Evidence based practice

Do older people with hip fractures benefit from multidisciplinary rehabilitation?

23 July, 2010

A Cochrane review compared multidisciplinary rehabilitation for fractured neck of femur with usual rehabilitation in inpatient and ambulatory settings

Keywords Interdisciplinary working, Rehabilitation, Frail older people, Hip fractures

Review question

What are the effects of multidisciplinary rehabilitation in inpatient or ambulatory care settings for older patients with hip fracture?

Nursing implications

Hip fractures are prevalent in older people and can contribute to loss of independence or death. The majority of patients with hip fracture (fractured neck of femur) undergo surgery and subsequent hospital care under the supervision of orthopaedic staff. It is therefore important for nurses to know whether patients would benefit from multidisciplinary rehabilitation.

Study characteristics

The review included 13 randomised and quasi randomised controlled trials, compromising of 2,498 patients, most of whom were women aged 65 years or older. The methodological quality of the trials was generally good; however, five showed important differences in key patient characteristics, such as age, which could have influenced trial findings. Three trials excluded men and six excluded patients with dementia.

Multidisciplinary rehabilitation was defined in this review as “services provided by a multidisciplinary team with the goal of reducing disability by improving task-oriented behaviour like walking and dressing”. The control group received usual care in an inpatient rehabilitation setting or an ambulatory rehabilitation setting or both. The trials provided multidisciplinary rehabilitation in different ways and settings.

There was an indication of improvement after multidisciplinary rehabilitation

Eleven out of the 13 included trials that investigated multidisciplinary rehabilitation in an inpatient setting.

The primary outcome was termed “poor outcome” and included a composite of death and deterioration of functional status leading to increased dependency in the community or hospital admission. Secondary outcomes included mortality, hospital readmission and care burden.

Summary of key evidence

Extensive clinical heterogeneity in the trial interventions and populations was evident but meta analyses were conducted. There was an indication of improvement after multidisciplinary rehabilitation compared with usual care in an inpatient rehabilitation setting, although most results were not statistically significant.

Eight trials were pooled for “poor outcome” based on death or deterioration in residential status. Pooled results showed a non statistically significant tendency in favour of the intervention (risk ratio (RR) 0.89; 95%, confidence interval (CI) 0.78 to 1.01) at long-term follow up (between four and 12 months).

For “poor outcome” at hospital discharge, based on mortality in hospital and discharge location, pooled data from seven trials showed a slightly statistically significant result in favour of multidisciplinary rehabilitation (RR 0.87; 95% CI 0.75 to 1.00).

Mortality, which was reported in 11 trials, did not differ between intervention and control groups (RR 0.90; 95% CI 0.76 to 1.07).

Hospital readmissions were analysed in six studies and showed no statistically significant differences (RR 0.99; 95% CI 0.82 to 1.19).

No serious harm on the participants was demonstrated.

Best practice recommendations:

The effectiveness of multidisciplinary inpatient rehabilitation following hip fracture surgery in older people is not verified. However, a non-significant trend towards effectiveness was demonstrated in all main outcomes assessed. No serious harmful effects were seen.
The introduction of the intervention is justifiable, but further evidence of the potential costs and benefits is needed.
The results provide no evidence about the optimal structure, setting and intensity of care for inpatient rehabilitation, nor for multidisciplinary rehabilitation in the ambulatory setting.

The full review report, including references, can be accessed by clicking here.

AUTHOR Sabine Lins, MScN, RN, is co-convenor of the European Languages Nodes of the Cochrane Nursing Care Field (CNCF) at the German Cochrane Centre, Freiburg, Germany

References:

Handoll HHG et al (2009) Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database of Systematic Reviews; 2009, Issue 4. Art. No.: CD007125. DOI: 10.1002/14651858.CD007125.pub2.