The effects of a Virtual Fracture Care review protocol on secondary healthcare utilization in trauma patients requiring non operative treatment: a retrospective cohort study

doi:10.21203/rs.3.rs-3902638/v1

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Research Article

The effects of a Virtual Fracture Care review protocol on secondary healthcare utilization in trauma patients requiring non operative treatment: a retrospective cohort study

https://doi.org/10.21203/rs.3.rs-3902638/v1

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Background

The strain on healthcare resources in the Dutch trauma care system is rising. In response, a Dutch adaptation of the Virtual Fracture Care (VFC) review protocol, designed to optimize trauma care quality within resource constraint, has been implemented to sustain high-quality trauma care. This study aimed to evaluate the influence of the VFC review protocol on the utilization of secondary healthcare resources in adult trauma patients who received non-operative treatment for musculoskeletal extremity injuries.

Methods

This retrospective cohort study assessed the impact of a VFC review protocol on secondary healthcare utilization in adult trauma patients treated non-operatively for a musculoskeletal extremity injury. Patients treated between July 1, 2018 – December 31, 2019 (pre-VFC group), and January 1, 2021 – June 30, 2022 (VFC group) were included. Outcomes included follow-up appointments and involved healthcare professionals, radiographic imaging, and emergency department (ED) reattendances.

Results

A total of 3791 patients were included, comprising 1819 pre-VFC patients and 1972 VFC patients. Following VFC review, the number of follow-up appointments was reduced by 8% and a shift towards remote delivery of care occurred. Furthermore, VFC review led to a 9% reduction in follow-up radiographs and a 29% decrease in ED reattendances.

Conclusion

Utilization of a VFC review protocol for management of adult patients with a musculoskeletal extremity injury requiring non-operative treatment improves reduces secondary healthcare utilization compared to traditional treatment protocols. This protocol results in a reduction of follow-up appointments, a transition from face-to-face to remote care delivery, fewer follow-up radiographs, and a reduction of ED reattendances.

Virtual Fracture Clinic

healthcare utilization

non-operative treatment

telemedicine

extremity injuries

In the Netherlands (NL), patients with musculoskeletal extremity injuries accounted for approximately 30% of all visits to the emergency department (ED) in 2022. (1) A substantial percentage of these patients requires additional follow-up treatment at the hospital after the ED visit, with the majority being treated non-operatively (± 80%).(2) This non-operative treatment generally consists of several outpatient clinic follow-up appointments and additional imaging, utilizing increasingly scarce hospital resources.(2–5) With its high volume, the orthopedic trauma patient population is a major consumer of hospital resources in the Dutch healthcare system. Furthermore, the non-operative treatment pathways and workflows are prone to inter-physician variation and limited physician perspectives, potentially resulting in additional (excessive) hospital resource utilization.(6) As the strain on healthcare resources is increasing, addressing these issues in non-operative management may be essential in sustaining high-quality orthopedic trauma care. (7)

The Virtual Fracture Care (VFC) model has emerged as a reorganizational solution for non-operative management musculoskeletal extremity injuries, adopted by various countries in several variations (8–12). Typically, the VFC model comprises two components: 1) a Direct Discharge protocol facilitating the direct discharge of patients with uncomplicated and stable injuries from the ED, and 2) a VFC review protocol, referring patients in need of further treatment to the most suitable healthcare professional. (12, 13). In the Netherlands, a version of such a VFC review protocol has been implemented in 2020, to streamline orthopedic trauma care and increase efficiency in hospital follow-up treatment.(13) However, in addition to other VFC models, the Dutch version uniquely extends beyond the initial treatment phase, employing a multidisciplinary team to formulate supervised follow-up treatment plans with a focus on uniformity, efficient planning, and remote care delivery, for the complete follow-up treatment pathway. These plans comprise all follow-up appointments, types of healthcare professionals performing follow-up (casting technician or physician), follow-up imaging and instructions for the recovery process (such as permitted weight bearing). Two examples of a VFC review treatment plan are provided in additional file 1. While previous studies have highlighted the efficiency, cost-effectiveness, and patient satisfaction of VFC models, they primarily addressed the Direct Discharge or VFC review protocols only focusing on optimal initial referrals (in contrast to the Dutch version that includes the complete follow-up treatment pathways). (10–12, 14, 15) The Dutch VFC review protocol potentially addresses the aforementioned issues in non-operative treatment pathways, yet its results remain unreported.

Therefore, this study aimed to fill this knowledge gap by evaluating the impact of the Dutch VFC review protocol on secondary healthcare utilization in adult trauma patients undergoing non-operative treatment for musculoskeletal extremity injuries. We hypothesized that the implementation of the VFC review protocol resulted in a reduction of secondary healthcare utilization..

Design and setting

This retrospective cohort study was conducted at an urban level 2 trauma centre and teaching hospital in the Netherlands. At our institution, a VFC review protocol was introduced in April 2020 and became standard care in January 2021 (11). This protocol included all Dutch or English-speaking orthopedic trauma patients of at least one year of age, who were not acutely admitted to the hospital ward within 24 hours of presentation but required subsequent hospital treatment (Fig. 1). Exclusion criteria for VFC review included pre-existing motor or cognitive impairment, Glasgow Coma Scale < 15 at presentation, multiple injuries, treatment at another hospital, lack of an available phone number, and initial treatment or follow-up elsewhere (e.g. due to the geographic location of the patients' residence or their preference).

For this study, all patients who presented to the ED of the study institution with a musculoskeletal extremity injury that required non-operative hospital follow-up treatment from 06-01-2019 to 12-31-2019 (pre-VFC group) and from 06-01-2022 to 12-31-2022 (VFC group) and met criteria for the VFC review protocol were included. No additional inclusion or exclusion criteria were used. To account for potential bias due to changed standards of care during the COVID pandemic and concomitant lockdown measures, the inclusion date for the VFC group was set after the pandemic, on June 1, 2022. This study was conducted in accordance with the declaration of Helsinki and was approved by the local ethical research committee (WO 23.073).

Treatment workflows

With the implementation of the VFC review protocol, several adjustments to the existing workflow were made. An overview of the differences between the pre-VFC and VFC workflows for non-operatively treated patients is shown in Table 1.

Table 1

Pre-VFC vs. VFC workflow for patients requiring non-operative treatment
Phases	Pre-VFC workflow	VFC – review workflow
Treatment protocols	• Local (hospital) and national orthopedic trauma guidelines • Routine scheduling of appointments with physician in outpatient clinic or casting room. Other healthcare professionals consulted during FU appointment as deemed necessary by the attending physician	• 180 complete multidisciplinary comprised treatment pathways, based on internal and external standards and guidelines • Focus on remote delivery of care, reduction of unnecessary healthcare utilization, and efficient allocation of tasks among healthcare professionals
Day 0	ED visit	ED visit
Day 0	• Initial care by ED healthcare professionals + consultation orthopedic resident if necessary • Treatment discussed at the ED by resident, or postponed to fracture clinic appointment shortly (within 5–7 days) after ED visit (e.g. if the resident or required supervision is not readily available) • Discharge from ED with only the first FU appointment scheduled • Acute surgical intervention or hospital admission are always directly discussed at the ED with the orthopedic consultant and treated accordingly	• Initial care by ED healthcare professionals • Check eligibility for VFC review by ED healthcare professionals according to in- and exclusion criteria • Patient electronically referred to the VFC review for the next workday • Discharge from ED without consultation orthopedic resident and without scheduled FU treatment • Acute surgical intervention or hospital admission are always directly discussed at the ED with the orthopedic consultant and treated accordingly
Day 1	Radiograph assessment meeting	Multidisciplinary VFC review meeting
	• All ED radiographs briefly assessed for correctness of diagnoses • Attended by radiologist, (orthopedic) trauma surgeon, ED staff • Patients contacted by telephone in case of incorrect diagnoses	• A multidisciplinary team, led by an orthopedic trauma surgeon, discusses referrals and documents a complete FU treatment plan, including FU appointments and imaging, required immobilization and specific instructions for attending physicians during each FU appointment • All referred patients contacted by phone directly after VFC review to discuss the complete treatment plan and reach consensus • Uniform patient information provision on treatment from start to finish under direct supervision of an experienced trauma surgeon • Complete pathway scheduled by administrative assistant directly after VFC review
First FU appointment to planned end of treatment	FU treatment pathway	FU treatment pathway
First FU appointment to planned end of treatment	• Further FU treatment planned by the varying healthcare professionals at each subsequent FU appointment, prone to inter-physician variability in treatment and information provision • Attending physician decides on further imaging and immobilization if necessary. • Step-by-step planning: repeated scheduling of FU until treatment is considered finished by the treating physician • Supervision is sought when deemed necessary by attending physicians and performed by the designated supervisor for that specific day, varying throughout the week • Planned duration of follow-up treatment unclear for healthcare professionals and patients. Prone to variance between healthcare professionals	• Complete treatment pathways according to VFC review treatment plan • Should any complications or concerns arise during FU, deviation from the scheduled treatment plan is discussed with the VFC review supervisor • Standard final functional recovery check-up at 8–10 weeks post-injury by phone
VFC = Virtual fracture care, FU = Follow-up, ED = Emergency department

Additionally, Fig. 2 provides a chronological representation of a standard non-operative treatment pathway in both pre-VFC and VFC review workflows.

Pre-VFC workflow

Before VFC review implementation, orthopedic trauma patients were primarily treated in the ED by (often inexperienced) residents, with varying levels of supervision from surgical staff. For patients requiring non-operative follow-up treatment, a follow-up appointment after 5–7 days in the outpatient clinic or casting room was routinely scheduled to discuss further follow-up treatment. These appointments were primarily conducted by residents, with on-call supervision if deemed necessary. Additionally, musculoskeletal ED radiographs and diagnoses from the previous day were checked in a daily radiograph assessment meeting (attended by a radiologist, ED staff and a trauma surgeon) and patients were contacted if any treatment adjustments were made. In this workflow, follow-up treatment was planned step-by-step by the varying attending physicians at each appointment without a predefined duration or final appointment of follow-up treatment. This stepwise process was prone to treatment variation, excessive healthcare resource utilization, and limited consistent information delivery and patient expectation management for the complete follow-up treatment pathway.

VFC – review workflow

ED healthcare professionals assessed VFC review eligibility and electronically referred eligible patients to a VFC review meeting on the next workday via the EPR system, EPIC. Patients were discharged from the ED and received digital and written information on the VFC workflow and their injury. During the VFC review meeting, a multidisciplinary team (comprising a casting technician, surgical resident, (orthopedic) trauma surgeon and administrative assistant) discussed all referrals and assigned treatment pathways to each patient. In total, 180 digital pre-defined treatment pathways were established based on national fracture treatment guidelines and joint consensus of orthopedic trauma staff, and were integrated into the EPR system. These comprehensive treatment plans were readily accessible for the VFC team through a VFC interface within the EPR system and focused on matching patient needs at each follow-up appointment to the expertise of selected healthcare professionals (additional file 1). Additionally, the VFC review team focused on remote delivery of care and uniform patient information provision (16). The attending surgical resident assigned each patient with a suitable treatment pathway within the EPR through a series of dropdown menus, directly entering and saving data to each patient's record. The VFC team could adjust treatment protocols for each patient based on expert opinion. This process resulted in an individualized, comprehensive, supervised plan for follow-up treatment within one workday after the initial ED visit. Directly after VFC review, patients were informed by phone and consent for definitive treatment was discussed. An administrative assistant then planned the complete follow-up treatment according to the documented treatment plan and notified the patient via the EPR patient portal or by mail.

Data collection

The following study data were anonymously extracted from an existing database. This database was set up as part of a clinical audit performed in our institution and included data from patients treated both before and after VFC review implementation. Comparability between groups was ensured by directly extracting data from the EPR using a query designed to only include patients eligible for the VFC review workflow. The query included registered patient characteristics in the EPR and detailed texts extracted from ED and outpatient clinic documentation. To check final query accuracy, 200 patients were manually sampled which showed an accuracy of 97% for VFC eligibility in non-operatively treated patients. For this study, anonymous data was extracted from all eligible non-operatively treated patients within the study inclusion periods. Study data included: age, sex, registered injury type (fracture, dislocation, tendon/ligament rupture), registered diagnosis related group (17), outpatient clinic follow-up appointments (face-to-face or remotely by phone) with each healthcare professional contact counting as one appointment, type of healthcare professionals performing follow-up appointments (physician or casting technician), imaging (radiograph, computed tomography (CT) scan and magnetic resonance imaging (MRI) scan), and ED reattendances. All data were collected for a period of up to one year after initial ED presentation per patient.

Outcomes

The primary outcome was the number and type of outpatient clinic follow-up appointments (face-to-face or remote).

Secondary outcomes included the number and type of healthcare professionals performing these follow-up appointments, number and type of radiographic imaging (in the ED and outpatient clinic), and the number of ED reattendances for this injury.

Analysis

Descriptive statistics for continuous variables included the median and interquartile range [IQR]). Categorical variables were presented using frequencies and percentages. Count outcomes were presented as totals, accompanied by the median count and IQR. Baseline comparisons between groups for categorical and continuous data were conducted using the Chi-squared test and the Mann-Whitney U test, respectively. Statistical significance was defined as a p-value below 0.05.

Regression analyses were performed to address potential baseline differences between groups. This included a Poisson regression and negative binomial regression depending on variable distribution (Poisson distribution or overdispersion).(18) Outcomes were presented as incidence rate ratios (IRR) with the pre-VFC group as a reference value (1.0) and included accessory confidence intervals and p-values to show statistical significance of effect measures.(19) Multiple imputation was not employed; any missing data encountered were excluded from the analysis. The analysis was conducted using SPSS software, version 22 (IBM).(20)

A total of 3791 patients were included in the study, with 1819 pre-VFC patients and 1972 VFC patients (Table 2).

Table 2

Baseline characteristics of pre-VFC and VFC patients
Variables	Pre-VFC (n = 1819)		VFC (n = 1972)		p-value
Age in years: median (IQR)	44	(29–62)	43	(28–62)	0.46
Sex: n (%)					0.57
Male	936	(52)	1033	(52)
Female	883	(48)	939	(48)
Registered injury type: n (%)					< 0.01
Fracture	1541	(85)	1580	(80)
Distortion	43	(2)	142	(7)
Luxation	170	(9)	190	(10)
Tendon/ligament rupture	65	(4)	60	(3)
Registered DRG: n (%)					< 0.01
AC/SC joint	28	(2)	78	(4)
Clavicle	81	(4)	84	(4)
Glenohumeral joint/proximal humerus	232	(13)	225	(11)
Distal humerus/olecranon	30	(2)	44	(2)
Radial head	16	(1)	33	(2)
Radial/ulnar shaft	18	(1)	31	(2)
Distal radius/ulna	295	(16)	264	(13)
Carpus	111	(6)	145	(7)
Metacarpus	137	(7)	138	(7)
Phalanges finger	347	(19)	308	(16)
Patella	23	(1)	39	(2)
Knee (distortion)	40	(2)	120	(6)
Tibial plateau	26	(1)	24	(1)
Tibia/fibula shaft	30	(2)	22	(1)
Ankle	113	(6)	125	(6)
Achilles tendon	37	(2)	55	(3)
Tarsus	56	(3)	45	(2)
Metatarsus	106	(6)	122	(6)
Phalanges foot	67	(4)	66	(3)
VFC = Virtual Fracture Care, IQR = interquartile range, DRG = Diagnosis related group, AC = Acromioclavicular, SC = Sternoclavicular

The groups were comparable in terms of sex and age at baseline, but differed in the composition of types of registered injuries and registered diagnostic related groups.

The total number of follow-up appointments was reduced by 8% following VFC review implementation (IRR = 0.92, 95%CI = 0.89–0.96, p < 0.01) (Table 3). Furthermore, the mode of care delivery shifted from face-to-face towards remote care. Following VFC review, face-to-face appointments were reduced by 29% (IRR = 0.71, 95%CI = 0.68–0.73, p < 0.01) and appointments by phone increased by 1395% (IRR = 13.95, 95%CI = 11.42–17.03, p < 0.01) compared to pre-VFC. In total, 98% of follow-up appointments was performed face-to-face and 2% by phone in the pre-VFC group, versus 75% face-to-face and 25% by phone in the VFC group (p < 0.01).

The distribution of follow-up appointment attendance among physicians and casting technicians was comparable between groups, with physicians performing 56% of follow-up appointments for pre-VFC patients versus 55% for VFC patients (p = 0.18). Additional regression analysis per type of healthcare professionals showed that the total reduction in follow-up appointments was mainly caused by a reduction for appointments performed by physicians. A 12% reduction was observed in the number of physician follow-up appointments (IRR = 0.88, 95%CI = 0.84–0.92), p < 0.01), whereas the number of casting technician follow-up appointments remained similar (IRR = 0.98, 95%CI = 0.93–1.04, p = 0.53).

In total, the VFC group underwent fewer radiographs compared to the pre-VFC group, with an overall reduction of 5% (IRR = 0.95, 95%CI = 0.90–0.99, p = 0.04) (Table 3).

Table 3

Secondary healthcare utilization for pre-VFC and VFC patients
	Descriptive outcome				Effect (regression pre-VFC vs. VFC)
Outcome; n (median, IQR)	Pre-VFC (n = 1819)		VFC (n = 1972)		IRR	95%CI	p-value
Total FU appointments^†	6474	(3, 2–5)	6332	(3, 2–4)	0.92**	0.89–0.96	< 0.01
Face-to-face	6370	(3, 2–4)	4737	(2, 1–4)	0.71**	0.68–0.73	< 0.01
By telephone	104	(0, 0–0)	1595	(1, 0–1)	13.95**	11.42–17.03	< 0.01
FU appointments per HP type^†
Physician	3635	(2, 1–2)	3480	(2, 1–2)	0.88**	0.84–0.92	< 0.01
Casting technician	2839	(1, 0–2)	2851	(1, 0–2)	0.98**	0.93–1.04	0.53
Total radiographs	3359	(2, 1–2)	3391	(2, 1–2)	0.95**	0.90–0.99	0.04
FU radiographs	1265	(0, 0–1)	1206	(0, 0–1)	0.91*	0.83–0.98	0.02
ED radiographs	2094	(1, 1–1)	2185	(1, 1–1)	0.97**	0.92–1.04	0.39
Total CT scans	329	(0, 0–0)	412	(0, 0–0)	1.12**	0.96–1.29	0.15
FU CT scans	99	(0, 0–0)	122	(0, 0–0)	1.08**	0.82–1.42	0.58
ED CT scans	230	(0, 0–0)	285	(0, 0–0)	1.12**	0.94–1.34	0.22
Total MRI scans	47	(0, 0–0)	58	(0, 0–0)	0.79**	0.53–1.18	0.25
FU MRI scans	47	(0, 0–0)	58	(0, 0–0)	0.79**	0.53–1.18	0.25
ED MRI scans	0	(0, 0–0)	0	(0, 0–0)	-	-	-
ED reattendances	222	(0, 0–0)	164	(0, 0–0)	0.71**	0.58–0.87	< 0.01
VFC = Virtual Fracture Care, IQR = interquartile range, IRR = incidence rate ratio, CI = Confidence interval, FU = Follow-up, HP = healthcare professional, ED = emergency department, CT = Computed tomography, MRI = Magnetic resonance imaging Analysed with a negative binomial regression model with a reference value of 1 for the pre-VFC group *Analysed with a Poisson regression model with a reference value of 1 for the pre-VFC group ^†Missing data in 1 pre-VFC patients and 3 VFC patients

The number of radiographs performed during the follow-up phase was reduced by 9% (IRR = 0.91, 95%CI = 0.83–0.98, p = 0.02) while the number of radiographs performed in the ED remained similar (IRR = 0.97, 95%CI = 0.92–1.04, p = 0.39) following VFC review. Regarding CT-scans, the VFC review protocol did not significantly influence the total number of performed CT scans (IRR = 1.12, 95%CI = 0.96–1.29, p = 0.15), both in the follow-up phase (IRR = 1.08, 95%CI = 0.82–1.42, p = 0.58) and in the ED (IRR = 1.12, 95%CI = 0.94–1.34, p = 0.22). The total number of performed MRI scans in the follow-up phase did not differ between groups (IRR = 0.79, 95%CI = 0.53–1.18, p = 0.25) and, as no MRI scans were performed in the ED, the total number of performed scans was comparable between groups.

With the use of the VFC review protocol, the number of ED reattendances was reduced by 29% compared to the pre-VFC protocol (IRR = 0.71, 95%CI = 0.58–0.87, p < 0.01) (Table 3).

Following the introduction of the VFC review workflow, the number of follow-up appointments with physicians in non-operative treatment pathways of musculoskeletal extremity injuries was reduced by 12%, while the number of follow-up appointments with casting technicians remained similar compared to pre-VFC review. Additionally, the adoption of VFC review resulted in a shift from face-to-face to remote care delivery, a reduction in radiographic imaging during hospital follow-up treatment, and fewer reattendances at the ED.

One of the main goals of the VFC review protocol is to organize and streamline the decision-making process for follow-up treatment. Instead of scattered decision-making processes involving different professionals at various times in pre-VFC workflows, the VFC protocol consolidates decision-making into one organized session. In this session, all relevant healthcare disciplines contribute, enabling comprehensive follow-up treatment decisions made under the direct supervision of a single supervisor. Furthermore, transferring part of the diagnostic phase of the ED visit to this organized setting enables the follow-up treatment team to schedule the required follow-up treatment, rather than solely ED healthcare professionals, This prevents varying (inexperienced) healthcare professionals from planning excessive follow-up appointments in the more disorganized and hectic environment of the ED and the outpatient clinic or casting room. (21) Furthermore, the VFC review meeting facilitates direct and effective supervision by medical specialists, which has proven to support healthcare professionals and improve care processes. (22, 23) The decrease in follow-up appointments noted in this study is likely linked to these aspects of the VFC review protocol.

Furthermore, by taking a multidisciplinary approach at the very start of the treatment through the VFC review meeting and extending the scope to the entire follow-up treatment period, the different tasks and follow-up appointments can be efficiently and responsibly divided among the treatment team. One of the main advantages of this is that physicians are not unnecessarily employed for activities and appointments that are mostly cast-related (e.g. removal of cast or switch of immobilization) and can be performed independently by casting technicians. These appointments account for a major part of non-operative follow-up treatment appointments. The observed reduction in follow-up appointments performed by physicians in this study may partly be due to this efficient allocation of personnel and allows physicians to provide other services elsewhere, where they are more needed. Studies on comparable VFC models have also reported improved efficiency on healthcare resource utilization. However, these mostly focused on the initial treatment phase and the referral of patients to the most appropriate caregiver at the start of the treatment process.(11, 14, 24, 25) Our results complement these studies and show that the VFC review protocol can improve efficiency of hospital follow-up treatment.

Following the VFC review implementation, we observed a significant shift of the mode of follow-up treatment delivery from face-to-face to remotely by phone. This is in line with previous studies on other similar VFC models (3, 24, 26). However, in our specific VFC review protocol, this shift can be mainly attributed to the routine follow-up function check appointments being performed via phone at 6–8 weeks post-injury. This is an addition to other known VFC models, only handling the initial referral remotely. In the VFC review meeting, the supervising (orthopedic) trauma surgeon can determine which patients and injuries are suitable for remote function checks. This approach promotes the incorporation of telemedicine in follow-up care, reducing the need for routinely scheduling face-to-face appointments for every patient. Telemedicine has undergone a rapid growth in recent years, catalyzed by the COVID-19 pandemic distancing measures, and has proven an efficient and satisfactory alternative to face-to-face care in orthopedic trauma patients. (27, 28) Not only does this shift to remote care improve efficiency in the outpatient clinic, it also prevents unnecessary traveling expenses and time for patients and holds environmental benefits due to the reduction of patient movements. (29, 30) Despite these advantages, it remains important to check for which patient remote care can be an adequate alternative. Healthcare professionals need to remain vigilant for those patients for whom face-to-face care is more suitable (e.g. patients who experience barriers to communication due to language differences or who have limited understanding of the recovery process).(31)

Similar to the reduction in follow-up appointments, the reduction in radiographs during follow-up treatment in the VFC group aligns with results from previous studies and can most likely be attributed to the more organized and supervised decision-making process during the VFC review meeting (24, 25). Notably, there may be room for further improvement in healthcare resource utilization in this regard. The majority of radiographs during non-operative follow-up treatment is performed routinely to evaluate bone healing after a fracture. However, recent studies have debated the added value of routine radiography in the follow-up of extremity injuries, stating routine imaging should be replace for imaging on indication. (32–35) Updating VFC review treatment plans to exclude routine radiographs and opting for imaging on indication, coupled with clear instructions in the VFC review documentation for healthcare professionals during follow-up, could help reduce excessive imaging and accelerate the uptake of these new findings regarding routine imaging in daily clinical practice. The number of CT-scans performed was similar in both groups. Yet, in orthopedic follow-up trauma care, there's a consistent increase in CT-scan usage. The lack of a corresponding increase in scans post VFC review suggests potentially more efficient CT-scan utilization in VFC protocols, similar to radiographs.(36)

Both our results and previous literature show that patients treated through VFC were less likely to reattend the ED compared to pre-VFC (11, 37). However, previous studies mainly focused on the Direct Discharge protocols, only including non-operative management of simple and stable injuries Our study extends this result to patients with more complex injuries requiring hospital follow-up treatment. We believe this can be primarily be attributed to the comprehensive information of the VFC review treatment plans encompassing the complete follow-up treatment pathway. This extended scope helps shape realistic patient expectations of treatment, addressing a key factor for ED reattendance—uncertainty about recovery progress and follow-up appointments (38). A reduction of ED reattendances contributes to prevent ED crowding, a significant global healthcare challenge increasingly impacting quality of care (39). However, based on our findings, we could not definitively state the reason for this reduction following VFC review implementation. A thorough examination of reasons for ED reattendances and patient experiences could complement these findings, offering deeper insights into the specific factors contributing to this reduction.

Strengths and limitations

Strengths of this study include the level of detail of secondary healthcare utilization analysis, accounting for every contact during follow-up treatment. Furthermore, the analysis was corrected for potential confounding due to baseline differences. Combined, this provided a detailed perspective on the independent effect of VFC review on the study outcome parameters. Additionally, to our knowledge, this was the first study focusing on the effect of a VFC review protocol on the complete hospital follow-up treatment pathway, rather than just the initial treatment phase. Finally, the inclusion period for VFC patients was timed in a period past the COVID-19 pandemic. This minimizes the chance for bias due to changed standards of care during the pandemic.

This study also had several limitations. First, due to its retrospective nature, study data accuracy and results on the resource utilization in daily practice relied on the accuracy of hospital data registration. This is a well-known limitation of retrospective studies.(40) However, we included only logistical data, which were all routinely registered in the EPR, directly from the EPR system. Therefore, we believe these data should accurately reflect reality and were sufficient for the purposes of this study. Second, we could not assess the number of missed follow-up appointments, as these were not registered in the study database. By changing the scheduling process and mode of delivery for follow-up appointments, the number of no-shows may have been affected. However, previous studies have shown that telemedicine reduces no-show rates suggesting a positive result following VFC review in this regard.(41–43) Finally, the reduction of follow-up appointments, improved allocation of tasks and shift to remote care following VFC review suggests a concomitant cost reduction. However, our study lacked the data to analyze the cost-effectiveness balance between resources required by the VFC review protocol and its benefits.

Future perspectives

Although our findings indicate the VFC review protocol reduced healthcare resource utilization in this study population, the current VFC review treatment pathways include a large number of routine function check appointments and imaging. Evaluation of the added value of this routine care could contribute to a further reduction of unnecessary healthcare resource utilization and optimize the VFC treatment pathways in providing the right amount of care and further improve efficiency. Furthermore, a gap in knowledge remains regarding patients perspectives on the VFC review workflow, warranting further research in patient satisfaction and experiences. Notably, the experiences of healthcare professionals should also be considered, as these changes often significantly impact their daily routines. These insights can aid successful integration of new workflows into daily clinical practice.

The utilization of a VFC review protocol for adult patients with a musculoskeletal extremity injury requiring non-operative hospital follow-up treatment reduces the number of follow-up appointments (8%) compared to the pre-VFC protocols, primarily due to a reduction in follow-up appointments performed by physicians (12%). Additionally, The number of follow-up radiographs (9%) and ED reattendances (29%) is also reduced following VFC review implementation. The VFC review protocol may provide an efficient alternative to provide orthopedic trauma follow-up care amidst increasingly scarce healthcare resources and medical personnel.

VFC

Virtual Fracture Care

Emergency Department

Computed Tomography

MRI

Magnetic Resonance Imaging

IQR

Interquartile Range

IRR

Incidence Rate Ratio

Ethics approval and consent to participate

The local ethical research committee (Advies Commissie Wetenschappelijk Onderzoek) approved this study (WO 23.073). The need for informed consent was waived due to the retrospective use of solely anonymous data.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request

Competing interests

The authors declare that they have no competing interests

Funding

No funding was received for this study

Author’s contributions

GJAW: Defining concept study, writing the research protocol, data collection and analysis, drafting and revising of manuscript

DAS: data collection and analysis, interpretation of data, drafting and revising of manuscript

JF Spierings: contributed to study design and interpretation of data, drafting and revising of manuscript

BA Twigt, JC Goslings and RN van Veen: Defining concept study, approval of research protocol, interpretation of data, drafting and revising of manuscript

All authors read and approved the final manuscript. All authors have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Acknowledgements

On behalf of all contributing authors, we would like to thank the Emergency Department staff and casting technicians for their contribution to the implementation of the Virtual Fracture Care review protocol and their efforts in sustaining high-quality trauma care. We would also like to thank G. Duijzings (BSc) for her efforts as project lead of the VFC project. Finally, we would like to thank B. Dronkert for this efforts in realizing an accurate clinical database for the VFC project.

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No competing interests reported.

VFCConsAdditionalfile1BMCR.docx
Additional files File name: additional file 1 File format including the correct file extension: Table, .txt, Word Title of data: Two examples of Virtual Fracture Care (VFC) review treatment plans for commonly seen injuries Description of data: Additional file 1 provides two examples of VFC review treatment plans to illustrate the format and contents of these treatments plans for the reader

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The effects of a Virtual Fracture Care review protocol on secondary healthcare utilization in trauma patients requiring non operative treatment: a retrospective cohort study

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INTRODUCTION

METHODS

Design and setting

Treatment workflows

Pre-VFC workflow

VFC – review workflow

Data collection

Outcomes

Analysis

RESULTS

DISCUSSION

Strengths and limitations

Future perspectives

CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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Version 1