A comprehensive multidisciplinary care pathway for hip fractures better outcome than usual care?

INTRODUCTION: Hip fracture surgery is among the most performed surgical procedures in elderly patients. Mortality rates are high, however, and patients often fail to live independently following a hip fracture. To improve outcome, multidisciplinary care pathways have been initiated, but longer-term results are lacking. Aim of this study was to compare functional outcome and living situation six months after hip fracture treatment with and without a care pathway. PATIENTS AND METHODS: A multicentre prospective controlled trial was conducted with three hospitals: in one hospital patients were treated with a care pathway, in the other hospitals patients received usual care. All patients aged ≥ 60 years with a hip fracture were asked to participate. Besides basic characteristics, health-related quality of life (EQ-5D) and performance scores of activities of daily living (Katz Index and Lawton IADL) were assessed. Differences in scores were analysed using linear regression. Propensity score adjustment was used to correct for differences between the care pathway and the usual care group. Missing data were imputed. RESULTS: No differences in rate of return to prefracture ADL level were found between patients in the care pathway group and the usual care group. The percentage of participants in the same situation as before the fracture was the same in both treatment groups (81%). There were no significant differences in quality of life, activities of daily living or mortality (15% vs 10%, p = 0.17), but hospital stay in the care pathway group was significantly shorter (median 7 vs 10 days). DISCUSSION: Treatment of elderly patients with a hip fracture is commonly organised in care pathways. Although short-term advantages are reported, positive effects on longer-term functional results could not be proven in our study. This study confirmed a shorter hospital stay in the care pathway group, which potentially may lead to a reduction in costs. CONCLUSIONS: Functional outcome and living situation six months after a hip fracture is the same for patients treated with or without a care pathway.

Early fixation versus conservative therapy of multiple, simple rib fractures (FixCon): protocol for a multicenter randomized controlled trial.

Background: Multiple rib fractures are common injuries in both the young and elderly. Rib fractures account for 10% of all trauma admissions and are seen in up to 39% of patients after thoracic trauma. With morbidity and mortality rates increasing with the number of rib fractures as well as poor quality of life at long-term follow-up, multiple rib fractures pose a serious health hazard. Operative fixation of flail chest is beneficial over nonoperative treatment regarding, among others, pneumonia and both intensive care unit (ICU) and hospital length of stay. With no high-quality evidence on the effects of multiple simple rib fracture treatment, the optimal treatment modality remains unknown. This study sets out to investigate outcome of operative fixation versus nonoperative treatment of multiple simple rib fractures. Methods: The proposed study is a multicenter randomized controlled trial. Patients will be eligible if they have three or more multiple simple rib fractures of which at least one is dislocated over one shaft width or with unbearable pain (visual analog scale (VAS) or numeric rating scale (NRS) > 6). Patients in the intervention group will be treated with open reduction and internal fixation. Pre- and postoperative care equals treatment in the control group. The control group will receive nonoperative treatment, consisting of pain management, bronchodilator inhalers, oxygen support or mechanical ventilation if needed, and pulmonary physical therapy. The primary outcome measure will be occurrence of pneumonia within 30 days after trauma. Secondary outcome measures are the need and duration of mechanical ventilation, thoracic pain and analgesics use, (recovery of) pulmonary function, hospital and ICU length of stay, thoracic injury-related and surgery-related complications and mortality, secondary interventions, quality of life, and cost-effectiveness comprising health care consumption and productivity loss. Follow-up visits will be standardized and daily during hospital admission, at 14 days and 1, 3, 6, and 12 months. Discussion: With favorable results in flail chest patients, operative treatment may also be beneficial in patients with multiple simple rib fractures. The FixCon trial will be the first study to compare clinical, functional, and economic outcome between operative fixation and nonoperative treatment for multiple simple rib fractures. Trial registration: www.trialregister.nl, NTR7248. Registered May 31, 2018.

Strict adherence to evidence-based protocol in choice of implants and surgical technique leads to fewer hip fracture reoperations.

BACKGROUND AND PURPOSE: Surgery for hip fractures is frequently followed by complications that hinder the rehabilitation. Only part of the complications are surgery-related, however these, including reoperation may have the highest impact. Operative protocols are designed to treat all patients equally, according to evidence based guidelines. Aim of this study was to investigate the association between strict adherence to an operative protocol and postoperative complications, especially reoperations. MATERIALS AND METHODS: A retrospective analyses of a prospective cohort. The cohort included all patients aged ≥60 treated for a hip fracture at University Medical Center Groningen between July 2009 and June 2013. The files of the patients were searched for complications, including reoperations. To evaluate adherence to the operative protocol all X-rays were retrospectively reviewed and the fracture type was reclassified. This retrospective fracture classification was compared with the treatment method used. Logistic regression analyses were used to assess whether patients that were not treated strictly according to the operative protocol have higher odds of developing a complication or of undergoing a reoperation. RESULTS: The study population consisted of 479 patients with a mean age of 78.4 (SD 9.5) years. Reoperation was performed in 11% of the patients during the follow-up period. The operative protocol was not followed strictly in 12% of the patients. When the operative protocol was not followed, the odds of having a reoperation was 2.41 times higher (p = 0.02). The overall complication rate was 75% and did not differ in both groups. CONCLUSION: Strict adherence to an evidence-based operative protocol is of major importance toward preventing implant-related problems and reoperations.

The development of a comprehensive multidisciplinary care pathway for patients with a hip fracture: design and results of a clinical trial.

BACKGROUND: Hip fractures frequently occur in older persons and severely decrease life expectancy and independence. Several care pathways have been developed to lower the risk of negative outcomes but most pathways are limited to only one aspect of care. The aim of this study was therefore to develop a comprehensive care pathway for older persons with a hip fracture and to conduct a preliminary analysis of its effect. METHODS: A comprehensive multidisciplinary care pathway for patients aged 60 years or older with a hip fracture was developed by a multidisciplinary team. The new care pathway was evaluated in a clinical trial with historical controls. The data of the intervention group were collected prospectively. The intervention group included all patients with a hip fracture who were admitted to University Medical Center Groningen between 1 July 2009 and 1 July 2011. The data of the control group were collected retrospectively. The control group comprised all patients with a hip fracture who were admitted between 1 January 2006 and 1 January 2008. The groups were compared with the independent sample t-test, the Mann-Whitney U-test or the Chi-squared test (Phi test). The effect of the intervention on fasting time and length of stay was adjusted by linear regression analysis for differences between the intervention and control group. RESULTS: The intervention group included 256 persons (women, 68%; mean age (SD), 78 (9) years) and the control group 145 persons (women, 72%; mean age (SD), 80 (10) years). Median preoperative fasting time and median length of hospital stay were significantly lower in the intervention group: 9 vs. 17 hours (p < 0.001), and 7 vs. 11 days (p < 0.001), respectively. A similar result was found after adjustment for age, gender, living condition and American Society of Anesthesiologists (ASA) classification. In-hospital mortality was also lower in the intervention group: 2% vs. 6% (p < 0.05). There were no statistically significant differences in other outcome measures. CONCLUSIONS: The new comprehensive care pathway was associated with a significant decrease in preoperative fasting time and length of hospital stay.

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

BACKGROUND: Hip fractures constitute an economic burden on healthcare resources. Most persons with a hip fracture undergo surgery. As morbidity and mortality rates are high, perioperative care leaves room for improvement. Improvement can be achieved if it is organized in comprehensive care pathways, but the effectiveness of these pathways is not yet clear. Hence the objective of this study is to compare the clinical effectiveness of a comprehensive care pathway with care as usual on self-reported limitations in Activities of Daily Living. METHODS/DESIGN: A controlled trial will be conducted in which the comprehensive care pathway of University Medical Center Groningen will be compared with care as usual in two other, nonacademic, hospitals. In this trial, propensity scores will be used to adjust for differences at baseline between the intervention and control group. Propensity scores can be used in intervention studies where a classical randomized controlled trial is not feasible. Patients aged 60 years and older will be included. The hypothesis is that 15% more patients at University Medical Center Groningen 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 for Activities of Daily Living. DISCUSSION: This study will yield new knowledge with respect to 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 consequent massive burden on the healthcare system. Additionally, this study will contribute to the growing knowledge of the application of propensity scores, a relatively novel statistical technique to simulate a randomized controlled trial in studies where it is not possible or difficult to execute this kind of design. TRIAL REGISTRATION: Nederlands Trial Register NTR3171.

External validation of the discharge of hip fracture patients score.

PURPOSE: This paper reports the external validation of a recently developed instrument, the Discharge of Hip fracture Patients score (DHP) that predicts discharge location on admission in patients living in their own home prior to hip fracture surgery. METHODS: The DHP (maximum score 100 points) was applied to 125 hip fracture patients aged 50 or more years admitted to an academic centre in the northern part of The Netherlands (Groningen cohort). The characteristics of this cohort, sensitivity, specificity and positive and negative predictive value (PPV, NPV) of the DHP for discharge to an alternative location (DAL) were calculated and compared with the original cohort of hip fracture patients from the western part of The Netherlands (Delft cohort). Scoring 30 points or higher indicated DAL. RESULTS: The Groningen cohort was younger compared to the Delft cohort, (mean age 75.4 vs. 78.5 years, P = 0.005) but was more often classified ASA III/IV (46.4% vs. 25.2%, P < 0.001). Sensitivity of the DHP for DAL in the Groningen cohort was 75% (vs. 83.8%), specificity of 66.7% (vs. 64.7%) and a PPV of 86.3% (vs. 79.2%), compared to the Delft cohort. CONCLUSION: External validation of the DHP was successful; it predicted discharge location of hip fracture patients accurately in another Dutch cohort, the sensitivity for DAL was somewhat lower but the PPV higher. Therefore, the DHP score is a useful valid and easily applied instrument for general hip fracture populations.

Current surgical treatment of diverticular disease in The Netherlands.

AIM: To evaluate the development of diagnostic tools, indications for surgery and treatment modalities concerning diverticular disease (DD) in The Netherlands. METHODS: Data were collected from 100 patients who underwent surgery for DD in three Dutch hospitals. All hospitals used the same standardized database. The collected data included patient demographics, patient history, type of surgery and complications. Patients were divided into two groups, one undergoing elective surgery (elective group) and the other undergoing acute surgery (acute group). RESULTS: Two hundred and ninety-nine patients were admitted between 2000 and 2007. One hundred and seventy-eight patients underwent acute surgery and 121 patients received elective operations. The median age of the 121 patients was 69 years (range: 28-94 years), significantly higher in acute patients (P = 0.010). Laparoscopic resection was performed in 31% of elective patients. In the acute setting, 61% underwent a Hartmann procedure. The overall morbidity and mortality were 51% and 10%, and 60% and 16% in the acute group, which were significantly higher than in the elective group (36% and 1%). Only 35% of the temporary ostomies were restored. CONCLUSION: This study gives a picture of current surgical practice for DD in The Netherlands. New developments are implemented in daily practice, resulting in acceptable morbidity and mortality rates.

Squamous cell carcinoma of the breast: a case report.

BACKGROUND: Squamous cells are normally not found inside the breast, so a primary squamous cell carcinoma of the breast is an exceptional phenomenon. There is a possible explanation for these findings. CASE PRESENTATION: A 72-year-old woman presented with a breast abnormality suspected for breast carcinoma. After the operation the pathological examination revealed a primary squamous cell carcinoma of the breast. CONCLUSION: The presentation of squamous cell carcinoma could be similar to that of an adenocarcinoma. However, a squamous cell carcinoma of the breast could also develop from a complicated breast cyst or abscess. Therefore, pathological examination of these apparent benign abnormalities is mandatory.