The impact of care pathways for patients with proximal femur fracture: rationale and design of a cluster-randomized controlled trial

Factors Informing the Development of a Clinical Pathway and Patients' Quality of Life after a Non-Union Fracture of the Lower Limb

Patients with non-union fractures spend extended periods of time in the hospital following poor healing. Patients have to make several follow-up visits for medical and rehabilitation purposes. However, the clinical pathways and quality of life of these patients are unknown. This prospective study aimed to identify the clinical pathways (CPs) of 22 patients with lower-limb non-union fractures whilst determining their quality of life. Data were collected from hospital records from admission to discharge, utilizing a CP questionnaire. We used the same questionnaire to track patients' follow-up frequency, involvement in activities of daily living, and final outcomes at six months. We used the Short Form-36 questionnaire to assess patients' initial quality of life. The Kruskal-Wallis test compared the quality of life domains across different fracture sites. We examined CPs using medians and inter-quantile ranges. During the six-month follow-up period, 12 patients with lower-limb non-union fractures were readmitted. All of the patients had impairments, limited activity, and participation restrictions. Lower-limb fractures can have a substantial impact on emotional and physical health, and lower-limb non-union fractures may have an even greater effect on the emotional and physical health of patients, necessitating a more holistic approach to patient care.

Multidisciplinary rehabilitation for older people with hip fractures

BACKGROUND

Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009.

OBJECTIVES

To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019).

SELECTION CRITERIA

We included randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older people (aged 65 years or over) with hip fracture. The primary outcome - 'poor outcome' - was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. The other 'critical' outcomes were health-related quality of life, mortality, dependency in activities of daily living, mobility, and related pain.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome.

MAIN RESULTS

The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding-related performance and detection biases. We summarise the findings for three comparisons below. Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care' Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials. Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate-certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences. Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low-certainty evidence). A similar finding applies at 4 to 12 months' follow-up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low-certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow-up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low-certainty evidence). Due to very low-certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow-up (measured in various ways by 11 studies), or at 6 to 12 months' follow-up (13 studies). Long-term hip-related pain was not reported. Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care' Three trials tested this comparison in 377 people mainly living at home. Due to very low-certainty evidence, we have very little confidence in the findings of little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long-term hip-related pain was not reported. One trial tested this comparison in 240 nursing home residents. There is low-certainty evidence that there may be no or minimal between-group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low-certainty evidence, we have very little confidence in the findings of no between-group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months.

AUTHORS' CONCLUSIONS

In a hospital inpatient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty. The generally very low-certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true. Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.

Impact of Bone Cement Augmentation on the Fixation Strength of TFNA Blades and Screws

Background and Objectives: Hip fractures constitute the most debilitating complication of osteoporosis with steadily increasing incidences in the aging population. Their intramedullary nailing can be challenging because of poor anchorage in the osteoporotic femoral head. Cement augmentation of Proximal Femoral Nail Antirotation (PFNA) blades demonstrated promising results by enhancing cut-out resistance in proximal femoral fractures. The aim of this study was to assess the impact of augmentation on the fixation strength of TFN-ADVANCED^TM Proximal Femoral Nailing System (TFNA) blades and screws within the femoral head and compare its effect when they are implanted in centre or anteroposterior off-centre position. Materials and Methods: Eight groups were formed out of 96 polyurethane low-density foam specimens simulating isolated femoral heads with poor bone quality. The specimens in each group were implanted with either non-augmented or cement-augmented TFNA blades or screws in centre or anteroposterior off-centre positions, 7 mm anterior or posterior. Mechanical testing was performed under progressively increasing cyclic loading until failure, in setup simulating an unstable pertrochanteric fracture with a lack of posteromedial support and load sharing at the fracture gap. Varus-valgus and head rotation angles were monitored. A varus collapse of 5° or 10° head rotation was defined as a clinically relevant failure. Results: Failure load (N) for specimens with augmented TFNA head elements (screw/blade centre: 3799 ± 326/3228 ± 478; screw/blade off-centre: 2680 ± 182/2591 ± 244) was significantly higher compared with respective non-augmented specimens (screw/blade centre: 1593 ± 120/1489 ± 41; screw/blade off-centre: 515 ± 73/1018 ± 48), p < 0.001. For both non-augmented and augmented specimens failure load in the centre position was significantly higher compared with the respective off-centre positions, regardless of the head element type, p < 0.001. Augmented off-centre TFNA head elements had significantly higher failure load compared with non-augmented centrally placed implants, p < 0.001. Conclusions: Cement augmentation clearly enhances the fixation stability of TFNA blades and screws. Non-augmented blades outperformed screws in the anteroposterior off-centre position. Positioning of TFNA blades in the femoral head is more forgiving than TFNA screws in terms of failure load.

Lean Six Sigma Approach for Reducing Length of Hospital Stay for Patients with Femur Fracture in a University Hospital

Surgical intervention within 48 h of hospital admission is the gold standard procedure for the management of elderly patients with femur fractures, since the increase in preoperative waiting time is correlated with the onset of complications and longer overall length of stay (LOS) in the hospital. However, national evidence demonstrates that there is still the need to provide timely intervention for this type of patient, especially in some regions of central southern Italy. Here we discuss the introduction of a diagnostic–therapeutic assistance pathway (DTAP) to reduce the preoperative LOS for patients undergoing femur fracture surgery in a university hospital. A Lean Six Sigma methodology, based on the DMAIC cycle (Define, Measure, Analyze, Improve, Control), is implemented to evaluate the effectiveness of the DTAP. Data were retrospectively collected and analyzed from two groups of patients before and after the implementation of DTAP over a period of 10 years. The statistics of the process measured before the DTAP showed an average preoperative LOS of 5.6 days (standard deviation of 3.2), thus confirming the need for corrective actions to reduce the LOS in compliance with the national guidelines. The influence of demographic and anamnestic variables on the LOS was evaluated, and the impact of the DTAP was measured and discussed, demonstrating the effectiveness of the improvement actions implemented over the years and leading to a significant reduction in the preoperative LOS, which decreased to an average of 3.5 days (standard deviation of 3.60). The obtained reduction of 39% in the average LOS proved to be in good agreement with previously developed DTAPs for femur fracture available in the literature.

Bone cement augmentation of femoral nail head elements increases their cut-out resistance in poor bone quality- A biomechanical study

The aim of this study was to analyze biomechanically the impact of bone cement augmentation on the fixation strength and cut-out resistance of Proximal Femoral Nail Antirotation (PFNA) and Trochanteric Fixation Nail Advanced (TFNA) head elements within the femoral head in a human cadaveric model with poor bone quality. Methodology: Fifteen pairs of fresh-frozen human cadaveric femoral heads were randomized to three sets of five pairs each for center-center implantation of either TFNA blade, TFNA screw, or PFNA blade. By splitting the specimens of each pair for treatment with or without bone cement augmentation, six study groups were created. All specimens were biomechanically tested under progressively increasing cyclic loading featuring a physiologic loading trajectory in a setup simulating a reduced intertrochanteric fracture with lack of posteromedial support. Number of cycles to 5° varus collapse was evaluated together with the corresponding load at failure. Results: Compared to the non-augmented state, all types of implants demonstrated significantly higher numbers of cycles to failure and load at failure following augmentation, p ≤ 0.03. Augmented TFNA blades resulted in highest numbers of cycles to failure and loads at failure (30492; 4049 N) followed by augmented PFNA blades (30033; 4003 N) and augmented TFNA screws (19307; 2930 N), p = 0.11. Augmented TFNA screws showed similar numbers of cycles to failure and loads at failure compared to both non-augmented TFNA and PFNA blades, P = 0.98. From a biomechanical perspective, bone cement augmentation significantly increases the cut-out resistance of instrumented TFNA and PFNA head elements and is a valid supplementary treatment option to these nailing procedures in poor bone quality.

Clinical pathways for geriatric patients with proximal femoral fracture improve process and outcome

OBJECTIVE

The objective of the current study was to evaluate the implementation of clinical pathways (CPs) in hip fracture management.

METHODS

Six hundred and five proximal femoral fractures were prospectively included into a hospital data-base. The effects of CPs were evaluated using a pre-during-post design. Different procedural (time to surgery, length of stay, discharge, etc.) and patient outcome parameters (mortality, complications, etc.) were evaluated.

RESULTS

In both categories significant changes could be detected during the three-year period. E.g. significant reduction of time to surgery, improvement of discharge management, reduction of internal complications. However, no significant changes could be demonstrated for mortality or revision rate.

CONCLUSION

We could show a relevant improvement with the implementation of clinical pathways for the treatment of proximal femoral fractures in elderly patients.

LEVEL OF EVIDENCE

III, prospective non-randomised cohort study.

Effects of implementing a care pathway for colorectal cancer surgery in ten European hospitals: an international multicenter pre-post-test study

Adherence to evidence-based recommendations is variable and generally low. This is also followed in colorectal surgery, despite the availability of the ERAS^® protocol. The aim of the study was to evaluate the effect of implementing a care pathway for perioperative care in colorectal cancer surgery on outcomes and protocol adherence. So, we performed an international pre-test-post-test multicenter study, performed in ten hospitals in four European countries. The measures used included length of stay, morbidity and mortality, and documentation and adherence on intervention and patient level. Unadjusted pre-test-post-test differences were analyzed following an analysis adjusted for patient-mix variables. Importance-performance analysis was used to map the relationship between importance and performance of individual interventions. In total, 381 patients were included. Length of stay decreased from 12.6 to 10.7 days (p = 0.0230). Time to normal diet and walking also decreased significantly. Protocol adherence improved from 56 to 62% (p < 0.00001). Adherence to individual interventions remained highly variable. Importance-performance analysis showed 30 interventions were scored as important, of which 19 had an adherence < 70%, showing priorities for improvement. Across hospitals, change in protocol adherence ranged from a 13% decrease to a 22% increase. Implementing a care pathway for colorectal cancer surgery reduced length of stay, time to normal diet and walking. Documentation and protocol adherence improved after implementing the care pathway. However, not in all participating hospitals protocol adherence improved. Only in 25% of patients, protocol adherence of ≥ 70% was achieved, suggesting a large group is at risk for underuse. Importance-performance analysis showed which interventions are important, but have low adherence, prioritizing improvement efforts.

Mapping the Status of Healthcare Improvement Science through a Narrative Review in Six European Countries

With the aim to explore how improvement science is understood, taught, practiced, and its impact on quality healthcare across Europe, the Improvement Science Training for European Healthcare Workers (ISTEW) project “Improvement Science Training for European Healthcare Workers” was funded by the European Commission and integrated by 7 teams from different European countries. As part of the project, a narrative literature review was conducted between 2008 and 2019, including documents in all partners’ languages from 26 databases. Data collection and analysis involved a common database. Validation took place through partners’ discussions. Referring to healthcare improvement science (HIS), a variety of terms, tools, and techniques were reported with no baseline definition or specific framework. All partner teams were informed about the non-existence of a specific term equivalent to HIS in their mother languages, except for the English-speaking countries. A lack of consensus, regarding the understanding and implementation of HIS into the healthcare and educational contexts was found. Our findings have brought to light the gap existing in HIS within Europe, far from other nations, such as the US, where there is a clearer HIS picture. As a consequence, the authors suggest further developing the standardization of HIS understanding and education in Europe.

Impact of care pathway implementation on interprofessional teamwork: An international cluster randomized controlled trial

This study evaluates whether the implementation of an in-hospital care pathway (CP) improves interprofessional teamwork across countries and tests whether improved communications ("relational coordination") is the mechanism of action. A hospital-based cluster randomized controlled trial in Ireland, Belgium, Italy, and Portugal was performed. Fifty-six interprofessional teams caring for patients admitted with an exacerbation of chronic obstructive pulmonary disease or for patients with a proximal femur fracture were included and randomly assigned to an intervention group (31 teams and 567 team members), where a CP was implemented, and a control group (25 teams and 417 team members) representing usual care. Multilevel regression and mediation analysis were applied. First, although no significant effect was found on our primary outcome relational coordination, our CP significantly improved several team inputs, team processes (team climate for innovation) and team output (the level of organized care, level of competence) indicators. Second, our team process indicator of team climate for innovation partially mediated the association between CP implementation and team output indicator of better level of organized care. In conclusion, a CP sets in motion various mechanisms that improve some but not all aspects of interprofessional teamwork. Relational coordination does not appear to be the mechanism by which team outputs are enhanced.

Continuous improvement process: ortho-geriatric co-management of proximal femoral fractures

OBJECTIVE

The objective of the current study was to evaluate the effect of a quality management system on treatment and care delivery of proximal femoral fractures. Specifically, our hypothesis was that the "plan-do-check-act (PDCA)" philosophy of the ISO 9001 quality management system results in a continuous improvement process.

METHODS

1015 proximal femoral fractures were prospectively included into a hip fracture database over a 5-year period, after a restructuring process with implementation of clinical pathways and standard operation procedures. A close and structured ortho-geriatric co-management (certified ortho-geriatric center) was the basis for treatment. ISO 9001 certification was granted for the first time in 2012. Procedural and patient outcome parameters were analyzed by year and evaluated statistically using SPSS 25.0.

RESULTS

In both categories (procedural and outcome) significant changes could be detected during the 5-year period, e.g., significant reduction of time to surgery for the first 2 years, improvement in discharge management, and reduction of surgical complications. However, no significant changes could be demonstrated for mortality or internal complications such as pneumonia, urinary tract infections, or postoperative delirium. However, the incidence of the latter was already on a very low level at the onset of the quality improvement process.

CONCLUSION

We could show a relevant and continuous improvement of several quality indicators during a 5-year period after implementation of a quality management system based on the PDCA philosophy for the treatment of proximal femoral fractures in elderly patients. However, other parameters (internal complications, cost-effectiveness, etc.) need our close attention in the future.

Protocol for process evaluation of evidence-based care pathways: the case of colorectal cancer surgery

BACKGROUND AND AIM

Care pathways are complex interventions, consisting of multiple 'active ingredients', to structure care processes around patient needs. Numerous studies have reported improved outcomes after implementation of care pathways. The structure-process-outcome framework and the context-mechanism-outcome framework both suggest that outcomes can only be achieved through a certain process within a context or structure. To understand how and why care pathways are effective, understanding of both this process and context is necessary. The aim of this article is to propose a study protocol to evaluate the implementation process of evidence-based care pathways, including the influence of the context. This protocol is explained by applying it to the implementation of a colorectal cancer surgery pathway in an international setting.

METHODS

The Medical Research Council (MRC) guidance on process evaluations for complex interventions is used as the basis for the protocol. The key components of process evaluation are intervention, context, implementation, mechanisms of impact and outcomes. In process evaluations, these components are studied using quantitative and qualitative methods. Among them are patient record analysis, questionnaires, on-site visits and interviews.

DISCUSSION

To guide our methodological choices, the MRC guidance for process evaluations of complex interventions, and published protocols for process evaluations of complex interventions were used. Our protocol is now tailored for the process evaluation of evidence-based care pathways and provides researchers and clinicians methods and tools, as well as a worked example, that can be used to study the process of care pathway implementation. As a result, healthcare professionals will be informed on context factors and implementation processes that can facilitate the implementation of care pathways, improving quality and effectiveness of care processes.

Patient and Health Care Professional Perspectives: A Case Study of the Lung Cancer Integrated Care Pathway

Introduction:

The purpose of this study was to evaluate the perception of the quality of care, considering both patient experience and health care professionals’ perceptions as well as patient outcome measures of an integrated lung cancer pathway.

Methods:

A cross-sectional study was conducted in 2016 at Ferrara University Hospital, Italy. OPportunity for Treatment In ONcology (OPTION) questionnaires were administered to 77 patients, and the Care Process Self-Evaluation Tool (CPSET) questionnaires were given to 38 health care professionals. The effectiveness of the pathway was evaluated by analysing the tool’s positive impact on lung cancer surgery volume and 30-day mortality.

Results:

Seventy-seven patients were enrolled, and 38 health care professionals assessed the CPSET questionnaire. The highest scores were related to “respect” (100%), “satisfaction” (98.7%), and “trust” (97.4%) on the OPTION and to “patient-focused vision” (97.2%) and “patient engagement” (94.4%) on the CPSET. The lowest scores were related to “information” (26%) and “cooperation with general practitioner” (17.6%) on the OPTION and “cooperation between the hospital and primary care” (23.5%) for the CPSET. The outcomes analysis shows an increase in the volume of activity and a decrease in 30-day mortality after pathway implementation.

Discussion:

The lung cancer pathway is a patient-centred intervention that enables care to be shaped for patient needs in order to improve the quality and efficiency of service and clinical outcome.

Recommended care received by geriatric hip fracture patients: where are we now and where are we heading?

INTRODUCTION

Despite the availability of clinical guidelines on the prevention and treatment of geriatric hip fractures, the percentage of recommended care received by patients is low. We conducted an importance-performance analysis for prioritizing interventions to improve the in-hospital management of these patients.

MATERIALS AND METHODS

A secondary data analysis was conducted on the in-hospital treatment of 540 geriatric hip fracture patients in 34 hospitals in Belgium, Italy, and Portugal. First, we assessed the level of expert consensus on the process indicators composing international guidelines on hip fracture treatment. Second, guideline adherence on in-hospital care was evaluated within and across hospitals. Third, an importance-performance analysis was conducted, linking expert consensus to guideline adherence.

RESULTS

Level of expert consensus was high (above 75%) for 12 of 22 process indicators identified from the literature. There is large between and within hospital variation in guideline adherence for these indicators and for none of the 540 patients were all 22 process indicators adhered to. Importance-performance analysis demonstrated that three indicators that had a high level of expert consensus also had a high level of adherence (above 80%). Nine indicators, most of which have been previously linked to patient outcomes, had a high level of expert consensus but a consistently low level of adherence across hospitals and are identified as priority areas for improvement.

CONCLUSIONS

Guideline adherence for the treatment of geriatric hip fracture patients is remarkably suboptimal. Importance-performance analysis is a useful strategic approach to assist practitioners and healthcare managers to improve the quality of care.

Minimal impact of a care pathway for geriatric hip fracture patients

BACKGROUND

Adherence to guidelines for patients with proximal femur fracture is suboptimal.

OBJECTIVE

To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes.

DESIGN

The European Quality of Care Pathways study is a cluster randomized controlled trial.

SETTING

26 hospitals in Belgium, Italy and Portugal.

SUBJECTS

Older adults with a proximal femur fracture (n = 514 patients) were included.

METHODS

Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures.

RESULTS

In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team.

DISCUSSION

Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00962910.

Development of key interventions and quality indicators for the management of an adult potential donor after brain death: a RAND modified Delphi approach

Background

A substantial degree of variability in practices exists amongst donor hospitals regarding the donor detection, determination of brain death, application of donor management techniques or achievement of donor management goals. A possible strategy to standardize the donation process and to optimize outcomes could lie in the implementation of a care pathway. The aim of the study was to identify and select a set of relevant key interventions and quality indicators in order to develop a specific care pathway for donation after brain death and to rigorously evaluate its impact.

Methods

A RAND modified three-round Delphi approach was used to build consensus within a single country about potential key interventions and quality indicators identified in existing guidelines, review articles, process flow diagrams and the results of the Organ Donation European Quality System (ODEQUS) project. Comments and additional key interventions and quality indicators, identified in the first round, were evaluated in the following rounds and a subsequent physical meeting. The study was conducted over a 4-month time period in 2016.

Results

A multidisciplinary panel of 18 Belgian experts with different relevant backgrounds completed the three Delphi rounds. Out of a total of 80 key interventions assessed throughout the Delphi process, 65 were considered to contribute to the quality of care for the management of a potential donor after brain death; 11 out of 12 quality indicators were validated for relevance and feasibility. Detection of all potential donors after brain death in the intensive care unit and documentation of cause of no donation were rated as the most important quality indicators.

Conclusions

Using a RAND modified Delphi approach, consensus was reached for a set of 65 key interventions and 11 quality indicators for the management of a potential donor after brain death. This set is considered to be applicable in quality improvement programs for the care of potential donors after brain death, while taking into account each country’s legislation and regulations regarding organ donation and transplantation.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3386-1) contains supplementary material, which is available to authorized users.

The COPDnet integrated care model

Introduction

This research project sets out to design an integrated disease management model for patients with COPD who were referred to a secondary care setting and who qualified for pharmacological and nonpharmacological intervention options.

Theory and methods

The integrated disease management model was designed according to the guidelines of the European Pathway Association and the content founded on the Chronic Care Model, principles of integrated disease management, and knowledge of quality management systems.

Results

An integrated disease management model was created, and comprises 1) a diagnostic trajectory in a secondary care setting, 2) a nonmedical intervention program in a primary care setting, and 3) a pulmonary rehabilitation service in a tertiary care setting. The model also includes a quality management system and regional agreements about exacerbation management and palliative care.

Discussion

In the next phase of the project, the COPDnet model will be implemented in at least two different regions, in order to assess the added value of the entire model and its components, in terms of feasibility, health status benefits, and costs of care.

Conclusion

Based on scientific theories and models, a new integrated disease management model was developed for COPD patients, named COPDnet. Once the model is stable, it will be evaluated for its feasibility, health status benefits, and costs.

Location of Femoral Fractures in Patients with Different Weight Classes in Fall and Motorcycle Accidents: A Retrospective Cross-Sectional Analysis

Background: This study aimed to determine the incidence of femoral fracture location in trauma patients with different weight classes in fall and motorcycle accidents. Methods: A total of 2647 hospitalized adult patients with 2760 femoral fractures from 1 January 2009 to 31 December 2014 were included in this study. Femoral fracture sites were categorized based on their location: proximal femur (type A, trochanteric; type B, neck; and type C, head), femoral shaft, and distal femur. The patients were further classified as obese (body mass index [BMI] of ≥30 kg/m²), overweight (BMI of <30 but ≥25 kg/m²), normal weight (BMI of <25 but ≥18.5 kg/m²), and underweight (BMI of <18.5 kg/m²). Odds ratios and 95% confidence intervals of the incidences of femoral fracture location were calculated in patients with different weight classes in fall or motorcycle accidents, and they were then compared with those in patients with normal weight. p values of <0.05 were considered statistically significant. Results: Most of the fractures sustained in fall accidents presented in the proximal type A (41.8%) and type B (45.3%) femur, whereas those sustained in motorcycle accidents involved the femoral shaft (37.1%), followed by the distal femur (22.4%) and proximal type A femur (21.2%). In fall accidents, compared with normal-weight patients, obese and overweight patients sustained lower odds of risk for proximal type B fractures but higher odds of risk for femoral shaft and distal femoral fractures. In motorcycle accidents, compared with normal-weight patients, obese patients sustained lower odds of risk for proximal type B fractures but no difference in odds of risk for femoral shaft and distal femoral fractures. Overweight and underweight patients who sustained fractures in a motorcycle accident did not have different fracture location patterns compared with normal-weight patients. Conclusions: This study revealed that femoral fracture locations differ between fall and motorcycle accidents. Moreover, greater soft tissue padding may reduce impact forces to the greater trochanteric region in obese patients during fall accidents, and during motorcycle accidents, the energy transmitted and the point of impact may dominantly determine the location of femoral fractures.

Variation in care for surgical patients with colorectal cancer: protocol adherence in 12 European hospitals

PURPOSE

Surgical care for patients with colorectal cancer has become increasingly standardized. The Enhanced Recovery After Surgery (ERAS) protocol is a widely accepted structured care method to improve postoperative outcomes of patients after surgery. Despite growing evidence of effectiveness, adherence to the protocol remains challenging in practice. This study was designed to assess the adherence rate in daily practice and examine the relationship between the importance of interventions and adherence rate.

METHODS

This international observational, cross-sectional multicenter study was performed in 12 hospitals in four European countries. Patients were included from January 1, 2014. Data was retrospectively collected from the patient record by the local study coordinator.

RESULTS

A total of 230 patients were included in the study. Protocol adherence was analyzed for both the individual interventions and on patient level. The interventions with the highest adherence were antibiotic prophylaxis (95%), thromboprophylaxis (87%), and measuring body weight at admission (87%). Interventions with the lowest adherence were early mobilization-walking and sitting (9 and 6%, respectively). The adherence ranged between 16 and 75%, with an average of 44%.

CONCLUSION

Our results show that the average protocol adherence in clinical practice is 44%. The variation on patient and hospital level is considerable. Only in one patient the adherence rate was >70%. In total, 30% of patients received 50% or more of the key interventions. A solid implementation strategy seems to be needed to improve the uptake of the ERAS pathway. The importance-performance matrix can help in prioritizing the areas for improvement.

Magic Mirror, on the Wall-Which Is the Right Study Design of Them All?-Part I

The assessment of a new or existing treatment or intervention typically answers 1 of 3 research-related questions: (1) "Can it work?" (efficacy); (2) "Does it work?" (effectiveness); and (3) "Is it worth it?" (efficiency or cost-effectiveness). There are a number of study designs that on a situational basis are appropriate to apply in conducting research. These study designs are classified as experimental, quasi-experimental, or observational, with observational studies being further divided into descriptive and analytic categories. This first of a 2-part statistical tutorial reviews these 3 salient research questions and describes a subset of the most common types of experimental and quasi-experimental study design. Attention is focused on the strengths and weaknesses of each study design to assist in choosing which is appropriate for a given study objective and hypothesis as well as the particular study setting and available resources and data. Specific studies and papers are highlighted as examples of a well-chosen, clearly stated, and properly executed study design type.

Association of Osteoporosis Self-Assessment Tool for Asians (OSTA) Score with Clinical Presentation and Expenditure in Hospitalized Trauma Patients with Femoral Fractures

Background: A cross-sectional study to investigate the association of Osteoporosis Self-Assessment Tool for Asians (OSTA) score with clinical presentation and expenditure of hospitalized adult trauma patients with femoral fractures. Methods: According to the data retrieved from the Trauma Registry System between 1 January 2009 and 31 December 2015, a total of 2086 patients aged ≥40 years and hospitalized for treatment of traumatic femoral bone fracture were categorized as high-risk patients (OSTA < -4, n = 814), medium-risk patients (-1 ≥ OSTA ≥ -4, n = 634), and low-risk patients (OSTA > -1, n = 638). Two-sided Pearson's, chi-squared, or Fisher's exact tests were used to compare categorical data. Unpaired Student's t-test and Mann-Whitney U-test were used to analyze normally and non-normally distributed continuous data, respectively. Propensity-score matching in a 1:1 ratio was performed using Number Crunching Statistical Software (NCSS) software (NCSS 10; NCSS Statistical Software, Kaysville, UT, USA), with adjusted covariates including mechanism and Glasgow Coma Scale (GCS); injuries were assessed based on the Abbreviated Injury Scale (AIS), and Injury Severity Score (ISS) was used to evaluate the effect of OSTA-related grouping on a patient's outcome. Results: High-risk and medium-risk patients were predominantly female, presented with significantly older age and higher incidences of co-morbidity, and were injured in a fall accident more frequently than low-risk patients. High-risk patients and medium-risk patients had a different pattern of femoral fracture and a significantly lower ISS. Although high-risk and medium-risk patients had significantly shorter lengths hospital of stay (LOS) and less total expenditure than low-risk patients did, similar results were not found in the selected propensity score-matched patients, implying that the difference may be attributed to the associated injury severity of the patients with femoral fracture. However, the charge of surgery is significantly lower in high-risk and medium-risk patients than in low-risk patients, regardless of the total population or the selected propensity score-matched patients. This lower charge of surgery may be attributed to a less aggressive surgery applied for older patients with high or medium risk of osteoporosis. Conclusions: This study of hospitalized trauma patients with femoral fracture according to OSTA risk classification revealed that high-risk and medium-risk patients had significantly higher odds of sustaining injury in a fall accident than low-risk patients; they also present a different pattern of femoral bone fracture as well as a significantly lower ISS, shorter hospital LOS, and less total expenditure. In addition, the significantly lower charge of surgery in high-risk and medium-risk patients than in low-risk patients may be because of the preference of orthopedists for less aggressive surgery in dealing with older patients with osteoporotic femoral bone fracture.

Should hospital managers read the orthopedic literature before surgeons? The example of femur fracture management

BACKGROUND

Early surgical intervention in the treatment of proximal femur fractures has been shown to significantly reduce mortality and complications. Our study intends to evaluate early surgery rates in a single-center analysis before the clinical advantages of early surgical intervention were demonstrated in the literature (G1), after the orthopedic team aimed to treat those fractures within 48 h (G2), and after early intervention became a primary objective for hospital management (G3).

MATERIALS AND METHODS

The hospital charts of 894 proximal femur fractures in patients aged >65 years between 2008 and 2015 were analyzed in a single teaching hospital. The patients were allocated to three groups according to admission date, relative to the introduction of the different targets for early intervention. Our primary aim was to evaluate the differences in the rate of surgical treatment within 48 h in the three groups, and our secondary aim was to see if those differences influenced clinical outcomes.

RESULTS

The rate of treatment before 48 h was 23, 49 and 72 % in groups 1, 2 and 3, respectively (p < 0.001). There were no statistically significant differences between the three groups regarding time from surgery to discharge and perioperative mortality. The length of hospitalization was different only between groups 1 and 2.

CONCLUSIONS

The adoption of an early treatment goal for proximal femur fractures by the orthopedic team significantly improved the results. However, it was only by introducing this goal into primary hospital management objectives that significantly increased the performance. Level of evidence Level IV (retrospective case-control study).

The European quality of care pathways (EQCP) study on the impact of care pathways on interprofessional teamwork in an acute hospital setting: study protocol: for a cluster randomised controlled trial and evaluation of implementation processes

Background

Although care pathways are often said to promote teamwork, high-level evidence that supports this statement is lacking. Furthermore, knowledge on conditions and facilitators for successful pathway implementation is scarce. The objective of the European Quality of Care Pathway (EQCP) study is therefore to study the impact of care pathways on interprofessional teamwork and to build up understanding on the implementation process.

Methods/design

An international post-test-only cluster Randomised Controlled Trial (cRCT), combined with process evaluations, will be performed in Belgium, Ireland, Italy, and Portugal. Teams caring for proximal femur fracture (PFF) patients and patients hospitalized with an exacerbation of chronic obstructive pulmonary disease (COPD) will be randomised into an intervention and control group. The intervention group will implement a care pathway for PFF or COPD containing three active components: a formative evaluation of the actual teams’ performance, a set of evidence-based key interventions, and a training in care pathway-development. The control group will provide usual care. A set of team input, process and output indicators will be used as effect measures. The main outcome indicator will be relational coordination. Next to these, process measures during and after pathway development will be used to evaluate the implementation processes. In total, 132 teams have agreed to participate, of which 68 were randomly assigned to the intervention group and 64 to the control group. Based on power analysis, a sample of 475 team members per arm is required. To analyze results, multilevel analysis will be performed.

Discussion

Results from our study will enhance understanding on the active components of care pathways. Through this, preferred implementation strategies can be defined.

Trail registration

NCT01435538