Intensive multidisciplinary rehabilitation programmes for older people with hip fractures may be beneficial but more research is needed

Context In industrialised countries, hip fracture is a major threat for frail older people and the healthcare system. Moreover, the burden on society is increasing: 1.6 million of fractures occurred in adults in 2000, with predictions of numbers rising to 7.3–21.3 million by the year 2050.1 Mean age of fracture is around 80 years, and about 80% are women. Despite successful surgical treatment, the 1-year mortality rate is 12%–37%, while 10%–20% will require a change to a more dependent residential status. Rehabilitation using a multidisciplinary approach could reduce disability by achieving the completion of activities. Methods The objective of this systematic review2 was to assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture. Randomised and quasi-randomised trials of postsurgical care were included comparing specialised multidisciplinary rehabilitation with conventional care. The primary combined ‘poor outcome’ included mortality and decline in long-term residential status. Health-related quality of life, mortality, dependency in activities of daily living, mobility, related pain and economic outcomes were also measured. Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. Data were pooled where appropriate; GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to assess the certainty of the evidence for each outcome. Findings This review included 28 studies with 5351 older people involved (mean ages ranged from 76.5 to 87 years), who underwent hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. In an inpatient setting, there was moderate-certainty evidence that multidisciplinary rehabilitation resulted in fewer cases of 'poor outcome' at 6-month and 12-month follow-up (risk ratio (RR) 0.88, 95% CI 0.80 to 0.98). There was low-certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4–12 months (RR 0.91, 95% CI 0.80 to 1.05). There was low-certainty evidence that multidisciplinary rehabilitation may reduce the number of people with poorer mobility at 12 months (RR 0.83, 95% CI 0.71 to 0.98). It was not possible to draw conclusions about other outcomes, assisted discharge and multidisciplinary home rehabilitation as the evidence was of very low certainty. Commentary Modern hip fracture management consists of a coordinated multidisciplinary approach including orthogeriatric assessment, early surgery, identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence.3 It is the current standard of care in rehabilitation after hip fracture surgery.4 In intervention studies for hip fracture patients, new interventions are often compared with ‘usual’ or ‘standard’ therapy. It is important for researchers to specify the intervention and the dose, including frequency, intensity, time and type, for both groups. For multidisciplinary interventions, researchers should report the percent receiving visits and the number of visits for both groups. Researchers should clarify the intent of the trial relative to (1) replacing existing services with new services, (2) extending/adding services, (3) distinguishing between skilled rehabilitation and training provided by alternative providers, and (4) distinguishing between providing rehabilitation and home programme instruction. Researchers should also report when the intervention occurs relative to hip fracture. In the trials included in this review, these aspects are often missing or unclear. To identify patients with the greatest potential benefit from an intensive multidisciplinary rehabilitation programme, researchers should consider stratifying the sample with the Comprehensive Geriatric Assessment before the fracture occurs. Moreover, trials should include more people with cognitive impairment/dementia or nursing home residents because excluding complex and frail patients could reduce the benefit of the multidisciplinary rehabilitation approach. Finally, in interpreting the results of this review, we should consider the clinical and methodological heterogeneity of the studies.