Effects of Protocol-driven Care by Internists on Adherence to Clinical Practice Guidelines for Hip Fracture Surgery Patients: An Interrupted Time Series Study Using a Nationwide Inpatient Database.

Abstract

Background Patients with hip fractures tend to have a poor prognosis. Although guideline-compliant practices are known to improve patient outcomes, there is a lack of evidence regarding the use of intervention to improve guideline adherence in hip fracture patients. The objective of our study was to evaluate guideline adherence by internists providing care to patients with hip fractures, using a protocol developed based on various guidelines. Method Protocol-driven care for hip fracture patients by internists began in April 2018 at our hospital. After its initiation, orthopedic surgeons performed the surgery, and the internists provided all other medical care. A controlled interrupted time-series analysis was used to evaluate the effects of protocol-driven care on guideline adherence to compare our hospital with other hospitals, using data extracted from a nationwide Japanese inpatient database covering the period April 2014 to March 2023. Results A total of 221,620 inpatients from 373 hospitals were included in the study. The initiation of protocol-driven care was associated with the guideline-recommended prescriptions: osteoporosis medication (Incidence rate ratio (IRR): 8.09; 95% CI 4.02-17.74), acetaminophen (IRR: 2.11; 95% CI 1.55-2.90), non-steroidal anti-inflammatory drugs (IRR: 0.16; 95% CI 0.11-0.24), and opioids (IRR: 5.96; 95% CI 3.14-12.15). However, there was no effect on the proportion of benzodiazepine prescriptions, surgery within 48 hours, deep venous thrombosis prophylaxis, or other perioperative outcomes, including medical fees. Conclusions The initiation of protocol-driven care by internists resulted in improved adherence to osteoporosis medication prescriptions and postoperative analgesic use compared with orthopedic care. This approach can be used as an effective method of care for elderly patients undergoing surgery.