Evaluation of the effect of a comprehensive multidisciplinary care pathway for hip fractures: design of a controlled study

Hip fractures constitute an economic burden on healthcare resources that will continue to rise. Approximately 17,000 older persons sustain a hip fracture in the Netherlands every year [1]. Costs of treatment, rehabilitation and home care are considerable (nearly EUR 400 million per year). Regardless of the costs, hip fractures have a negative effect on activities of daily living and quality of life. One year after the fracture, less than 50% of patients have fully recovered [2]. Most persons with a fracture undergo surgery. However, perioperative care in hip fracture patients leaves much room for improvement, as convalescence after surgery is often hindered by complications. As a consequence, hip fracture is associated with high mortality and considerable loss of function [3]. Complications may occur in many organ systems and require the involvement of various medical specialties. In theory, the involvement of many specialties should guarantee the best possible treatment, yet in practice the care tends to be rather fragmented. Therefore, it is generally felt that perioperative care can be improved if care is organized in comprehensive care pathways. Aim of care pathways is to optimize care during the entire process of surgery and rehabilitation. The effectiveness of care pathways for persons with a hip fracture was investigated in studies that show a tendency for the pathways being more effective than usual care [4‐6]. However, the extensiveness of these care pathways differs and most care pathways deal with only one or a few aspects of the care (e.g. the postoperative rehabilitation in hospital care).

To overcome this shortcoming a comprehensive care pathway for the treatment of patients with a hip fracture was developed at University Medical Center Groningen (UMCG). In this pathway the care is described from arrival at the emergency room until discharge from the nursing home. The objective of this study is to determine the clinical effectiveness of this pathway. To that end, a controlled trial will be conducted in which the new comprehensive care pathway of UMCG will be compared with care as usual at Martini Hospital Groningen (MHG) and Ommelander Hospital in Winschoten (OHW). It is hypothesized that 15% more patients treated in the new comprehensive care pathway compared with patients in the care-as-usual condition will have recovered at least as well at 6 months follow-up to pre-fracture levels in terms of Activities of Daily Living (ADL). As a randomized controlled trial (RCT) is not feasible, propensity scores will be used to adjust for differences at baseline between the intervention and control group.

Based on available reviews in the literature, it can be concluded that there is no level-1 evidence for the effectiveness of comprehensive care pathways for elderly patients with a hip fracture [11, 12]. Also this study will not reveal level-1 evidence, however it will reveal new knowledge on the clinical effectiveness of a comprehensive care pathway for the treatment of hip fractures. This is relevant because of the growing incidence of hip fractures and the ensuing massive burden on the healthcare system. So far, there is no definitive answer as to whether a care pathway is better than usual care [11]. Non-randomized studies into the effectiveness of pathways have reported promising results in decreasing waiting time, length of hospital stay and complication rate [13‐18]. However, a major drawback is that they are only dealing with one or a few aspects of care. A strong point of the current research is the fact that the clinical effectiveness of a comprehensive care pathway is subject of study. The rehabilitation of a hip fracture patient does not stop after discharge from the surgical ward, but continues for at least six months. It is thus important to include all the aspects of care and all involved disciplines in the care pathway, from the nurse in the emergency room to the doctor at the nursing home.

In addition, this study will also reveal new knowledge on the application of propensity scores, a novel statistical tool to simulate RCTs in situations in which a classical RCT is not feasible. As already mentioned, there is no definitive answer yet as to whether a care pathway is more effective than usual care. Especially with respect to comprehensive care pathways, this evidence is lacking. An important issue in this respect is the fact that RCTs are difficult to perform in hip fracture patients, who are characterized by advanced age and frailty. In general, a RCT is considered the highest standard for determining the effectiveness of a new intervention. However, it is not always feasible to use random assignment. For such situations, propensity scores are considered an useful alternative [19, 20]. With propensity scores, adjustments can be made for observed variables to minimize or remove the bias, which normally disturbs the results in observational studies. When the observed covariates are on average balanced between exposure groups, the advantages of a randomization process are approached, except that it is not possible to adjust for unobserved covariates [21]. However, studies comparing RCTs and observational studies using propensity scores have shown that the method is reliable. This is the reason why propensity scores has been used more often in recent times and why it will be used in this study [22].