Multidisciplinary rehabilitation of older patients with hip fractures

Hip fracture is a serious injury in older people and can contribute to their death or loss of independence. Normally surgery is performed and followed by care in a ward under the supervision of orthopaedic staff. Additional rehabilitation within the hospital is sometimes provided by a geriatrician and other health professionals. Sometimes, the emphasis is on early discharge from hospital with multidisciplinary rehabilitation provided to the patient at home. There is enormous variety in these rehabilitation programmes.

This review included 13 trials, which involved a total of 2498 older, usually female, patients who had undergone surgery for hip fracture. Generally the trials appeared well conducted, although some were at risk of bias that could affect the reliability of their results. For example, despite randomisation, in five trials there were some important differences in patient characteristics, such as age, at the start of the trial that could have influenced trial findings. The trial interventions were very varied but all compared multidisciplinary rehabilitation with usual care. In 11 trials, care was provided either totally or mainly in an inpatient or hospital setting. While there was a tendency for a better outcome after multidisciplinary rehabilitation, the results were not statistically significant and thus cannot be considered conclusive. However, the overall evidence indicates that multidisciplinary rehabilitation is not harmful. Additionally, there was some inconclusive evidence that multidisciplinary rehabilitation did not add to the burden of carers. In one trial that compared home-based multidisciplinary rehabilitation with usual inpatient care, carers reported significantly lower burden in the long term after multidisciplinary rehabilitation. Participants in the home-based rehabilitation group of this trial had shorter hospital stays, but longer periods of rehabilitation. One other trial found no significant effect from doubling the number of weekly contacts at the patient's home by a multidisciplinary rehabilitation team.

Overall, the results of this review suggest that multidisciplinary rehabilitation may help more older people recover after a hip fracture. However, the results are not conclusive and more research is needed.

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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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.

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