The relationship between short-term mortality and quality of care for hip fracture: a meta-analysis of clinical pathways for hip fracture.

OBJECTIVES

To assess the association between use of clinical pathways for hip fracture and changes in the rates of five inpatient complications and short-term mortality.

DESIGN

Meta-analysis of published studies examining clinical pathways for hip fracture, identified through systematic searches of electronic databases (MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials) and hand searches of selected article bibliographies.

SETTING

Observational and interventional studies of clinical pathways for hip fracture examining rates of deep venous thrombosis, pressure ulcer, surgical site infection, urinary tract infection, pneumonia, and inpatient or 30-day mortality.

PARTICIPANTS

Two reviewers.

MEASUREMENTS

Reviewers independently assessed eligibility and quality of studies and extracted data for outcomes of interest.

RESULTS

Meta-analysis of nine studies (4,637 patients) demonstrated lower odds of deep venous thrombosis (odds ratio (OR)=0.33, 95% CI=0.14-0.75), pressure ulcer (OR=0.48, 95% CI=0.30-0.75), surgical site infection (OR=0.48, 95% CI=0.25-0.89), and urinary tract infection (OR=0.71, 95% CI=0.52-0.98) in patients managed according to clinical pathways than in those receiving usual care. Statistically significant differences were not observed in the odds of pneumonia (OR=1.01, 95% CI=0.67-1.53) or in a combined outcome of in-hospital or 30-day mortality (OR=0.86, 95% CI=0.66-1.13).

CONCLUSION

An association was observed between clinical pathway use and lower odds of four common complications of hospitalization after hip fracture; only a small, statistically insignificant association was observed between pathway use and changes in short-term mortality, suggesting that assessments of hospital quality based on short-term mortality may not reflect important improvements in patient outcomes that hospitals may achieve using clinical pathways.