduction to the bootstrap. New York: Chapman & Hall, 1993. Australia's health 1998: the sixth biennial health report of the Australian Institute of Health and Welfare. Canberra: AGPS, 1998. Abraham B, d'Espaignet E, Stevenson C. Australian health trends 1995. Canberra: Australian Institute of Health and Welfare, 1995. Orwoll ES. The special problem of hip fracture. In: Favus MJ, editor. Primer on the metabolic bone diseases and disorders of mineral metabolism. 3rd ed. Philadelphia: Lippincott-Raven, 1996: 272-282. Keene G, Parker M, Pryor G. Mortality and morbidity after hip fractures. BMJ 1993; 307: 1248-1250. Center J, Nguyen TV, Schneider D, et al. Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 1999; 353: 878-882. Randell A, Sambrook P, Nguyen T, et al. Direct clinical and welfare costs of osteoporotic fractures in elderly men and women. Osteoporos Int 1995; 5: 427-432. Gray R. Insurance: the long term funding of aged care. National Healthcare 1998; 8(4): 32-33. Melton L, Atkinson EJ, Madhok R. Downturn in hip fracture incidence. Public Health Rep 1996; 111 (March/April): 146-150. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 1996; 348: 1535-1541. Jonsson B, Christiansen C, Johnell O, Hedbrandt J. Cost-effectiveness of fracture prevention in established osteoporosis. Osteoporos Int 1995; 5: 136-142. Cooper C, Campion G, Melton LJ III. Hip fractures in the elderly: A world-wide projection. Osteoporos Int 1992; 2: 285-289. Sernbo I, Johnell O. Consequences of a hip fracture: A prospective study over 1 year. Osteoporos Int 1993; 3: 148-153. Melton LJI, O'Fallon WM, Riggs BL. Secular trends in the incidence of hip fractures. Calcif Tissue Int 1987; 41: 57-64. Bacon W. Secular trends in hip fracture occurrence and survival: Age and sex differences. J Aging Health 1996; 8: 538-553. Seeman E. Osteoporosis: trials and tribulations. Am J Med 1997; 103 (2A): 74S-87S. Kanis JA, McCloskey EV. Epidemiology of vertebral osteoporosis. Bone 1992; 13 Suppl 2: S1-S10. Cooper C, Atkinson EJ, O'Fallon M, Melton L. Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985-1989. J Bone Min Res 1992; 7: 221-227. Falch JA, Kaastad TS, Bohler G, et al. Secular increase and geograpical differences in hip fracture incidence in Norway. Bone 1993; 14: 643-645. Agnusdei D, Camporeale A, Gerardi D, et al. Trends in the incidence of hip fracture in Siena, Italy, from 1980 to 1991. Bone 1993; 14: S31-S34. (Received 13 Nov 1998, accepted 13 Apr 1999) Author's Detials University of Melbourne Department of Medicine, Barwon Health-The Geelong Hospital, Geelong, VIC Kerrie M Sanders, MNutrition, PhD, Research Fellow; Geoffrey C Nicholson, PhD, FRACP, Professor of Medicine; Julie A Pasco, PhD, Study Coordinator; Mark A Kotowicz, FRACP, Senior Lecturer in Medicine. Department of General Practice and Public Health, The University of Melbourne, Melbourne, VIC. Antony M Ugoni, BSc(Hons), Lecturer in Biostatistics. Austin and Repatriation Medical Centre, Melbourne, VIC. Ego Seeman, MD, FRACP, Associate Professor of Medicine, The University of Melbourne. Reprints will not be available from the authors. Correspondence: Dr M A Kotowicz, University Department of Medicine, Barwon Health-Geelong Hospital, PO Box 281, Geelong, VIC 3220. Email: m.kotowiczATmedicine.unimelb.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Back to textBack to textBack to textBack to textBack to textBack to text

Kerrie M Sanders · Geoffrey C Nicholson · Antony M Ugoni · Julie A Pasco · Ego Seeman · Mark A Kotowicz

Abstract Objective: To ascertain the effectiveness of clinical pathways for improving patient outcomes and decreasing lengths of stay after hip and knee arthroplasty. Design and setting: Twelve-month randomised prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care at a single tertiary referral university hospital. Participants: 163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty, and randomly allocated to the clinical pathway (92 patients) and the control group (71 patients). Main outcome measures: Time to sitting out of bed and walking; rates of complications and readmissions; match to planned discharge destination; and length of hospital stay. Results: Clinical pathway patients had a shorter mean length of stay (P = 0.011), earlier ambulation(P = 0.001), a lower readmission rate (P = 0.06) and closer matching of discharge destination. There were beneficial effects of attending patient seminars and preadmission clinics for both pathway and control patients. Conclusion: Clinical pathway is an effective method of improving patient outcomes and decreasing length of stay following hip and knee arthroplasty. Introduction The past two decades have seen an 85% rise in Australian health costs to 36.6 billion dollars, with the largest proportion of this expended in acute hospital care.1 Newer health policies now incorporate measures to rationalise and improve the efficiency of many services. Such policies, however, are economically driven and frequently fail to consider the optimum level of service required by the community.2 Treatment protocols, variously known as clinical pathways, critical pathways and care paths, that aim to streamline and standardise management through a systematic approach so that high quality care may be provided in a timely and cost effective manner3,4 have been developed. Clinical pathways describe the course of hospitalisation for patients with a specified illness and encompass a predetermined plan of treatment. The use of clinical pathways is now well established and their successes are widely reported.5-7 Joint arthroplasty is a common and costly procedure associated with high resource use that is frequently performed in the elderly who may have many coexisting morbidities. These characteristics suggest that joint arthroplasty may be a suitable procedure to incorporate into a clinical pathway.8 As part of a "best practice" initiative in line with quality assurance activities at St Vincent's Hospital, the hospital's Orthopaedic Service has developed clinical pathways for hip and knee joint arthroplasty for treating osteoarthritis which aim to maximise the use of all available resources and minimise negative patient outcomes, thereby improving patient care. To this end, we report the effects of introducing clinical pathways at our hospital on quality indicators such as mobilisation, complication rates, discharge planning and readmission rates while also exploring the impact on length of stay. Methods We used a prospective randomised control group design to compare the outcomes of patients who underwent hip or knee joint arthroplasty at St Vincent's Hospital, Melbourne (a tertiary referral hospital affiliated with the University of Melbourne), between 1 January 1996 and 30 December 1997. All such patients were randomly allocated to either the control or clinical pathway group by a clerical assistant who was blinded to their demographic and clinical profiles. Diagnostic category and comorbidities had no bearing on the allocation of patients to either the pathway or control groups, but patients were excluded from the study after randomisation if they were having revision arthroplasty, simultaneous bilateral joint arthroplasty, arthroplasty for acute trauma or complex tumour surgery. The management of patients undergoing joint arthroplasty at St Vincent's Hospital, Melbourne, is outlined in Box 1. Outcome measures Length of stay (calculated from the time of the patient's admission to the time of discharge and expressed in days); Time to sitting out of bed and ambulation (time between surgery and the patient's first day of sitting out of bed or walking with assistance); Complications (wound infections, including all wound erythema lasting more than 24 hours, chest infections, deep vein thrombosis [DVT] as diagnosed by clinical features and confirmed by ultrasonography, joint dislocation, decubitus pressure areas, failure to cope at home and a decreased range of motion after discharge); Readmission (for complications during a follow-up period of three months from discharge); and Discharge matching (between the presumptive discharge destination given at the preadmission clinic and the patient's postdischarge destination). Clinical pathway and control patients Patients randomly allocated to the clinical pathway received proactive treatment whereby specific goals were set each day for the patient and treating team. Their hospital records included a special written protocol which listed milestones to be achieved, identified tests that should be ordered, set daily tasks for patients and members of the treating team, and provided space for documenting any variation in treatment or patient response. Each intervention was signed by the treating health professional and the discharge plan was re-evaluated daily to ensure it remained realistic and appropriate to the patient's needs. The clinical pathway formalised in writing the participation of the various members of the treating team. Patients not allocated to the pathway received "reactive" treatment whereby the treating team responded to the will and condition of the patient in providing postoperative care. Statistical analysis Results were analysed with SigmaStat V2 software.9 Data were compared using t tests for independent groups and multiple linear regression where appropriate. We used the z test for comparisons of proportions between groups. As the data for length of stay (LOS), time to sitting out of bed and time to ambulation were not normally distributed, these data were transformed using a logarithmic transformation before analysis with t tests. We calculated the sample size for this study after reviewing all hip and knee arthroplasty patient data for 1995, which showed a mean LOS of 13 days (range, 5.8-43.3; SD, 5.3). We believed that a 20% reduction in LOS (2.6 days) would represent a clinically significant outcome. Therefore, we calculated that to detect a reduction of 2.6 days in LOS at a significance level of 0.05 with a power of 0.8 would require two groups with a minimum of 65 subjects in each group. Results During the study period 175 patients underwent hip or knee joint arthroplasty and were randomly allocated to the pathway (94 patients) and control (81 patients) groups. Twelve patients were then excluded by the crtiteria listed in the methods, leaving 163 patients -- 92 in the clinical pathway group and 71 in the control group. The sample comprised 56 men and 107 women, with a mean age of 66 years (range, 67-93 years). All patients were followed for a minimum of three months and none were lost to follow-up. Our findings are summarised in Box 2. There was no significant difference between control and pathway patients in terms of age or weight. Although the clinical pathway group included more patients with premorbid conditions than the control group, this difference was not statistically significant (95% CI, - 0.03 to 0.21). Length of stay (LOS) was significantly shorter for the pathway group than for the control group (t = 2.585; P = 0.011). When LOS was analysed for the subgroups of patients in each group with premorbid conditions, this was still significantly shorter for the pathway group than the control group (t = 3.152; P = 0.001) despite the larger number of patients with premorbid conditions in the pathway group. Patients in the clinical pathway group sat out of bed and walked earlier after surgery than control patients. Multiple linear regression for each group showed that time to ambulation was the only significant contributor to reduction in log LOS in the clinical pathway group (time to ambulation -- coeff = 19.6, standard error [SE] = 9.6, P = 0.04; time to sitting out of bed -- coeff = - 4.35, SE = 9.3, P = 0.64, R2 = 0.127). Neither time to ambulation nor time to sit out of bed was significantly associated with reduced log LOS in the control group (time to ambulation -- coeff = 21.05; SE = 26.28, P = 0.42; time to sit out of bed -- coeff = - 4.13, SE = 28.54, P = 0.88, R2 = 0.0251). Patients from both the clinical pathway and control groups who attended either the preadmission clinic (n = 122) or the patient information seminar (n = 61) had a shorter LOS (7.22 days and 6.84 days, respectively) than patients who attended neither (n = 36; LOS, 8.55 days). The 54 patients who attended both the clinic and seminar had the shortest LOS at 6.6 days, and t tests showed that the shorter LOS for these patients relative to those who attended neither the clinic nor seminar was significant (t = 2.66; P = 0.009). Post-hoc t tests showed that the shorter LOS for patients who had attended both preadmission clinics and information seminars relative to those who had attended neither was significant (t = 2.66; P = 0.009). Box 2 shows that a greater proportion of clinical pathway patients were discharged to their planned discharge destination than control patients (95% CI, - 0.05 to 0.23), and that there were fewer readmissions in clinical pathway patients (95% CI, 0.006-0.174), although neither result was statistically significant. However, there were significantly fewer complications in clinical pathway patients (95% CI, 0.036-0.27). Discussion We found that a clinical pathway for hip and knee joint arthroplasty had a beneficial impact on the duration of admission, with patients on the pathway having a 1.5-day shorter stay than control patients. The seven-day LOS for our pathway patients compared favourably with that of Gregor et al,10 who showed a reduction in LOS from 12 to nine days for pathway patients. Length of stay was significantly shorter for the pathway group than the control group despite the larger proportion of pathway patients with premorbid conditions. This result should be interpreted cautiously, as the small overall number of patients with premorbid conditions meant that the test had less than optimal power (0.45). However, we conclude that comorbidities per se should not exclude patients from clinical pathways. Patients with comorbid conditions may actually be better served because of the greater fastidiousness and vigilance imposed by the daily protocol. While our findings that there were fewer complications and readmissions in clinical pathway patients were not significant, we believe that given the appropriate number of subjects in future studies both of these areas may approach significance. We noted that reducing the length of stay did not increase the complication rate, a finding corroborated by others.11 In addition, the readmission rate for complications for pathway patients was one-third that of controls. This contrasts with some studies which have reported an inverse relationship between length of stay and readmission rates.11 We, like other authors,12 believe that it is a lower quality of care and not length of stay per se that increases the risk of unplanned readmission. Discharge planning is an important part of the clinical pathway which appears to be closely linked with the length of stay. Appropriate matching of predetermined discharge destinations is a correlate of shorter admissions. If we are able to improve on our destination matching rate of 70%, we may be able to further reduce our length of stay, thereby making more resources available for other patients. Education of patients and their relatives appeared to have a positive influence on the patients' recovery after joint arthroplasty, with earlier mobilisation and discharge from hospital. Attending information seminars and preadmission clinics assisted in reducing the length of stay by almost two days. Patients and their relatives who understand the disease and the necessary treatment may be in a better position to assist with care and rehabilitation. Attendances for our information seminar and preadmission clinic were 38% and 74%, respectively, and we are endeavouring to increase these. First introduced by the New England Medical Center, clinical pathways are now incorporated into the management philosophy of many hospitals worldwide.13,14 Pathways involve input from medical, nursing, paramedical and administrative staff, and reflect the expertise of all members of the healthcare team while highlighting the interdependent nature of these roles in achieving positive outcomes for patients.15 A valuable subsidiary purpose of pathways is in providing information from which the financial cost of care may also be derived.16 Accurate costing of treatment is fundamental to the operation of institutions where prospective payments are made in accordance with diagnosis-related groups (DRGs), standardised lengths of stay and fixed reimbursement for care. Clinical pathways thus provide an important tool for coordinating and managing clinical resources. However, the driving force behind clinical pathways must remain the need to improve the quality of care and patient outcomes, and not their utility as a tool to ensure that budgetary demands are met. We are encouraged by our findings, which indicate substantial improvements for patients on a clinical pathway. To our knowledge, no other study has investigated the effect of clinical pathways on joint arthroplasty using a contemporaneous control group. 1 Management of joint arthroplasty patients at St Vincent's Hospital, Melbourne Preadmission clinics Preoperative review for patients undergoing elective joint replacement involves a multidisciplinary approach and includes medical, nursing, physiotherapy and occupational therapy consultation and anaesthetic and social work screening. Preexisting conditions are identified and testing and treatment are undertaken to achieve an optimum level of preoperative health. A discharge destination is determined based on medical and projected rehabilitation needs. Appropriate referrals are initiated. Patient information seminars Groups of patients and their families are invited to attend an information seminar about the surgery. The surgeon explains the aetiology of the disease, principles of management, nature of potential risks and their prevention. The nursing staff discuss acute postoperative care, including pain relief, pressure and wound care, intravenous therapy, and prophylaxis for deep venous thrombosis. The physiotherapist discusses the regimen of postoperative exercises, cautions and mobilisation. The occupational therapist describes the availability and use of various personal aids which assist the patient in preventing complications such as falls, injury or dislocation. Patients are able to raise any questions related to their surgery. Patients and their families are encouraged to take an active role in the postoperative management, and are acquainted with their very important role in the postdischarge phase. All members of the team stress the philosophy that the primary intention is to return patients home in preference to a rehabilitation hospital after the surgery. Discharge Patients are discharged home or to a rehabilitation unit. For those discharged home, community nursing care is provided at regular intervals for the first three weeks after discharge. Community nurses pay special attention to the nature of the patient's wounds, their exercise regimen and general medical condition. Any concerns are immediately related to the medical staff for further attention. Patients are followed up on a regular basis in the outpatient department. 2 References MacIntyre CR, Brook CW, Chandraraj E, Plant AJ. Changes in bed resources and admission patterns in acute public hospitals in Victoria, 1987-95. Med J Aust 1997; 167: 186-189. Parry TG. Health expenditure in Australia -- the current dilemma. Med J Aust 1992; 156: 592-594. Wigfield A, Boon E. Critical care pathway development: the way forward. Br J Nursing 1996; 5: 732-735. Grudich G. The critical path system. AORN J 1991; 53: 705-714. Gouveia WA, Massaro FJ. Critical pathway experience at New England Medical Center. Am J Health-Syst Pharm 1995; 52: 1068-1070. Saltiel E. Critical pathway experience at Cedars-Sinai Medical Center. Am J Health-Syst Pharm 1995; 52: 1063-1068. Stevenson LL. Critical pathway experience at Saratosa Memorial Hospital. Am J Health-Syst Pharm 1995; 52: 1071-1073. Leininger SM. Tools for building a successful orthopaedic pathway. Orthop Nurs 1996; 15: 11-19. SigmaStat [computer program]. Version 2. San Rafael, CA: Jandel Scientific Software, 1995. Gregor C, Pope S, Werry D, Dodek P. Reduced length of stay and improved appropriateness of care with a clinical path for total knee or hip arthroplasty. Joint Commiss J Qual Improv 1996; 22: 617-628. Rushworth RL, Rob MI. Readmissions to hospital: the contribution of morbidity data to the evaluation of asthma management. Aust J Public Health 1995; 19: 363-367. Ashton CM, Kuykendall DH, Johnson ML, et al. The association between the quality of inpatient care and early readmission. Ann Intern Med 1995; 122: 415-421. Zander K. Managed care within acute care settings: design and implementation via nursing case management. Health Care Supervisor 1988; 6: 27-43. Bower KA. Managed care: controlling costs, guaranteeing outcomes. Definition 1988; 3: 14. Heacock D, Brobst RA. A multidisciplinary approach to critical path development: a valuable CQI tool. J Nurs Care Qual 1994; 8: 38-41. Weilitz PB, Potter PA. A managed care system. Financial and clinical evaluation. J Nurs Admin 1993; 23: 51-7. (Received 27 Jan, accepted 20 Aug, 1998) Authors' details Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC. Michelle M Dowsey, BN, GradCertOrth, Clinical Nurse Specialist; Meredith L Kilgour, BN, GradDipAdvClinPrac, Nurse Unit Manager; Nick M Santamaria, BAppSc, PhD, Director of Nursing Research; Peter F M Choong, MD, FRACS, Professor, and Director of Orthopaedics. Reprints: Professor P F M Choong, Department of Orthopaedics, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065. Email: PeterChoongATc031.aone.net.au

Michelle M Dowsey · Meredith L Kilgour · Nick M Santamaria

Rescue Orthopaedic surgery after the Aitape tsunami "No gat mama, no gat papa, no gat pikinini -- olgera i lus pinis long solwara" Got no mother, got no father, got no children -- all lost forever in the salt water Annette C Holian and Prue P Keith MJA 1998; 169: 606-609 Introduction - Vanimo Hospital - Surgery at Vanimo - Coordination with the ADF - Medevac - Wewak - Farewell, for now - Authors' details - - More articles on Orthopaedic surgery Introduction There is a sense of fascination, horror and helplessness as the news of a vast natural disaster breaks. With the Aitape tsumani these feelings were heightened immensely -- we had been to this area of Papua New Guinea as members of surgical teams that had recently visited Aitape, Vanimo and Wewak. On these occasions congenital foot deformities and other orthopaedic problems were our targets -- a far cry from disaster medicine! As the magnitude of the disaster became apparent, there was a flurry of telephone calls between team members. The only thing we could not do was to do nothing. We knew the local hospitals' resources would be quickly overwhelmed, and that, at best, only limited orthopaedic care could be offered. The rapid announcement that an Australian Defence Force (ADF) medical team was to be dispatched was heartening news. We needed to ensure that orthopaedic expertise arrived too. We contacted the ADF on Sunday 19 July to offer the services of our surgical team (Box 1). They readily agreed and our core team of orthopaedic surgeon, registrar and theatre nurse left as part of the ADF's deployed Joint Task Force, but took almost three days to get to Vanimo (via Sydney, Brisbane, Townsville and Port Moresby). Some days later the remainder of the team made the same journey in 12 hours. Vanimo Hospital We went to Vanimo, where the ADF had established its base, as we were familiar with the medical resources at the Vanimo Hospital, and were sure the local Catholic mission and our good friend Brother James Coucher of the Passionist order would provide accommodation. Arriving in the early afternoon of Wednesday 22 July we met with the ADF surgical team and were most impressed! There were over 250 patients in the ADF base. Surgery was constantly being performed and a sense of intense urgency prevailed. At Vanimo Hospital the situation was quite different. Patients with every imaginable limb injury had been arriving for five days. The two local doctors were coping with over 200 patients and there was an acute shortage of space, beds, linen and nursing staff. Dr Les Roberts-Thompson had spent the first few days in the disaster area giving first aid and sending the injured to the hospital, where Dr John Novette and the health extension officers (who have three years' medical training and assist in the emergency department) provided what further medical care they could. Only the most severely injured patients had beds in the wards; others slept on the verandahs or on the grass outside under a tarpaulin (Figure 1). Some single beds accommodated two patients. Sheets, not normally provided by the hospital, were in short supply, with people sleeping directly on the vinyl-covered mattresses. There were very few pillows, and bags of belongings, which on previous visits we had used to elevate limbs, were notably absent. At times only one nurse was responsible for up to 50 patients. Beds were crammed in so closely that there was barely room to step between them (Figure 2). Each patient had at least one other person sleeping nearby to help care for them. The Vanimo Hospital's main operating theatre was so small that a trolley could not fit into the room unless the operating table was moved. It opened directly off a covered walkway and had no holding bay or recovery area. A kitchen sink in one corner doubled as a scrub sink and clean-up area. The orthopaedic equipment available was laid out for use: an amputation saw and a T-handled chuck. Fortunately, we had brought with us a general orthopaedic surgical instrument tray. Lois van Heuzen, our theatre nurse, ran between the theatre and the labour ward (where Elizabeth Lewis, one of the surgeons, was attending to wounds), and managed to ensure that our equipment was washed, dried and resterilised ready for each patient. Frequently, this involved only soaking in spirit. It was a challenging environment for orthopaedic surgery. Surgery at Vanimo The immediate aims in wound and fracture management were simple: to diagnose the injuries, debride soft-tissue wounds, establish effective traction and immobilise the fractures. This would provide the best preparation for definitive surgery in the second week, when internal fixation equipment was expected to arrive. Many hours were spent examining patients and establishing treatment plan priorities. There were numerous patients with dirty lacerations, penetrating joint injuries, and closed and open fractures who had spent days in salt water or mangrove swamps until help arrived. In addition to their orthopaedic problems, almost all had soft-tissue injuries and most had aspirated salt water. Not surprisingly, some had concurrent malaria. Record keeping and accurate patient identification were difficult. Before our arrival patients were identified by bed numbers. There were no identification bands and the medical records and radiographs were stored on patients' beds. Unfortunately, some beds had two numbers and other beds had two patients! We identified our patients creatively using key tags, baggage labels and, later, arm bands. Given the limited orthopaedic tools available, Thursday 23 July was designated as Steinman pin day; we inserted some eight pins and aspirated six knee effusions. The pins were extremely sharp and double-ended. The chuck would not lock reliably on the pins, even with encouragement from the local plumber's pliers. After we had both received penetrating injuries to the palm, we resorted to an unorthodox technique. Holding the sterile pin in one sterile hand, the other, unsterile hand put the plumber's unsterilisable hammer to good use, driving the pin home. We then covered the sharp pin ends with any available tubing, including the rubber tubing from spearfishing slings. Hard work by a team of Port Moresby theatre nurses, cleaning and hanging curtains to create a recovery area, allowed us to move to the larger outpatients operating theatre, and over the next few days we concentrated on drainage of pus, debridement and stump revision. Surgical priority was based largely on the intensity of odour. Necrotising fasciitis was rampant (Figure 3). Extensive debridement of fascial sheaths was often required, and wounds were packed open and reviewed regularly to ensure that we kept ahead of infection. It became obvious that several people with swollen limbs and grazes actually had wringer injuries, with degloving, fat necrosis and devitalised muscle. We were still finding foreign bodies in soft tissue a week after our arrival, but as far we are aware no further infections necessitating amputation occurred. Chris Blackburn, the team's physiotherapist, and John Kinealy, the cast technician, spent every day in the wards. They set up traction on patients as we returned them with their pins or new skin traction. This was difficult, as there were very few traction beds, no proper weights, no knee slings and the adults were too long for the beds. Brother Martin, also of the Passionist order, was engaged to construct some wooden frames to elevate limbs. These were lined with rice bags held in place by thumbtacks. The rice bags were also used to construct pelvic traction for a girl with diastasis of the pelvis. Fruit juice bottles filled with sand were used as weights (Figure 4). As beds with overhead beams were scarce, beds were positioned under the partly demolished partitions when required and traction suspended from the roof. Chest physiotherapy was vital for most of the patients. Chris spent hours making "bubble-pep" equipment from mineral water bottles, oxygen tubing and dish-washing liquid, then encouraging the children to blow, breathe, blow. As the days wore on, the condition of the patients on the grass became of increasing concern. Several were able to walk, but with significant limps and a swollen knee. When examined their expression of pain was so minimal that our initial clinical diagnosis was of a complete rupture of the medial ligament of the knee. A radiograph performed before casting revealed the true diagnosis -- a depressed lateral tibial plateau fracture. Patients with these fractures and with medial ligament injuries to the knee were immobilised in plaster cylinders topped with fibreglass to counteract the negative effect of humidity on the plaster. Coordination with the ADF There was considerable cooperation between the civilian orthopaedic team and the ADF medical team. ADF personnel supplied drinking water, Steinman pins, surgical consumables, and occasionally food. They visited us at the hospital several times each day to offer assistance. Their presence was an invaluable physical and mental support when we were stressed by the heat and humidity, and overwhelmed by the enormity of the task and the limited facilities. Medically, we performed complementary functions, each taking responsibility for patients on our own site, but readily transferring patients between sites to facilitate their care. Vanimo Hospital took patients who needed immediate specialist orthopaedic care or were stable enough to rest in bed with the available level of nursing care. To expedite their surgery, we temporarily transferred to the ADF some patients who needed dressing changes and possible further wound debridement. The ADF also helped to conduct a large scale transfer of patients from Vanimo to Wewak. Medevac from Vanimo to Wewak During the first week it became apparent that the facilities at Vanimo were unsuitable for many aspects of orthopaedic surgery and we contemplated moving patients to Wewak, some 40 minutes' flying time to the east. Wewak Hospital is the surgical centre for the Sandaun and East Sepik Provinces of PNG. It offered many attractions for the management of our patients, none more so than its remarkable resident general surgeon, Sister Martin Joseph, a British vascular surgeon trained at St Bartholomew's Hospital, London, and belonging to the Passionist order. Sister Joseph informed us that their operating theatres were open and staff ready for surgery. We knew from previous visits that the theatres, equipment, sterilising capabilities and nursing staff cover were all superior to those at Vanimo. As the surgeon responsible for the region, Sister Joseph would also be the most capable hands in which to leave the more complex cases for ongoing medical care. Careful thought was given as to which patients to take. The need for further surgery, including internal fixation, as well as the need for continuing close observation, physiotherapy, and proximity to family and friends were all taken into consideration. Patients were transferred to Wewak on two C-130 Hercules aircraft flights: the first occurred on Sunday 26 July and the second, larger group followed on Tuesday 28 July. These were both impeccably organised events and constituted, we were informed later, the largest transfers of injured patients performed by the ADF since the Vietnam War. Preparation for transfer included femoral nerve blocks, application of Donway splints, tying off traction, and splitting some encircling casts. Patients were ferried to the airfield by open truck, assembled and loaded on to the aircraft. Personal luggage, walking wounded, families, stretcher patients and finally our mission-made frames and other supplies were all neatly stacked in the aircraft. Stretchers were suspended three deep on taut seatbelt webbing that hung vertically from the aircraft's roof. We could only begin to imagine the anxiety that the children on board must have been experiencing. Wewak A fleet of tray-back light utility vehicles met us at Wewak Airport and transferred us to the Wewak Hospital. Patients were assigned to wards according to a plan arranged by Sister Joseph using a previously faxed list. Traction was re-established where required and split casts repaired. We reviewed our surgical capabilities. Our orthopaedic tools now included a Mathys rechargeable drill/wire driver/oscillating saw, boxes of Howmedica GK intramedullary nails (size 12-16) without reamers, a K-rod set with an almost complete set of T-handled reamers up to size 12, an assortment of external fixation equipment, as well as various loose screws and recycled plates without the appropriate drills, taps or depth gauge; nothing matched and no "set" was complete. Desperate attempts over the next few days to get better equipment from various sources were largely unsuccessful. Equipment was stalled in Customs, held up by transport companies, arrived incomplete or just disappeared. We planned a surgery list each day by trying to match up the fixation devices available with patient requirements. Tibial external fixateurs were constructed mostly from old Hoffman blocks, but as one type of connector was missing constructs were not always optimal. One frame was put on an open fracture of the ulna for which there were two blocks but only three pins. The fourth pin was created by putting some split intravenous tubing around a long cortical screw. The bar was a Steinman pin that fitted the block beautifully. One child had a fractured neck of femur, which we decided needed to be internally fixed to reduce the risk of non-union. In the absence of any conventional implant or image intensifier, we did an open reduction and secured the fracture with a tibial plateau T-plate with two cancellous screws along the femoral neck. The postoperative radiograph looked promising. In the third week we managed to obtain some basic and small-fragment instruments that allowed us to spend a satisfying, albeit difficult, day fixing the adult forearm fractures. On Thursday 6 August, nearly three weeks after injury, the remaining adults with complex, segmental and comminuted femoral fractures were treated. Open reduction was not easy but was ultimately achieved. Only two patients with fractures that we had expected to treat with internal fixation remained. One, an adult with a forearm fracture, had nearly succumbed to pneumonia and was not fit enough for anaesthesia, and the other had refused surgery. Farewell, for now Late at night on 6 August we completed our last ward round. The children's orthopaedic ward had become a centre of intense activity. Fifteen children in split Hamilton-Russell traction, four children with amputations and just about everybody else were watching the television/video that a mining company had donated. Everyone seemed comfortable and happy. Over 15 days we had performed 134 surgical procedures and treated a further 50 injuries conservatively (Box 2). We left knowing that we had made a difference. However, the orthopaedic disaster is not over yet. There will be people with non-union, delayed union, malunion, infections, physeal arrest and other unforeseen complications. Further operations will be necessary. Ideally, these should occur close to the patient's home and family and with the optimal equipment available to the surgical team. We will be back. Authors' details Monash Medical Centre, Melbourne, VIC. Annette C Holian, MB BS, FRACS, Paediatric Orthopaedic Surgeon. Prue P Keith, MB BS, Senior Orthopaedic Registrar. Reprints: Miss A C Holian, Monash Medical Centre, Locked Bag 29, Clayton, VIC 3168. Email: pruekATozemail.com.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Annette C Holian · Prue P Keith