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Systematic review
Do we understand each other when we develop and implement hip fracture models of care? A systematic review with narrative synthesis
  1. Elizabeth Armstrong1,2,
  2. Lara A Harvey1,2,
  3. Narelle L Payne2,
  4. Jing Zhang1,
  5. Pengpeng Ye3,4,
  6. Ian A Harris5,6,7,
  7. Maoyi Tian3,8,
  8. Rebecca Q Ivers1,3
  1. 1School of Population Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
  2. 2Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
  3. 3The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
  4. 4National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
  5. 5Orthopaedic Department, Liverpool Hospital, Sydney, New South Wales, Australia
  6. 6Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
  7. 7School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
  8. 8School of Public Health, Harbin Medical University, Harbin, China
  1. Correspondence to Elizabeth Armstrong; elizabeth.armstrong{at}unsw.edu.au

Abstract

Background A hip fracture in an older person is a devastating injury. It impacts functional mobility, independence and survival. Models of care may provide a means for delivering integrated hip fracture care in less well-resourced settings. The aim of this review was to determine the elements of hip fracture models of care to inform the development of an adaptable model of care for low and middle-income countries (LMICs).

Methods Multiple databases were searched for papers reporting a hip fracture model of care for any part of the patient pathway from injury to rehabilitation. Results were limited to publications from 2000. Titles, abstracts and full texts were screened based on eligibility criteria. Papers were evaluated with an equity lens against eight conceptual criteria adapted from an existing description of a model of care.

Results 82 papers were included, half of which were published since 2015. Only two papers were from middle-income countries and only two papers were evaluated as reporting all conceptual criteria from the existing description. The most identified criterion was an evidence-informed intervention and the least identified was the inclusion of patient stakeholders.

Conclusion Interventions described as models of care for hip fracture are unlikely to include previously described conceptual criteria. They are most likely to be orthogeriatric approaches to service delivery, which is a barrier to their implementation in resource-limited settings. In LMICs, the provision of orthogeriatric competencies by other team members is an area for further investigation.

  • hip fractures
  • health services research
  • healthcare quality improvement
  • health policy

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2023-002273

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Models of care are developed and implemented to translate research into clinical practice; however, the term is ambiguously defined and described which may be a factor hindering their application to new settings.

    WHAT THIS STUDY ADDS

    • Provides an overview of the elements of hip fracture models of care and proposes a practical definition for ensuring consistent application of the term to new interventions.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • The findings can be used to inform the development of hip fracture models of care, as a consistent definition will aid comprehension of the core components among those tasked with their development and implementation.

    Introduction

    A hip fracture in an older person is a devastating injury impacting a person’s functional mobility, independence and survival.1 2 Definitive surgical management provides patients with the best opportunity for recovery, and high-income countries (HICs) have implemented complex, multicomponent interventions targeting different levels of their respective health systems to address deficiencies in the provision of recommended care to older people with a hip fracture.3 4 The objectives of these interventions are consistent: early ward admission; preoperative assessment and management of pain, nutritional status and cognition; medical optimisation for expedited surgery; early postoperative ambulation to prevent hospital-derived complications; and the prevention of further falls and fractures.5

    In countries with fewer resources, health systems are facing emerging challenges associated with the burden of fragility fractures.6 There is evidence of gaps in hip fracture care between what has been shown to improve patient outcomes and what is available to patients in these settings.7 8 Non-operative treatment or delayed surgery has been shown to increase postoperative complications, including an increased risk of death.9 10 Factors contributing to these outcomes may include a lack of access to emergency trauma transport, delayed patient or family decisions to seek treatment, lack of hospital infrastructure or biases against admitting the oldest and sickest patients for treatment.11 12 Once admitted, the provision of surgical treatment is impacted by organisational or system-based factors, such as the availability of clinical staff, prostheses supply or the patient’s level of health insurance.13

    As these factors involve health system, patient, clinician and organisational influences,14 a hip fracture model of care (MoC) may provide a coordinated approach for less well-resourced health systems to address any gaps in the delivery of hip fracture care.15 Therefore, we explored the literature specific to hip fracture to identify interventions described as an MoC and identify their key characteristics. We evaluated the included papers against conceptual criteria adapted from an existing description provided by Davidson and Elliott,16 and subsequently expanded by Davidson and colleagues, to encompass elements from quality improvement, change management theory and project management processes (Davidson’s definition).17 The aim of this review was to identify the elements of hip fracture MoCs and evaluate the models with an equity lens against conceptual criteria adapted from Davidson’s definition. This will inform the development of an adaptable MoC for implementation in resource-limited settings.

    Methods

    This review was registered a priori (PROSPERO CRD42020165680) and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.18 Members of the public were not involved in the design, conduct, reporting or dissemination plans of our research.

    Search strategy and study selection

    A preliminary search of Medline was completed using Medical Subject Headings and keyword terms to identify uses of the term ‘model of care’. This preliminary search identified heterogeneous interventions (clinical pathways, protocols, practice guidelines, quality standards and care bundles) that were termed an MoC. Iterative development of the final search terms was carried out with the assistance of a UNSW Sydney librarian. The final Medline search terms (online supplemental file 1) were adjusted for the other databases.

    Supplemental material

    Eight databases were searched on 30 March 2020: Medline, Embase, Emcare, Cumulative Index to Nursing and Allied Health Literature, Scopus, Web of Science, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects through Evidence-Based Medicine Reviews. Informed by the findings of Bramer et al,19 and using the terms ‘hip fracture’ AND ‘model of care’, the first 100 results in both Google and Google Scholar were also searched on 2 July 2020. Electronic database searches were supplemented by manual searches of reference lists from eligible studies, systematic reviews and reports from known hip fracture networks. Results were limited to publications from the year 2000 to reflect contemporary hip fracture care. Search results were imported into EndNote and duplicates removed. The remaining records were uploaded to Covidence review software (Veritas Health Innovation, Melbourne, Australia) for management of the screening and selection process.20 21 Duplicate screening of the title and abstract of all records was independently completed by five reviewers (EA, NLP, LAH, JZ and PY). Discussion resolved disagreements; however, if agreement of title and abstract screening was not achieved, the paper was progressed to full-text review.

    Inclusion and exclusion criteria

    We included individual studies or papers if they reported an MoC for adults with a minimal trauma hip fracture managed in the prehospital, hospital or posthospital period of care. Systematic reviews, meta-analyses and meta-syntheses of qualitative research were screened for relevant literature but were not included. The inclusion and exclusion criteria are more fully described in table 1.

    View this table:
    Table 1

    Eligibility criteria for studies/reports describing a model of care for hip fracture

    Data extraction

    A data extraction spreadsheet (Microsoft Excel) was developed and five authors piloted the spreadsheet by extracting data from six randomly selected papers. The spreadsheet was modified after discussion, and another 13 randomly selected papers were used to further refine the spreadsheet. One author (EA) extracted the data for all 13 papers and a second independent data extraction was completed by one of three authors (NLP, LAH, JZ). After reviewing the second extraction and further refining the data extraction spreadsheet, the remaining papers were completed by a single author (EA). We extracted publication information, study characteristics, MoC elements, participant inclusion and exclusion criteria, the country and scale of implementation, the multidisciplinary team members involved and reported outcomes. Each paper was assessed with an equity lens22 against the criteria adapted from Davidson et al.17 These criteria for the MoC included: informed by baseline data relevant to the scale of implementation; based on evidence or accepted theory; informed by patients or relatives; informed by the needs of non-patient stakeholders; included two or more clinical specialties (multidisciplinary); equity of access for all patients; efficient use of resources; and an evaluation or feedback loop.

    Quality assessment and risk of bias

    Quality or risk of bias assessment was not completed as we were interested in detailing the characteristics of the hip fracture MoC to clarify the MoC concept, rather than evaluate the accuracy or effectiveness of the results of individual papers.

    Results

    Database searches yielded 8865 records. After removal of duplicates (n=3383), and ineligible papers identified with title and abstract screening (n=5061), 421 papers had their full text assessed for inclusion. Full text review excluded 340 papers leaving 81 papers. One additional paper was identified by searching the reference lists of included papers. This resulted in 82 papers being included in the final review (figure 1).

    Figure 1
    Figure 1

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of the systematic approach to the literature search.18

    Study characteristics

    The characteristics of the 82 papers included in this review are summarised in online supplemental file 2. Half of the included papers were published since 2015, and they represent 22 countries from five global regions: Europe and the UK (n=34)23–56; the Americas (n=24)57–80; South-East Asia (n=11)81–91; Australia and New Zealand (n=8)92–99; and the Middle East (n=5).100–104 HICs were represented in 80 papers and two studies were undertaken in upper middle-income countries, one each in China,84 and Colombia.59 Two papers were state/provincial MoCs describing redesign initiatives for a specific health system: one in Alberta, Canada,70 and one in South Australia.94 Five papers reported quality improvement approaches.30 57 58 77 85 Three papers used experimental designs,43 83 91 and the remaining papers used observational designs: prospective observational, prospective with retrospective or historical control, or retrospective analyses of data. No qualitative studies were identified that investigated patient perspectives of hip fracture MoCs. The 82 papers included 84 233 patients with study sample sizes ranging from 31 to 23 973 participants. The minimum age of participants eligible for each MoC varied; 48 papers included participants aged 65 and over. Several papers evaluated different outcomes for the same MoC.61 66 69 71–74 77–80 89 100–104

    Supplemental material

    Interventions termed an MoC

    The papers used different terms to describe their intervention and included orthogeriatric, integrated, comanaged, coordinated, integrative, interdisciplinary, comprehensive or multidisciplinary MoCs or care models. Other terms used were pathways, protocols, care bundles, fracture centres, process management, services or programmes. One paper provided an MoC definition.50 Online supplemental file 3 includes a description of the interventions in the included papers and details the MoC components, period of care, time point for outcome measures and a summary of the authors findings.

    Supplemental material

    Scale of implementation

    Seven papers reported MoCs implemented at two hospitals,26 32 42 61 65 66 97 and six papers reported multisite implementation or participation.24 33 38 50 70 94 The remaining 69 papers reported single-site implementation.

    Clinical roles in the delivery of the MoC

    The MoCs were delivered by teams consisting of two or more clinicians from multiple medical specialties or from diverse multidisciplinary clinical areas. Only three papers reported a model that was not multidisciplinary.51 65 67 Most types of service delivery described orthogeriatric care; that is, orthopaedic surgeons and geriatric medicine physicians working together to lead the delivery of clinical care. Various methods for providing orthogeriatric care were described. Most papers (n=78) reported interventions involving two or more clinical disciplines, and this is likely to reflect the high representation of orthogeriatric service delivery. Figure 2 shows the clinician groups providing the various MoCs in the included papers. The length of the bar indicates the frequency with which the role was specified as part of the multidisciplinary team.

    Figure 2
    Figure 2

    Clinician groups identified as members of the multidisciplinary team. DM, diabetes mellitus; OP, osteoporosis.

    Evaluation of MoC characteristics against Davidson’s definition

    Online supplemental file 4 details the assessment of the MoCs against the elements adapted from Davidson et al.17 Only two of the 82 included papers met all criteria,57 58 with another three papers meeting all but one criterion.63 73 93 The most commonly included components were multidisciplinary teams (n=79) and the use of theory or existing evidence (n=78). The least identified component was the inclusion of patient stakeholders to inform the intervention (n=2). Only 25 papers described a baseline assessment using data relevant to the scale of planned implementation, giving a locally applicable, contextual rationale for the intervention.

    Supplemental material

    Equity characteristics and outcomes

    Age for inclusion to the MoC varied although 65 years was the most common age used for eligibility. Discounting younger age, pathological fracture, non-operative treatment or multitrauma injury as criteria for exclusion, 31 papers reported characteristics common to older people as a reason for excluding participants from the MoC intervention (see online supplemental file 2). The most frequent reasons for exclusion were the presence of a cognitive impairment, a nursing home as the prefracture residence or discharge destination, or the presence of medical comorbidities. Fifteen papers did not report any personal characteristics of patients, 15 papers reported race or ethnicity as demographic characteristics, 6 papers reported level of education, 4 papers reported marital status and 1 paper reported a ‘living with others’ category. Outcome measures used to evaluate the MoC were diverse and were most often clinical outcomes, process outcomes or financial outcomes (see table 2). Less commonly included were structural measures of provider systems and capacity (six papers) or balancing measures (26 papers) which are measures to identify unanticipated changes caused by the MoC. The most commonly used clinical outcome was mortality, measured at different time points, and length of stay was the most often used proxy measure for costs of care.

    View this table:
    Table 2

    Measures used to evaluate the models of care of included studies

    Discussion

    In this review, we have identified hip fracture MoCs and assessed them against eight adapted criteria from Davidson’s definition. Davidson’s concepts were represented in all 82 included papers; however, only two papers were assessed as including all adapted criteria. Only two papers reported an MoC implemented in a middle-income country, and none in low-income countries, suggesting MoCs may not be commonly implemented outside HICs, or they may be known by another term. We suggest the former, highlighting an opportunity to investigate multicomponent interventions for older people with hip fracture in resource-limited settings.

    Only one paper included a conceptual definition for their MoC.50 The authors recognised that models are created from existing evidence, but ‘should also take into consideration the healthcare resources available, financial resources, and the organization of the Health Care System in a given Country’ (p 317). This definition is consistent with Davidson’s, who also included resource utilisation and cultural acceptability, both of which are important considerations when developing and implementing interventions in new settings. Since Davidson et al,17 further attempts have been made to define an MoC. Briggs et al described them as ‘an evidence-informed policy or framework that outlines the optimal manner in which condition-specific care should be made available and delivered to consumers at a system level’ (p 361).15 They differentiated an MoC from clinical practice guidelines and models of service delivery; however, our review identified the majority of hip fracture MoCs as single-site approaches to delivering hip fracture services, suggesting that organisational service delivery at the clinician-patient interface is a core component. More recently, Jones et al105 concluded that an MoC is intended to ‘operationalise how best practice care is delivered at a disease, service or system level’ (p 328), and this is more consistent with our findings specific to hip fracture as this review found hip fracture MoCs may be targeted at different levels of the health system.

    We found a lack of clarity and consistency in the terminology used to describe MoCs. This may be an additional factor hindering their application to new settings. The term was used for a broad range of interventions, and this ambiguity makes translating ‘what works’ complicated, as new adopters may not understand each other when planning and implementing an MoC.106 Lack of clarity is not a finding limited to MoCs: Lawal and colleagues found a similar issue with clinical pathways when seeking to assess their effectiveness.107 108 We suggest there are important consequences of a lack of clarity for the application of what works to other settings and for evaluation of the intervention. Terms that are clearly defined, and consistently applied, give the best chance of common understanding among those tasked with developing interventions informed by existing theory or evidence.

    The most commonly identified elements of MoCs were the inclusion of two or more clinical disciplines and the use of existing evidence or theory. This is likely due to the large majority of included papers reporting orthogeriatric approaches to the delivery of patient care. Orthogeriatrics is the care of older people with fractures and is a subspecialty of geriatric medicine,109 although the term also encompasses clinical service delivery in which orthopaedic surgeons and geriatricians (or other medical physicians) share defined responsibilities for the clinical management of older people with a hip fracture. It primarily describes comanaged medical care rather than care that is broadly multidisciplinary, and while it is still unclear which specific service configuration is most effective, the surgeon-physician approach has been shown to improve patient survival, resource use and the coordination of clinical care to medically complex patients in complex healthcare environments.110

    A challenge for resource-limited settings is the lack of geriatric medicine specialists to share the medical-surgical care with orthopaedic surgeons. In the absence of geriatricians, medical care is provided by physician specialists. Zhang and colleagues111 have recently provided a successful example of coordinated surgeon-physician care, where orthogeriatric care is commenced in the emergency department by the emergency physician and anaesthetist before handing the patient’s care to the geriatrician when the patient is admitted to the ward. This sharing of geriatric medicine competencies with locally available physicians reflects a reorganisation of clinical service delivery using the available human resources. Their findings may move the emphasis of future research from the concept of a ‘most effective’ configuration of surgeon-geriatrician care to instead exploring the contextual factors that influence and support coordinated, timely surgeon-physician care. In addition to orthopaedic surgeons and geriatricians, we also identified other clinical disciplines represented in the MoCs, and this is consistent with a multidisciplinary approach. Physiotherapists, social workers, occupational therapists, anaesthetists and nurses are integral to the provision of multidisciplinary MoCs. Forty-two different clinician groups (and one category containing unspecified roles) were identified, although interestingly, anaesthetists were less likely than physiotherapists to be specified as members of the multidisciplinary team. As hip fractures are most effectively treated with surgery, and in the absence of other physician specialists in resource-limited settings, recognition of anaesthetists as members of the team, and in the early medical management of these patients, is essential.

    There are some limitations of this review. Due to variable use of the MoC concept term, some relevant papers may have been excluded; however, the search terms were broad to accommodate this diversity. The ambiguity of the meaning of an MoC may have led to the exclusion of papers reporting similar interventions to those included. The identification of only two papers from middle-income countries may be due to the English language requirement for full-text papers and this may have limited the identification of multicomponent interventions for hip fracture in low and middle-income countries (LMICs).

    The findings of this review lead us to propose a practical definition of an MoC: a contextually appropriate, culturally safe, evidence-based delivery of health services for a specific disease, injury or health condition, which optimises patient and family experience, clinical effectiveness and system-wide efficiency. Being able to consistently define this intervention will aid those tasked with their development and implementation and ensure consistent understanding and evaluation.

    Conclusion

    Interventions described as a hip fracture MoC are unlikely to include all the concepts identified as essential elements of an MoC. It is acknowledged that the identified papers were not written with the expectation of assessment against an MoC definition; however, using the existing literature to inform development of interventions for other settings is essential. Only two of the MoCs were implemented in countries with middle-income economies and this highlights a potential lack of applicability to LMICs. We also identified orthogeriatric service delivery as the most common feature of an MoC, which creates a need for workforce skill development to allow orthogeriatric concepts to be implemented in settings where geriatric specialists are uncommon. Future research should place less emphasis on the specific clinical specialties making up the multidisciplinary team, and more on understanding the characteristics of how successful teams function in their provision of hip fracture care for older people in various contexts, if progress in improving outcomes is to be seen globally.

    Data availability statement

    Data sharing not applicable as no datasets generated and/or analysed for this study.

    Ethics statements

    Patient consent for publication

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    Supplementary materials

    Footnotes

    • Contributors EA, LAH, NLP, RQI conceived the study; EA ran the searches; EA, LAH, NLP, JZ, PY screened and extracted data and performed initial analysis. ALL authors contributed to interpretation. EA wrote the first draft and ALL authors critically reviewed the paper and contributed to the final version. ALL authors approved the final version for submission and EA is the author acting as guarantor for this review.

    • Funding EA is the recipient of an Australian Government Research Training Programme Scholarship. JZ is the recipient of a UNSW University International Postgraduate Award. RQI has grant funding for salary support provided by the National Health and Medical Research Council (APP1136430).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.