Study reference

Study characteristics

Patient characteristics

Intervention (I)

Control (C)

Outcome measures and effect size

Comments

Handoll, 2009

Type of study: systematic review and meta-analysis of (quasi-) randomised controlled trials

Country: Australia

Source of funding: University of Teesside, Middlesbrough, UK and Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney, Australia. External soruces: The Cochrane Collaboration, Prioritisation Project Fund.

Literature search up to: April 2009

Inclusion criteria: (quasi-) randomised controlled trials of post-surgical care using multidisciplinary rehabilitation of older people (most participants >65 yr) with hip fracture. Multidisciplinary rehabilitation is supervised by a geriatrician, a rehabilitation physician or a specialised clinician in geriatrics or rehabilitation and is compared with usual care.

Exclusion criteria: Not reported.

N of included studies:

13

A: Cameron, 1993

B: Crotty, 2003

C: Fordham, 1986

D: Galvard, 1995

E: Gilchrist, 1988

F: Huusko, 2002

G: Kennie, 1988

H: Naglie, 2002

I: Ryan, 2006

J: Shyu, 2008

K: Stenvall, 2007

L: Swanson, 1998

M: Vidan, 2005

Important patient characteristics at baseline:

N, mean age(yr)

A: 252, mean 84 yr

B: 66, mean 82.5 yr

C: 108, Mean age not stated

D: 378, mean 79 yr

E: 222, mean 81 yr

F: 260, mean 80 yr

G: 108, mean79 and 84 yr

H: 280, mean 84 yr

I: 71, mean 81 yr

J: 162, mean 78 yr

K: 199, mean 82 yr

L: 71, mean 78 yr

M: 321, mean 82 yr

Sex (%female/%male):

A: 83%/17%

B: 67%/33%

C: 100% women

D: 74%/26%

E: 100% women

F: 72%/28%

G: 100% women

H: 80%/20%

I: 76%/24%

J: 68.5%/31.5%

K: 74%/26%

L: 78%/22%

M: 81.5%/18.5%

Although 17 trials had comparability of the groups at baseline (item d) or only a small chance of confounding, details of the nutritional status of the groups were often missing. Related to this is the lack of information on anthropometric parameters.

Intervention:

A: Accelerated rehabilitation and early discharge: early assessment by physician experienced in rehabilitation and geriatric medicine to assess rehabilitation goals, early commencement, greater emphasis on retraining for physical independence, closer family care-giver contact and more detailed discharge planning.

B: Accelerated discharge (<48h postsurgery) and home-based interdisciplinary rehabilitation. Home visits by physiotherapists, occupational therapists, speech pathologists, social workers and therapy aides. Standard therapy service provided as required. Weekly multidisciplinary conference attended by specialist in rehabilitation or geriatrician.

C: Joint geriatric and orthopaedic management involving early post-admission assessment by geriatrician, joint decision for transfer to ortho-geriatric ward, joint clinical rounds once a week, joint responsibility for rehabilitation programme, joint decisions about and facilitation of discharge or transfer, joint junior medical staff.

D: Geriatric rehabilitation: transfer to geriatric hospital and weekly visit by orthopedic surgeon.

E: Combined ortho-geriatric care in special designated unit. Weekly ward round with a geriatrician, an orthopaedic senior registrar and a senior ward nurse; followed by a case conference with in addition a physiotherapist, occupational therapist and a social worker.

F: Intensive geriatric rehabilitation within hospital: multidisciplinary geriatric team (geriatrician, trained GP, nurses, occupational therapists, physiotherapists, social workers, neuropsychologists) provided intensive rehabilitation programme based in geriatric ward. During first 2 months, independent living patients were visited 10 times by physiotherapists.

G: Multidisciplinary care (GP, geriatrician and advice when needed from orthopaedic specialist) in orthopaedic beds at peripheral hospital. Day to day care by GP, geriatrician attended each week 2 ward rounds and one multidisciplinary team conference.

H: Interdisciplinary care consisting of routine postoperative surgical care plus daily medical care by internist-geriatrician, and regular care by physiotherapist, occupational therapist, social worker and clinical nurse specialist. Twice weekly interdisciplinary rounds to set goals and monitor progress.

I: Intensive rehabilitation: 6 or more face-to-face contacts per week from members of a multidisciplinary rehabilitation team (physiotherapist, occupational therapist, speech and language therapist or therapy assistant).

J: Interdisciplinary programme of geriatric consultation, continuous rehabilitation and discharge planning. Assessment by geriatrician, rehabilitation by physiotherapist, geriatric nurses, and rehabilitation physician.

K: Geriatric unit specializing in geriatric orthopaedic care. Multidisciplinary team providing assessments and rehabilitation program.

L: Accelerated rehabilitation programme involving multidisciplinary team (orthopaedic surgeon, geriatrician, nurse-coordinator, physiotherapist, occupational therapist, social worker) based in orthopaedic ward.

M: Multidisciplinary care: geriatric team (geriatrician, rehabilitation specialist, specific social worker. Daily geriatric assessment, physical therapy, assessment of social environment and a comprehensive treatment plan.

Control:

A: Conventional care and rehabilitation (of these 56% had multidisciplinary rehabilitation).

B: Usual or conventional care (routine interdisciplinary hospital care and rehabilitation in hospital).

C: Orthopaedic management on orthopaedic rehabilitation unit. Geriatrician available for advice.

D: Usual orthopedic care.

E: Usual orthopaedic care in orthopaedic ward. Referral to geriatrician by letter.

F: Discharge to local community hospitals, treatment by GP with physiotherapists usually available.

G: Routine orthopaedic care in orthopaedic admission ward.

H: Usual care on orthopaedic unnits which included access to geriatric consultation and allied health care professionals if requested.

I: Less intensive rehabilitation: 6 or more face-to-face contacts per week from members of a multidisciplinary rehabilitation team (physiotherapist, occupational therapist, speech and language therapist or therapy assistant).

J: Usual care on trauma or orthopaedic ward. Some consultations of other disciplines made depending on patient’s condition.

K: Usual care on specialist orthopaedic ward. Care included that by physiotherapists, occupational therapist and care staff, not including dietician.

L: Standard orthopaedic management including daily visits from physiotherapist. Social worker or occupational therapist by request, geriatrician on referral.

M: Usual orthopaedic care: management by orthopaedic surgeon and nurses. Counselling from different specialists as required.

Inpatient rehabilitation vs usual care

1. Mortality

1a. mortality at end of follow-up. Effect measure: RR [99% CI]:

0.90 [0.76-1.07]

A: 0.98 [0.59-1.64]

C: 1.29 [0.57-2.92

D: 1.21 [0.83-1.75]

E: 0.78 [0.43-1.44]

F: 0.92 [0.51-1.66]

G: 0.56 [0.28-1.09]

H: 0.79 [0.44-1.44]

J: 1.03 [0.38-2.79]

K: 0.85 [0.46-1.56]

L: 0.72 [0.24-2.16]

M: 0.76 [0.49-1.17]

1b. mortality at discharge. Effect measure: RR [99% CI]:

0.77 [0.56-1.06]

C: 1.29 [0.57-2.92]

D: 1.02 [0.56-1.85]

E: 0.40 [0.13-1.18]

F: 1.03 [0.30-3.45]

G: 1.25 [0.35-4.40]

H: 0.53 [0.22-1.28]

K: 0.82 [0.44-1.44]

L: 1.87 [0.13-5.83]

M: 0.12 [0.002-0.92]

2. Functional outcome

Effect measure: RR [99% CI]:

Measures of physical functioning varied between studies, and data pooling was either inappropriate or not possible. Data were often incomplete.

2a. More dependent (based on Katz index) at 1 year

G: 0.64 [0.46-0.89]

K: 0.65 [0.48-0.88]

2b. Non-recovery/decline in walking at long term follow-up

H: 0.99 [0.76-1.29]

J: 0.59 [0.37-0.95]

3. quality of life

No data

Study reference

(first author, publication year)

Appropriate and clearly focused question?¹

Yes/no/unclear

Comprehensive and systematic literature search?²

Yes/no/unclear

Description of included and excluded studies?³

Yes/no/unclear

Description of relevant characteristics of included studies?⁴

Yes/no/unclear

Appropriate adjustment for potential confounders in observational studies?⁵

Yes/no/unclear/notapplicable

Assessment of scientific quality of included studies?⁶

Yes/no/unclear

Enough similarities between studies to make combining them reasonable?⁷

Yes/no/unclear

Potential risk of publication bias taken into account?⁸

Yes/no/unclear

Handoll, 2009

yes

yes

yes

yes

Not applicable

yes

yes

yes

Study reference

Study characteristics

Patient characteristics

Intervention (I)

Comparison / control (C)

Follow-up

Outcome measures and effect size

Comments

Shyu, 2013

Type of study:

RCT

Setting: Teaching hospital

Country: Taiwan

Source of funding: National Health Research Institute of Taiwan

Inclusion criteria:

Patients >60 yr submitted to surgery for unilateral hip fracture, prefracture Chinese Barthel index >70

Exclusion criteria:

Severe cognitive impairment, completely unable to follow instructions (<10 on Chinese mini-mental state examination) or terminally ill.

N total: 200

N intervention: 101

N control: 99

Age:

76 (age per intervention group not reported)

Sex:

32.7-40.4% M (sex per intervention group not reported)

Groups comparable at baseline?

Yes (no significant differences)

The subacute care model consisted of geriatric consultation, a continuous rehabilitation programme, and early discharge-planning intervention.

Comprehensive geriatric assessment and medical supervision were provided initially by the geriatric nurse before surgery. The geriatrician examined high-risk patients who were >80 years old, at high operative risk, had poor nutritional status, had cognitive impairment or disorientation, or had unstable comorbid conditions. The geriatrician then suggested various strategies to the primary surgeon.

Rehabilitation started on the first day after surgery and continued into the home setting after hospital discharge.

In-hospital rehabilitation included one visit per day by a geriatric nurse and at least two assessments by a physical therapist. For in-home rehabilitation, subjects received four nursing visits in the first month after discharge, four visits from 2 to 4 months following discharge, and one visit each time from a physical therapist within the first week, third week, and third month after discharge.

Geriatric nurses provided structured discharge assessment with home environment assessment, referral, and reminders for clinical follow-up. Within 3

days after each patient’s discharge, the geriatric nurse visited his/her home to assess its environment and to suggest environmental modifications.

Usual care: Patients are usually sent directly to the hospital emergency room and are cared for by orthopaedists. Consultations for internal medicine care are occasionally made depending on the patient’s condition. Physical therapy usually starts on the second or third day without any in-home rehabilitation provided or telephone follow-ups. Patients are encouraged to ambulate with protected weight bearing for 3 months.

Length of follow-up: 12 months after discharge

Loss-to-follow-up:

Intervention

N (%): 9/101 (9%)

Reasons: mortality (5) and refusal (4)

Control

N (%): 14/99 (14%)

Reasons: mortality (5) and refusal (9)

Mortality at end of follow-up:

I: 5/101 (5%)

C: 5/99 (5%)

HRQoL- Health Related Quality of Life (SF36):

The SF-36 exists of several dimensions, there is no total score. At the end of follow-up the intervention group scored better in physical-related function (physical functioning, disability due to physical health and physical component summary) and in health outcomes (vitality and social functioning)

Three programmes are studies, of which one is usual care, one is mainly inpatient rehabilitation and one is mainly focused on home-based rehabilitation. Only the programme focused on inpatient rehabilitation versus usual care is desribed here, as the other comparements are not relevant in our case.

Study reference

(first author, publication year)

Describe method of randomisation¹

Bias due to inadequate concealment of allocation?²

(unlikely/likely/unclear)

Bias due to inadequate blinding of participants to treatment allocation?³

(unlikely/likely/unclear)

Bias due to inadequate blinding of care providers to treatment allocation?³

(unlikely/likely/unclear)

Bias due to inadequate blinding of outcome assessors to treatment allocation?³

(unlikely/likely/unclear)

Bias due to selective outcome reporting on basis of the results?⁴

(unlikely/likely/unclear)

Bias due to loss to follow-up?⁵

(unlikely/likely/unclear)

Bias due to violation of

intention to treat analysis?⁶

(unlikely/likely/unclear)

Shyu, 2013

Throw of a dice by a neutral person

unlikely

unlikely

Unlikely

Unclear

Unclear

unlikely

Not applicable