Fracture of the proximal femur constitutes one of the most devastating complications of osteoporosis. Within the European Union, more than 400,000 women and 100,000 men sustain a hip fracture every year . The worldwide annual number of hip fractures amounts to about 1,800,000. Because the number of elderly people is rising, a continued increase in incidence of fractures is expected . People with a proximal femur fracture experience a clinically important decline in functional status with considerable loss in quality of life [2, 3]. Within one year after sustaining a hip fracture, close to 20% of individuals will have to be institutionalized because of the fracture and because of its functional consequences. Overall, hip fractures represent one of the main causes of hospitalization, institutionalization, and mortality in old age . According to a meta-analysis published in 2010, older adults have a 5- to 8-fold increase in their risk of all-cause mortality during the first 3 months after hip fracture (3). This excess mortality persists over time, even 10 years after sustaining the fracture; both women and men are affected, although, at any given age, excess annual mortality after hip fracture is higher in men than in women .
Organizing and standardizing the care process for these patients, with a focus on quality, efficiency, and accessibility should be one of the priorities over the next few years for clinicians, healthcare managers, and policy makers. One of the methods to (re)organize a care process is the development and implementation of a care pathway. Care pathways, also known as clinical pathways or critical pathways, are used worldwide for a variety of patient groups [5–13]. A care pathway is defined as a complex intervention for mutual decision making and organization of predictable care for a well-defined group of patients during a well-defined period. Defining characteristics of pathways include: explicitly stating the goals and key elements of care based on evidence, best practice and patient expectations; facilitating communication and coordination of roles and sequencing the activities of the interprofessional care team; optimizing communication with patients and their relatives; documenting, monitoring, and evaluating variances and outcomes; and, finally, identifying relevant resources [12, 14–16].
A care pathway is explicitly defined as a “complex intervention” [12, 17–19]. Complex interventions, also known as multi-component interventions, have been built from a number of components that may act both independently and interdependently [20, 21]. Although they may be difficult to specify, these interacting components seem essential for the proper functioning of the intervention. Considering a spectrum of low to high complexity, developing a drug would be at the low end of the spectrum while assessing the effect of a stroke unit would be at the high end. The more it is difficult to exactly define the “active components” of an intervention and how these interrelate, the more it is likely that the intervention is a complex one [19, 20, 22]. Care pathways seem to be at the higher end of the complexity spectrum. Typical active ingredients of a care pathway include the promotion of interdisciplinary teamwork, the integration of a package of evidence-based key interventions, and the active follow-up of care processes [6, 12, 13, 23, 24].
A recent Cochrane review concluded that care pathways result in reduced in-hospital complications and improved documentation, without negatively impacting length of stay or hospital costs . However, these effects may vary widely and may not always meet expectations. To gain insight into the active components of complex care pathways, one needs to evaluate the context of the interventions and the mechanisms involved [14, 20, 21, 26, 27]. Multicenter trials that include these evaluations are critical to fully understand how and when care pathways are effective [12, 28, 29].
A literature search identified six reviews on the effect of pathways in patient groups that included hip fracture patients [25, 30–34]. Because various types of patients were included in the reviews by Rotter et al. (2008, 2010), it was not possible to address any effect on hip fracture patients specifically [25, 30]. A more patient-specific meta-analysis by Neuman et al. (2009) was limited by the lack of a common definition and concept on care pathway  and did not allow a formal comparison of the outcomes of the included studies. Moreover, in many of the primary studies included in the reviews, the components of the complex interventions were not always described [32–34]. Therefore, even when a care pathway was developed, many of the observed results could not be attributed directly to the pathway. Also, study designs were substantially different. Despite these limitations, the major conclusion that emerged from these reviews is that care pathways can significantly reduce the length of stay and have a positive impact on different outcomes. The results also suggest that mortality in hip fracture patients may not be the best parameter to assess quality of care as they may ignore important improvements in other outcomes that can be achieved by care pathways. Additional research is needed to evaluate the impact of care pathways on quality of care and clinical outcome in hip fracture patients.
To evaluate care pathway effectiveness, the European Pathway Association (E-P-A), an international not-for-profit association, launched the European Quality of Care Pathways (EQCP)-study on proximal femur fracture. Earlier, E-P-A launched a similar study on exacerbation of chronic obstructive pulmonary disease (COPD) [12, 29].
The primary goal of the EQCP study on PFF is to evaluate care pathway effectiveness in the acute hospital setting. A secondary goal is to understand how and under what circumstances the implementation of a pathway for PFF is successful .