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Sarkies MN, Testa L, Carrigan A, Roberts N, Gray R, Sherrington C, Mitchell R, Close JCT, McDougall C, Sheehan K. Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis. Age Ageing 2023; 52:afad154. [PMID: 37596922 PMCID: PMC10439513 DOI: 10.1093/ageing/afad154] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND Perioperative interventions could enhance early mobilisation and physical function after hip fracture surgery. OBJECTIVE Determine the effectiveness of perioperative interventions on early mobilisation and physical function after hip fracture. METHODS Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched from January 2000 to March 2022. English language experimental and quasi-experimental studies were included if patients were hospitalised for a fractured proximal femur with a mean age 65 years or older and reported measures of early mobilisation and physical function during the acute hospital admission. Data were pooled using a random effect meta-analysis. RESULTS Twenty-eight studies were included from 1,327 citations. Studies were conducted in 26 countries on 8,192 participants with a mean age of 80 years. Pathways and models of care may provide a small increase in early mobilisation (standardised mean difference [SMD]: 0.20, 95% confidence interval [CI]: 0.01-0.39, I2 = 73%) and physical function (SMD: 0.07, 95% CI 0.00 to 0.15, I2 = 0%) and transcutaneous electrical nerve stimulation analgesia may provide a moderate improvement in function (SMD: 0.65, 95% CI: 0.24-1.05, I2 = 96%). The benefit of pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision on mobilisation and function remains uncertain. Evidence of no effect on mobilisation or function was identified for pre-emptive analgesia, intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training or nutritional supplements. CONCLUSIONS Perioperative interventions may improve early mobilisation and physical function after hip fracture surgery. Future studies are needed to model the causal mechanisms of perioperative interventions on mobilisation and function after hip fracture.
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Affiliation(s)
- Mitchell N Sarkies
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney NSW 2006, Australia
| | - Luke Testa
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia
| | - Ann Carrigan
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia
| | - Natalie Roberts
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia
| | - Rene Gray
- James Paget University Hospital Foundation Trust, Norfolk NR31, UK
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney NSW 2006, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney NSW 2006, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia
| | - Jacqueline C T Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney NSW 2031, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney NSW 2052, Australia
| | - Catherine McDougall
- The University of Queensland, Brisbane 4072, Australia
- The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane 4032, Australia
| | - Katie Sheehan
- Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London WC2R, UK
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2
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Hsu YF, Chou FH, Wang HH, Chu YC, Liao KL. Effectiveness of integrated care for elderly patients with hip fractures: A systematic review and meta-analysis. Geriatr Nurs 2023; 49:65-73. [PMID: 36446147 DOI: 10.1016/j.gerinurse.2022.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 11/27/2022]
Abstract
Hip fractures in the elderly often cause many complications after surgery. Although ample evidence shows that integrated care can effectively improve postoperative conditions, the effectiveness of specific interventions remains inconsistent across studies. This study was conducted following the Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The database was from November 1998 to July 2022. Twelve studies (3,010 participants) implemented integrated care for elderly patients with hip fractures. Overall, integrated care improved Activities of Daily Living (ADL) levels within 6 months, at 12 months, Quality of Life (QoL) at 6 months, and decreased Length of Stay (LOS) and mortality rate at 3 months. At least 3 months of integrated care intervention for hip fractures in the elderly to reduce patient complications and medical costs, can be used as a reference for future policies and clinical care.
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Affiliation(s)
- Yi-Fen Hsu
- College of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 807, Taiwan
| | - Fan-Hao Chou
- College of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 807, Taiwan
| | - Hsiu-Hung Wang
- College of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 807, Taiwan.
| | - Yi-Chin Chu
- College of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 807, Taiwan; Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Kuei-Lin Liao
- College of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 807, Taiwan; Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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3
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Curtis K, Moules P, McKenzie J, Weidl L, Selak T, Binks S, Hernandez D, Rijsdijk J, Risi D, Wright J, O'Rourke L, Knapman M, Ristevski M, Stephens T, Harris I, Close JCT. Development of an Early Activation Hip Fracture Care Bundle and Implementation Strategy to Improve Adherence to the National Hip Fracture Clinical Care Standard. J Multidiscip Healthc 2021; 14:2891-2903. [PMID: 34703242 PMCID: PMC8524060 DOI: 10.2147/jmdh.s323678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/27/2021] [Indexed: 12/17/2022] Open
Abstract
Objective To develop and implement a multidisciplinary early activation mechanism and bundle of care (eHIP) to improve adherence to ACSQHC standards in a regional trauma centre. Methods Barriers to implementation were categorised using the Theoretical Domains Framework, then linked to specific strategies guided by the Behaviour Change Wheel and Behaviour Change Technique Taxonomy (BCTT). The resulting implementation strategies were assessed using Affordable, Practical, Effective, Acceptable, had Side-effects (APEASE) criteria. Results Eighty-three barriers to implementation of the hip fracture care bundle were identified. The behaviour change wheel process resulted in the identification of 41 techniques to address these barriers. The predominant mechanisms to achieve this were development and implementation of 1) formal policy that outlines eHIP roles; 2) video promotion; 3) pager group; 4) fascia iliaca block enabling; 5) eMR modifications; 6) face-to-face reinforcement and modelling; 7) communication and prompts; 8) environmental restructuring. Conclusion We applied behaviour change theory through a pragmatic evidence-based process. This resulted in a codesigned strategy to overcome staff and organisational barriers to the implementation of a multidisciplinary early activation mechanism and bundle of care (eHIP). Future work will include evaluation of the uptake and clinical impact of the care bundle.
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia.,Illawarra Health and Medical Research Institute, Wollongong, NSW, Australia.,George Institute for Global Health, Newtown, NSW, Australia
| | - Peter Moules
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - John McKenzie
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia.,Illawarra Health and Medical Research Institute, Wollongong, NSW, Australia
| | - Lauren Weidl
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - Tanya Selak
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - Simon Binks
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - Daniel Hernandez
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - Joshua Rijsdijk
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - Dante Risi
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - James Wright
- Agency for Clinical Innovation, St Leonards, NSW, Australia
| | - Lauren O'Rourke
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - Myles Knapman
- Western NSW LHD, Department of Surgery, Dubbo, NSW, Australia
| | - Meagan Ristevski
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - Teala Stephens
- Illawarra Shoalhaven LHD, Emergency Department, Wollongong, NSW, Australia
| | - Ian Harris
- Ingham Institute of Applied Medical Research, South Western Sydney Clinical School, UNSW, Sydney, NSW, Australia
| | - Jacqueline C T Close
- Prince Wales Clinical School, UNSW, Sydney, NSW, Australia.,Neuroscience Research Australia, UNSW, Sydney, NSW, Australia
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Sermon A, Slock C, Coeckelberghs E, Seys D, Panella M, Bruyneel L, Nijs S, Akiki A, Castillon P, Chipperfield A, El Attal R, Foss NB, Frihagen F, Gerich TG, Gümbel D, Kanakaris N, Kristensen MT, Malchau I, Palm H, Pape HC, Vanhaecht K. Quality indicators in the treatment of geriatric hip fractures: literature review and expert consensus. Arch Osteoporos 2021; 16:152. [PMID: 34625842 DOI: 10.1007/s11657-021-00995-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/29/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Even though hip fracture care pathways have evolved, mortality rates have not improved during the last 20 years. This finding together with the increased frailty of hip fracture patients turned hip fractures into a major public health concern. The corresponding development of an indicator labyrinth for hip fractures and the ongoing practice variance in Europe call for a list of benchmarking indicators that allow for quality improvement initiatives for the rapid recovery of fragile hip fractures (RR-FHF). The purpose of this study was to identify quality indicators that assess the quality of in-hospital care for rapid recovery of fragile hip fracture (RR-FHF). METHODS A literature search and guideline selection was conducted to identify recommendations for RR-FHF. Recommendations were categorized as potential structure, process, and outcome QIs and subdivided in-hospital care treatment topics. A list of structure and process recommendations that belongs to care treatment topics relevant for RR-FHF was used to facilitate extraction of recommendations during a 2-day consensus meeting with experts (n = 15) in hip fracture care across Europe. Participants were instructed to select 5 key recommendations relevant for RR-FHF for each part of the in-hospital care pathway: pre-, intra-, and postoperative care. RESULTS In total, 37 potential QIs for RR-FHF were selected based on a methodology using the combination of high levels of evidence and expert opinion. The set consists of 14 process, 13 structure, and 10 outcome indicators that cover the whole perioperative process of fragile hip fracture care. CONCLUSION We suggest the QIs for RR-FHF to be practice tested and adapted to allow for intra-hospital longitudinal follow-up of the quality of care and for inter-hospital and cross-country benchmarking and quality improvement initiatives.
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Affiliation(s)
- An Sermon
- KU Leuven, Leuven, Belgium.,Traumatology Department at University Hospitals Leuven, Leuven, Belgium
| | | | - Ellen Coeckelberghs
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium.,European Pathway Association, Leuven, Belgium
| | - Deborah Seys
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium
| | - Massimiliano Panella
- European Pathway Association, Leuven, Belgium.,Università Degli Studi del Piemonte Orientale "Amedeo Avogadro", Novara, Italy
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium
| | | | - Alain Akiki
- Hôpital Riviera Chablais, Rennaz, Switzerland
| | - Pablo Castillon
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España.,Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, España
| | - Alex Chipperfield
- Consultant Trauma and Orthopaedic Surgeon, East Kent Hospitals NHS Trust, Kent, UK
| | - René El Attal
- Klinik für Orthopädie und Unfallchirurgie, Sporttraumatologie, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Nicolai Bang Foss
- Departments of Anaesthesia and Intensive Care, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Frede Frihagen
- Orthopaedic Department, Østfold Hospital Trust, Grålum, Norway.,Associate Professor, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Torsten G Gerich
- Head of Orthopaedic Trauma, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Denis Gümbel
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany.,Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | - Nikolaos Kanakaris
- Leeds Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
| | - Morten Tange Kristensen
- Departments of Physiotherapy and Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark.,Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Henrik Palm
- Head of Department, Department of Orthopedics, Copenhagen University Hospital Bispebjerg, Bispebjerg, Denmark
| | - Hans-Christoph Pape
- Department of Trauma, University of Zurich, Universitäts Spital Zurich, Zurich, Switzerland
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium. .,European Pathway Association, Leuven, Belgium. .,Department of Quality, University Hospitals Leuven, Leuven, Belgium.
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Tittel S, Burkhardt J, Roll C, Kinner B. Clinical pathways for geriatric patients with proximal femoral fracture improve process and outcome. Orthop Traumatol Surg Res 2020; 106:141-147. [PMID: 31870558 DOI: 10.1016/j.otsr.2019.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 05/04/2019] [Accepted: 07/22/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of the current study was to evaluate the implementation of clinical pathways (CPs) in hip fracture management. METHODS Six hundred and five proximal femoral fractures were prospectively included into a hospital data-base. The effects of CPs were evaluated using a pre-during-post design. Different procedural (time to surgery, length of stay, discharge, etc.) and patient outcome parameters (mortality, complications, etc.) were evaluated. RESULTS In both categories significant changes could be detected during the three-year period. E.g. significant reduction of time to surgery, improvement of discharge management, reduction of internal complications. However, no significant changes could be demonstrated for mortality or revision rate. CONCLUSION We could show a relevant improvement with the implementation of clinical pathways for the treatment of proximal femoral fractures in elderly patients. LEVEL OF EVIDENCE III, prospective non-randomised cohort study.
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Affiliation(s)
- Sandra Tittel
- Department of Orthopaedic and Trauma Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Janosch Burkhardt
- Department of Orthopaedic and Trauma Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Christina Roll
- Zentrum für Ambulante Rehabilitation, Regensburg, Germany
| | - Bernd Kinner
- Department of Orthopaedic and Trauma Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
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6
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Svenøy S, Watne LO, Hestnes I, Westberg M, Madsen JE, Frihagen F. Results after introduction of a hip fracture care pathway: comparison with usual care. Acta Orthop 2020; 91:139-145. [PMID: 31928088 PMCID: PMC7144204 DOI: 10.1080/17453674.2019.1710804] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - We established a care pathway for hip fracture patients, a "Hip Fracture Unit" (HFU), aiming to provide better in-hospital care and thus improve outcome. We compared the results after introduction of the HFU with a historical control group.Patients and methods - The HFU consisted of a series of measures within the orthopedic ward, such as reducing preoperative waiting time, increased use of nerve blocks, early mobilization, and osteoporosis treatment. 276 patients admitted from May 2014 to May 2015 constituted the HFU group and 167 patients admitted from September 2009 to January 2012 constituted the historical control group. Patients were followed prospectively up to 12 months post fracture.Results - Mean preoperative waiting time was 24 hours in the HFU group and 29 hours in the control group (p = 0.003). 123 patients (47%) in the HFU were started on anti-osteoporosis treatment while in hospital. "Short Physical Performance Battery" score (SPPB) was mean 5.5 in the HFU group and 3.8 in the control group at 4 months (p < 0.001), and 5.7 vs. 3.6 at 12 months (p < 0.001). The mortality rate at 4 months was 15% in both groups. No statistically significant differences were found in readmissions, complications, new nursing home admissions, in Barthel ADL index or a mental capacity test at the follow-ups.
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Affiliation(s)
- Stian Svenøy
- Division of Orthopaedic Surgery, Oslo University Hospital; ,Institute of Clinical Medicine, University of Oslo; ,Correspondence:
| | - Leiv Otto Watne
- Department of Geriatric Medicine, Oslo University Hospital, Norway
| | | | | | - Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital; ,Institute of Clinical Medicine, University of Oslo;
| | - Frede Frihagen
- Division of Orthopaedic Surgery, Oslo University Hospital;
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Tedesco D, Gibertoni D, Rucci P, Hernandez-Boussard T, Rosa S, Bianciardi L, Rolli M, Fantini MP. Impact of rehabilitation on mortality and readmissions after surgery for hip fracture. BMC Health Serv Res 2018; 18:701. [PMID: 30200950 PMCID: PMC6131904 DOI: 10.1186/s12913-018-3523-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 09/05/2018] [Indexed: 12/15/2022] Open
Abstract
Background Hip fracture in elderly patients is a rising global public health concern because of population ageing, and increasing frailty. Long-term morbidity related to poor management of hip fracture is associated with decreased quality of life, survival, and increase in healthcare costs. Receiving postoperative rehabilitation is associated with better outcomes and a higher likelihood of returning to pre-existing level of functioning. However little is known about which postoperative rehabilitation pathways are more effective to optimize patient outcomes. Few studies have analyzed postoperative rehabilitation pathways in a universal healthcare system. The aim of this study is to analyze the impact of post-acute rehabilitation pathways on mortality and readmission in elderly patients undergoing surgery for hip fracture in a large metropolitan area in Italy. Methods In this retrospective cohort study, we analyzed 6-month mortality from admission and 6-month readmission after hospital discharge in patients who underwent surgical repair for hip fracture in the hospitals of the Bologna metropolitan area between 1.1.2013 and 30.6.2014. Data were drawn from the regional hospital discharge records database. Kaplan-Meier estimates and multiple Cox regression were used to analyze mortality as a function of rehabilitation pathways. Multiple logistic regression determined predictors of readmission. Results The study population includes 2208 patients, mostly women (n = 1677, 76%), with a median age of 83.8 years. Hospital rehabilitation was provided to 519 patients (23.5%), 907 (41.1%) received rehabilitation in private inpatient rehabilitation facilities (IRF) accredited by the National Health System, and 782 (35.4%) received no post-acute rehabilitation. Compared with patient receiving hospital rehabilitation, the other groups showed significantly higher mortality risks (no rehabilitation, Hazard Ratio (HR) = 2.19, 95%CI = 1.54–3.12, p < 0.001; IRF rehabilitation, HR = 1.66, 95%CI = 1.54–1.79, p < 0.001). The risk of readmission did not differ significantly among rehabilitation pathways. Conclusions Intensive hospital rehabilitation was significantly associated with a lower risk of mortality compared to IRF rehabilitation and no rehabilitation. Our results may help in the development of evidence-based recommendations aimed to improve resource utilization and quality of care in hip fracture patients. Further research is warranted to investigate the impact of the rehabilitation pathway on other outcomes, such as patients’ functional status and quality of life.
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Affiliation(s)
- Dario Tedesco
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy.
| | - Dino Gibertoni
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy
| | - Tina Hernandez-Boussard
- Department of Medicine, Stanford University, 1265 Welch Road, 94305, Stanford, California, USA
| | - Simona Rosa
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy
| | - Luca Bianciardi
- Rizzoli Orthopedic Institute, Via Giulio Cesare Pupilli, 40138, Bologna, Italy
| | - Maurizia Rolli
- Rizzoli Orthopedic Institute, Via Giulio Cesare Pupilli, 40138, Bologna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Via San Giacomo, 12, 40126, Bologna, Italy
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