Beaupre L A, Cinats J G, Senthilselvan A, Lier D, Jones C A, Scharfenberger A, Johnston D W C, Saunders L D
Capital Health, Caritas Health Group, Edmonton, AB, Canada.
Qual Saf Health Care. 2006 Oct;15(5):375-9. doi: 10.1136/qshc.2005.017095.
Hip fractures, common in the elderly population, result in significant morbidity and mortality. A study was undertaken to determine how an evidence based clinical pathway (CP) for treatment of elderly patients with hip fracture affected morbidity, in-hospital mortality, and health service utilization.
A pre-post study design using two population based inception cohorts of hip fracture patients aged > or =65 years was used. The control group (n = 678) was enrolled between July 1996 and September 1997 before implementation of the pathway and the CP group (n = 663) was enrolled between July 1999 and September 2000 following pathway implementation. Chart reviews were completed during study time frames to determine complications, mortality, and health service utilization.
Only nine patients (1%) in the CP group experienced postoperative congestive heart failure compared with 37 (5%) control patients (p<0.001). Postoperative cardiac arrythmias were significantly lower in the CP group than in the control group (8 (1%) v 36 (5%); p<0.001). Postoperative delirium occurred in 22% of the CP group and 51% of the control group (p<0.001). There was no difference in risk adjusted in-hospital mortality between the two groups. Overall length of stay (LOS) and costs were unchanged between the groups; however, hospital LOS increased while rehabilitation LOS decreased in the CP group.
Implementation of an evidence based clinical pathway reduced postoperative morbidity and did not affect in-hospital mortality or overall costs of inpatient care. The effect of changing trends in medical care cannot be ruled out, but the reduction in complications in several clinical areas lends support to the positive impact of the clinical pathway. Perioperative CP is one successful management approach for this fragile patient population as patient morbidity was reduced without negatively affecting resource utilization.
髋部骨折在老年人群中很常见，会导致显著的发病率和死亡率。开展了一项研究，以确定基于证据的老年髋部骨折患者治疗临床路径（CP）如何影响发病率、住院死亡率和卫生服务利用情况。
采用前后对照研究设计，使用两个基于人群的≥65岁髋部骨折患者起始队列。对照组（n = 678）于1996年7月至1997年9月在该临床路径实施前入组，CP组（n = 663）于1999年7月至2000年9月在该临床路径实施后入组。在研究时间段内完成病历审查，以确定并发症、死亡率和卫生服务利用情况。
CP组仅有9例患者（1%）术后发生充血性心力衰竭，而对照组有37例（5%）（p<0.001）。CP组术后心律失常明显低于对照组（8例（1%）对36例（5%）；p<0.001）。CP组术后谵妄发生率为22%，对照组为51%（p<0.001）。两组经风险调整后的住院死亡率无差异。两组的总住院时间（LOS）和费用未变；然而，CP组的医院住院时间增加，而康复住院时间减少。
实施基于证据的临床路径可降低术后发病率，且不影响住院死亡率或住院护理的总体费用。不能排除医疗护理趋势变化的影响，但几个临床领域并发症的减少支持了临床路径的积极影响。围手术期CP是针对这一脆弱患者群体的一种成功管理方法，因为患者发病率降低，且未对资源利用产生负面影响。
