title: Mortality and morbidity after hip fracture: can evidence based clinical pathways make a difference?
abstract: OBJECTIVE
  To evaluate whether evidence based clinical pathways for acute management of hip fracture have an effect on patient care, short term mortality, or residential status.
  
  
  METHODS
  Observational cohort study comparing management, as determined by medical record review, and outcomes, as determined by telephone followup 4 months post-fracture, before (n = 455) and after (n = 481) clinical pathway implementation within pathway hospitals as well as between patients admitted to hospitals with (n = 2) and without (n = 4) pathways.
  
  
  RESULTS
  Mean age was 82 years, 80% were women and 30% were admitted from nursing homes. Significant improvement in best practice as recommended by evidence based clinical guidelines was evident in pathway hospitals for most components of care. However, compliance was variable and nonpathway hospitals performed better for some (use of spinal anesthesia, avoidance of urinary catheters). After adjusting for potential confounders, no difference was found in 4 month mortality between the pathway (17.6%) and non-pathway (16.8%) patients (OR 0.8, 95% CI 0.5-1.5). There was a nonsignificant reduction in median acute care hospital length of stay of 1 day (p = 0.200) for non-nursing home patients and a significant reduction of 1 day (p = 0.038) for nursing home patients in the pathway hospitals. There was a nonsignificant decrease in admission rates for new patients to nursing homes in pathway hospitals (18.5%) compared to non-pathway hospitals (24.3%) (OR 0.5, 95% CI 0.3-1.1).
  
  
  CONCLUSIONS
  Clinical pathways were associated with increased use of evidence based best practice, some reduction in acute hospital length of stay, but no significant effect on 4 month mortality or residential status. Their development and maintenance were resource intensive and further work on the implementation of evidence based guidelines is needed to determine whether they can influence patient outcomes.
authors.affiliation: University of Sydney Professorial Department of Rheumatology, Royal North Shore Hospital, St. Leonards, NSW, Australia. lmarc@health.doh.nsw.gov.au
authors.forename: L M
authors.initials: LM
authors.lastname: March
authors.forename: I D
authors.initials: ID
authors.lastname: Cameron
authors.forename: R G
authors.initials: RG
authors.lastname: Cumming
authors.forename: A C
authors.initials: AC
authors.lastname: Chamberlain
authors.forename: J M
authors.initials: JM
authors.lastname: Schwarz
authors.forename: A J
authors.initials: AJ
authors.lastname: Brnabic
authors.forename: P
authors.initials: P
authors.lastname: O'Meara
authors.forename: T F
authors.initials: TF
authors.lastname: Taylor
authors.forename: S
authors.initials: S
authors.lastname: Riley
authors.forename: P N
authors.initials: PN
authors.lastname: Sambrook
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019091:Critical Pathways / Q000592:standards* / Q000706:statistics & numerical data*; D005260:Female; D006620:Hip Fractures / Q000401:mortality* / Q000628:therapy*; D006761:Hospitals / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D009735:Nursing Homes / Q000706:statistics & numerical data; D016896:Treatment Outcome