- Compared with usual care, care provided by a team of healthcare professionals with different specialities (multidisciplinary rehabilitation teams) led by a geriatrician or other medical specialist may help more older people in hospital to recover after a hip fracture.
- We don’t know if multidisciplinary rehabilitation is better than usual care after hospital discharge because there is insufficient evidence.
- Future research should aim to identify the best treatments provided by the mix of specialties that make up multidisciplinary teams, so people can leave hospital early and be supported in the community.
How are hip fractures treated?
Hip fractures are common but serious injuries in older people. About a third of people with hip fractures die within a year of their injury. People with hip fractures may also have other conditions that slow their recovery. Many do not regain the mobility and independence they had before the fracture, and may need residential care in a nursing home afterwards.
Usual care for people with hip fracture is surgery, followed by therapy on the hospital ward to restore mobility and basic functions of daily living, such as bathing and dressing. This may involve people from other departments in the hospital. However, people with hip fractures need help with a range of activities, and may suffer mental as well as physical problems after surgery. So, a better approach to help their recovery, or ‘rehabilitation’, may be to involve a team of people with expertise from different areas, or ‘disciplines’. They develop a rehabilitation plan for each person, depending on their needs. This ‘multidisciplinary rehabilitation’ team, which is typically led by a doctor specialising in the care of older people or other medical specialist in rehabilitation, could also include other doctors, nurses, physiotherapists, dieticians, social workers and mental health specialists. Multidisciplinary rehabilitation could take place in hospital, in acute (short-stay treatment) or rehabilitation wards, or in a person's home residence. Some types of multidisciplinary rehabilitation involve early discharge from hospital with support at home.
What did we want to find out?
We wanted to know if multidisciplinary rehabilitation helps people recover better from hip fracture than usual care. We were particularly interested in how many people had a ‘poor outcome’ at up to a year after surgery; that is, whether they died or were more dependent such that they needed to be cared for in a nursing home. We also looked at:
- health-related quality of life;
- need for help with daily activities;
- mobility; and
What did we do?
We searched for studies that compared multidisciplinary rehabilitation with usual care in older people after hip fracture surgery.
We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 28 studies with 5351 older people who’d had hip fracture surgery. They were aged on average from 76.5 to 87 years and most were women.
Multidisciplinary rehabilitation after surgery compared with usual care in hospital (20 studies):
- probably results in fewer cases of 'poor outcome' at 6 to 12 months than usual care. Of 1000 people with hip fracture who received usual care, 347 would have a ‘poor outcome’ between 6 and 12 months after surgery; 41 fewer people (12% of 347) would have a ‘poor outcome’ with multidisciplinary rehabilitation;
- may reduce the risk of death in hospital, and in the longer term for up to 1 year.
- may result in fewer people with poorer mobility at 6 to 12 months.
We don’t know if multidisciplinary rehabilitation improves or worsens quality of life and activities of daily living. There was no evidence on long-term, hip-related pain.
Multidisciplinary rehabilitation after surgery compared with usual care at home (3 studies):
We don’t know if multidisciplinary rehabilitation makes any difference to:
- a ‘poor outcome’ at 1 year;
- quality of life at 1 year;
- deaths at 4 or 12 months;
- whether people need help with daily living activities;
- moving into a nursing home; or
There was no evidence on long-term, hip-related pain.
Multidisciplinary rehabilitation after surgery compared with usual care for nursing home residents (1 study) may make no difference to:
- a 'poor outcome' (died or unable to walk) at 12 months; or
- deaths at 4 or 12 months.
We don’t know if multidisciplinary rehabilitation makes a difference to:
- whether people need help with daily living activities at 4 weeks or 12 months;
- quality of life, mobility or pain at 12 months.
What are the limitations of the evidence?
We are moderately confident in the evidence about ‘poor outcome’ for people in hospital but much less confident in all the other evidence because less was available and all the studies had weaknesses that could affect the reliability of their results.
How up to date is this evidence?
The evidence is up to date to October 2020.
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.
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.
To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019).
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.
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.
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.