Medicine (Northwest Academic Centre)

Fragility fractures are the most severe clinical outcome of osteoporosis and lead to limitations in physical functioning, increased risk of mortality, and reduced health-related quality of life (HRQoL). Post-fracture health care pathways have been developed to improve the care of older patients following a fracture by guiding healthcare professionals with evidence-based treatment recommendations in accordance with clinical guidelines. Previous studies report consistent benefits of post-fracture care pathways for older people including elevated treatment rates, decreases in subsequent fractures, and decreased rates in long-term mortality. However, the benefits on patient-reported outcomes such as HRQoL is not well established, particularly for non-hip fracture sites. The overarching aim of this thesis is to enhance the evidence-base of post-fracture care pathways for the optimal recovery of HRQoL. This thesis includes five interrelated research components: 1) a meta-analysis to investigate the effect of existing post-fracture care pathways on HRQoL and physical function compared to usual care; 2) a before and after study to evaluate the effect of an electronic care pathway on patient outcomes compared to a traditional paper-based care pathway; 3) a series of analyses using data from a multinational observational study – the International Costs and Utilities Related to Osteoporotic Fractures Study (ICUROS) – to identify distinct, multidisciplinary care pathways associated with recovery of HRQoL post-fracture; 4) a micro-costing study to estimate the cost per patient of each post-fracture care pathway identified; and 5) a data linkage study to investigate the association between HRQoL recovery 12-months post-fracture and 5-year mortality using data from the Australian arm of ICUROS (the AusICUROS study). The main findings of these studies are presented below. Existing post-fracture care pathways have short and long-term improvements for both HRQoL and physical function in hip fracture patients, however there is an insufficient number of non-hip fracture studies to establish the same conclusions. Implementation of an electronic care pathway can reduce the total number of delays to surgery in hip fracture patients, an important mediating variable for lower risk of mortality and improved HRQoL, compared to a traditional paper-based care pathway. The latent class analyses identified several multifaceted care pathways (i.e. common combinations of health services used by older adults post-fracture) associated with improved HRQoL recovery 12-months post-fracture across individual fracture sites (hip, wrist, vertebrae, humerus) at a lower cost per patient. Recovery of HRQoL was also determined to be associated with improved 5-year survival in older adults post-fracture, providing indirect evidence that these care pathways may have the potential to reduce mortality post-fracture. Together, the findings of this thesis present significant new knowledge about the understanding, development, and evaluation of post-fracture health care pathways. The multidisciplinary care pathways identified can be utilised by clinicians worldwide to achieve benefits in HRQoL post-fracture at a considerably lower cost to the patient and healthcare system. However, further clinical trials are required to develop evidence-based post-fracture care pathways that will increase the diagnosis of osteoporosis, improve initiation and adherence to osteoporosis treatment and fracture prevention strategies, and improve patient outcomes following fragility fracture.

This thesis explores pragmatic research methodologies that can be embedded into routine clinical practice to simultaneously implement and evaluate health-system interventions. It is centred around the design and implementation of the IMPROVing Evidence-based GAPs and outcomes in community-acquired pneumonia (IMPROVE-GAP) project, which evaluated the effectiveness of a multidisciplinary care bundle for treatment of Australia’s most common illness requiring hospitalisation. This project addressed three key barriers restricting generalisability of experimental results to routine clinical practice for hospitalised multimorbid populations: i) limited representativeness of participants, setting or intervention delivery, ii) failure to utilise randomisation and minimise potential for confounding and bias, and iii) failure to select outcomes that measure the value of interventions to end users. IMPROVE-GAP’s novelty lay in the way it facilitated clinical practice and evaluation operating in tandem, eliminating costly parallel data and outcome collection. It represents a vital precedent for conducting robust clinical trials in the hospitalised elderly, and provides a template for future high-quality, low-cost health-services research.

Medicine (Northwest Academic Centre) - Theses

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