The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison

Abstract

Objectives: To assess the clinical and cost-effectiveness of a virtual fracture clinic (VFC) model, and supplement the literature regarding this service as recommended by The National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association (BOA).

Methods: This was a retrospective study including all patients (17 116) referred to fracture clinics in a London District General Hospital from May 2013 to April 2016, using hospital-level data. We used interrupted time series analysis with segmented regression, and direct before-and-after comparison, to study the impact of VFCs introduced in December 2014 on six clinical parameters and on local Clinical Commissioning Group (CCG) spend. Student's t-tests were used for direct comparison, whilst segmented regression was employed for projection analysis.

Results: There were statistically significant reductions in numbers of new patients seen face-to-face (140.4, sd 39.6 versus 461.6, sd 61.63, p < 0.0001), days to first orthopaedic review (5.2, sd 0.66 versus 10.9, sd 1.5, p < 0.0001), discharges (33.5, sd 3.66 versus 129.2, sd 7.36, p < 0.0001) and non-attendees (14.82, sd 1.48 versus 60.47, sd 2.68, p < 0.0001), in addition to a statistically significant increase in number of patients seen within 72-hours (46.4% 3873 of 8345 versus 5.1% 447 of 8771, p < 0.0001). There was a non-significant increase in consultation time of 1 minute 9 seconds (14 minutes 53 seconds sd 106 seconds versus 13 minutes 44 seconds sd 128 seconds, p = 0.0878). VFC saved the local CCG £67 385.67 in the first year and is set to save £129 885.67 annually thereafter.

Conclusions: We have shown VFCs are clinically and cost-effective, with improvement across several clinical performance parameters and substantial financial savings for CCGs. To our knowledge this is the largest study addressing clinical practice implications of VFCs in England, using robust methodology to adjust for pre-existing trends. Further studies are required to appreciate whether our results are reproducible with local variations in the VFC model and payment tariffs.Cite this article: A. McKirdy, A. M. Imbuldeniya. The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison. Bone Joint Res 2017;6:-269. DOI: 10.1302/2046-3758.65.BJR-2017-0330.R1.

Keywords: Interrupted time-series; Orthopaedics; Virtual fracture clinic.

Fig. 1

Referral pathways to fracture clinics before the intervention. Emergency department (ED), GPs and minor injuries units (MIU) could directly book patients into face-to-face clinics in addition to the on-call orthopaedic team.

Fig. 2

Referral pathways to fracture clinics after the intervention. Emergency department (ED), GPs and minor injuries units (MIU) can book patients directly to VFC only, or refer to the on-call orthopaedic team which is the only route for booking into face-to-face clinic. Patients reviewed in VFC can subsequently be followed-up in face-to-face clinics.

Fig. 3

All new referrals to outpatient fracture clinics over the study period. Face-to-face (FTF) attendances are shown in dark orange whilst virtual fracture clinic (VFC) appointments are in pale orange. The solid black line indicates the trend line for total number of new referrals, which is a non-significant increase over time.

Fig. 4

Interrupted time series (ITS) segmented regression for number of new patients seen in face-to-face fracture clinic per month, showing a level-and-slope change at 20 months (December 2014, the intervention). Solid dark orange line, regression line for each segment; Dashed dark orange line, counterfactual scenario; light orange dotted line, difference between counterfactual and actual scenario at six months post-intervention; Grey shading, post-intervention period.

Fig. 5

Interrupted time series (ITS) segmented regression for number of days to first clinical review by an orthopaedic doctor, showing a level-and-slope change at 20 months (December 2014, the intervention). Pre-intervention slope, 0.12; post-intervention slope, 0.013. Solid dark orange line, regression line for each segment; Dashed dark orange line, counterfactual scenario; light orange dotted line, difference between counterfactual and actual scenario at six months post-intervention; Grey shading, post-intervention period.

Fig. 6

Graph of Student’s t-test results comparing the percentage of patients reviewed within the BOAST 7 72-hour target time-frame in the post-intervention vs pre-intervention groups. There was a significant increase from 5.1% (± 0.49) to 46.4% (± 3.29), Student’s t-test, p < 0.0001.

Fig. 7

Graph of study site Virtual fracture clinic (VFC) discharge rates per month over the entire study period. Mean discharge rate is 32.9% (range 25.9 to 39.5%).

Fig. 8

Interrupted time series (ITS) segmented regression for number of patients per month discharged directly from their first face-to-face clinic. There is a clear level and slope change. Pre-intervention slope, +3.7; post-intervention slope, –1.5; Solid dark orange line, regression line for each segment; Dashed dark orange line, counterfactual scenario; light orange dotted line, difference between counterfactual and actual scenario at six months post-intervention; Grey shading, post-intervention period.

Fig. 9

Interrupted time series (ITS) segmented regression of absolute number of non-attendances per month for face-to-face clinic. There is a clear level change. Pre-intervention slope, 0.063; post-intervention slope, 0.11; Solid dark orange line, regression line for each segment; Dashed dark orange line, counterfactual scenario; Grey shading, post-intervention period.

Fig. 10

Graphical representation of the changes in key clinical performance parameters over the study period (see legend). The solid dark orange line shows the intervention (virtual fracture clinic (VFC) introduction in December 2014).