Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures

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 August 1999), and reference lists of published papers 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 of data from primary outcomes, supplementary analyses were performed to combine clinically relevant outcomes and investigate possible explanatory factors.

Main results: In this substantive update, three new trials have been included. The eight included trials involved 1609 patients. The combined outcomes of death or requiring institutional care showed no significant difference between intervention and control groups (relative risk 0.91; 95% confidence interval 0.80 to 1.03). 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 0.90 (95% confidence interval 0.81 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 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 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.