Tsunemitsu Ayako, Shin Jung-Ho, Hamada Osamu, Tsutsumi Takahiko, Sasaki Noriko, Kunisawa Susumu, Imanaka Yuichi
Department of General Internal Medicine, Takatsuki General Hospital, Japan.
Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Japan.
Intern Med. 2025 Jul 15;64(14):2124-2135. doi: 10.2169/internalmedicine.4358-24. Epub 2025 Jan 3.
Objective Patients with hip fractures tend to have a poor prognosis. Although guideline-compliant practices are known to improve patient outcomes, there is a lack of evidence regarding the use of intervention to improve guideline adherence in hip fracture patients. The objective of our study was to evaluate guideline adherence by internists providing care to patients with hip fractures, using a protocol developed based on various guidelines. Method Protocol-driven care for hip fracture patients by internists began in April 2018 at our hospital. After its initiation, orthopedic surgeons performed the surgery, and the internists provided all other medical care. A controlled interrupted time-series analysis was used to evaluate the effects of protocol-driven care on guideline adherence to compare our hospital with other hospitals, using data extracted from a nationwide Japanese inpatient database covering the period April 2014 to March 2023. Results A total of 221,620 inpatients from 373 hospitals were included in the study. The initiation of protocol-driven care was associated with the guideline-recommended prescriptions: osteoporosis medication (incidence rate ratio (IRR): 8.09; 95% confidence interval (CI) 4.02-17.7), acetaminophen (IRR: 2.11; 95% CI 1.55-2.90), non-steroidal anti-inflammatory drugs (IRR: 0.16; 95% CI 0.11-0.24), and opioids (IRR: 5.96; 95% CI 3.14-12.2). However, there was no effect on the proportion of benzodiazepine prescriptions, surgery within 48 hours, deep venous thrombosis prophylaxis, or other perioperative outcomes, including medical fees. Conclusion The initiation of protocol-driven care by internists resulted in improved adherence to osteoporosis medication prescriptions and postoperative analgesic use compared with orthopedic care. This approach can be used as an effective method of care for elderly patients undergoing surgery.
目的 髋部骨折患者预后往往较差。尽管已知遵循指南的做法可改善患者预后，但缺乏关于使用干预措施来提高髋部骨折患者对指南依从性的证据。我们研究的目的是使用基于各种指南制定的方案，评估为髋部骨折患者提供护理的内科医生对指南的依从性。方法 内科医生对髋部骨折患者的方案驱动式护理于2018年4月在我院开始。启动后，骨科医生进行手术，内科医生提供所有其他医疗护理。使用对照中断时间序列分析来评估方案驱动式护理对指南依从性的影响，以将我院与其他医院进行比较，使用从2014年4月至2023年3月期间的全国性日本住院患者数据库中提取的数据。结果 该研究共纳入了来自373家医院的221,620名住院患者。方案驱动式护理的启动与指南推荐的处方相关：骨质疏松症药物（发病率比（IRR）：8.09；95%置信区间（CI）4.02 - 17.7）、对乙酰氨基酚（IRR：2.11；95%CI 1.55 - 2.90）、非甾体抗炎药（IRR：0.16；95%CI 0.11 - 0.24）和阿片类药物（IRR：5.96；95%CI 3.14 - 12.2）。然而，对苯二氮䓬类药物处方比例、48小时内手术、深静脉血栓预防或其他围手术期结果（包括医疗费用）没有影响。结论 与骨科护理相比，内科医生启动方案驱动式护理可提高对骨质疏松症药物处方和术后镇痛药物使用的依从性。这种方法可作为老年手术患者的有效护理方法。
