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JAN

JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

A cost-effectiveness study of a patient-centred integrated care pathway


Lars-Eric Olsson, Elisabeth Hansson, Inger Ekman & Jon Karlsson
Accepted for publication 27 February 2009

Correspondence to L.E. Olsson:


e-mail: lars-eric.olsson@vgregion.se
Lars-Eric Olsson PhD RN
Assistant Professor
Institute of Health and Care Sciences,
Sahlgrenska Academy at Goteborg University
and Department of Orthopaedics, The
Sahlgrenska University Hospital, Goteborg
Elisabeth Hansson PhD RN
Assistant Professor
Department of Orthopaedics, Institute of
Clinical Sciences, Sahlgrenska Academy at
Goteborg University
Inger Ekman PhD RN
Professor
Institute of Health and Care Sciences,
Sahlgrenska Academy at Goteborg University
Jon Karlsson PhD MD
Professor of Orthopaedics
Department of Orthopaedics, Sahlgrenska
University Hospital, Goteborg, and
Department of Orthopaedics, Institute of
Clinical Sciences, Sahlgrenska Academy at
Goteborg University

O L S S O N L . - E . , H A N S S O N E . , E K M A N I . & K A R L S S O N J . ( 2 0 0 9 ) A costeffectiveness study of a patient-centred integrated care pathway. Journal of


Advanced Nursing 65(8), 16261635.
doi: 10.1111/j.1365-2648.2009.05017.x

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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each year in the world was estimated in a study to be 166


million in 1990, a figure that is predicted to increase to 626
million by 2050, i.e. an annual increase of 62% (Cooper
et al. 1992). The economic impact is considered important
and is growing accordingly (Johnell 1997). It has been

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JAN: ORIGINAL RESEARCH

estimated that the cost is approximately US$21,000 for the


first year, with an increased cost for subsequent years (Johnell
1997). The worldwide cost of hip fracture treatment was
estimated to be US$34,800 billion in 1990, rising to an
expected US$131,500 billion in 2050 (Johnell 1997). For
obvious reasons, it is necessary to develop not only preventive
measures but also methods for more clinically and costeffective hospital care for patients who sustain a hip fracture.
This group comprises about 18,000 people every year in
Sweden, and they consume approximately 25% of the total
number of care days in orthopaedic departments (Thorngren
2003). In Sweden, almost 75% of hip fractures as a clinical
group are accounted for by older women (average age
84 years; Thorngren 2003). The majority of these patients are
admitted to hospital from their private residence. The
rehabilitation of a patient with a hip fracture consists of
training in the hospital as well as additional help and training
from community care staff. For both human and economic
reasons, it is important for hospitals to adopt methods of care
that can safeguard these older patients physical function and
potential for independent living. Because these patients easily
develop dependence, care that does not create unnecessary
dependence is particularly relevant to their treatment and
rehabilitation (Olsson et al. 2007a). It is a challenge,
however, to provide high-quality care based on clinical
evidence for the least amount of money.
Integrated care pathways (ICPs) have been proposed as a
means of providing high-quality care in a timely, costeffective manner (Zander 1998, Dowsey et al. 1999). ICPs
are structured multidisciplinary care plans that provide
detailed descriptions and control the steps of the care
process. They consist of treatment protocols designed to
produce streamlined, standardized management with multidisciplinary input from the medical, nursing and paramedical staff. Although ICPs have been developed for more
than 45 conditions (Campbell et al. 1998) and are used in
many countries, they are still relatively unknown in
Sweden.

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

Study of a patient-centred integrated care pathway

attaining good knowledge of each participant and their


prerequisites, would lead to more cost-effective care.

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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L.-E. Olsson et al.

hypothetical comparisons (Drummond et al. 1997, Kobelt


2002).
Costing
All the costs are given at 2004 rates and converted from
Swedish crowns (SEK) to Euros () using the annual average
exchange rate for 2004 (91268 SEK/) (Sveriges Riksbank
2004).

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.

Development and implementation of the ICP


The intervention is described in more detail in a previous
paper (Olsson et al. 2007a). It was specifically designed to
focus on each patients motivation and their prerequisites for
rehabilitation, and to guide the transition process (Schumacher et al. 1999). To assist patients through the transition, it
was necessary to explore their prefracture condition, which
would work as a baseline as well as a guide for care planning.
A thorough interview was performed during the patients
admission to the ward to create an individual rehabilitation
prognosis. The intention was to create a care path with rapid
preoperative attention and very early first ambulation. As
part of the intervention, patients in the intervention group
1628

were not transferred to other departments for other than


medical reasons, and remained on the orthopaedic ward until
they had attained activities of daily living (ADL) level
equivalent to their prefracture level or until they did not
progress further in their rehabilitation.
The ICP was developed by an experienced multidisciplinary team of 12 people (four registered nurses, including the
project leader, three nursing assistants, two physical therapists, one occupational therapist, one orthopaedic surgeon
and a hospital welfare officer) that represented all the
vocational groups and departments that cared for patients
with hip fracture (Table 2). Development of the ICP
continued over a period of almost 4 months. Meetings were
scheduled on a weekly basis, with group members meeting in
different constellations: on average, five people were present
at a time and the whole group met only once. The reason for
this was the difficulty involved in co-ordinating free time for
the group members; nevertheless, working in this manner was
found to be effective. However, information was shared
constantly by email. Nineteen 2-hour meetings were scheduled but two of these were cancelled; in addition, the project
leader spent approximately 350 hours on the project. Some
costs, such as those of physicians, could not be measured, as
most of the work was carried out using email and brief
discussions on the ward in connection with rounds. Other
costs, such as discussions within each vocational group, were
could also not be measured. Before implementing the ICP on
the orthopaedic ward, a 2-hour training session was offered
to orthopaedic department staff.

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

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Study of a patient-centred integrated care pathway

Table 1 Baseline data for both the


comparison and integrated care pathway
(ICP) groups

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.

Pfeiffers test (Pfeiffer 1975).

Functional Recovery Scale (Zuckerman et al. 2000a, 2000b).

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L.-E. Olsson et al.

Table 2 Hourly costs


Vocational group

Cost per hour ()

Registered nurses
Enrolled nurses
Physiotherapists
Occupational therapists
Hospital welfare officer
Physician

248
207
231
234
241
502

Average hourly costs for each vocational group 2004 in Sweden


including social fees.

in-hospital expenses. These costs were retrieved from the


hospitals financial database, where all the monetary data for
each individual participant were available. The database
made it possible not only to retrieve the total treatment cost,
but also to calculate the costs for different parts of the care.
Hospital cost is made up of treatment and hotel costs.
Treatment costs consist of costs for radiology, surgery,
postoperative care, chemistry, microbiology, haematology
and clinical physiology (Table 3). Hotel costs include salary,

Table 3 Hospital costs


Hotel cost

Cost per bed day ()

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

drugs, food, accommodation, health care and administration


(Table 3). However, because the number of staff was kept
similar in both groups throughout the study period, the daily
hotel cost also remained similar. In addition to the cost of
care, the cost of developing the ICP was calculated.
Effectiveness
Effectiveness was measured by comparing participants selfestimated prefracture ADL level to their actual ADL level at
discharge (using the tool developed by Katz et al. 1963). The
ADL index used is a hierarchical scale with steps from AG,
where level A is completely independent living and level
G completely dependent living concerning personal ADL
(Table 4). This study was hospital-based and the outcome
was to be presented within that perspective in such a way
that successful cases could be defined. For this purpose, the
ADL index was used as a tool to assign patients either to a
low-dependent group, ADL levels AC, or a high-dependent
group, ADL levels DG (Table 4). The basis for this reasoning was that low-dependent patients have a limited need
for support and thus could continue recuperating in their own
homes, assisted by community home help or a significant
other (Robinson 1999, Curry-Cox et al. 2003).

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.

Sodium (Na*), Potassium (K*), Creatinin (Crea), Haemoglobin


(Hb), Leucocyte platelet count (LPC), Protrombin KomplexInternational Normalised Ratio (PK-INR), Activated Partial
Thromboplastin-time (APTT).

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
groups. A non-parametric MannWhitney U-test was used to
display the results further. Effectiveness was analysed using a
chi-squared test to calculate the difference in rank sums
between the groups. The data were analysed using SPSS
(version 10.0, SPSS Inc., Chicago, IL, USA) and SAS (version
8.0, SAS Institute Inc., Cary, NC, USA).
Cost-effectiveness analysis
The two treatments in this study were treatment A (ICP
intervention) and treatment B (usual care). The two

Table 4 The modified Katz ADL index score (Katz et al. 1963)

1630

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

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Study of a patient-centred integrated care pathway

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

Figure 1 The four different outcome possibilities for cost effec-

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.

tiveness (Borgstrom 2006).

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.

There was a statistically significant difference between the


groups for both costs and effectiveness. The analysis revealed
that treatment A (ICP intervention) was both less expensive
and more effective than treatment B (usual care). In the
intervention group, 75% of the patients who were admitted
as low-dependent (ADL levels AC) (Table 4) were restored
back to ADL levels AC at an average cost per participant of
9685 (SD 2219). In the comparison group, 52% of the
participants who were admitted as low-dependent were
restored back to ADL levels AC (Table 4) at an average
cost per participant of 15,984 (SD 7959) (Table 5). Hotel
costs accounted for approximately 72% of the total hospital
cost, and this cost was reduced by 40% (Table 5). Costs for
blood transfusions were higher in the intervention group, but
not statistically significantly so. Hospital savings totalled
1611 for chemistry, 3408 for radiology and 295,158 for
hotel costs. The total saving was 327,282.

Table 5 Mean costs of treatment


Comparison group (n = 53)

Intervention group (n = 55)

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

7548 7209 (7118)

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.
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L.-E. Olsson et al.

Cost of developing the ICP


The project leader spent 350 hours working on the ICP
intervention programme at an approximate cost of 8680.
The team members, on average five people, spent a total of
170 hours at meetings and, including the physician, the total
cost was 3997. The cost of the two-hour training session
offered to the staff before implementing the ICP was
estimated at approximately 1858. The grand total for
developing the ICP came to approximately 14,535.

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
1632

appearance before and immediately after surgery served to


guide the care process. This way of assessing patients resulted
in a wait-and-see policy in which the nurses were overly
prudent, leading to cautious rehabilitation. Postoperative
patient training in the first few days essentially consisted of
sitting or standing up once a day with assistance from
physiotherapists. Hence, a negative spiral developed in those
who appeared frail and who were mobilized at a very slow
pace, leading to loss of physical power. We also found that,
with increased hospital stay in the standard care group, the
cost of radiology and chemistry increased statistically significantly, a cost that appeared to be unrelated to patients
medical conditions. The true cause of this is difficult to
discern, but could perhaps be explained by the use of routine
care in an emergency hospital.
The ICP was developed in an unconventional fashion.
However, the fact that all team members were not able to be
present at all the meetings did not affect the results
negatively. The topics discussed at the meetings were dependent on the vocational groups that were present. The ICP was
put together piece by piece and the team members were
constantly updated by phone and email. The team was
stimulated by the opportunity to participate in developing the
care pathway. This way of working on the ICP probably kept
the costs to a minimum. However, it was not possible to
calculate all the costs related to the work. The cost of time,
such as team members working on their own, could not be
calculated. Office supplies and the cost of using conference
rooms and similar expenditures were also not calculated.
Despite this, the largest part of the cost of preparing the ICP
was accounted for in the study.
Comparing the costs for a group such as patients treated for
a hip fracture involves problems at both the individual level
(because not all patients can be restored to their prefracture
state) and at the organizational level (because every country
has its own healthcare system). Comparisons at the individual
level need to account for the patients status at both admission
and discharge in order to show the extent to which the
rehabilitation was successful during the hospital stay. At the
organizational level, these patients are often transferred to
other rehabilitation units inside or outside hospital. Moreover, in some countries home rehabilitation has been developed, which further reduces hospital stay. Despite these
difficulties, comparisons are still needed. Lawrence et al.
(2005) reported a mean hospital stay of 23 days. The average
costs were 17,946 (GB 12,163). Haentjens et al. (2001),
after a review of 31 studies published between 1980 and 2000,
found that the average cost of hospital stay was 5204
(US$7000), with the lowest cost of 549 (US$739) (Sreide
et al. 1980) and the highest 32,713 (US$44,000) (Schurch

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JAN: ORIGINAL RESEARCH

What is already known about this topic


Integrated care pathways work well for patients
undergoing elective surgery.
Interprofessional collaboration is essential to ensure
clinically effective care.
The concept of patient-centred care highlights the need
for individualization and the central role of the patient
as a person in the clinical encounter.

What this paper adds


Combining the structure of the integrated care pathway
with individualized care appeared to improve costeffectiveness.
The individualized integrated care pathway led to more
successful rehabilitation than usual care.
The individualized integrated care pathway reduced
treatment costs.

Implications for practice and/or policy


Nurses effect on the quality of care and results of
rehabilitation appears to be more extensive than previously anticipated.
Assessment of patients previous level of activity on
admission facilitates proactive cost-effective rehabilitation.
To enhance the mobility of older patients after hip
fracture surgery, interventions should be tailored to
each individual patient.

et al. 1996). These studies, in most cases, involved studying


only costs and they failed to reveal the extent to which the
patients had recovered. In other studies concerned with
comparing ICPs with usual care, the rehabilitation result is
also missing (Choong et al. 2000, Tarling et al. 2002, Kwan
et al. 2004, Roberts et al. 2004, Gholve et al. 2005). However,
it is important not merely to shift the costs from hospital to the
community (Cheah 2002). In the present study, baseline
statistics showing participants physical abilities were
revealed, making it possible to determine the extent to which
they had recovered (Olsson et al. 2007a).

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

Study of a patient-centred integrated care pathway

evaluation should cover a longer time frame to follow up


on results also after discharge. The study could have been
improved if we had compared the costs for the first few
months after discharge. However, it was assumed that as the
patients in the intervention group had been rehabilitated to a
better physical standard, evaluation of only the hospital costs
would be satisfactory. Moreover, to verify the consequences
of the two care systems further, the 30-day re-admission and
1-year survival rates were also checked and found to be the
same in both groups (Olsson et al. 2007a).
The study was carried out using a quasi-experimental,
prospective design in which consecutive patients in an
intervention group were compared with those in a comparison group (Polit and Hungler 1995), with the comparison
group representing standard care. A disadvantage of this
design is that it precludes conclusions about the true effects
of an intervention, i.e. whether the between-group differences are due to the intervention or to other unknown
factors. A randomized, controlled trial design would have
been preferred but was discarded for practical reasons,
namely concerns about the difficulty for nursing staff of
working with two care systems at the same time and for
patients possibly comparing the treatment they received.
However, most studies of ICPs in patients with hip
fractures have been conducted using this method (Choong
et al. 2000, Tarling et al. 2002, Roberts et al. 2004, Gholve
et al. 2005).
Further limitations of this study were that the number of
participants was relatively small. Nevertheless, the statistically significant reductions found in outcomes would
probably also remain statistically significant in a larger
sample.
Another problem related to the design was that not all
participants could be rehabilitated to their former level of
physical ability, which made it necessary to create a definition
for successful cases. No patients, young or old, have
completely recovered when they are discharged from hospital
after a serious injury. They will always need additional time
to recuperate. Patients who were independent before the hip
fracture have been found to be able to regain independence
on their own after being discharged from hospital (CurryCox et al. 2003). Robinson (1999) describes the ingenuity of
patients treated for hip fracture in the way they develop their
own methods to enhance their ability to become more
independent. Older patients who are restored to a low
dependence level during hospital rehabilitation can further
develop their abilities in their homes to gain more independence. The improvement in physical capacity of patients in
the intervention group probably generated decreased costs
also for the community care aspect.

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1633

L.-E. Olsson et al.

The strength of this study was the enhanced knowledge of


participants and the detailed collection of data accounting for
each participants costs during hospital stay. The effectiveness was determined by comparing the participants ability at
discharge based on the ADL results and discharge destinations. Participants admitted as independent and discharged as
independent or low dependent, ADL levels AC (Table 4),
were regarded as successful. Those admitted as independent
and discharged as high dependent, ADL levels DG (Table 4),
were regarded as unsuccessful. Participants admitted as high
dependent were, naturally, discharged as high dependent.
Although these participants could be counted as successful,
they were not calculated as such. However, most results in
the study were improved, including complication rates and
gait capacity, as reported elsewhere (Olsson et al. 2007a).
The increased number of high-dependent participants in the
comparison group who were independent or low dependent
before the fracture was discharged to a nursing home on a
temporary or permanent basis. This group of participants
created higher costs for the community healthcare system,
but this was not calculated as it was not within the scope of
this study. Moreover, to verify the consequences of the two
care systems further, 30-day re-admission and 1-year survival
rates were checked and found to be similar in both groups
(Olsson et al. 2007a).

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
1634

the data analysis. LEO, EH, IE and JK were responsible for


the drafting of the manuscript. EH and JK made critical
revisions to the paper for important intellectual content. EH
provided statistical expertise. LEO obtained funding. IE and
JK supervised the study.

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