Primary care pathway- a novel way to reduce the burden on orthopaedic fracture clinics within the pediatric subgroup: A Queensland multi-centered review.

ABSTRACT: Emergency departments receive an increasing amount of musculoskeletal injuries, with the majority referred to a fracture clinic (FCs). A literature review revealed certain orthopaedic injuries can be safely managed away from the FC pathway by general practitioners (GPs) or allied health professionals (AHPs). The present study aims to review all paediatric presentations to FCs at 2 Queensland hospitals, identifying low risk injuries that could potentially be managed by GPs or AHPs. This study is a continuation from Cleary et al in which a primary care pathway (PCP) was proposed for the management of low risk adult orthopaedic injuries. A PCP has the potential to have significant savings to the health system.A retrospective study was conducted looking at paediatric patients (<16 years) referrals to 2 FCs over 8 weeks. Injuries were categorised into those requiring FC care supervised by an orthopaedic surgeon, and those that can be safely managed by GPs or AHPs via a PCP.Four hundred ninety (57.7%) of the 849 patients referred to FC were assessed as suitable for PCP care. The most common upper limb injury deemed suitable was radius and ulna buckle fractures (18.4%), while the most common lower limb injury is ankle sprains (8%). Total failure to attend rate in the PCP group was 6.7%.Adopting the PCP has the potential to significantly reduce FC referrals. With proven success of similar pathways abroad, the PCP may generate significant time and financial savings for both the health care system and patient.

Comparison of the Charlson Comorbidity Index with the ASA score for predicting 12-month mortality in acute hip fracture.

BACKGROUNDS: The ASA (American Society of Anaesthesiologists) Score is the current standard for measuring comorbidity in the Australian Hip Fracture registry, however it has never been validated for this purpose. Subsequently, a more appropriate and useful measure should be investigated. This study aimed to compare the ASA and Charlson Comorbidity Index (CCI) scores in predicting 12-month mortality following acute hip fracture. METHODS: A retrospective analysis was performed on an audit database of patients who were admitted to an orthogeriatric unit in a public metropolitan hospital from November 2010 to October 2011. 12-month mortality data was linked through a dual search of Queensland Health and mortality registry data. The Charlson comorbidity index was retrospectively applied. Demographics (age, gender, admission residence) and covariates including ASA, CCI, fracture type, fixation type, cognitive impairment on admission, BMI and time to surgery were analysed with logistic regression. ROC curve analysis was performed to assess varying thresholds for each comorbidity system. RESULTS: A total of 320 patients were available for audit. Unadjusted bivariate analysis demonstrated significant difference between groups regarding increased age (p = 0.004), ASA score (p<0.001), CCI (p = 0.002), age-adjusted CCI (p = 0.002) and admission from a care facility (p<0.001). Logistic regression analysis demonstrated that only ASA (p<0.001) and admission from a care facility (p<0.001, OR=3.36, 95% CI = 1.9 - 6.0) independently predicted 12-month mortality; CCI was not a significant predictor in any models (p = 0.827, age-adjusted CCI: p = 0.864). Using ROC analysis, the ASA (AUC=0.668) outperformed either CCI (AUC=0.607 (CCI), AUC=0.614 (CCI age-adjusted). CONCLUSIONS: The ASA score is independently associated with 12-month mortality; this was not replicated using either version of the CCI. The data does not suggest using the CCI in registry level datasets for the purposes of predicting 12-month mortality.