Optimizing the pathway for simple stable fractures

Introduction

In the Netherlands, general practitioners (GPs) can request radiographs in hospitals. Once a fracture is diagnosed by the radiologist, the patient is immediately referred to the emergency department (ED) and reviewed by the ED team (consisting of emergency physicians).¹ There, a plaster cast is applied if repositioning or surgery is not necessary. Only when surgery is needed will a patient be reviewed by someone from the surgery or orthopaedic department at the ED. After this conservative treatment, a fracture check takes place after five to eight days in the traumatology outpatient clinic (OC). At the OC, patients will be reviewed by someone from the surgery or orthopaedic department. In some cases, a new radiograph may need to be obtained before the scheduled appointment.¹

As they are given the lowest priority, trauma patients referred secondarily often must endure lengthy waiting times in the ED before receiving treatment.² Therefore, Máxima Medical Centre (MMC), a 614-bed teaching hospital in the Netherlands, has changed its care pathway regarding minor trauma. Since April 2020, when a fracture is diagnosed, patients are immediately referred to the trauma OC instead. To our knowledge, this adjustment to the care pathway for fracture patients has not been studied before. Literature on slightly different adjustments is scarce, but results are promising.^3,4Figure 1 shows a flow diagram of the former and new care pathways.

Fig. 1

Flow diagram of the former and new care pathways. ED, emergency department; GP, general practitioner; TOC, traumatology outpatient clinic.

Accordingly, this study aimed to describe beneficial healthcare consumption and costs of immediately referring patients to the traumatology OC after diagnosis instead of the ED. We hypothesized that the new care pathway leads to shorter duration of hospital visits, fewer hospital visits, less imaging, fewer medical procedures, and a decrease in healthcare costs.

Methods

Participants

During the period of August to October 2019 and August to October 2020, 739 patients meeting inclusion criteria were admitted to the ED or were seen at the traumatology OC. A total of 105 of these patients were excluded, for reasons shown in Figure 2. Consequently, 321 patients were retrospectively included in the control group and 313 patients were included in the research group. The flowchart depicting inclusion and exclusion is summarized in Figure 2.

Fig. 2

Flowchart of patients included and excluded in the study groups.

An interesting difference between the number of excluded patients who needed reposition between both study groups is presented in the flowchart. This difference might be explained by variation in training levels of the staff in both groups. ED staff might be more guarding than the (orthopaedic) surgeons because they have less experience, and therefore may perform more repositions to optimize the fracture position.

Results

Discussion

The present analyses show that the new care pathway leads to shorter initial hospital visits, fewer hospital visits, a reduction in the number of medical procedures, and a considerable overall decrease in healthcare costs. No reduction in imaging was found.

The new fracture care pathway implemented by MMC provides a novel model of care resulting in a decrease in workload at the ED. The intervention involved referring patients with radiologically diagnosed fractures, identified through a radiograph requested by their GP, to the traumatology OC instead of the ED. The implementation of the new care pathway did not lead to an increase in workload at the traumatology OC, as a pilot was conducted to determine when and how many appointment slots at the clinic should be kept vacant for these fracture patients.

The efficacy of various care pathways for fracture patients remains unclear. Several initiatives on other care pathways have been studied. First, the Trauma Triage clinic (TTC) in Edinburgh, UK presents a new way of triaging in the ED. The presence of risk factors in relation to the complication of recovery of a fracture was examined by a consultant-supervised nurse practitioner directly via the ED or after a telephone consultation. If these risk factors applied, a medical specialist was immediately involved. Otherwise, a patient was sent home with a removable orthosis. A patient was also referred to the TTC to receive a definitive treatment plan.³ Our study showed that this care pathway is a safe and effective method for the treatment of minor traumas. Although all patients in our study were seen by a medical specialist, we found similar results: fewer hospital visits were necessary to accomplish the same treatment outcome, making it an effective care pathway. Moreover, both studies found a decrease in healthcare costs per patient (£130 (€155, 22 November 2021) for the TTC versus €303 for this present study). However, we found a larger decrease in healthcare costs, since our patients did not visit the ED at their initial hospital visit. This saved approximately €200 per patient for the first hospital visit alone. The other €100 per patient was saved because of one fewer hospital visit. Although the research group overall had fewer medical procedures, no difference was found in costs for medical procedures since circular casts and walking casts were more common in the research group than in the control group. Such casts are more expensive than plaster casts (which were more common in the control group). No difference was found in imaging costs in this present study.

The Virtual Fracture Clinic (VFC) 1.0, implemented in Amsterdam, Netherlands, is akin to the TTC. Patients with a radiologically diagnosed fracture in the ED were provided a brace or pressure bandage to be removed themselves. Since these patients did not receive a plaster cast, they did not need follow-up visitations in the OC or plaster room. This resulted in a decrease of 91% in repeat consultations and a decrease of 72% in imaging, while patient satisfaction and treatment outcomes remained the same.⁵ In the present study, we did not see a reduction in imaging because in our former protocol, no routine follow-up imaging was enclosed except for proximal humeral fractures. Furthermore, we found a decrease in repeat consultations. However, we only found a decrease of 33% in repeat consultations and no significant difference in imaging between both care pathways. Meanwhile, the VFC 1.0 had fewer physical repeat consultations than MMC (mean 1.3 vs 1.9 repeat consultations) and repeat imaging (mean 0.3 vs 0.7 repeat imaging) per patient at baseline.⁵ This difference in number of repeat consultations may be attributable to a difference in definition; the VFC 1.0 only calculated physical repeat consultations, while we calculated both physical consultations and consultations by telephone. In the VFC 1.0 study, most follow-up checks were planned by telephone. Nevertheless, if follow-up by telephone or video calling would have been included, the VFC 1.0 would still have found a larger reduction in the number of repeat consultations than the present study. On the other hand, the VFC 1.0 found a smaller mean decrease in healthcare costs per patient (€86 versus €291.73). Although a median was used for healthcare costs in the current study, we here present the mean to enable comparison with results of the VFC 1.0. This difference between both studies is caused by the difference in costs for an ED visit versus an OC visit. Both study groups in the VFC 1.0 visited the ED, whereas patients in our study visited the traumatology OC, saving approximately €200 per patient. The decrease in health costs in the VFC 1.0 can be explained by a reduction in repeat consultations and imaging.

Another initiative, the VFC 2.0, also implemented in Amsterdam, is a fast-track process in the ED in which patients receive a plaster, bandage, or removable brace after a radiologically diagnosed fracture. The next working day, the patient’s case is discussed by a specially equipped team, led by a medical specialist, after which the patient receives a treatment proposal and the dates of the planned telephone or video call follow-up. The VFC study found a shorter hospital stay during the initial hospital visit, comparable to the present study.⁶

Consequently, three systematic reviews concluded that other VFCs appeared to be safe, cost-effective, and efficient in treating patients with minor traumas.^7-9 These VFCs are different from VFC 1.0 and VFC 2.0 implemented in Amsterdam, and different from the care pathway presented in the current study. In the case of a suspected fracture, patients who visit VFCs undergo a radiograph, but they do not receive the results or visit the ED, nor are they contacted by a traumatologist afterwards. The next working day, the radiograph is reviewed by the radiologist, after which the patient is called by a traumatologist and informed about the policy. Although patients in the reviewed studies had to return to the hospital the day after their radiograph, unlike patients in the present study, these studies also demonstrated a decrease in healthcare costs.

The present study has several strengths. To our knowledge, this is the first study to assess the effectiveness of a care pathway in which patients do not visit the ED after the diagnosis of a simple stable fracture. Second, the present study had a large sample size (n = 634), providing a reasonably accurate representation of the outcomes that could be expected if this care pathway was implemented in the population. Third, as far as we know, this is also the first study to evaluate the number of medical procedures for a new care pathway for minor trauma patients. Other studies have analyzed cost-effectiveness and differences in frequency of imaging and number of hospital visits, but not the differences in the number of medical procedures. Finally, the cost-effectiveness of a comparable, albeit not identical, care pathway has been analyzed by Mackenzie et al.⁴ While they recommend further research into the clinical effectiveness and cost-effectiveness of the TTC, the present study assessed these two factors and is therefore a complement to the known literature about new care pathways for fracture patients.

This study also has several limitations. First, the data were obtained retrospectively, hence we were not able to analyze patient satisfaction. Nevertheless, the information for the most relevant outcome measures to analyze cost-effectiveness was present. Second, obtaining data on the time spent by patients in the hospital was somewhat challenging for the research group, as it involved using the time log from the notes in the electronic patient file. However, we believe that any potential information bias resulting from this challenge is minimal, based on our understanding of daily practice. It is recommended that future research into other care pathways for minor trauma patients focuses on other relevant outcome measures, such as treatment outcome and patient satisfaction.

We conclude that our new care pathway results in shorter initial hospital visits, fewer hospital visits, a reduction in medical procedures, and a substantial reduction in healthcare costs. Therefore, we recommend that each patient with a simple stable fracture diagnosed by a radiologist is referred to the traumatology OC instead of the ED. It is a cost-effective method of treating fracture patients that can prevent crowding at the ED.