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Phang JK, Lim ZY, Yee WQ, Tan CYF, Kwan YH, Low LL. Post-surgery interventions for hip fracture: a systematic review of randomized controlled trials. BMC Musculoskelet Disord 2023; 24:417. [PMID: 37231406 DOI: 10.1186/s12891-023-06512-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Interventions provided after hip fracture surgery have been shown to reduce mortality and improve functional outcomes. While some systematic studies have evaluated the efficacy of post-surgery interventions, there lacks a systematically rigorous examination of all the post-surgery interventions which allows healthcare providers to easily identify post-operative interventions most pertinent to patient's recovery. OBJECTIVES We aim to provide an overview of the available evidence on post-surgery interventions provided in the acute, subacute and community settings to improve outcomes for patients with hip fractures. METHODS We performed a systematic literature review guided by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). We included articles that were (1) randomized controlled trials (RCTs), (2) involved post-surgery interventions that were conducted in the acute, subacute or community settings and (3) conducted among older patients above 65 years old with any type of non-pathological hip fracture that was surgically treated, and who were able to walk without assistance prior to the fracture. We excluded (1) non-English language articles, (2) abstract-only publications, (3) articles with only surgical interventions, (4) articles with interventions that commenced pre-surgery or immediately upon completion of surgery or blood transfusion, (5) animal studies. Due to the large number of RCTs identified, we only included "good quality" RCTs with Jadad score ≥ 3 for data extraction and synthesis. RESULTS Our literature search has identified 109 good quality RCTs on post-surgery interventions for patients with fragility hip fractures. Among the 109 RCTs, 63% of the identified RCTs (n = 69) were related to rehabilitation or medication/nutrition supplementation, with the remaining RCTs focusing on osteoporosis management, optimization of clinical management, prevention of venous thromboembolism, fall prevention, multidisciplinary approaches, discharge support, management of post-operative anemia as well as group learning and motivational interviewing. For the interventions conducted in inpatient and outpatient settings investigating medication/nutrition supplementation, all reported improvement in outcomes (ranging from reduced postoperative complications, reduced length of hospital stay, improved functional recovery, reduced mortality rate, improved bone mineral density and reduced falls), except for a study investigating anabolic steroids. RCTs involving post-discharge osteoporosis care management generally reported improved osteoporosis management except for a RCT investigating multidisciplinary post-fracture clinic led by geriatrician with physiotherapist and occupational therapist. The trials investigating group learning and motivational interviewing also reported positive outcome respectively. The other interventions yielded mixed results. The interventions in this review had minor or no side effects reported. CONCLUSIONS The identified RCTs regarding post-surgery interventions were heterogeneous in terms of type of interventions, settings and outcome measures. Combining interventions across inpatient and outpatient settings may be able to achieve better outcomes such as improved physical function recovery and improved nutritional status recovery. For example, nutritional supplementation could be made available for patients who have undergone hip fracture surgery in the inpatient settings, followed by post-discharge outpatient osteoporosis care management. The findings from this review can aid in clinical practice by allowing formulation of thematic program with combination of interventions as part of bundled care to improve outcome for patients who have undergone hip fracture surgery.
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Affiliation(s)
- Jie Kie Phang
- Centre for Population Health Research and Implementation (CPHRI), SingHealth Regional Health System, SingHealth, Singapore, Singapore
- Program in Health Systems and Services Research, Duke-NUS Medical School, Singapore, Singapore
| | - Zhui Ying Lim
- Population Health & Integrated Care Office (PHICO), Singapore General Hospital, Singapore, Singapore
| | - Wan Qi Yee
- Population Health & Integrated Care Office (PHICO), Singapore General Hospital, Singapore, Singapore
| | - Cheryl Yan Fang Tan
- Bright Vision Community Hospital, SingHealth Community Hospitals, Singapore, Singapore
| | - Yu Heng Kwan
- SingHealth Internal Medicine Residency Programme, Singapore, Singapore
- Program in Health Systems and Services Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Lian Leng Low
- Centre for Population Health Research and Implementation (CPHRI), SingHealth Regional Health System, SingHealth, Singapore, Singapore.
- Population Health & Integrated Care Office (PHICO), Singapore General Hospital, Singapore, Singapore.
- Department of Family Medicine & Continuing Care, Singapore General Hospital, Singapore, Singapore.
- SingHealth Duke-NUS Family Medicine Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore.
- Department of Post-Acute & Continuing Care, SingHealth Community Hospitals, 10 Hospital Boulevard, Singapore, 168852, Singapore.
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Does anatomical type of proximal hip fracture affect rehabilitation outcomes among older adults? Injury 2022; 53:3407-3415. [PMID: 35843752 DOI: 10.1016/j.injury.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 04/26/2022] [Accepted: 06/11/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Numerous studies have detailed the potential benefits of inpatient geriatric rehabilitation for older adults with hip fractures. However, data regarding effect of fracture type (femoral neck, intertrochanteric, or subtrochanteric) on rehabilitation outcomes are limited. This study assessed whether the anatomical type of proximal hip fracture affects rehabilitation outcomes among disabled older adults. METHODS A population-based study was conducted comparing all patients with a recent hip fracture who were admitted to a geriatric rehabilitation facility in Israel. Data were collected retrospectively from an electronic database during a 5-year period (2014-2019). The Functional Independence Measure (FIM) was used to assess physical and cognitive function at admission and discharge. RESULTS The analyses included 624 older adults with hip fractures. We found significant differences in motor FIM score at admission, as patients with femoral neck fracture performed better than patients with intertrochanteric and subtrochanteric fracture did. The disparity in motor FIM score remained consistent through discharge, with all groups achieving a median gain of 14 points. Within one month of rehabilitation, about a third of all patients achieved a higher functional level. CONCLUSIONS Patients with femoral neck fracture have better motor ability than do those with intertrochanteric and subtrochanteric fractures, which were retained throughout the course of rehabilitation; yet, the level of improvement remained similar. Clinicians should be aware of such differences in functional ability when discussing goals of care with older adults with hip fractures and consider them when implementing individual rehabilitation programs .
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Yee DKH, Lau TW, Fang C, Ching K, Cheung J, Leung F. Orthogeriatric Multidisciplinary Co-Management Across Acute and Rehabilitation Care Improves Length of Stay, Functional Outcomes and Complications in Geriatric Hip Fracture Patients. Geriatr Orthop Surg Rehabil 2022; 13:21514593221085813. [PMID: 35433103 PMCID: PMC9006372 DOI: 10.1177/21514593221085813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/10/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction As the global number of geriatric hip fracture cases continues to proliferate, a newly developed orthogeriatric co-management multidisciplinary care model has been implemented since November 2018 to meet further increases in demand. Our objective was to evaluate the effectiveness of the new pathway in improving the clinical outcomes of fragility hip fractures. Methods The data of geriatric hip fracture patients from 1 April 2018 till 30 October 2018 was collected as the conventional orthopaedic care model (pre-orthogeriatric care model) to compare with data from the orthogeriatric co-management model, 1 Feb 2019 till 31 August 2019. Clinical outcomes were analyzed between the groups, with the efficiency of the programme reflected in the total length of stay in acute and convalescent hospitals. Results 194 patients were recruited to the conventional group and 207 were recruited to the orthogeriatric group, 290 patients (72.3%) were female. The mean (SD) patient age was 84.2 (7.9) years. The median length of stay in the acute and rehabilitation hospitals decreased by 1 day and 2 days, respectively (P=.001). The orthogeriatric group was associated with a higher Modified Barthel Index score on discharge from the rehabilitation hospital and more patients in the orthogeriatric collaboration group received osteoporosis medication prescription within one year after the index fracture. There was no difference in the 28-days unplanned readmission rate, complication rate, mortality rate or Elderly Mobility Scale scores on discharge from the rehabilitation hospital between the two groups. Conclusion Orthogeriatric collaboration has been proven to be effective in terms of a decreased length of stay in both the acute and the rehabilitation hospitals.
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Affiliation(s)
- Dennis King Hang Yee
- The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Tak-Wing Lau
- The Unviersity of Hong Kong, Pokfulam, Hong Kong
| | | | - Kathine Ching
- The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Jake Cheung
- The Unviersity of Hong Kong, Pokfulam, Hong Kong
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Handoll HH, Cameron ID, Mak JC, Panagoda CE, Finnegan TP. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database Syst Rev 2021; 11:CD007125. [PMID: 34766330 PMCID: PMC8586844 DOI: 10.1002/14651858.cd007125.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009. OBJECTIVES To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019). SELECTION CRITERIA We included randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older people (aged 65 years or over) with hip fracture. The primary outcome - 'poor outcome' - was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. The other 'critical' outcomes were health-related quality of life, mortality, dependency in activities of daily living, mobility, and related pain. DATA COLLECTION AND ANALYSIS Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. MAIN RESULTS The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding-related performance and detection biases. We summarise the findings for three comparisons below. Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care' Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials. Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow-up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate-certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences. Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low-certainty evidence). A similar finding applies at 4 to 12 months' follow-up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low-certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow-up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low-certainty evidence). Due to very low-certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow-up (measured in various ways by 11 studies), or at 6 to 12 months' follow-up (13 studies). Long-term hip-related pain was not reported. Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care' Three trials tested this comparison in 377 people mainly living at home. Due to very low-certainty evidence, we have very little confidence in the findings of little to no between-group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long-term hip-related pain was not reported. One trial tested this comparison in 240 nursing home residents. There is low-certainty evidence that there may be no or minimal between-group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low-certainty evidence, we have very little confidence in the findings of no between-group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months. AUTHORS' CONCLUSIONS In a hospital inpatient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty. The generally very low-certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true. Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.
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Affiliation(s)
- Helen Hg Handoll
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
- Department of Orthopaedics and Trauma, The University of Edinburgh, Edinburgh, UK
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Jenson Cs Mak
- Healthy Ageing, Mind & Body Institute, Sydney, Australia
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Claire E Panagoda
- John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and Faculty of Medicine and Health, The University of Sydney, St Leonards, Australia
| | - Terence P Finnegan
- Department of Aged Care and Rehabilitation Medicine, Royal North Shore Hospital of Sydney, St Leonards, Australia
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Levi Y, Punchik B, Zikrin E, Shacham D, Katz D, Makulin E, Freud T, Press Y. Intensive Inpatient vs. Home-Based Rehabilitation After Hip Fracture in the Elderly Population. Front Med (Lausanne) 2020; 7:592693. [PMID: 33163503 PMCID: PMC7581791 DOI: 10.3389/fmed.2020.592693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/10/2020] [Indexed: 01/30/2023] Open
Abstract
Background: As the population ages, the rate of hip fractures and the need for rehabilitation increases. Home-based rehabilitation (HBR) is an alternative to classic inpatient rehabilitation (IR), which is an expensive framework with non-negligible risks. Methods: A retrospective study of patients 65 years and above following surgery to repair a hip fracture who underwent HBR or IR between 2016 and 2019. The two rehabilitation frameworks were compared for rehabilitation outcome and factors predicting successful rehabilitation. The outcome was determined with the Montebello Rehabilitation Factor Score-Revised (MRFS-R). Results: Data were collected for 235 patients over 3 years. The mean age was 81.3 ± 8.0 and 172 (73.3%) were women. Of these, 138 underwent IR and 97 HBR. The HBR group had better family support and fewer lived alone. There were also differences in the type of fracture and surgery. The medical condition of the IR group was more complex, as reflected in a higher Charlson's comorbidity scores, higher rates for delirium and more infectious complications, a lower Norton score, lower serum hemoglobin, and albumin levels, and higher serum creatinine and urea levels. It also had a more significant functional decline after surgery and required a longer rehabilitation period. However, no difference was found in the rehabilitation outcomes between the two groups (MRFS-R ≥ 50). The independent predictors for rehabilitation in the IR group were serum albumin level, comorbidity, and cognitive state. There were no independent predictors in the HBR group. Conclusions: In this retrospective study, there was no significant difference in short-term rehabilitation outcomes between the HBR and IR groups event though the patients in the IR group were medically more complex. This result should be taken into account when planning rehabilitation services after hip fracture and tailoring rehabilitation frameworks to patients.
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Affiliation(s)
- Yael Levi
- Faculty of Health Sciences, Joyce and Irving Goldman Medical School, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Boris Punchik
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Unit for Community Geriatrics, Division of Health in the Community, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Home Care Unit, Clalit Health Services, Beer-Sheva, Israel.,Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Evgeniya Zikrin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - David Shacham
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Dori Katz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Evgeni Makulin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Tamar Freud
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yan Press
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Unit for Community Geriatrics, Division of Health in the Community, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel.,Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Smith TO, Gilbert AW, Sreekanta A, Sahota O, Griffin XL, Cross JL, Fox C, Lamb SE. Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery. Cochrane Database Syst Rev 2020; 2:CD010569. [PMID: 32031676 PMCID: PMC7006792 DOI: 10.1002/14651858.cd010569.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hip fracture is a major injury that causes significant problems for affected individuals and their family and carers. Over 40% of people with hip fracture have dementia or cognitive impairment. The outcomes of these individuals after surgery are poorer than for those without dementia. It is unclear which care and rehabilitation interventions achieve the best outcomes for these people. This is an update of a Cochrane Review first published in 2013. OBJECTIVES (a) To assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared to usual care. (b) To assess for people with dementia the effectiveness of models of care including enhanced rehabilitation strategies that are designed for all older people, regardless of cognitive status, following hip fracture surgery, compared to usual care. SEARCH METHODS We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 16 October 2019. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials evaluating the effectiveness of any model of enhanced care and rehabilitation for people with dementia after hip fracture surgery compared to usual care. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion and extracted data. We assessed risk of bias of the included trials. We synthesised data only if we considered the trials to be sufficiently homogeneous in terms of participants, interventions, and outcomes. We used the GRADE approach to rate the overall certainty of evidence for each outcome. MAIN RESULTS We included seven trials with a total of 555 participants. Three trials compared models of enhanced care in the inpatient setting with conventional care. Two trials compared an enhanced care model provided in inpatient settings and at home after discharge with conventional care. Two trials compared geriatrician-led care in-hospital to conventional care led by the orthopaedic team. None of the interventions were designed specifically for people with dementia, therefore the data included in the review were from subgroups of people with dementia or cognitive impairment participating in randomised controlled trials investigating models of care for all older people following hip fracture. The end of follow-up in the trials ranged from the point of acute hospital discharge to 24 months after discharge. We considered all trials to be at high risk of bias in more than one domain. As subgroups of larger trials, the analyses lacked power to detect differences between the intervention groups. Furthermore, there were some important differences in baseline characteristics of participants between the experimental and control groups. Using the GRADE approach, we downgraded the certainty of the evidence for all outcomes to low or very low. The effect estimates for almost all comparisons were very imprecise, and the overall certainty for most results was very low. There were no data from any study for our primary outcome of health-related quality of life. There was only very low certainty for our other primary outcome, activities of daily living and functional performance, therefore we were unable to draw any conclusions with confidence. There was low-certainty that enhanced care and rehabilitation in-hospital may reduce rates of postoperative delirium (odds ratio 0.04, 95% confidence interval (CI) 0.01 to 0.22, 2 trials, n = 141) and very low-certainty associating it with lower rates of some other complications. There was also low-certainty that, compared to orthopaedic-led management, geriatrician-led management may lead to shorter hospital stays (mean difference 4.00 days, 95% CI 3.61 to 4.39, 1 trial, n = 162). AUTHORS' CONCLUSIONS We found limited evidence that some of the models of enhanced rehabilitation and care used in the included trials may show benefits over usual care for preventing delirium and reducing length of stay for people with dementia who have been treated for hip fracture. However, the certainty of these results is low. Data were available from only a small number of trials, and the certainty for all other results is very low. Determining the optimal strategies to improve outcomes for this growing population of patients should be a research priority.
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Affiliation(s)
- Toby O Smith
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Anthony W Gilbert
- Royal National Orthopaedic HospitalTherapies DepartmentBrockley HillStanmoreUKHA7 4LP
| | - Ashwini Sreekanta
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Opinder Sahota
- Nottingham University Hospitals NHS Trust, QMCHealthcare of Older PeopleDerby RoadNottinghamUKNG7 3UH
| | - Xavier L Griffin
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Jane L Cross
- University of East AngliaFaculty of Medicine and Health SciencesNorwich Research ParkNorwichUKNR4 7TJ
| | - Chris Fox
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Sarah E Lamb
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
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Talevski J, Sanders KM, Duque G, Connaughton C, Beauchamp A, Green D, Millar L, Brennan-Olsen SL. Effect of Clinical Care Pathways on Quality of Life and Physical Function After Fragility Fracture: A Meta-analysis. J Am Med Dir Assoc 2019; 20:926.e1-926.e11. [PMID: 30975586 DOI: 10.1016/j.jamda.2019.02.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/15/2019] [Accepted: 02/18/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To evaluate the effect of clinical care pathways (CCPs) on health-related quality of life (HRQoL) and physical function following fragility fracture and identify the specific characteristics of CCPs that are associated with improved outcomes. DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Randomized controlled studies and nonrandomized studies that involved participants aged ≥50 years who sustained a fragility fracture, evaluated the effects of a CCP compared to usual care, and reported outcomes of HRQoL or physical function. METHODS We systematically searched Ovid Medline, CINAHL, Embase, and the Cochrane Central Register of Controlled Trials from the earliest records to July 25, 2018. Two reviewers independently extracted study data and assessed methodologic quality. RESULTS Overall, 22 studies (17 randomized controlled trials, 5 nonrandomized studies) were included, comprising 5842 participants. Twenty-one studies included hip fracture patients, and 1 included wrist fracture patients. Majority of studies (82%) were assessed as high quality. Meta-analyses showed moderate improvements in the CCP group for HRQoL [standardized mean difference (SMD) = 0.24, 95% confidence interval (CI) 0.12, 0.35] and physical function (SMD 0.21, 95% CI 0.10, 0.33) compared with usual care post hip fracture. Inpatient CCPs that extended to the outpatient setting showed greater improvements in HRQoL and physical function compared to CCPs that were only inpatient or outpatient. CCPs that included a care coordinator, geriatric assessment, rehabilitation, prevention of inpatient complications, nutritional advice, or discharge planning also showed greater improvements in outcomes. CONCLUSIONS AND IMPLICATIONS Treatment with CCPs following fragility fracture showed greater improvements in HRQoL and physical function compared with usual care. Further research is warranted to assess the combination of CCP components that provide the most beneficial results, evaluate the effect of CCPs in patients with nonhip fractures, and determine which patient groups are more likely to benefit from CCPs.
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Affiliation(s)
- Jason Talevski
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia.
| | - Kerrie M Sanders
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Gustavo Duque
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Catherine Connaughton
- Institute for Health and Ageing, Australian Catholic University, Melbourne, Victoria, Australia
| | - Alison Beauchamp
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia; School of Rural Health, Monash University, Moe, Victoria, Australia
| | - Darci Green
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Lynne Millar
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Sharon L Brennan-Olsen
- Department of Medicine-Western Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, Victoria, Australia
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Villa JC, Koressel J, van der List JP, Cohn M, Wellman DS, Lorich DG, Lane JM. Predictors of In-Hospital Ambulatory Status Following Low-Energy Hip Fracture Surgery. Geriatr Orthop Surg Rehabil 2019; 10:2151459318814825. [PMID: 30671280 PMCID: PMC6328945 DOI: 10.1177/2151459318814825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/12/2018] [Accepted: 10/14/2018] [Indexed: 11/16/2022] Open
Abstract
Introduction: Twenty-five percent to seventy-five percent of independent patients do not walk independently after hip fracture (HF), and many patients experience functional loss. Early rehabilitation of functional status is associated with better long-term outcomes; however, predictors of early ambulation after HF have not been well described. Purposes: To assess the impact of perioperative and patient-specific variables on in-hospital ambulatory status following low-energy HF surgery. Methods: This is a retrospective analysis of 463 geriatric patients who required HF surgery at a metropolitan level-1 trauma center. The outcomes were time to transfer (out of bed to chair) and time to walk. Results: Three hundred ninety-two (84.7%) patients were able to transfer after surgery with a median time of 43.8 hours (quartile range: 24.7-53.69 hours), while 244 (52.7%) patients were able to walk with a median time of 50.86 hours (quartile range: 40.72-74.56 hours). Preinjury ambulators with aids (hazard ratio [HR]: 0.70, confidence interval [CI]: 0.50-0.99), age >80 years (HR: 0.66, CI: 0.52-0.84), peptic ulcer disease (HR: 0.57, CI: 0.57-0.82), depression (HR: 0.66, CI: 0.49- 0.89), time to surgery >24 hours (HR: 0.77, CI: 0.61-0.98), and surgery on Friday (HR: 0.73, CI: 0.56-0.95) were associated with delayed time to transfer. Delayed time to walk was observed in patients over 80 years old (HR: 0.74, CI: 0.56-0.98), females (HR: 0.67, CI: 0.48-0.94), peptic ulcer disease (HR: 0.23, CI: 0.84-0.66), and depression (HR: 0.51, CI: 0.33-0.77). Conclusions: Operative predictors of delayed time to transfer were surgery on Friday and time to surgery >24 hours after admission. Depression is associated with delayed time to transfer and time to walk. These data suggest that is important to perform surgeries within 24 hours of admission identify deficiencies in care during the weekends, and create rehabilitation programs specific for patient with depression. Improving functional rehabilitation after surgery may facilitate faster patient discharge, decrease inpatient care costs, and better long-term functional outcomes.
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Affiliation(s)
- Jordan C Villa
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA.,New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Joseph Koressel
- Orthopaedic Trauma Service, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | | | - Matthew Cohn
- Orthopaedic Trauma Service, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - David S Wellman
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA.,Orthopaedic Trauma Service, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Dean G Lorich
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA.,Orthopaedic Trauma Service, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Joseph M Lane
- Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA.,Orthopaedic Trauma Service, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
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Meeting Management Standards and Improvement in Clinical Outcomes Among Patients With Hip Fractures. J Healthc Qual 2018; 40:336-343. [DOI: 10.1097/jhq.0000000000000127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shinoda S, Mutsuzaki H, Watanabe A, Morita H, Kamioka Y. Factors influencing period from surgery to discharge in patients with femoral trochanteric fractures. J Phys Ther Sci 2017; 29:1976-1980. [PMID: 29200639 PMCID: PMC5702829 DOI: 10.1589/jpts.29.1976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/13/2017] [Indexed: 12/25/2022] Open
Abstract
[Purpose] The purpose of this study was to investigate factors influencing the period
from surgery to discharge in patients with femoral trochanteric fractures. [Subjects and
Methods] Sixty patients with femoral trochanteric fractures were investigated
retrospectively. Based on the mean period from surgery to discharge (85.6 ± 26.6 days),
the patients were divided into two groups: an under-85-day group (range, 29–78 days) and
an over-85-day group (87–128 days). Age, gender, fracture type, presence of lesser
trochanteric displacement, discharge destination, and walking ability were investigated.
The relationship between these factors and the period from surgery to discharge was
analyzed with logistic regression analysis. [Results] Age and lesser trochanteric
displacement were significantly higher in the over-85-day group, and walking ability
before fracture and at discharge were significantly lower in the over-85-day group.
Logistic regression analysis showed that lesser trochanteric displacement and age were
predictors of the length from surgery to discharge. Lesser trochanteric displacement were
observed in 87.5% of these. Immediate displacement after surgery occurred in 57.8% of
lesser trochanteric fractures, while 26.3% displaced 1 to 3 weeks after surgery.
[Conclusion] This study revealed that lesser trochanteric displacement, higher age, and
lower walking ability before fracture and at discharge were associated with longer
hospitalizations in patients with femoral trochanteric fractures. Lesser trochanteric
displacement were observed in 87.5% of lesser trochanteric fractures. These displacements
occurred within 3 weeks after surgery in 84.1% of cases.
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Affiliation(s)
- Soichiro Shinoda
- Department of Physical Therapy, Ichihara Hospital: 3681 Ozone, Tsukuba, Ibaraki 300-3295, Japan
| | - Hirotaka Mutsuzaki
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences, Japan
| | - Arata Watanabe
- Department of Orthopaedic Surgery, Ichihara Hospital, Japan
| | - Hidetaka Morita
- Department of Physical Therapy, Ichihara Hospital: 3681 Ozone, Tsukuba, Ibaraki 300-3295, Japan
| | - Yumiko Kamioka
- Department of Physical Therapy, School of Healthcare, Ibaraki Prefectural University of Health Sciences, Japan
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Sims-Gould J, Byrne K, Hicks E, Franke T, Stolee P. "When Things Are Really Complicated, We Call the Social Worker": Post-Hip-Fracture Care Transitions for Older People. HEALTH & SOCIAL WORK 2015; 40:257-265. [PMID: 26638501 DOI: 10.1093/hsw/hlv069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Social workers play a key role in the delivery of interdisciplinary health care. However, in the past decade, concerns have been raised about social work's sustainability and contributions in a changing health care sector. These changes come at a time when older patients are more complex and vulnerable than ever before. In this article, using a strengths-based approach, the authors examine the key contributions made by social workers working with older patients with hip fracture as they strive to achieve successful care transitions. Twenty-five interviews with health care professionals (HCPs) were conducted and then analyzed using an analytical coding framework. Although social workers are vital, they are often underused and overlooked in the care of hip fracture patients. The authors sketch the important contributions that social workers make to care transitions after hip fracture, specifically informational continuity; patient-HCP relational continuity; conflict resolution; mediation among family, patient, and HCP (for example, doctors and nurses); collaboration with family caregivers and community supports; and relocation counseling.
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Scrivener K, Jones T, Schurr K, Graham PL, Dean CM. After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review. J Physiother 2015; 61:61-7. [PMID: 25801362 DOI: 10.1016/j.jphys.2015.02.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/05/2014] [Accepted: 02/17/2015] [Indexed: 11/16/2022] Open
Abstract
QUESTION In adults undergoing inpatient rehabilitation, does additional after-hours rehabilitation decrease length of stay and improve functional outcome, activities of daily living performance and physical activity? DESIGN Systematic review with meta-analysis of randomised trials. PARTICIPANTS Adults participating in an inpatient rehabilitation program. INTERVENTION Additional rehabilitation provided after hours (evening or weekend). OUTCOME MEASURES Function was measured with tests such as the Motor Assessment Scale, 10-m walk test, the Timed Up and Go test, and Berg Balance Scale. Performance on activities of daily living was measured with the Barthel index or the Functional Independence Measure. Length of stay was measured in days. Physical activity levels were measured as number of steps or time spent upright. Standardised mean differences (SMD) or mean differences (MD) were used to combine these outcomes. Adverse events were summarised using relative risks (RR). Study quality was assessed using PEDro scores. RESULTS Seven trials were included in the review. All trials had strong methodological quality, scoring 8/10 on the PEDro scale. Among the measures of function, only balance showed a significant effect: the MD was 14 points better (95% CI 5 to 23) with additional after-hours rehabilitation on a 0-to-56-point scale. The improvement in activities of daily living performance with additional after-hours rehabilitation was of borderline statistical significance (SMD 0.10, 95% CI 0.00 to 0.21). Hospital length of stay did not differ significantly (MD -1.8 days, 95% CI -5.1 to 1.6). Those receiving additional rehabilitation had significantly higher step counts and spent significantly more time upright. Overall, the risk of adverse events was not increased by the provision of after-hours or weekend rehabilitation (RR 0.87, 95% CI 0.70 to 1.10). CONCLUSION Additional after-hours rehabilitation can increase physical activity and may improve activities of daily living, but does not seem to affect the hospital length of stay. REVIEW REGISTRATION PROSPERO CRD42014007648. [Scrivener K, Jones T, Schurr K, Graham PL, Dean CM (2015) After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review.Journal of Physiotherapy61: 61-67].
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Affiliation(s)
| | - Taryn Jones
- Department of Health Professions, Macquarie University
| | - Karl Schurr
- Physiotherapy Department, Bankstown-Lidcombe Hospital
| | - Petra L Graham
- Department of Statistics, Macquarie University, Sydney, Australia
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McKillop A, Parsons J, Slark J, Duncan L, Miskelly P, Parsons M. A day in the life of older people in a rehabilitation setting: an observational study. Disabil Rehabil 2014; 37:963-70. [PMID: 25113571 DOI: 10.3109/09638288.2014.948968] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE Nurses' contribution during inpatient rehabilitation is well documented. However, despite being the largest professional group in this setting, the specialty of rehabilitation nursing is poorly recognised. This article reports on the first of a four-phase study that aimed to clarify and develop the nursing contribution to inpatient rehabilitation for older persons. The aim of this study was to identify activity patterns and time use during daytime and evenings of older adult patients undergoing inpatient rehabilitation. METHODS Direct observation using behavioural modelling was undertaken of a convenience sample of 37 older people undergoing inpatient rehabilitation in a specialist unit of a large tertiary hospital in New Zealand. The primary outcome was the observation of meaningful activity. Binomial logistic regression was used to study the association between relevant variables. FINDINGS Meaningful activity was most likely to involve walking without assistance and to occur 08:00 to 14:00 h and 16:00 to 21:00 h during weekdays. Patients were more likely to receive treatment during the weekend. Irrespective of time, registered nurses were the health professionals most often present with patients. CONCLUSIONS There is likely to be unrealised opportunities for registered nurses to support improved rehabilitation outcomes. Registered nurses' involvement in rehabilitation needs to be actively optimised. IMPLICATIONS FOR REHABILITATION Nurses' engagement with older adults in rehabilitation settings is likely to be substantial, placing them as key members of the rehabilitation team. Nurses make a pivotal contribution to inpatient rehabilitation based on specialised knowledge and skills but this contribution is not well understood. Opportunities are likely, at times when allied health professionals are less often present, e.g. evenings and weekends, for registered nurses to more intentionally overlap rehabilitation activities with other care requirements.
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Affiliation(s)
- Ann McKillop
- School of Nursing, The University of Auckland and the Institute of Healthy Ageing, Waikato District Health Board , Auckland , New Zealand
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The effect of care pathways for hip fractures: a systematic overview of secondary studies. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 23:737-45. [PMID: 23412217 DOI: 10.1007/s00590-012-1085-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 09/09/2012] [Indexed: 12/27/2022]
Abstract
The aim of this paper was to perform a systematic overview of secondary literature studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO-host, and The Cochrane Library were searched. A total of six papers, corresponding to six secondary studies, were included but only four secondary studies were HF-specific and thus assessed. Secondary studies were evaluated for patients' clinical outcomes. There were wide differences among the studies that assessed the effects of CPs on HF patients, with some contrasting clinical outcomes reported. Secondary studies that were non-specific for CPs and included other multidisciplinary care approaches as well showed, in some cases, a shorter hospital length of stay (LOS) compared to usual care; studies that focused on promoting early mobilization showed better outcomes of mortality, morbidity, function, or service utilization; CPs mainly based on intensive occupational therapy and/or physical therapy exercises improved functional recovery and reduced LOS, with patients also discharged to a more favorable discharge destination; CPs principally focused on early mobilization improved functional recovery. A secondary study specifically designed for CPs showed lower odds of experiencing common complications of hospitalization after HF. In conclusion, although our overview suggests that CPs can reduce significantly LOS and can have a positive impact on different outcomes, data are insufficient for formal recommendations. To properly understand the effects of CPs for HF, a systematic review is needed of primary studies that specifically examined CPs for HF.
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Determining current physical therapist management of hip fracture in an acute care hospital and physical therapists' rationale for this management. Phys Ther 2011; 91:1490-502. [PMID: 21817011 DOI: 10.2522/ptj.20100310] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Physical therapy has an important role in hip fracture rehabilitation to address issues of mobility and function, yet current best practice guidelines fail to make recommendations for specific physical therapy interventions beyond the first 24 hours postsurgery. OBJECTIVES The aims of this study were: (1) to gain an understanding of current physical therapist practice in an Australian acute care setting and (2) to determine what physical therapists consider to be best practice physical therapist management and their rationale for their assessment and treatment techniques. DESIGN AND METHODS Three focus group interviews were conducted with physical therapists and physical therapist students, as well as a retrospective case note audit of 51 patients who had undergone surgery for hip fracture. RESULTS Beyond early mobilization and a thorough day 1 postoperative assessment, great variability in what was considered to be best practice management was displayed. Senior physical therapists considered previous clinical experience to be more important than available research evidence, and junior physical therapists modeled their behavior on that of senior physical therapists. The amount of therapy provided to patients during their acute inpatient stay varied considerably, and none of the patients audited were seen on every day of their admission. CONCLUSIONS Current physical therapist management in the acute setting for patients following hip fracture varies and is driven by system pressures as opposed to evidence-based practice.
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Singh NA, Quine S, Clemson LM, Williams EJ, Williamson DA, Stavrinos TM, Grady JN, Perry TJ, Lloyd BD, Smith EUR, Singh MAF. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial. J Am Med Dir Assoc 2011; 13:24-30. [PMID: 21944168 DOI: 10.1016/j.jamda.2011.08.005] [Citation(s) in RCA: 218] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 08/07/2011] [Accepted: 08/08/2011] [Indexed: 01/29/2023]
Abstract
RATIONALE Excess mortality and residual disability are common after hip fracture. HYPOTHESIS Twelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions will result in lower mortality, nursing home admissions, and disability compared with usual care after hip fracture. DESIGN Randomized, controlled, parallel-group superiority study. SETTING Outpatient clinic PARTICIPANTS Patients (n = 124) admitted to public hospital for surgical repair of hip fracture between 2003 and 2007. INTERVENTION Twelve months of geriatrician-supervised high-intensity weight-lifting exercise and targeted treatment of balance, osteoporosis, nutrition, vitamin D/calcium, depression, cognition, vision, home safety, polypharmacy, hip protectors, self-efficacy, and social support. OUTCOMES Functional independence: mortality, nursing home admissions, basic and instrumental activities of daily living (ADLs/IADLs), and assistive device utilization. RESULTS Risk of death was reduced by 81% (age-adjusted OR [95% CI] = 0.19 [0.04-0.91]; P < .04) in the HIPFIT group (n = 4) compared with usual care controls (n = 8). Nursing home admissions were reduced by 84% (age-adjusted OR [95% CI] = 0.16 [0.04-0.64]; P < .01) in the experimental group (n = 5) compared with controls (n = 12). Basic ADLs declined less (P < .0001) and assistive device use was significantly lower at 12 months (P = .02) in the intervention group compared with controls. The targeted improvements in upper body strength, nutrition, depressive symptoms, vision, balance, cognition, self-efficacy, and habitual activity level were all related to ADL improvements (P < .0001-.02), and improvements in basic ADLs, vision, and walking endurance were associated with reduced nursing home use (P < .0001-.05). CONCLUSION The HIPFIT intervention reduced mortality, nursing home admissions, and ADL dependency compared with usual care.
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Affiliation(s)
- Nalin A Singh
- Department of Aged Care, Balmain and Royal Prince Alfred Hospitals, Balmain and Camperdown, Australia
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Dudkiewicz I, Burg A, Salai M, Hershkovitz A. Gender Differences Among Patients With Proximal Femur Fractures During Rehabilitation. ACTA ACUST UNITED AC 2011; 8:231-8. [DOI: 10.1016/j.genm.2011.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 05/02/2011] [Accepted: 06/14/2011] [Indexed: 11/16/2022]
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Validation on Efficiency Pattern Analysis for Geriatric Hip Fractures Rehabilitation. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2010. [DOI: 10.1016/j.jotr.2010.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Seven hundred and sixty-three elderly patients with hip fractures were recruited in the study. The Functional Independence Measure (FIM) was used to measure their functional status on admission and upon discharge, and their difference was defined as functional change. An Efficiency Pattern Analysis Matrix was formed with Efficiency Pattern Analysis (EPA) and was used for in-depth matrix characteristics analysis. A validation study was also conducted with another group of patients (n = 455) so that the stability of EPA across time was affirmed. We found that 23.3% of patients are in “higher efficiency” group [higher motor-FIM gains with shorter length of stay (LOS)], 8.5% in “higher gain and longer stay” group (higher motor-FIM gains with longer LOS), 32.5% in “average efficiency” group, 12% in “lower gain and shorter stay” (lower motor-FIM gain and shorter LOS), and 23.7% of patients in “lower efficiency” group (intermediate motor-FIM gains with longer LOS). The demographic and functional characteristics among these groups would be also analysed.
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Cameron ID. Models of rehabilitation – commonalities of interventions that work and of those that do not. Disabil Rehabil 2010; 32:1051-8. [DOI: 10.3109/09638281003672377] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. BMJ 2010; 340:c1718. [PMID: 20406866 PMCID: PMC2857746 DOI: 10.1136/bmj.c1718] [Citation(s) in RCA: 314] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the effects of inpatient rehabilitation specifically designed for geriatric patients compared with usual care on functional status, admissions to nursing homes, and mortality. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, Cochrane database, and reference lists from published literature. Review methods Only randomised controlled trials were included. Trials had to report on inpatient rehabilitation and report at least one of functional improvement, admission to nursing homes, or mortality. Trials of consultation or outpatient services, trials including patients aged <55, trials of non-multidisciplinary rehabilitation, and trials without a control group receiving usual care were excluded. Data were double extracted. Odds ratios and relative risks with 95% confidence intervals were calculated. RESULTS 17 trials with 4780 people comparing the effects of general or orthopaedic geriatric rehabilitation programmes with usual care were included. Meta-analyses of effects indicated an overall benefit in outcomes at discharge (odds ratio 1.75 (95% confidence interval 1.31 to 2.35) for function, relative risk 0.64 (0.51 to 0.81) for nursing home admission, relative risk 0.72 (0.55 to 0.95) for mortality) and at end of follow-up (1.36 (1.07 to 1.71), 0.84 (0.72 to 0.99), 0.87 (0.77 to 0.97), respectively). Limited data were available on impact on health care or cost. Compared with those in control groups, weighted mean length of hospital stay after randomisation was longer in patients allocated to general geriatric rehabilitation (24.5 v 15.1 days) and shorter in patients allocated to orthopaedic rehabilitation (24.6 v 28.9 days). CONCLUSION Inpatient rehabilitation specifically designed for geriatric patients has the potential to improve outcomes related to function, admission to nursing homes, and mortality. Insufficient data are available for defining characteristics and cost effectiveness of successful programmes.
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Affiliation(s)
- Stefan Bachmann
- Department of Geriatrics, Inselspital, University of Bern Hospital, Freiburgstrasse 10, CH-3010 Bern, Switzerland
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Crotty M, Unroe K, Cameron ID, Miller M, Ramirez G, Couzner L. Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people. Cochrane Database Syst Rev 2010:CD007624. [PMID: 20091644 DOI: 10.1002/14651858.cd007624.pub3] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Social and psychological factors such as fear of falling, self-efficacy and coping strategies are thought to be important in the recovery from hip fracture in older people. OBJECTIVES To evaluate the effects of interventions aimed at improving physical and psychosocial functioning after hip fracture. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 4), MEDLINE and EMBASE (to December 2008), other databases and reference lists of related articles. SELECTION CRITERIA Randomised and quasi-randomised trials of rehabilitation interventions applied in inpatient or ambulatory settings to improve physical or psychosocial functioning in older adults with hip fracture. Primary outcomes were physical and psychosocial function and 'poor outcome' (composite of mortality, failure to return to independent living and/or readmission). DATA COLLECTION AND ANALYSIS Two authors independently selected trials based on pre-defined inclusion criteria, extracted data and assessed risk of bias. Disagreements were moderated by a third author. MAIN RESULTS Nine small heterogeneous trials (involving 1400 participants) were included. The trials had differing interventions, including 'usual care' comparators, providers, settings and outcome assessment. Although most trials appeared well conducted, poor reporting hindered assessment of their risk of bias.Three trials testing interventions (reorientation measures, intensive occupational therapy, cognitive behavioural therapy) delivered in inpatient settings found no significant differences in outcomes. Two trials tested specialist-nurse led care, which was predominantly post-discharge but included discharge planning in one trial: this trial found some benefits at three months but the other trial found no differences at 12 months. Coaching (educational and motivational interventions) was examined in two very different trials: one trial found no effect on function at six months; and the other showed coaching improved self-efficacy expectations at six months, although not when combined with exercise. Two trials testing interventions (home rehabilitation; group learning program) started several weeks after hip fracture found no significant differences in outcomes at 12 months. AUTHORS' CONCLUSIONS Some outcomes may be amenable to psychosocial treatments; however, there is insufficient evidence to recommend practice changes. Further research on interventions described in this review is required, including attention to timing, duration, setting and administering discipline(s), as well as treatment across care settings. To facilitate future evaluations, a core outcome set, including patient-reported outcomes such as quality of life and compliance, should be established for hip fracture trials.
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Affiliation(s)
- Maria Crotty
- Department of Rehabilitation and Aged Care, Repatriation General Hospital, Daws Road, Daw Park, South Australia, Australia, 5041
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Chong CP, Savige J, Lim WK. Orthopaedic-geriatric models of care and their effectiveness. Australas J Ageing 2009; 28:171-6. [DOI: 10.1111/j.1741-6612.2009.00368.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Handoll HH, Cameron ID, Mak JC, Finnegan TP. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database Syst Rev 2009:CD007125. [PMID: 19821396 DOI: 10.1002/14651858.cd007125.pub2] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Hip fracture is a major cause of morbidity and mortality in older people and its impact on society is substantial. OBJECTIVES To examine the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older patients with hip fracture. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2009), The Cochrane Library (2009, Issue 2), MEDLINE and EMBASE (both to April 2009). SELECTION CRITERIA Randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older patients (aged 65 years or over) with hip fracture. The primary outcome, 'poor outcome' was a composite of mortality and decline in residential status at long-term (generally one year) follow-up. DATA COLLECTION AND ANALYSIS Trial selection was by consensus. Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate. MAIN RESULTS The 13 included trials involved 2498 older, usually female, patients who had undergone hip fracture surgery. Though generally well conducted, some trials were at risk of bias such as from imbalances in key baseline characteristics.There was substantial clinical heterogeneity in the trial interventions and populations. Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 11 trials. Pooled results showed no statistically significant difference between intervention and control groups for poor outcome (risk ratio 0.89; 95% confidence interval 0.78 to 1.01), mortality (risk ratio 0.90, 95% confidence interval 0.76 to 1.07) or hospital readmission. Individual trials found better results, often short-term only, in the intervention group for activities of daily living and mobility. There was considerable heterogeneity in length of stay and cost data. Three trials reporting carer burden showed no evidence of detrimental effect from the intervention. Overall, the evidence indicates that multidisciplinary rehabilitation is not harmful.The trial comparing primarily home-based multidisciplinary rehabilitation with usual inpatient care found marginally improved function and a clinically significantly lower burden for carers in the intervention group. Participants of this group had shorter hospital stays, but longer periods of rehabilitation. One trial found no significant effect from doubling the number of weekly contacts at the patient's home from a multidisciplinary rehabilitation team. AUTHORS' CONCLUSIONS While there was a tendency to a better overall result in patients receiving multidisciplinary inpatient rehabilitation, these results were not statistically significant.Future trials of multidisciplinary rehabilitation should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than evaluate its components.
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Affiliation(s)
- Helen Hg Handoll
- Centre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social Care, University of Teesside, School of Health and Social Care, Middlesborough, Tees Valley, UK, TS1 3BA
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Cameron ID, Handoll HHG, Finnegan TP, Madhok R, Langhorne P. WITHDRAWN: Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures. Cochrane Database Syst Rev 2009; 2009:CD000106. [PMID: 19821265 PMCID: PMC10823768 DOI: 10.1002/14651858.cd000106.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hip fracture is a major cause of morbidity and mortality in older people and its impact, both on the individual and to society, is substantial. OBJECTIVES To examine the effects of co-ordinated multidisciplinary inpatient rehabilitation, compared with usual (orthopaedic) care, for older patients with hip fracture. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (December 2002), MEDLINE (1966 to December 2002), conference proceedings and reference lists of articles and books. We also contacted colleagues and trialists. SELECTION CRITERIA Randomised and quasi-randomised trials of post-surgical care using specialised rehabilitation of mainly older patients (aged 65 years or over) with hip fracture. DATA COLLECTION AND ANALYSIS Trial assignment to included, excluded and awaiting assessment categories, was by consensus. Two reviewers independently assessed trial quality and extracted data. Limited additional information was sought from most trialists. As well as pooling data from primary outcomes, supplementary analyses were performed to combine clinically relevant outcomes and investigate possible explanatory factors. MAIN RESULTS In this minor update, new data for two already included trials have been incorporated, resulting in only slight changes to the pooled results.The nine included trials involved 1887 patients. The combined outcomes of death or requiring institutional care showed no significant difference between intervention and control groups (relative risk 0.93; 95% confidence interval 0.83 to 1.05). There was considerable heterogeneity in length of stay and cost data. Using death and deterioration in function as a further combined outcome variable yielded a relative risk of 0.91 (95% confidence interval 0.83 to 1.01). This should be interpreted with caution due to heterogeneity. No quality of life measures were reported and the two trials investigating carer burden showed no evidence of detrimental effect from the intervention. The review update did not result in any new data for these outcomes. AUTHORS' CONCLUSIONS The available trials reviewed had different aims, interventions and outcomes. Combined outcome measures (e.g. death or institutional care) tended to be better for patients receiving co-ordinated inpatient rehabilitation, but the results were heterogeneous and not statistically significant.Future trials of post-surgical care involving inpatient rehabilitation, or other models such as 'early supported discharge' and 'hospital at home' schemes, should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than attempt to evaluate its components.
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Affiliation(s)
- Ian D Cameron
- Sydney Medical School, The University of SydneyRehabilitation Studies Unit, Northern Clinical SchoolPO Box 6RydeNSWAustralia1680
| | - Helen HG Handoll
- University of TeessideCentre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social CareSchool of Health and Social CareMiddlesboroughTees ValleyUKTS1 3BA
| | - Terence P Finnegan
- Royal North Shore Hospital of SydneyDepartment of Aged Care and Rehabilitation MedicineBuilding 12St LeonardsNSWAustraliaNSW 2065
| | - Rajan Madhok
- University of ManchesterCochrane Bone, Joint and Muscle Trauma GroupSchool of Translational Medicine2nd Floor Stopford Building, Oxford RoadManchesterUKM13 9PT
| | - Peter Langhorne
- University of GlasgowAcademic Section of Geriatric Medicine3rd Floor, Centre BlockRoyal InfirmaryGlasgowUKG4 0SF
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Brusco NK, Paratz J. The effect of additional physiotherapy to hospital inpatients outside of regular business hours: A systematic review. Physiother Theory Pract 2009; 22:291-307. [PMID: 17166820 DOI: 10.1080/09593980601023754] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Provision of out of regular business hours (OBH) physiotherapy to hospital inpatients is widespread in the hospital setting. This systematic review evaluated the effect of additional OBH physiotherapy services on patient length of stay (LOS), pulmonary complications, discharge destination, discharge mobility status, quality of life, cost saving, adverse events, and mortality compared with physiotherapy only within regular business hours. A literature search was completed on databases with citation tracking using key words. Two reviewers completed data extraction and quality assessment independently by using modified scales for historical cohorts and case control studies as well as the PEDro scale for randomized controlled trials and quasi-randomised controlled trials. This search identified nine articles of low to medium quality. Four reported a significant reduction in LOS associated with additional OBH physiotherapy, with two articles reporting overall significance and two reporting only for specific subgroups. Two studies reported significant reduction in pulmonary complications for two different patient groups in an intensive care unit (ICU) with additional OBH physiotherapy. Three studies accounted for discharge destination and/or discharge mobility status with no significant difference reported. Quality of life, adverse events, and mortality were not reported in any studies. Cost savings were considered in three studies, with two reporting a cost saving. This systematic review was unable to conclude that the provision of additional OBH physiotherapy made significant improvement to patient outcomes for all subgroups of inpatients. One study in critical care reported that overnight physiotherapy decreased LOS and reduced pulmonary complications of patients in the ICU. However, the studies in the area of orthopaedics, neurology, postcardiac surgery, and rheumatology, which all considered additional daytime weekend physiotherapy intervention, did not provide strong evidence to indicate effective reduction in patient LOS or improving patient discharge mobility status or discharge destination. Investigation should continue in this area, but future trials should ensure factors such as random allocation, groups equal at baseline, blinded investigators, and proven intervention are included in the study design.
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Tierney AJ, Vallis J. Multidisciplinary teamworking in the care of elderly patients with hip fracture. J Interprof Care 2009. [DOI: 10.3109/13561829909025534] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Chudyk AM, Jutai JW, Petrella RJ, Speechley M. Systematic review of hip fracture rehabilitation practices in the elderly. Arch Phys Med Rehabil 2009; 90:246-62. [PMID: 19236978 DOI: 10.1016/j.apmr.2008.06.036] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 06/02/2008] [Accepted: 06/05/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To address the need for a research synthesis on the effectiveness of the full range of hip fracture rehabilitation interventions for older adults and make evidence based conclusions. DATA SOURCES Medline, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched from 1980 to 2007 for studies published in English. The terms rehabilitation and hip fracture were exploded in order to obtain related search terms and categories. STUDY SELECTION In the initial search of the databases, a combined total of 1031 articles was identified. Studies that did not focus on hip fracture rehabilitation, did not include persons over the age of 50 years, and/or did not include measures of physical outcome were excluded. DATA EXTRACTION Only studies with an Oxford Center for Evidence-Based Medicine Levels of Evidence level of I (randomized controlled trial, RCT) or II (cohort) were reviewed. The methodologic quality of both types of studies was assessed using a modified version of the Downs and Black checklist. DATA SYNTHESIS There were 55 studies that met our selection criteria: 30 RCTs and 25 nonrandomized trials. They were distributed across 6 categories for rehabilitation intervention (care pathways, early rehabilitation, interdisciplinary care, occupational and physical therapy, exercise, intervention not specified) and 3 settings (acute care hospital, postacute care/rehabilitation, postrehabilitation). CONCLUSIONS When looking across all of the intervention types, the most frequently reported positive outcomes were associated with measures of ambulatory ability. Eleven intervention categories across 3 settings were associated with improved ambulatory outcomes. Seven intervention approaches were related to improved functional recovery, while 6 intervention approaches were related to improved strength and balance recovery. Decreased length of stay and increased falls self-efficacy were associated with 2 interventions, while 1 intervention had a positive effect on lower-extremity power generation.
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Affiliation(s)
- Anna M Chudyk
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada.
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Uy C, Kurrle SE, Cameron ID. Inpatient multidisciplinary rehabilitation after hip fracture for residents of nursing homes: a randomised trial. Australas J Ageing 2008; 27:43-4. [PMID: 18713215 DOI: 10.1111/j.1741-6612.2007.00277.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the effectiveness of interdisciplinary rehabilitation for women with hip fracture who were residents of nursing homes. DESIGN Randomised controlled trial. SUBJECTS Eleven cognitively impaired women with hip fracture who were previously ambulant. METHODS Participants were randomly allocated to usual care (discharge back to the nursing home soon after surgery to the hip fracture) or an inpatient interdisciplinary rehabilitation program. RESULTS Participants were severely cognitively impaired and the majority used a walking aid prior to fracturing their hip. There was one early death, and at final follow up (4 months after hip fracture) median (range) Barthel Index was 28 (0-82) for control group and 68 (0-88) for the intervention group. CONCLUSION No definite conclusion can be drawn about the effectiveness of the intervention because of its premature termination. However, the study established that it is feasible to provide an interdisciplinary rehabilitation for older people with hip fracture and severe disablement.
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Affiliation(s)
- Cesar Uy
- Rehabilitation and Aged Care Service, Hornsby Ku-ring-gai Hospital, New South Wales, Australia
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Rösler A, Krause T, Niehuus C, von Renteln-Kruse W. Dementia as a cofactor for geriatric rehabilitation-outcome in patients with osteosynthesis of the proximal femur: a retrospective, matched-pair analysis of 250 patients. Arch Gerontol Geriatr 2008; 49:e36-9. [PMID: 18834639 DOI: 10.1016/j.archger.2008.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 08/08/2008] [Accepted: 08/14/2008] [Indexed: 10/21/2022]
Abstract
A raising number of patients with osteosynthesis of the proximal femur and additional dementia will be seen in hospitals in the future due to demographic changes. There is an ongoing discussion, if and to what extent cognitive abilities do influence functional outcome in geriatric rehabilitation. We therefore compared 250 patients with osteosynthesis of the proximal femur of whom one half had additional dementia, by a matched-pair analysis for the improvement of mobility assessed by the mobility items of the Barthel Index and the Tinetti mobility index. Dementia was an important cofactor for the success of geriatric rehabilitation. Patients with additional dementia reached lower mobility scores at discharge. Also, patients with dementia had significantly more in-hospital falls. Furthermore, the study revealed that demented patients received less individual and group therapy per hospital day. The study underlines the need for specialized wards treating demented patients with additional illnesses.
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Affiliation(s)
- Alexander Rösler
- Medizinisch-Geriatrische Klinik, Albertinen-Haus, Wissenschaftliche Einrichtung an der Universität Hamburg, Sellhopsweg 18-22, 22459 Hamburg, Germany.
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Chaudhry S. The management of subcapital fractures in the elderly — with an emphasis on economic aspects. TRAUMA-ENGLAND 2007. [DOI: 10.1177/1460408607084358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
About 86 000 hip fractures occur each year in the United Kingdom (Donaldson et al., 1990) and approximately half are intracapsular (Singer et al., 1994). Mortality is 5—10% after 1 month and one third of patients will have died by 1 year (Johnell et al., 1992; French et al., 1995, 2006). The total estimated cost to society is almost £726 million per annum with over half of the cost attributed to social care of patients recovering from a broken hip as more than 10% of survivors will be unable to return to their previous residence (Keene et al.,1993). Hip fractures account for approximately 20% of orthopaedic bed occupancies in the UK, and based on current population trends, the number of hip fractures may rise to 120 000 per annum by 2015 (Johnell et al., 1992). In this article the management of elderly patients with subcapital or intracapsular type fractures is described with an emphasis on economic aspects.
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Beaupre LA, Cinats JG, Senthilselvan A, Lier D, Jones CA, Scharfenberger A, Johnston DWC, Saunders LD. Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway. Qual Saf Health Care 2007; 15:375-9. [PMID: 17074877 PMCID: PMC2565826 DOI: 10.1136/qshc.2005.017095] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hip fractures, common in the elderly population, result in significant morbidity and mortality. A study was undertaken to determine how an evidence based clinical pathway (CP) for treatment of elderly patients with hip fracture affected morbidity, in-hospital mortality, and health service utilization. METHODS A pre-post study design using two population based inception cohorts of hip fracture patients aged > or =65 years was used. The control group (n = 678) was enrolled between July 1996 and September 1997 before implementation of the pathway and the CP group (n = 663) was enrolled between July 1999 and September 2000 following pathway implementation. Chart reviews were completed during study time frames to determine complications, mortality, and health service utilization. RESULTS Only nine patients (1%) in the CP group experienced postoperative congestive heart failure compared with 37 (5%) control patients (p<0.001). Postoperative cardiac arrythmias were significantly lower in the CP group than in the control group (8 (1%) v 36 (5%); p<0.001). Postoperative delirium occurred in 22% of the CP group and 51% of the control group (p<0.001). There was no difference in risk adjusted in-hospital mortality between the two groups. Overall length of stay (LOS) and costs were unchanged between the groups; however, hospital LOS increased while rehabilitation LOS decreased in the CP group. CONCLUSION Implementation of an evidence based clinical pathway reduced postoperative morbidity and did not affect in-hospital mortality or overall costs of inpatient care. The effect of changing trends in medical care cannot be ruled out, but the reduction in complications in several clinical areas lends support to the positive impact of the clinical pathway. Perioperative CP is one successful management approach for this fragile patient population as patient morbidity was reduced without negatively affecting resource utilization.
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Affiliation(s)
- L A Beaupre
- Capital Health, Caritas Health Group, Edmonton, AB, Canada.
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Allegrante JP, Peterson MG, Cornell CN, MacKenzie CR, Robbins L, Horton R, Ganz SB, Ruchlin HS, Russo PW, Paget SA, Charlson ME. Methodological challenges of multiple-component intervention: lessons learned from a randomized controlled trial of functional recovery after hip fracture. HSS J 2007; 3:63-70. [PMID: 18751772 PMCID: PMC2504100 DOI: 10.1007/s11420-006-9036-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We conducted a randomized controlled trial to assess the efficacy and safety of a multiple-component intervention designed to improve functional recovery after hip fracture. One hundred seventy-six patients who underwent surgery for a primary unilateral hip fracture were assigned randomly to receive usual care (control arm, n = 86) or a brief motivational videotape, supportive peer counseling, and high-intensity muscle-strength training (intervention arm, n = 90). Between-group differences on the physical functioning, role-physical, and social functioning domains of the SF-36 were assessed postoperatively at 6 months. At the end of the trial, 32 intervention and 27 control patients (34%) completed the 6-month outcome assessment. Although patient compliance with all three components of the intervention was uneven, over 90% of intervention patients were exposed to the motivational videotape. Intervention patients experienced a significant (P = 0.03) improvement in the role-physical domain (mean change, -11 +/- 33) compared to control patients (mean change, -37 +/- 41). Change in general health (P = 0.2) and mental health (P = 0.1) domain scores was also directionally consistent with the study hypothesis. Although our findings are consistent with previous reports of comprehensive rehabilitation efforts for hip fracture patients, the trial was undermined by high attrition and the possibility of self-selection bias at 6-month follow-up. We discuss the methodological challenges and lessons learned in conducting a randomized controlled trial that sought to implement and assess the impact of a complex intervention in a population that proved difficult to follow up once they had returned to the community.
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Affiliation(s)
- John P. Allegrante
- Department of Health and Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, New York, NY 10027 USA ,Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032 USA
| | - Margaret G.E. Peterson
- Research Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Charles N. Cornell
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - C. Ronald MacKenzie
- Department of Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Laura Robbins
- Education Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Roberta Horton
- Department of Patient Care and Quality Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Sandy B. Ganz
- The Virginia F. and William R. Salomon Rehabilitation Department, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Hirsch S. Ruchlin
- Department of Public Health, Weill Medical College of Cornell University, 525 East 68th Street, New York, NY 10021 USA
| | - Pamela Williams Russo
- The Robert Wood Johnson Foundation, P.O. Box 2316, College Road East and Route 1, Princeton, NJ 08543 USA
| | - Stephen A. Paget
- Department of Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Mary E. Charlson
- Department of Medicine, Weill Medical College of Cornell University, 525 East 68th Street, New York, NY 10021 USA
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Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM. Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma 2006; 20:172-8; discussion 179-80. [PMID: 16648698 DOI: 10.1097/01.bot.0000202220.88855.16] [Citation(s) in RCA: 200] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the impact of a specifically designed model of orthopedic-geriatric cocare on hip fracture (HF) outcomes. SETTING Tertiary teaching hospital (level I trauma center). DESIGN Prospective observational study with a retrospective (historical) control. Data on 951 consecutive patients 60 years of age or older admitted to the authors' institution with a nonpathologic HF over a 7-year period (1995 to 2002) were analyzed. Between 1995 and 1997, medical problems were managed by a geriatric medicine (GM) consultation-only service (retrospective audit). In 1998, a GM registrar began overseeing daily medical care with weekly geriatrician consultant review (prospective study). Outcomes for 2 time periods were compared: a 3-year period before (no GM; 504 patients) and a 4-year period after (GM; 447 patients) the introduction of GM cocare. MAIN OUTCOME MEASUREMENTS Postoperative medical complications, mortality, length of stay, discharge destination, use of thromboprophylaxis, and antiosteoporotic treatment. RESULTS While comparing 2 periods (GM and no GM), significant reductions in postoperative medical complications and comorbid conditions (in total 49.5% vs. 71.0%, P<0.001) and mortality (4.7% vs. 7.7%, P<0.01) occurred and rehospitalization to medical wards within 6 months decreased (28% vs. 7.6%). However, no differences were observed in median length of hospital stay (10.8 vs. 11.0 days) or in discharge destination. Antiosteoporotic treatment (12% to 69%) and specific thromboprophylaxis (63% to 94%) increased in the GM period. CONCLUSIONS Orthopedic-geriatric cocare for the older patients with HF was associated with significant reductions in morbidity and mortality, and increases in optimal postoperative care. Options for further improvement of orthopedic-GM cocare need to be investigated.
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Affiliation(s)
- A A Fisher
- Department of Geriatric Medicine, ACT, Australia.
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Beaupre LA, Jones CA, Saunders LD, Johnston DWC, Buckingham J, Majumdar SR. Best practices for elderly hip fracture patients. A systematic overview of the evidence. J Gen Intern Med 2005; 20:1019-25. [PMID: 16307627 PMCID: PMC1490246 DOI: 10.1111/j.1525-1497.2005.00219.x] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To determine evidence-based best practices for elderly hip fracture patients from the time of hospital admission to 6 months postfracture. DATA SOURCES MEDLINE, Cochrane Library, CINAHL, Embase, PEDro, Ageline, NARIC, and CIRRIE databases were searched for potentially eligible articles published between 1985 and 2004. REVIEW METHODS Two independent reviewers determined studies appropriate for inclusion using standardized selection criteria, extracted data, evaluated internal validity, and then rated studies according to levels of evidence. Only Level 1 or 2 evidence was included in our summary of clinical recommendations. RESULTS Spinal anesthesia, pressure-relieving mattresses, perioperative antibiotics, and deep vein thromboses prophylaxes had consistent evidence of benefit. Routine preoperative traction was not associated with any benefits and should be abandoned. Types of surgical management, postoperative wound drainage, and even "multidisciplinary" care, lacked sufficient evidence to determine either benefit or harm. There was little evidence to either determine best subacute rehabilitation practices or to direct ongoing medical issues (e.g., nutrition). Studies conducted during the subacute recovery period were heterogeneous in terms of treatment settings, interventions, and outcomes studied and had no clear evidence for best treatment practices. CONCLUSIONS The evidence for perioperative practices is relatively robust and evidence-based perioperative treatment guidelines can be easily established. Conversely, more evidence is required to better guide the care of elderly patients with hip fracture during the subacute recovery period and convalescence.
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Affiliation(s)
- Lauren A Beaupre
- Department of Surgery, Division of Orthopaedics, Capital Health, Edmonton, AB, Canada
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Raivio M, Korkala O, Pitkälä K, Tilvis R. Rehabilitation Outcome in Hip-Fracture: Impact of Weight-Bearing Restriction–A Preliminary Investigation. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2005. [DOI: 10.1080/j148v22n04_01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mendelsohn ME, Overend TJ, Petrella RJ. Effect of Rehabilitation on Hip and Knee Proprioception in Older Adults After Hip Fracture. Am J Phys Med Rehabil 2004; 83:624-32. [PMID: 15277964 DOI: 10.1097/01.phm.0000133448.69652.b5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Impaired proprioception may predispose patients with hip fracture to increased risk of future disability. The purpose of the study was to determine the effect of rehabilitation on proprioceptive changes in both the hip and knee joints of patients after hip fracture. DESIGN Data were collected on 30 patients with hip fracture (mean age, 79.6 +/- 6.7 yrs) who attended physical and occupational therapy sessions five times per week during a rehabilitation hospital stay of 24.8 +/- 8.1 days. Proprioception was assessed with an electrogoniometer within 48 hrs of admission to and discharge from the rehabilitation unit. The passive-to-active reproduction of joint angle technique determined absolute angular error in non-weight-bearing positions at 15, 30, and 60 degrees of hip flexion and knee extension in both injured and noninjured sides. RESULTS Absolute angular error decreased significantly (P < 0.05) from admission (5.3 +/- 2.6 degrees, 4.1+/- 3.1 degrees) to discharge (3.0 +/- 2.3 degrees, 2.8 +/- 3.1 degrees) in hip flexion and knee extension, respectively, on the injured side. Absolute angular error was significantly less (P < 0.05) at 15 degrees compared with 30 and 60 degrees of hip flexion at admission and discharge on the injured side. CONCLUSIONS Hip and knee joint proprioception significantly improved in the injured side after the rehabilitation program. This may be an important outcome regarding future disability in this population.
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Affiliation(s)
- Marissa E Mendelsohn
- Canadian Centre for Activity and Aging, 1490 Richmond Street, London, Ontario N6G 2M3, Canada
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Penrod JD, Boockvar KS, Litke A, Magaziner J, Hannan EL, Halm EA, Silberzweig SB, Sean Morrison R, Orosz GM, Koval KJ, Siu AL. Physical therapy and mobility 2 and 6 months after hip fracture. J Am Geriatr Soc 2004; 52:1114-20. [PMID: 15209649 PMCID: PMC1454714 DOI: 10.1111/j.1532-5415.2004.52309.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine the relationship between early physical therapy (PT), later therapy, and mobility 2 and 6 months after hip fracture. DESIGN Prospective, multisite observational study. SETTING Four hospitals in the New York City area. PARTICIPANTS Four hundred forty-three hospitalized older patients discharged after surgery for hip fracture in 1997-98. MEASUREMENTS Patient demographics, fracture type, comorbidities, dementia, number of new impairments at discharge, amount of PT between day of surgery and postoperative day (POD) 3, amount of therapy between POD4 and 8 weeks later, and prefracture, 2-, and 6-month mobility measured using the Functional Independence Measure. RESULTS More PT immediately after hip fracture surgery was associated with significantly better locomotion 2 months later. Each additional session from the day of surgery through POD3 was associated with an increase of 0.4 points (P=.032) on the 14-point locomotion scale, but the positive relationship between early PT and mobility was attenuated by 6 months postfracture. There was no association between later therapy and 2- or 6-month mobility. CONCLUSION PT immediately after hip fracture surgery is beneficial. The effects of later therapy on mobility were difficult to assess because of limitations of the data. Well-designed randomized, controlled trials of the effect of varying schedules and amounts of therapy on functional status after hip fracture would be informative.
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Affiliation(s)
- Joan D Penrod
- Program of Research on Serious Physical and Mental Illness and Geriatric Research, Education, and Clinical Center, Bronx Veterans Affairs Medical Center, New York, New York, USA.
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Polder JJ, van Balen R, Steyerberg EW, Cools HJM, Habbema JDF. A cost-minimisation study of alternative discharge policies after hip fracture repair. HEALTH ECONOMICS 2003; 12:87-100. [PMID: 12563657 DOI: 10.1002/hec.690] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
It is widely assumed that health care costs can be reduced considerably by providing care in appropriate health care institutions without unnecessary technological overhead. This assumption has been tested in a prospective study. Conventional discharge after hip fracture surgery was compared with an early discharge policy in which patients were discharged to a nursing home with specialised facilities for rehabilitation. We compared costs for both strategies from a societal perspective, using comprehensive and detailed data on type of residence and all kinds of medical consumption during a 4-month follow-up period. As expected, early discharge reduced the hospital stay (with 13 days, p=0.001). More patients were discharged to a nursing home (76% versus 53%). Total medical costs during follow-up were reduced from an average of euro;15338 to euro;14281, representing relatively small and not significant savings (p=0.3). There are two explanations for this unexpected result. First, costs incurred by hip fracture patients were relatively less while in hospital. Hence, nursing home costs almost equalled hospital costs per admission day. Second, compared with the conventionally discharged group early discharged patients were subjected to more medical procedures during the first post-operative days. We conclude that: (1). early discharge shifted rather than reduced costs; (2). the details of costing have a major influence on the cost-effectiveness of alternative discharge policies.
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Affiliation(s)
- Johan J Polder
- Department of Public Health, Faculty of Medicine, Erasmus University, Rotterdam, The Netherlands.
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Lai FHY, Soo AKW, Wong SKM, Lau BSY, Chow ACP. Admission Cognitive Performance and Functional Gain Following Inpatient Rehabilitation in Geriatric Patients with Hip Fractures. Hong Kong J Occup Ther 2003. [DOI: 10.1016/s1569-1861(09)70020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Jones GR, Miller TA, Petrella RJ. Evaluation of rehabilitation outcomes in older patients with hip fractures. Am J Phys Med Rehabil 2002; 81:489-97. [PMID: 12131174 DOI: 10.1097/00002060-200207000-00004] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study evaluated functional outcomes in patients with hip fracture after inpatient rehabilitation. DESIGN The physical and cognitive functioning of 100 patients with hip fracture were determined by using the FIM instrument. The Montebello rehabilitation factor score was used to reflect rehabilitative outcome. Follow-up data were collected from 44 patients by using a telephone FIM interview. RESULTS Discharge total FIM scores improved. The Montebello rehabilitation factor score for rehabilitation efficacy and efficiency scores both demonstrated improvement for patient function during inpatient rehabilitation. The mean motor FIM domain scores for transfer mobility and locomotion were lower at discharge compared with the domains of self-care and sphincter control. A subgroup of 44 patients showed no change in mean motor FIM domain scores. CONCLUSIONS Inpatient rehabilitation improves overall functional independence as measured by the FIM instrument. Relative change, as measured by the Montebello rehabilitation factor score, indicated that rehabilitation outcome for locomotion was not maximized, despite exhibiting large absolute gains during inpatient rehabilitation. The improvements demonstrated at discharge were maintained at follow-up for a subgroup of 44 patients. Improved locomotion skills and maximizing ability to transfer independently are areas in which inpatient rehabilitation may be targeted to improve function in the future.
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Affiliation(s)
- Gareth R Jones
- Canadian Centre for Activity and Aging, London, Ontario, Canada
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Kirke PN, Sutton M, Burke H, Daly L. Outcome of hip fracture in older Irish women: a 2-year follow-up of subjects in a case-control study. Injury 2002; 33:387-91. [PMID: 12095716 DOI: 10.1016/s0020-1383(02)00025-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
To assess outcome after hip fracture in older Irish women, 106 consecutive females aged over 50 years admitted to a general hospital with a hip fracture were compared to 89 age- and gender-matched controls from the same catchment area. Interview-based data were collected on socio-demographic factors, mobility and activities of daily living before recruitment and 2 years later. Information was also collected on residence, further falls and fractures and use of health and community support services during the 2-year period. Mortality at 2 years was higher in cases (23.6%) compared to controls (10.1%; P = 0.01). Cases were significantly less mobile and more dependent in the activities of daily living. Of the cases who were community dwellers at baseline, 26.6% were institutionalised at 2 years compared with 9.2% of controls (P = 0.01). During the 2 years cases were significantly more likely to have multiple falls and a further hip or pelvic fracture. Hospital and nursing home admissions and use of physiotherapy, day centre and home help services were also significantly greater among cases. The marked adverse impact of hip fracture reported in this study underlines the importance of public health strategies to prevent these injuries in older people.
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Affiliation(s)
- P N Kirke
- Health Research Board, 73 Lower Baggot Street, Dublin 2, Ireland.
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Crotty M, Whitehead CH, Gray S, Finucane PM. Early discharge and home rehabilitation after hip fracture achieves functional improvements: a randomized controlled trial. Clin Rehabil 2002; 16:406-13. [PMID: 12061475 DOI: 10.1191/0269215502cr518oa] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To compare hospital and home settings for the rehabilitation of patients following hip fracture. DESIGN Randomized controlled trial comparing accelerated discharge and home-based rehabilitation (n = 34) with conventional hospital care (n = 32) for patients admitted to hospital with hip fracture. SETTING Three metropolitan hospitals in Adelaide, Australia. SUBJECTS Sixty-six patients with fractured hip. INTERVENTIONS Patients assigned to the home-based rehabilitation group were discharged within 48 hours of randomization. The project team therapists made visits to the patient's home and negotiated a set of realistic, short-term and measurable treatment goals with both the patient and carer. Those randomized to usual care remained in hospital for conventional rehabilitation. MAIN OUTCOME MEASURES Physical and social dependence, balance confidence, quality of life, carer strain, patient and carer satisfaction, use of community services and incidence of adverse events such as re-admission and falls. RESULTS While there was no difference between the groups for all measures of quality of life, patients in the accelerated discharge and home-based rehabilitation group recorded a greater improvement in MBI from randomization (p < 0.05) and scored higher on the Falls Efficacy Scale (p < 0.05) at four months. There was no difference in falls rates. Patients in the home-based rehabilitation group had a shorter stay in hospital (p < 0.05) but a longer stay in rehabilitation overall (p < 0.001). The groups were comparable on the rate and length of admissions after discharge, use of community services, need for carer input and contact with general practitioner (GP) after discharge. CONCLUSIONS This trial further supports the practice of accelerated discharge from hospital and home-based rehabilitation in selected patients recovering from hip fracture. Such a practice appears to improve physical independence and confidence in avoiding subsequent falls which may have implications for longevity and overall quality of life.
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Affiliation(s)
- Maria Crotty
- Department of Rehabilitation and Aged Care, Repatriation General Hospital, Daw Park, Australia.
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Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ (CLINICAL RESEARCH ED.) 2000; 321:1107-11. [PMID: 11061730 PMCID: PMC27517 DOI: 10.1136/bmj.321.7269.1107] [Citation(s) in RCA: 190] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/10/2000] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the effect of intensive geriatric rehabilitation on demented patients with hip fracture. DESIGN Preplanned subanalysis of randomised intervention study. Settting: Jyväskylä Central Hospital, Finland. PARTICIPANTS 243 independently living patients aged 65 years or older admitted to hospital with hip fracture. INTERVENTION After surgery patients in the intervention group (n=120) were referred to the geriatric ward whereas those in the control group were discharged to local hospitals. MAIN OUTCOME MEASURES Length of hospital stay, mortality, and place of residence three months and one year after surgery for hip fracture. RESULTS The median length of hospital stay of hip fracture patients with moderate dementia (mini mental state examination score 12-17) was 47 days in the intervention group (n=24) and 147 days in the control group (n=12, P=0.04). The corresponding figures for patients with mild dementia (score 18-23) were 29 days in the intervention group (n=35) and 46.5 days in the control group (n=42, P=0.002). Three months after the operation, in the intervention group 91% (32) of the patients with mild dementia and 63% (15) of the patients with moderate dementia were living independently. In the control group, the corresponding figures were 67% (28) and 17% (2). There were no significant differences in mortality or in the lengths of hospital stay of severely demented patients and patients with normal mini mental state examination scores. CONCLUSIONS Hip fracture patients with mild or moderate dementia can often return to the community if they are provided with active geriatric rehabilitation.
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Affiliation(s)
- T M Huusko
- Department of Rehabilitation, Division of Geriatrics, Central Hospital of Central Finland, 40930 Kinkomaa, Finland.
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Choong PF, Langford AK, Dowsey MM, Santamaria NM. Clinical pathway for fractured neck of femur: a prospective, controlled study. Med J Aust 2000; 172:423-6. [PMID: 10870534 DOI: 10.5694/j.1326-5377.2000.tb124038.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess outcomes of using a clinical pathway for managing patients with fractured neck of femur. DESIGN Prospective, pseudorandomised, controlled trial. SETTING St Vincent's Hospital, Melbourne, Victoria (a tertiary referral, university teaching hospital), 1 October 1997 to 30 November 1998. PARTICIPANTS 111 patients (80 women and 31 men; mean age, 81 years) admitted via the emergency department with a primary diagnosis of fractured neck of femur. INTERVENTIONS Management guided by a clinical pathway (55 patients) or established standard of care (control group, 56 patients). MAIN OUTCOME MEASURES Timing of referrals and discharge planning; total length of stay; and complication and readmission rates within 28 days of discharge. RESULTS Patients managed according to the clinical pathway had a shorter total stay (6.6 versus 8.0 days; P = 0.03), even if assessment for placement by the Aged Care Assessment Service was required (9.5 versus 13.6 days; P = 0.03). There were no significant differences in complication and readmission rates between pathway and control patients (complication rates, 24% versus 36%; P = 0.40; readmission rates, 4% versus 11%; P = 0.28). CONCLUSION Coordinated multidisciplinary care of patients with fractured neck of femur reduces length of stay without increasing complications.
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Affiliation(s)
- P F Choong
- Department of Orthopaedics, St Vincent's Hospital, Melbourne, Vic.
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Petrella RJ, Payne M, Myers A, Overend T, Chesworth B. Physical function and fear of falling after hip fracture rehabilitation in the elderly. Am J Phys Med Rehabil 2000; 79:154-60. [PMID: 10744190 DOI: 10.1097/00002060-200003000-00008] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the relationship between physical function and fall-related self-efficacy in older patients with a hip fracture who are undergoing an intensive rehabilitation program. DESIGN We used a prospective cohort study over 12 mo to determine the effect of a specialized hip fracture rehabilitation program in a geriatric hospital on physical function and fear of falling. Fifty-six patients were admitted consecutively from acute care. Physical function was assessed using the Functional Independence Measure, and fall-related self-efficacy was measured using two scales: the Falls-Efficacy scale and the Activities-Specific Balance Confidence scale. We also used the Vitality scale to measure quality of life. All measures, represented by change scores, were determined at the beginning and end of the patients' rehabilitation programs. RESULTS Significant improvement in physical function and fall self-efficacy was observed. The Vitality scale was also improved after rehabilitation. The Falls-Efficacy scale appeared to be more sensitive to change than the Activities-Specific Balance Confidence scale, whereas no correlation was found between changes in the fall-related self-efficacy measures and the Functional Independence Measure. CONCLUSIONS These findings may represent a discrepancy between attention of the rehabilitation program on functional outcomes and less emphasis on confidence building behaviors. Restrictions in function from a fear of falling may negate any gains made through rehabilitation, and this could limit the long-term success of these programs and patient outcomes after hip fracture.
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Affiliation(s)
- R J Petrella
- Faculties of Medicine, Department of Family Medicine, The University of Western Ontario London, Canada
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Cameron ID, Handoll HH, Finnegan TP, Madhok R, Langhorne P. Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures. Cochrane Database Syst Rev 2000:CD000106. [PMID: 11686951 DOI: 10.1002/14651858.cd000106] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hip fracture is a major cause of morbidity in older people and its impact, both on the individual and to society, is substantial. OBJECTIVES To examine the effects of co-ordinated multidisciplinary inpatient rehabilitation, compared with usual orthopaedic care, for older patients with hip fracture. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Injuries Group trials register, Medline (up to April 1998), and reference lists of published papers and books. We also contacted colleagues and trialists. SELECTION CRITERIA Randomised and quasi-randomised trials of postsurgical care using specialised rehabilitation of mainly older patients (aged 65 years or over) with hip fracture. DATA COLLECTION AND ANALYSIS Trial assignment to included, excluded and awaiting assessment categories, was by consensus. Two reviewers independently assessed trial quality and extracted data. Limited additional information was sought from most trialists. As well as pooling of data from primary outcomes, supplementary analyses were performed to combine clinically relevant outcomes and investigate possible explanatory factors. MAIN RESULTS In this minor update, one new trial is identified and has been placed in "studies awaiting assessment". Of another three trials previously pending assessment, one has now been excluded. The five included trials involved 1068 patients. The combined outcomes of death or requiring institutional care at final follow-up showed no significant difference between intervention and control groups (Peto odds ratio 0.92; 95% confidence interval 0.71 to 1.18). There was considerable heterogeneity in length of stay and cost data. Using death and deterioration in function as a further combined outcome variable yielded a Peto odds ratio of 0.83 (95% confidence interval 0.64 to 1. 07). This should be interpreted with caution due to heterogeneity. No quality of life measures were reported and the two trials investigating carer burden showed no detrimental effect from the intervention. The review update did not result in any new data for these outcomes. REVIEWER'S CONCLUSIONS The trials reviewed had different aims, interventions and outcomes. As a consequence, results were heterogeneous and the question of effectiveness of different types of co-ordinated inpatient rehabilitation after hip fracture cannot be answered conclusively. There is a trend to effectiveness when combined outcome variables (death and institutional care, death and deterioration in function) are considered. Future trials of postsurgical care involving inpatient rehabilitation, or other models such as 'early supported discharge' and 'hospital at home' schemes, should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than attempt to evaluate its components.
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Affiliation(s)
- I D Cameron
- Rehabilitation Studies Unit, University of Sydney, PO Box 6, Ryde, New South Wales, Australia, NSW 1680.
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Tinetti ME, Baker DI, Gottschalk M, Williams CS, Pollack D, Garrett P, Gill TM, Marottoli RA, Acampora D. Home-based multicomponent rehabilitation program for older persons after hip fracture: a randomized trial. Arch Phys Med Rehabil 1999; 80:916-22. [PMID: 10453768 DOI: 10.1016/s0003-9993(99)90083-7] [Citation(s) in RCA: 140] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether a home-based systematic multicomponent rehabilitation strategy leads to improved outcomes relative to usual care. DESIGN A randomized controlled trial with 12 months of follow-up. SETTING General community; 27 home care agencies. PARTICIPANTS Three hundred four nondemented persons at least 65 years of age who underwent surgical repair of a hip fracture at two hospitals in New Haven, CT, and returned home within 100 days. INTERVENTION Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments (physical therapy) and activities of daily living (ADL) disabilities (functional therapy) versus usual care. MAIN OUTCOME MEASURES A battery of self-report and performance-based measures of physical and social function. RESULTS There was no significant difference in the proportion of participants in the two groups who recovered to prefracture levels in self-care ADL at 6 months (71% vs 75%) or 12 months (74% in both groups) or in home management ADL at 6 months (35% vs 44%) or 12 months (44% vs 48%). There also was no difference between the two groups in social activity levels, two timed mobility tasks, balance, or lower extremity strength at either 6 or 12 months. Compared with participants who received usual care, those in the multicomponent rehabilitation program showed slightly greater upper extremity strength at 6 months (p = .04) and a marginally better gait performance (p = .08). CONCLUSIONS The systematic multicomponent rehabilitation program was no more effective in promoting recovery than usual home-based rehabilitation. Compared with previous cohorts, however, participants randomized to usual care in our study received more rehabilitative and home care services and experienced a higher rate of recovery. This finding is important given the current pressures to reduce home services. The challenge is to determine the composition and duration of rehabilitation and home services that will ensure optimal functional recovery most efficiently in older persons after hip fracture.
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Affiliation(s)
- M E Tinetti
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
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