Methodological challenges of multiple-component intervention: lessons learned from a randomized controlled trial of functional recovery after hip fracture. To evaluate the effectiveness of a discharge-planning programme for hip fracture patients. Two-year effects of interdisciplinary intervention for hip fracture in older Taiwanese. A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling. Effects of extended outpatient rehabilitation after hip fracture: a randomized controlled trial. Interdisciplinary inpatient care for elderly people with hip fracture: a randomized controlled trial. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. Early discharge and home rehabilitation after hip fracture achieves functional improvements: a randomized controlled trial.
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. This study aimed to evaluate the effectiveness of a comprehensive discharge-planning service for hip fracture patients, including length of stay, functional status, self-care knowledge and quality of life (QOL).
                Hip fractures are the most devastating result of osteoporosis. Care of these patients from the moment they enter the hospital until discharge and postdischarge is a challenging task, requiring a coordinated approach by an interdisciplinary team.
                An experimental design was used. Methods. Fifty hip fracture patients were recruited from a medical centre in Taipei, Taiwan and randomly divided into two groups. The control group received routine discharge nursing care and the experimental group received comprehensive discharge planning. After patient admission, researchers assessed discharge-planning needs, provided discharge nursing instruction, coordinated services and determined discharge placement based on assessment results.
                (i) Mean age of 50 hip fracture patients was 78.75 (SD 6.99) years. Mean length of stay was 6.04 (SD 2.41) days for the experimental group and 6.29 (SD 2.17) for the control group. Difference between groups was not significant (t = -0.394, p = 0.696). (ii) The self-care knowledge of the experimental group was higher than that of the control group (F = 11.569, p = 0.001). (iii) Significant improvements were observed in functional status of both groups at three months postdischarge, with no significant differences observed between groups. However, the functional status of experimental group patients showed a slightly better trend than that of the control group. (iv) At three months postdischarge, QOL of experimental group patients was better than control group patients.
                A comprehensive discharge-planning service can improve hip fracture patients' self-care knowledge and QOL. Relevance TO CLINICAL PRACTICE: Results of this study can be used clinically as a basis for practical implementation of discharge-planning services in fracture patients. To explore the 2-year outcomes of an interdisciplinary intervention for elderly patients with hip fracture.
                Randomized experimental design.
                A 3,000-bed medical center in northern Taiwan.
                Patients with hip fracture (N=162): 80 in the intervention group and 82 in the usual care control group.
                An interdisciplinary program of geriatric consultation, continuous rehabilitation, and discharge planning.
                Outcomes (clinical outcomes, self-care ability, health-related quality of life (HRQoL), service utilization, and depressive symptoms) were assessed 1, 3, 6, 12, 18, and 24 months after discharge. Self-care ability (ability to perform activities of daily living (ADLs)) was measured using the Chinese Barthel Index. HRQoL was measured using the Medical Outcomes Study 36-item Short Form Survey, Taiwan version (SF-36). Depressive symptoms were measured using the Chinese Geriatric Depression Scale, short form.
                Subjects in the intervention group had significantly better ratios of hip flexion (beta=5.43, P<.001), better performance on ADLs (beta=9.22, P<.001), better recovery of walking ability (odds ratio (OR)=2.23, P<.001), fewer falls (OR=0.56, P=.03), fewer depressive symptoms (beta=-1.31, P=.005), and better SF-36 physical summary scores (beta=6.08, P<.001) than the control group during the first 24 months after discharge. The intervention did not affect the peak force of the fractured limb's quadriceps, mortality, service utilization, or SF-36 mental summary score.
                The interdisciplinary intervention for hip fracture benefited elderly persons with hip fracture by improving clinical outcomes, self-care ability, and physical health-related outcomes and by decreasing depressive symptoms during the first 24 months after hospital discharge. The objective of this study was to examine the effectiveness of a discharge plan in hospitalized elderly patients with hip fracture due to falling.
                Hip fractures are an important cause of morbidity and mortality among older people. Hip fracture patients require ongoing medical and long-term care services. Discharge plan services can play a very important role for these patients, since the services improved their outcome conditions.
                Hip fracture patients aged 65 years and older (n = 126), hospitalized due to falling and discharged from a medical centre in northern Taiwan, were randomly assigned to either a comparison group (the routine care) or experimental group (the discharge planning intervention). The outcomes used to determine the effectiveness of the intervention were: length of hospitalized stay, rate of readmission, repeat falls and survival, and activities of daily living.
                The discharge planning intervention decreased length of stay, rate of readmission and rate of survival and improved activities of daily living for intervention group compared with those of control group. Mean total SF-36 scores of patients in the experimental group were higher than for the control group and both groups had improved quality of life.
                The discharge planning benefited older people with hip fractures.
                A discharge planning intervention by a nurse can improve physical outcomes and quality of life in hip fracture patients. Hip fractures are common in the elderly, and despite standard rehabilitation, many patients fail to regain their prefracture ambulatory or functional status.
                To determine whether extended outpatient rehabilitation that includes progressive resistance training improves physical function and reduces disability compared with low-intensity home exercise among physically frail elderly patients with hip fracture.
                Randomized controlled trial conducted between August 1998 and May 2003 among 90 community-dwelling women and men aged 65 years or older who had had surgical repair of a proximal femur fracture no more than 16 weeks prior and had completed standard physical therapy.
                Participants were randomly assigned to 6 months of either supervised physical therapy and exercise training (n = 46) or home exercise (control condition; n = 44).
                Primary outcome measures were total scores on a modified Physical Performance Test (PPT), the Functional Status Questionnaire physical function subscale (FSQ), and activities of daily living scales. Secondary outcome measures were standardized measures of skeletal muscle strength, gait, balance, quality of life, and body composition. Participants were evaluated at baseline, 3 months, and 6 months.
                Changes over time in the PPT and FSQ scores favored the physical therapy group (P =.003 and P =.01, respectively). Mean change (SD) in PPT score for physical therapy was +6.5 (5.5) points (95% confidence interval [CI], 4.6-8.3), and for the control condition was +2.5 (3.7) points (95% CI, 1.4-3.6 points). Mean change (SD) in FSQ score for physical therapy was +5.2 (5.4) points (95% CI, 3.5-6.9) and for the control condition was +2.9 (3.8) points (95% CI, 1.7-4.0). Physical therapy also had significantly greater improvements than the control condition in measures of muscle strength, walking speed, balance, and perceived health but not bone mineral density or fat-free mass.
                In community-dwelling frail elderly patients with hip fracture, 6 months of extended outpatient rehabilitation that includes progressive resistance training can improve physical function and quality of life and reduce disability compared with low-intensity home exercise. Hip fractures in elderly people are associated with impaired function and ambulation and high rates of death and admission to institutions. Interventions designed to improve the outcomes of hip fracture (e.g., mobility and discharge to own home) that have incorporated interdisciplinary care have had mixed results. We compared the effectiveness of postoperative interdisciplinary care with that of usual care for elderly patients with hip fracture.
                The study population consisted of 279 patients at least 70 years of age from the community and from nursing homes who underwent surgical repair of hip fracture at a university-affiliated acute care hospital. The subjects were randomly assigned to receive postoperative interdisciplinary care (n = 141) or usual care (n = 138) during their hospital stay. Interdisciplinary care included routine assessment and care by an internist-geriatrician, physiotherapist, occupational therapist, social worker and clinical nurse specialist, as well as twice-weekly interdisciplinary rounds to set goals for the patients and to monitor their progress. The primary outcome measure was the proportion of patients alive with no decline in ambulation or transfers in and out of a chair or bed and no change in place of residence at 6 months after surgery.
                At 6 months, 56 patients (39.7%) in the interdisciplinary care group and 47 (34.1%) in the usual care group were alive and had no decline from baseline in terms of ambulation, chair and bed transfers or place of residence (difference 5.6%, 95% confidence interval -5.6% to 17.0%). Multiple logistic regression analysis with adjustment for baseline factors showed no significant difference between treatment groups for the primary outcome measure at 3 months (p = 0.44) or at 6 months (p = 0.67). The initial length of stay in hospital was longer for patients receiving interdisciplinary care: 29.2 (standard deviation [SD] 22.6) v. 20.9 (SD 18.8) days (p < 0.001). However, the mean number of days spent in an institution (including hospital, inpatient rehabilitation and nursing home) over the 6-month follow-up period was similar in the 2 groups (p = 0.84). A subgroup analysis suggested a trend to benefit from interdisciplinary care in patients with mild to moderate cognitive impairment.
                Postoperative inpatient interdisciplinary care did not result in significantly better 3- or 6-month outcomes in elderly patients with hip fracture. To evaluate whether an early multidisciplinary geriatric intervention in elderly patients with hip fracture reduced length of stay, morbidity, and mortality and improved functional evolution.
                Randomized, controlled intervention trial.
                Orthopedic ward in a university hospital.
                Three hundred nineteen patients aged 65 and older hospitalized for hip fracture surgery.
                Participants were randomly assigned to a daily multidisciplinary geriatric intervention (n=155) or usual care (n=164) during hospitalization in the acute phase of hip fracture.
                Primary endpoints were in-hospital length of stay and incidence of death or major medical complications. Secondary endpoints were the rate of recovery of previous activities of daily living and ambulation ability at 3, 6, and 12 months.
                Median length of stay was 16 days in the geriatric intervention group and 18 days in the usual care group (P=.06). Patients assigned to the geriatric intervention showed a lower in-hospital mortality (0.6% vs 5.8%, P=.03) and major medical complications rate (45.2% vs 61.7%, P=.003). After adjustment for confounding variables, geriatric intervention was associated with a 45% lower probability of death or major complications (95% confidence interval=7-68%). More patients in the geriatric intervention group achieved a partial recovery at 3 months (57% vs 44%, P=.03), but there were no differences between the groups at 6 and 12 months.
                Early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in elderly patients with hip fracture, but there is not a significant effect on length of hospital stay or long-term functional recovery. To compare hospital and home settings for the rehabilitation of patients following hip fracture.
                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.
                Three metropolitan hospitals in Adelaide, Australia.
                Sixty-six patients with fractured hip.
                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.
                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.
                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.
                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.
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.