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

BACKGROUND: Hip fracture is a major cause of morbidity and mortality 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 specialised register (March 2001), MEDLINE (1966 to February 2001), PREMEDLINE (March 28th 2001), and reference lists of articles 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 data from primary outcomes, supplementary analyses were performed to combine clinically relevant outcomes and investigate possible explanatory factors. MAIN RESULTS: In this substantive update, one new trial has been included. The nine included trials involved 1869 patients. The combined outcomes of death or requiring institutional care showed no significant difference between intervention and control groups (relative risk 0.92; 95% confidence interval 0.82 to 1.04). 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 0.92 (95% confidence interval 0.82 to 1.02). 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 available trials reviewed had different aims, interventions and outcomes. Combined outcome measures (e.g. death or institutional care) tended to be better for patients receiving co-ordinated inpatient rehabilitation, but the results were heterogeneous and not statistically significant. 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.