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Abstract
Every year there are 1.3 million hip fractures globally; this is expected to rise to 6 million by 2050. Estimates of global cost is 1.75 million disability adjusted life years, and in established market economies, costs associated with hip fracture represent 1.4% of the total healthcare burden. New models of care will be required to meet this demand. Advance physiotherapy roles in elective arthroplasty across global settings have demonstrated benefit in safely reducing time burden on surgical teams and healthcare costs. The utility of similar roles in the care of hip fracture is unclear. This quality initiative (2020–2023) aimed to implement and evaluate a new model of care substituting a surgical registrar with an advanced physiotherapist in a post-discharge hip fracture clinic. Across many nonlinear, action/reflection cycles, a multi-disciplinary team engaged to operationalize key implementation strategies, mapped to the Expert Recommendations for Implementing Change (ERIC) project. Across the reporting period, 346 patients were seen by an advanced physiotherapist. Eighty-one patients seen by an advanced physiotherapist required informal discussion with the consultant surgeon. Fifteen patients required a formal consultant review. There were no patient complaints, critical incidents or other unintended consequences. The net surgical time realized over the three years was 110 hours.
- Hip Fractures
- Rehabilitation
- Outpatients
- Implementation science
- Quality improvement
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Every year, there are 1.3 million hip fractures globally; this is expected to rise to 6 million by 2050. Estimates of global cost are 1.75 million disability-adjusted life-years, and in established market economies costs associated with hip fracture represent 1.4% of the total healthcare burden.1 New models of care will be required to meet this demand, particularly given workforce shortages, particularly for skilled surgical specialists. Advance physiotherapy roles in elective arthroplasty across global settings have demonstrated benefit in safely reducing time burden on surgical teams and healthcare costs,2 3 although further economic evaluation work is needed to explain patient costs.4 The utility of similar roles in the care of hip fracture is unclear. This quality initiative aimed to implement and evaluate a new model of care substituting a surgical registrar with an advanced physiotherapist in a postdischarge hip fracture clinic.
Implementation and evaluation considered constructs within key process models5 6 determinant frameworks6 7 and evaluation frameworks.8 9 After engaging executive and senior leadership support, an interdisciplinary team was established. This purposively targeted those with clinical leadership, technical expertise and day-to-day leadership. The final team led by a physiotherapist included orthopaedic surgeons, an administration officer, nurses and interdisciplinary outpatient staff. Across many non-linear, action/reflection cycles, the team engaged broadly to (1) consider the clinical problem, (2) garner evidence to support change, (3) plan, select, test and implement locally tailored changes, (4) identify, collect, report and adapt evaluation opportunities and measures to understand the context, (5) inform the next steps and outcomes evaluation and (6) embed sustainability into the translation to practice approach. Although not exhaustive, some key implementation strategies, mapped to the Expert Recommendations for Implementing Change project, are provided in table 1.10
Key implementation strategies
A basic flow diagram highlighting the process for the new model is provided in figure 1.
Flow diagram: model for improvement for patients recently discharged following surgical intervention for hip fracture. NOF, neck of femur.
The primary outcomes measure was a crude estimate of surgical time released calculated as the total number of patients seen by the advanced physiotherapist multiplied by the scheduled clinic time (20 min). Rudimentary cost comparison data considered the difference in 2022 hourly rates for advanced physiotherapy (top tier, $A68/hour) and medical registrar (mid-tier, $A65/hour).
Results
Data were presented from implementation of the new model (October 2020) to end January 2023. Across the reporting period, 346 patients (median age 75 years, 63% female, median time from surgery to clinic 101 days) were seen by an advanced physiotherapist. Surgical type for patients varied and included 42% intramedullary nail, 22% hemiarthroplasty, 17% dynamic hip screws, 9% total hip arthroplasty, 3% cannulated screws and 7% other including periprosthetic fracture fixation. There was some fluctuation in the number of patients seen across the course of the programme (October–December 2020: n=52; 2021: n=170; 2022: n=111; January 2023: n=13). Eighty-one (23.4%) patients seen by an advanced physiotherapist required brief (<5 min) informal discussion with the consultant surgeon during physiotherapy management sessions (with no extra clinic allocations or scheduling). Fifteen patients required a formal consultant review and ongoing management by the surgeon; these were routinely patients with complex pain management (n=6) or requiring surgical revision (n=5). There have been no patient complaints, critical incidents or other unintended consequences following implementation. The overall net surgical time realised over the 3 years was 110 hours. Cost comparative data suggest a very small cost of $A330 across the entirety of the programme. While there were no physiotherapy overtime hours, 5347 hours of registrar surgical overtime were incurred during the evaluation period.
Discussion
This is the first Australian study, and to the authors knowledge the first globally, to demonstrate that an advanced physiotherapist model in hip fracture care is cost neutral, may reduce overtime and associated penalty payments, and free up surgical registrar time for full scope surgical tasks, without adversely influencing patient satisfaction or leading to harm.
While this is encouraging, key unanswered questions should be considered prior to recommending broad uptake. For example, was the fluctuating numbers of patients across the course of implementation related to changes in clinic throughput, referral rates or limited availability of advanced physiotherapists. Results presented are inadequate to enable a formal comparison between patients seen by the advanced physiotherapist and the surgical registrar. Ongoing works must consider, for example, process measures such as comparisons between referral and escalation rates. Differences in patient reported experience or outcomes measures, health outcomes measures, cost-effectiveness or balancing measures (such as the number of referrals to other health professionals) also required evaluation. Exploratory qualitative interviews or focus groups might also be useful to unpack potential barriers and enablers to implementation, to support both iterative improvements to the process locally and uptake elsewhere.
Nevertheless, this single site quality initiative provides a passing glance at the potential benefit of an advanced physiotherapy clinic for hip fracture patients. The authors look forward to ongoing research to rigorously evaluate this innovative approach to meeting the foreseen challenge of unmet surgical demand for service in this vulnerable population.
Ethics statements
Patient consent for publication
Acknowledgments
We thank The Prince Charles Hospital - Queensland Health for supporting RF and JB in collecting and analyzing the data presented.
Footnotes
Twitter @doctadiet, @emmasuttPhysio
Contributors RF led the study design/methodology and data collection, RF and JB analysed and presented the data, all authors contributed to study design, editing the manuscript and dissemination.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests ES and JB are co-chairs of the Fragility Fracture Network (FFN) Fragility Fracture Recovery Research Special Interest Group, which is the organising committee for the supplement. FFN has also provided financial contribution to support publication of the special edition.
Provenance and peer review Not commissioned; externally peer reviewed.