ORIGINAL RESEARCH
Abstract
Title. A cost-effectiveness study of a patient-centred integrated care pathway.
Aim. The aim of the study was to compare costs and consequences for an integrated
care pathway intervention group with those of a usual care group for patients
admitted with hip fracture.
Background. Rehabilitation for patients with hip fracture consists of training in
hospital and/or in a rehabilitation unit, and on their own at home with assistance
from community care staff. It is important for hospitals to provide methods of care
that can safeguard these older patients physical function and potential for independent living.
Methods. A consecutive sample of 112 independently living participants, aged
65 years or older and admitted to hospital with a hip fracture, were included in
the study. Data were collected over an 18-month period in 20032005. A costeffectiveness analysis was performed to compare an integrated care pathway
intervention (treatment A) with usual care (treatment B).
Results. There was a 40% reduction for each participant in the average total cost of
treatment A of 9685 vs. 15,984 for treatment B. Moreover, clinical effectiveness
was much improved. The cost-effectiveness ratio for treatment A was 14,840 vs.
31,908 for treatment B. In addition, 75% of the participants in treatment A were
successfully rehabilitated vs. 55% in treatment B.
Conclusions. The recovery trajectory for hip fracture surgery may be shortened if
nurses pay more attention to the individual patients resources and motivation for
rehabilitation. The application of an integrated care pathway with individualized
care appears to enhance both rehabilitation outcomes and cost-effectiveness.
Keywords: cost-effectiveness, hip fracture, integrated care pathway, nursing,
patient-centred care, rehabilitation
Introduction
Hip fractures are common throughout the world, with the
highest incidence occurring in the Scandinavian countries
(Thorngren 2003). The number of hip fractures that occur
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The study
Aim
The aim of the study was to compare costs and consequences
for the ICP intervention group with those of the usual care
group for patients admitted with acute hip fractures.
We hypothesized that the participants treated under a
streamlined, individualized management protocol developed
with input from nursing, medical and paramedical staff,
designed solely for the purpose of the study and based on
Methodology
The economic evaluation was performed using a costeffectiveness method within the framework of an intervention
study in which two care systems were compared: ICP vs.
usual care (Olsson et al. 2007a). The intervention study had a
prospective before-and-after design, and consecutive selection
was used to assign participants to the comparison (usual care)
group (n = 56) and the intervention group (n = 56). The level
to which participants are restored at discharge from hospital
could affect the cost to the community, i.e. if participants are
discharged prematurely; there is no true cost reduction, but
merely a shift in the cost.
The data for this study were derived from hospital care
alone. It was assumed that, if the physical function of
participants in the intervention group was equal to or better
than that in the comparison group and they returned to their
previous mode of living, then the costs after discharge would
be equal or possibly less. A positive result for the intervention
group would therefore not represent a shift in costs from
hospital care to community care, but would instead be a true
gain in terms of health and cost. This enabled the cost
analysis to be calculated from a hospital perspective.
Validity and reliability
Evaluating a new treatment method involving the whole care
organization includes evaluations of three measures. The
most important measure is the effectiveness of the method,
but the cost of the treatment and the cost of developing the
new care organization are also important. There are four
main methods for making economic evaluations in health
care, two of which were considered for use in this study [costminimization analysis and cost-effectiveness analysis (CEA)].
Cost-minimization analysis compares treatments solely on
the basis of costs, and therefore the outcomes have to be
identical (Drummond et al. 1997, Kobelt 2002). Because the
health consequences were not identical in the present study,
cost-effectiveness analysis was preferable (Olsson et al.
2007a). CEA, a technique for selecting among competing
wants wherever resources are limited, assesses both costs and
consequences. In health care, CEA is used for two basic
purposes: to determine the most efficient way to allocate
limited resources among a variety of interventions for different illnesses and to choose between two or more mutually
exclusive treatment possibilities for the same health problem.
CEA can be based on experimental observations of competing interventions or on secondary data analysis involving
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Sample-size calculation
A total of 112 patients, consecutively selected, participated
and were divided into two equal groups of 56 patients. The
sample size was based on an audit of hospital records
(Kallstrom 2000). In the audit, the mean length of hospital
stay was 31 days (range 369, median 30 and SD 145). We
then assumed that we would be able to reduce the hospital
length of stay by 8 days. We found that 53 patients would be
required in each group to achieve 80% power for detecting
an 8-day reduction in the length of hospital stay at a
statistical significance level of P 005.
Participants
Patients aged 65 years or older admitted for a hip fracture
and living independently participated in the study. The
exclusion criteria were pathological fracture and severe
intellectual impairment according to Pfeiffers test (<3 points)
(Pfeiffer 1975). All eligible patients agreed to participate in
the study. Three patients in the comparison group died before
discharge from hospital. The two study groups were equal in
terms of all prefracture demographics (Table 1). There were
no readmissions related to hip fracture within 30 days of
discharge in either group. One-year survival after surgery was
84% in both groups.
Data collection
The data were collected over an 18-month period in 2003
2005 (see also Olsson et al. 2007a).
Costs
The study was designed from a hospital perspective, i.e. only
direct hospital health care costs were studied. Direct nonmedical costs, i.e. costs generated from relatives (e.g. having
to take time off from work for participating in care planning
or escort their relative on discharge) were believed to be
unaffected by the intervention and therefore were not studied. Indirect costs were not calculated because of the high age
of the participants (mean 84 years), suggesting that no loss of
income or fall in production occurred. The costs were studied
using a bottom-up methodology, i.e. costs were collected
directly from a patient sample prospectively for a given time,
but were not discounted (Drummond et al. 1997, Kobelt
2002). Discounting was not considered useful because the
follow-up was only 1 year. All costs were actual, covering all
Data
Female/male
Mean age
SD
Living (%)
With someone
Alone
Place of accident (%)
At home
Outside home
Number of co-morbidities
Mean
Range
General medical health (%)
A
B
C
Intra-capsular fracture (%)
Hemiarthroplasty
Osteosynthesis
with 2 parallel nails
Extra capsular fracture (%)
Type of living (%)
Flat
House
Service flat
Need of home help (%)
None
Once a week
Daily
Type of walking aid (%)
None
Stick
Walking frame
Gait capacity (%)
Walking outdoors alone
Walking outdoors with assistance
Walking indoors alone
Walking indoors with assistance
Cognitive functioning at admission
Mean
Median
Range
Prefracture independence,
80100%
6079%
<60%
Mean
SD
Comparison
(n = 56)
ICP
(n = 56)
42/14
84
70
41/15
84
69
10
09
19 (34)
37 (66)
14 (25)
42 (75)
04
41 (73)
15 (27)
43 (77)
13 (23)
08
2
08
3
08
P-value
03
10 (18)
33 (59)
13 (23)
5 (9)
29 (52)
22 (39)
01
29 (52)
28
1
27 (48)
21 (38)
18
3
35 (62)
01
31 (55)
13 (23)
12 (21)
37 (66)
7 (12)
12
03
34 (61)
7 (12)
15 (27)
28 (50)
9 (16)
19 (34)
04
27 (48)
11 (20)
18 (32)
22 (39)
8 (14)
26 (46)
03
31 (55)
9 (16)
13 (23)
2 (4)
26 (46)
11 (20)
13 (23)
6 (11)
04
8
9
310
7
8
310
04
36
13
6
84
165
35
10
11
82
231
03
Students t-test was used to compare age, cognitive functioning and prefracture independence.
Fishers exact test was used for all others.
Ceder Scale (Ceder et al. 1980).
Missing data. Three patients died in the comparison group. Their available data were used.
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Registered nurses
Enrolled nurses
Physiotherapists
Occupational therapists
Hospital welfare officer
Physician
248
207
231
234
241
502
Clinic
Orthopaedic ward
Geriatric ward
592
438
Treatment cost
Radiology (X-ray)
Hip
Lung
Clinical physiology
UCG
Chemistry
Routine blood test
Microbiology
Urine culture and swab
Blood culture
Haematology
Blood grouping
Unit of blood
Theatre
Postoperative unit
Data analysis
Cost per unit ()
628
873
3506
199
96
206
316
944
207/minutes
426/hours
Hotel cost includes cost of housing, food, drugs, health care and
administration.
Costs for radiology, chemistry, haematology, theatre and care in the
postoperative unit relate to all patients. Urine cultures and swab was
frequent. Ultrasound cardiogram (UCG) and blood cultures was less
frequent.
Table 4 The modified Katz ADL index score (Katz et al. 1963)
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Independent
Dependent for bathing
Dependent for bathing and dressing
Dependent for bathing, dressing and toileting
Dependent for bathing, dressing, toileting
and transferring
Dependent for bathing, dressing, toileting,
transferring and continence
Dependent
A
B
C
D
E
F
G
Q1
Treatment A costs more than
treatment B and is less
effective
Q3
Treatment A costs more than
treatment B and is more
effective
Q2
Treatment A costs less than
treatment B and is less
effective
Q4
Treatment A costs less than
treatment B and is more
effective
Results
The Students t-test (two-tailed) was used to compare mean
differences in costs between the intervention and comparison
groups. Means, 5% trimmed means and medians are
provided in Table 5 to show whether the cost is normally
distributed. A non-parametric MannWhitney U-test was
used to further display the results (Table 5). A 5% significance level was applied throughout.
Costs
treatments were compared on costs and effects,
cost A=effect A vs. cost B=effect B, which could yield four
combinations (Borgstrom 2006; Figure 1). If the result was
found to be the same as in the first two quadrants (Q1 and
Q2), the result was considered unsuccessful because the
intervention treatment was less effective and the cost then
becomes irrelevant. If the result turned out to be the same as
in the last two quadrants (Q3 and Q4), it was considered
successful because the intervention treatment is more effective and it then becomes a matter of cost.
Ethical considerations
The study was approved by the appropriate research ethics
committee. Patients received both oral and written information about the study at admission, and written consent was
obtained before participation.
Mean () (5%
trimmed mean)
Mean ()
(5% trimmed Median
mean)
()
Median
()
Hotel cost
12,768 (12,405) 11,082
Treatment cost
Radiology
448 (431)
338
Clinical physiology
97 (77)
46
Chemistry
103 (94)
68
Microbiology
21 (20)
17
Blood transfusions
206 (187)
130
Theatre/postop
1471 (1423)
1312
Total cost
15,984 (15,645) 14,031
SD
SD
95% CI of the
difference
P-value
Lower
Upper
Nonparametric
Parametric test
test (t-test) (MannWhitney)
3687
79930 0001
6950
2155
244
374 (364)
139
94 (86)
79
69 (63)
17
21 (18)
210
263 (242)
617 1157 (1126)
7959 9685 (9629)
330
26
50
9
230
1157
9654
167
18
1586
137 1990
2048
45
82
577
26 1290
149
241 1492
232
459
943
5117
2219 42550 88280
005
09
0009
09
01
0005
0001
0000
02
09
002
05
01
0007
0000
The costs were calculated using Students t-test (two-tailed) for independent groups and a 95% confidence interval to compare means between
the intervention and comparison group. A non-parametric MannWhitney test was to confirm the results. All costs are given at the year 2004
rates, and they were then converted from Swedish crowns (SEK) to euros () using the yearly average exchange rate for the year 2004
(91268 SEK/). All italic values are not significant.
Three patients in the comparison group died.
Data missing from one patient.
2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd
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Cost-effectiveness ratio
The effectiveness of the intervention has been described and
explained in more detail in a previous paper (Olsson et al.
2007a). Treatment A produced 36 successfully rehabilitated
participants at a cost of 534,249; this compares with
treatment B, which produced 27 successfully rehabilitated
participants at a cost of 861,532.
The equation
cost A534; 249=effect A36 successful casesvs.
cost B861; 532=effective 27 successful cases
yielded a cost-effectiveness ratio of 14,840 per successfully
rehabilitated participant and a fail percentage of 25% in
treatment A, and 31,908 per successfully rehabilitated
participant and a fail percentage of 45% in treatment B.
Discussion
The main finding of this study was that the ICP intervention
treatment was less expensive and more effective. The cost
reduction originated mostly from the decrease in hotel costs
owing to the reduced length of stay. However, the reduction
was also statistically significant in some areas of the treatment
cost, such as chemistry, radiology and theatre/postoperative
care. With the increasing number of hip fractures, the
economic aspect is becoming increasingly important, something previous researchers have also recognized (Autier et al.
2000, Haentjens et al. 2001, Braithwaite et al. 2003,
Lawrence et al. 2005). The intervention appears to be a step
in the right direction, as both costs and effectiveness were
improved. The most effective aspect of the intervention was
the thorough interview of patients on admission to the ward.
The interview generated valuable information about the
patients and their prerequisites for rehabilitation. From the
admission interview, an understanding was developed that
provided a starting point for our prognostic reasoning.
In the standard care group, assessment of the patients was
primarily built on clinical experience. Thus, the patients
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Study limitations
Performing an economic evaluation of the intervention
involved a multitude of difficulties as the study was not
specifically designed for this evaluation. Preferably, the
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Conclusion
Although older patients are often frail, they have a strong zest
for life and desire to remain independent (Olsson et al. 2007b).
Our results indicate that the recovery trajectory for hip fracture surgery might be shortened if nurses paid more attention
to individual patients resources and motivations for rehabilitation. The application of patient-centred care appears to
enhance both rehabilitation outcomes and cost-effectiveness.
Funding
This study was supported by grants from the local research
council for Gothenburg and southern Bohuslan (no grant
numbers provided).
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
LEO and EH were responsible for the study conception and
design. LEO performed the data collection. LEO performed
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References
Autier P., Haentjens P., Bentin J., Ballion J.M., Grivegnee A.R.,
Closon M.C. & Boonen S. (2000) Costs induced by hip fractures: a
prospective controlled study in Belgium. Osteoporosis International 11, 373380.
Borgstrom F. (2006) Health Economics of Osteoporosis. Dissertation, Karolinska Institutet, Stockholm, Sweden.
Braithwaite R.S., Nanada F.C. & Wong J.B. (2003) Estimating hip
fracture morbidity, mortality and costs. Journal of American
Geriatric Society 51, 364370.
Campbell H., Hotchkiss R., Bradshaw N. & Porteous M. (1998)
Integrated care pathways. British Medical Journal 316, 133137.
Ceder L., Thorngren K.G. & Wallden B. (1980) Prognostic indicators
and early home rehabilitation in elderly patients with hip fractures.
Clinical Orthopaedics 152, 173184.
Cheah J. (2002) Development and implementing of a clinical pathway programme in acute care general hospital in Singapore.
International Journal for Quality in Health Care 12, 403412.
Choong P.F.M., Langford A.K., Dowsey M.M. & Santamaoa N.M.
(2000) Pathway for fractured neck of femur: a prospective, controlled study. The Medical Journal of Australia 172, 423426.
Cooper C., Campion G. & Melton I.J. 3rd (1992) Hip fractures in
the elderly: a world wide projection. Osteoporosis International 2,
285289.
Curry-Cox L., Hogstel M.O. & Davies G.C. (2003) Functional status
in older women following hip fracture. Journal of Advanced
Nursing 42, 347354.
Dowsey M.M., Kilgour M.L., Santamaria N.M. & Choong P.F.
(1999) Clinical pathways in hip and knee arthroplasty: a prospective, randomised controlled study. The Medical Journal of
Australia 170, 5962.
Drummond M.F., OBrien B., Stoddart G.L. & Torrance G.W.
(1997) Methods for the Economic Evaluation of Health Care
Programmes, 2nd edn. Oxford Medical Publications, Oxford
University Press, Oxford, New York, Toronto, pp. 96131
Gholve K.A., Kosygan K.P., Sturdee S.W. & Faraj A.A. (2005)
Multidisciplinary integrated care pathway for fractured neck of
femur: a prospective trial with improved outcome. Injury 36, 9398.
Haentjens P., Autier P., Barette M. & Boonen S. (2001) The economic cost of hip fractures among elderly women: a one-year,
prospective, observational cohort study with matched-pair analysis. Journal of Bone and Joint Surgery 4, 493500.
Johnell O. (1997) The socioeconomic burden of fractures: today and
in the 21st century. The American Journal of Medicine 103, 2025.
Kallstrom L. (2000) Effektivitet i SU-sjukvarden Granskningsresultat av en vardkedjestudie varen 2000 (Efficiency of the
Sahlgrenska University hospitals Medical service Result from an
audit of the care in the spring of year 2000) Revisionsenheten
for Vastra Gotaland i Vanersborg Komrev AB, September 2000
(Regional auditors of Vastra Gotaland in Vanersborg).
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