Cost-effectiveness of individualized nutrition and exercise therapy for rehabilitation following hip fracture

Effect of Individual Nutrition Therapy and Exercise Regime on Gait Speed, Physical Function, Strength and Balance, Body Composition, Energy and Protein, in Injured, Vulnerable Elderly: A Multisite Randomized Controlled Trial (INTERACTIVE)

It is imperative that the surgical treatment of hip fractures is followed up with rehabilitation to enhance recovery and quality of life. This randomized controlled trial aimed to determine if an individualised, combined exercise–nutrition intervention significantly improved health outcomes in older adults, after proximal femoral fracture. We commenced the community extended therapy while in hospital, within two weeks post-surgery. The primary outcome was gait speed and secondary outcomes included physical function, strength and balance, body composition, energy and protein intake. Eighty-six and 89 participants were randomized into six months individualised exercise and nutrition intervention and attention-control groups, respectively. There were no statistically significant differences in gait speed between the groups at six and 12 months. There were no major differences between groups with respect to the secondary outcomes, except estimated energy and protein intake. This may be explained by the sample size achieved. Participants in the intervention group had greater increment in energy (235 kcal; 95% CI, 95 to 375; p = 0.01) and protein intake (9.1 g; 95% CI, 1.5 to 16.8; p = 0.02), compared with those in the control group at six months but not significant at 12 months. This study has demonstrated that providing early, combined exercise and nutrition therapy can improve dietary energy and protein intake in older adults with hip fractures.

Identifying and Managing Malnutrition, Frailty and Sarcopenia in the Community: A Narrative Review

Malnutrition, frailty and sarcopenia are becoming increasingly prevalent among community-dwelling older adults; yet are often unidentified and untreated in community settings. There is an urgent need for community-based healthcare professionals (HCPs) from all disciplines, including medicine, nursing and allied health, to be aware of, and to be able to recognise and appropriately manage these conditions. This paper provides a comprehensive overview of malnutrition, frailty and sarcopenia in the community, including their definitions, prevalence, impacts and causes/risk factors; and guidance on how these conditions may be identified and managed by HCPs in the community. A detailed description of the care process, including screening and referral, assessment and diagnosis, intervention, and monitoring and evaluation, relevant to the community context, is also provided. Further research exploring the barriers/enablers to delivering high-quality nutrition care to older community-dwelling adults who are malnourished, frail or sarcopenic is recommended, to inform the development of specific guidance for HCPs in identifying and managing these conditions in the community.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

OBJECTIVE

The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries.

METHODS

Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method.

RESULTS

A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost.

CONCLUSION

This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

Effects of Home-Based Physical Exercise on Days at Home, Health Care Utilization, and Functional Independence Among Patients With Hip Fractures: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effects of a physical exercise program on days lived at home, the use and costs of health care and social services, mortality, and functional independence among patients with hip fractures.

DESIGN

Randomized controlled trial with a parallel 2-group design consisting of a 12-month intervention and 12-month registry follow-up.

SETTING

Home-based intervention.

PARTICIPANTS

Patients aged ≥60 years (N=121) with operated hip fracture and who were living at home were randomized into physical exercise (n=61) and usual care (n=60) groups.

INTERVENTIONS

Supervised physical exercise twice a week.

MAIN OUTCOME MEASURES

The primary outcome was the number of days lived at home over 24 months. Secondary outcomes were the use and costs of health care and social services, mortality over 24 months, and Functional Independence Measure (FIM) over 12 months.

RESULTS

Over 24 months, there was no significant difference between the groups in terms of days lived at home (incidence rate ratio, 1.01; 95% confidence interval [CI], 0.90-1.14) or mortality (hazard ratio, 1.01; 95% CI, 0.42-2.43). The mean total costs of health care and social services did not differ between the groups. The costs per person-year were 1.26-fold (95% CI, 0.87-1.86) greater in the physical exercise group than in the usual care group over 12 months and 1.08-fold (95% CI, 0.77-1.70) over 24 months. The mean difference between the change in FIM of the groups over 12 months was 4.5 points (95% CI, 0.5-8.5; P=.029) in favor of the physical exercise group.

CONCLUSIONS

Long-term home-based physical exercise had no effect on the number of days lived at home over 24 months among patients with hip fractures. The intervention was cost neutral over these 24 months. The FIM scores improved in both groups over 12 months, but the improvement was significantly greater in the physical exercise group than in the usual care group.

A Systematic Review of Cost-Effectiveness Studies of Interventions With a Personalized Nutrition Component in Adults

OBJECTIVES

Important links between dietary patterns and diseases have been widely applied to establish nutrition interventions. However, knowledge about between-person heterogeneity regarding the benefits of nutrition intervention can be used to personalize the intervention and thereby improve health outcomes and efficiency. We performed a systematic review of cost-effectiveness analyses (CEAs) of interventions with a personalized nutrition (PN) component to assess their methodology and findings.

METHODS

A systematic search (March 2019) was performed in 5 databases: EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar. CEAs involving interventions in adults with a PN component were included; CEAs focusing on clinical nutrition or undernutrition were excluded. The CHEERS checklist was used to assess the quality of CEAs.

RESULTS

We identified 49 eligible studies among 1792 unique records. Substantial variation in methodology was found. Most studies (91%) focused only on psychological concepts of PN such as behavior and preferences. Thirty-four CEAs were trial-based, 13 were modeling studies, and 4 studies were both trial- and model-based. Thirty-two studies used quality-adjusted life year as an outcome measure. Different time horizons, comparators, and modeling assumptions were applied, leading to differences in costs/quality-adjusted life years. Twenty-eight CEAs (49%) concluded that the intervention was cost-effective, and 75% of the incremental cost-utility ratios were cost-effective given a willingness-to-pay threshold of $50 000 per quality-adjusted life year.

CONCLUSIONS

Interventions with PN components are often evaluated using various types of models. However, most PN interventions have been considered cost-effective. More studies should examine the cost-effectiveness of PN interventions that combine psychological and biological concepts of personalization.

Effectiveness of combined exercise and nutrition interventions in prefrail or frail older hospitalised patients: a systematic review and meta-analysis

OBJECTIVES

To determine the effectiveness of combined exercise-nutrition interventions in prefrail/frail hospitalised older adults on frailty, frailty-related indicators, quality of life (QoL), falls and its cost-effectiveness.

DESIGN

Randomised controlled trials (RCTs) of combined exercise-nutrition interventions on hospitalised prefrail/frail older adults ≥65 years were collated from MEDLINE, Emcare, CINAHL, Ageline, Scopus, Cochrane and PEDro on 10 October 2019. The methodological quality was appraised, and data were summarised descriptively or by meta-analysis using a fixed effects model. The standardised mean difference (SMD) or difference of means (MD) with 95% CIs was calculated.

RESULTS

Twenty articles from 11 RCTs experimenting exercise-nutrition interventions on hospitalised older adults were included. Seven articles were suitable for the meta-analyses. One study had low risk of bias and found improvements in physical performance and frailty-related biomarkers. Exercise interventions were mostly supervised by a physiotherapist, focusing on strength, ranging 2-5 times/week, of 20-90 min duration. Most nutrition interventions involved counselling and supplementation but had dietitian supervision in only three studies. The meta-analyses suggest that participants who received exercise-nutrition intervention had greater reduction in frailty scores (n=3, SMD 0.25; 95% CI 0.03 to 0.46; p=0.02) and improvement in short physical performance battery (SPPB) scores (n=3, MD 0.48; 95% CI 0.12 to 0.84; p=0.008) compared with standard care. Only the chair-stand test (n=3) out of the three SPPB components was significantly improved (MD 0.26; 95% CI 0.09 to 0.43; p=0.003). Patients were more independent in activities of daily living in intervention groups, but high heterogeneity was observed (I²=96%, p<0.001). The pooled effect for handgrip (n=3)±knee extension muscle strength (n=4) was not statistically significant. Nutritional status, cognition, biomarkers, QoL, falls and cost-effectiveness were summarised descriptively due to insufficient data.

CONCLUSIONS

There is evidence, albeit weak, showing that exercise-nutrition interventions are effective to improve frailty and frailty-related indicators in hospitalised older adults.