20170517 hip fracture v2 - sign.ac.uk · 68% of patients have their hip fracture repaired within 36...

$: 20170517 hip fracture V2 - sign.ac.uk · 68% of patients have their hip fracture repaired within 36 hours of admission however this drops as low as 34% in some hospitals ... This$
File name : 20170517 hip fracture V2.2 Version 0.3 17/05/2017 Produced by: Roberta James Page 1 Review date: 24/05/17

Topic proposal

I understand that this proposal will be retained by the SIGN Programme Lead and be made available on the SIGN website for time period that the proposal is being considered. Only proposals with a completed Declaration of Interests for the principal proposer will be considered

1. What is the problem/need for a guideline/clinical scenario? To develop evidence based National Guidelines for the care of a patient with a hip fracture

(formally SIGN 111) This will reduce significant variation in practice and improve outcomes across Scotland.

2. Burden of the condition

Based on data collected between October - December 2016 ( Outcomes June –August) (please note data not yet published and available as management information only)

68% of patients have their hip fracture repaired within 36 hours of admission however this drops as low as 34% in some hospitals

17% of patients are repeatedly fasted in preparation for surgery ( range 3% - 040%) and 424% of patients are denied oral fluids for in excess of 10 hours, again there is notable variation nationally with a range of 0 – 83%

Between 7 and 96% of patients have geriatric assessment within three days of admission

Nationally, 35% of people had a total hospital stay of greater than 4 weeks. 45% of patients died before leaving acute orthopaedic care and 7% by 30 days post-

admission At 30 days post admission, 59% of had returned home. (range 43 – 69%). Mortality is estimated to be 28% within one year ( SMR01 average 2011-15)

Incidence

Estimated Population

2015

Number of inpatient

episodes with Hip Fractures

2015 Incidence (##/1000)

65+ Male 435884 1668 3.8

65+ Female 547525 4486 8.2

65+ Total 983409 6154 6.3

3. Variations In practice in Scotland

The Scottish Hip Fracture Audit provides national and local level data on hospitals compliance with the Scottish Standards for Hip Fracture Patients (revised 2016). Monthly reporting on these measures shows continued variation in practice, most notably due to lack of consistent and efficient planning for surgical intervention which can results in either the patient being repeatedly fasted in preparation for theatre and/ or having oral fluids withheld for extended periods of time. There also exists extensive variation in the timing and availability of geriatric


assessment during these patients acute inpatient stay. In health outcomes in Scotland There is a notable variation nationally in the acute length of stay as well as destination following discharge; however this may be due to local service configuration and availability rather than inconsistent practice. Minimizing the long term impact of sustaining a hip fracture, particularly for people who lived at home prior to the injury, is seen as being an important goal of the audit. There is, however wide variation in the percentage of people who were admitted from home and are again resident at home within 30 days of admission. This figure ranges from 43% to 69% across Scottish hospitals (national 56%).

4. Areas of uncertainty to be covered Key question 1; What methods are effective in reducing obstacles to providing surgical repair

within 36 hours of admission to hospital? These may include anaesthetic practice, theatre or hospital capacity.

Key question 2; What factors can reduce delays to discharge?

Key question 3: What factors can increase the probability of home as a destination for people who originated from there.

5. Areas that will not be covered Prevention of hip fracture through falls or osteoporosis prevention as this work is covered

elsewhere. Due to the fast pace of change with recommendations for current medical or pharmaceutical practice, guidance on anaesthetic or, surgical technique or antithrombotic therapy will not be included. If consensus can be reached amongst relevant clinical specialties on best practice then these would be covered in a best practice statement.

6. Aspects of the proposed clinical topic that are key areas of concern for patients, carers and/or the organisations that represent them

Patients and carers report that functional ability post discharge and returning to their own home as quickly as possible with support where required, is of utmost importance to them. They also report that clear communication regarding expectations of hospital stay and discharge is often lacking from clinical teams, which often causes distress and anxiety for all involved.

7. Population Included

All patients with a hip fracture in Scotland who are over the age of 50 years. Not included Patients who do not have a hip fracture such as peri-prosthetic fractures, shaft of femur or acetabular fractures., non fragility hip fractures i.e. those under the age of 50 years


8. Healthcare setting Included

Secondary care and Primary care, including community setting

Not included nil

9. Potential Potential to improve current practice

Significant potential to improve current practice nationally, leading to better outcomes for patients and their respective families/carers. Potential impact on important health outcomes (name measureable indicators)

Access to treatment in ED Reduction in time to theatre Reduced length of stay Reduced infection Improved numbers of patients returning to own residence home within 30 days

with appropriate support Improved functional outcomes Reduced readmission rate within 14 days Reduced morbidity and mortality Improved patient and relative/carer experience

Potential impact on resources

(name measureable indicators)

Reduction in acute health care costs by reducing length of hospital stay Reduction in requirement for social care and long term rehabilitation

10. What evidence based guidance is currently available?

Out-of-date (list) SIGN 111 Current (list) Scottish Standards of Care for Hip Fracture Patients 2016 NICE Clinical Guideline 124 Older People Acute Care

11. Relevance to current Scottish Government policies

Scottish Government MSK Quality Improvement Care 2020 Vision for health and social care in Scotland Realistic Medicine

12. Who is this guidance for?

Patients, Relatives, Carers, Public, Medical staff, Nursing staff, Trainees, Allied Health Practitioners, , General Practitioners, Social Workers, Dieticians, Ambulance Service, Community Providers.


13. Implementation Links with existing audit programmes – the Scottish Hip Fracture Audit

Scottish Standards of care for Hip Fracture Patients 2016 Existing educational initiatives Strategies for monitoring implementation Scottish hip Fracture audit Local NHS Multidisciplinary Meetings for the care of patients with Hip Fractures.

14. Primary contact for topic proposal Mr Graeme Holt, Consultant Orthopaedic Surgeon and Chair of the Scottish Hip Fracture

Audit and Advisory Group Karen Adam, Scottish Government MSK Quality Improvement Advisor Kirsty Ward, National Clinical Coordinator, MSk Audit

15. Group(s) or institution(s) supporting the proposal

Scottish Hip Fracture Audit and Advisory Group. Scottish Orthopaedic Services Development Group Scottish Government Directorate of Health performance and delivery NHS National Service Scotland, ISD


Declaration of Interests Please complete all sections and if you have nothing to declare please put ‘N/A

Having read the SIGN Policy on Declaration of Competing Interests I declare the following competing interests for the previous year, and the following year. I understand that this declaration will be retained by the SIGN Programme Lead and be made available on the SIGN website for time period that the proposal is being considered.

Signature:

Name: Graeme Holt

Relationship to SIGN: Topic proposal primary contact

Date: 25/11/2016

Date received at SIGN:

Personal Interests Remuneration from employment

Name of Employer and Post held

Nature of Business Self or partner/ relative

Specific?

Details of employment held which may be significant to, or relevant to, or bear upon the work of SIGN

NHS Ayrshire & Arran, Consultant Orthopaedic Surgeon.

Orthopaedic surgery Self

Remuneration from self employment

Name of Business Nature of Business Self or partner/ relative

Specific?

Details of self employment held which may be significant to, or relevant to, or bear upon the work of SIGN

Remuneration as holder of paid office

Nature of Office held

Organisation

Self or partner/ relative

Specific?

Details of office held which may be significant to, or relevant to, or bear upon the work of SIGN


Remuneration as a director of an undertaking Name of

Undertaking

Nature of Business


Specific?

Details of directorship held which may be significant to, or relevant to, or bear upon the work of SIGN

Remuneration as a partner in a firm

Name of Partnership

Nature of Business


Specific?

Details of Partnership held which may be significant to, or relevant to, or bear upon the work of SIGN

Shares and securities

Description of organisation

Description of nature of holding (value need not be

disclosed)


Specific?

Details of interests in shares and securities in commercial healthcare companies, organisations and undertakings

Remuneration from consultancy or other fee paid work commissioned by, or gifts from, commercial healthcare companies, organisations and undertakings

Nature of work For whom undertaken and

frequency


Specific?

Details of consultancy or other fee paid work which may be significant of to, or relevant to, or bear upon the work of SIGN


Details of gifts which may be significant to, or relevant to, or bear upon the work of SIGN

Non-financial interests

Description of interest Self or partner/ relative

Specific?

Details of non-financial interests which may be significant to, or relevant to, or bear upon the work of SIGN

Chair of Scottish Hip Fracture Audit, Advisory Group

self

Non-personal interests Name of company, organisation or

undertaking

Nature of interest

Details of non- personal support from commercial healthcare companies, organisations or undertakings

Signature Date: 25/11/2016

Thank you for completing this form.

Please return to Roberta James SIGN Programme Lead SIGN Executive, Healthcare Improvement Scotland, Gyle Square | 1 South Gyle Crescent | Edinburgh | EH12 9EB t: 0131 623 4735 e:[email protected]

Data Protection

Your details will be stored on a database for the purposes of managing this guideline topic proposal. We may retain your details so that we can contact you about future Healthcare Improvement Scotland activities. We will not pass these details on to any third parties. Please indicate if you do not want your details to be stored after the proposal is published.


Initial screen

Purpose: initial screening by SIGN Senior Management Team to exclude proposals that are neither clinical, nor multi-professional, nor appropriate for the SIGN process.

1. Is this an appropriate clinical topic for a SIGN guideline? Is it a clinical topic, what is the breadth of the topic and is there a need for the guideline as identified in the proposal?

Yes, this would update sections of SIGN 111 on management of hip fracture.

2. Is there a suitable alternative product which would address this topic? Would another Healthcare Improvement Scotland product better address the topic?

No

3. Has this topic been considered before and rejected? What were the reasons for rejection and are they still applicable

No

4. Outcome Go forward to the next stage of topic selection

22/2/2017

Reject


Scope of recent evidence

Summary: Guidelines Three guidelines and a quality standard were identified published between 2012 and 2018. The guidelines were from the UK, and the US and covered surgical timing, comorbidities affecting surgery delays, transitional care, including early supported discharge, and barriers to successful transition Health technology assessments Eight health technology assessments were identified published between 2000 and 2016. The HTAs were from the UK and Canada. Canada. The topics explored were timing of surgery and preoperative delay, inpatient compared to community rehabilitation, timing and intensity of rehabilitation, pain management and secondary fracture prevention. Cochrane reviews Fourteen Cochrane reviews published between 2002 and 2016. The reviews covered anaesthesia, analgesia, transfusion, anticoagulants, antibiotic prophylaxis, fluid therapy, 'Early discharge hospital at home', rehabilitation interventions, and rehabilitation setting. One review specifically included patient with dementia. A further 38 systematic reviews and 3452 randomised controlled trials were identified. See Annex 1 for further details


Suitability screen

Purpose: screening by the Guideline Programme Advisory Board to select applications suitable for inclusion in the SIGN topic selection process.

1. Is there an owner for the project? (preferably an individual)

Yes

2. Is this a clinical priority area for NHSScotland?

Minimising the long term impact of sustaining a hip fracture, particularly for people who lived at home prior to the injury is a priority.

3. Is there a gap between current and optimal practice? OR Is there wide variation in current practice? (is this an area of clinical uncertainty)

There is variation in practice, most notably due to lack of consistent and efficient planning for surgical intervention which can results in either the patient being repeatedly fasted in preparation for theatre and/ or having oral fluids withheld for extended periods of time. There also exists extensive variation in the timing and availability of geriatric assessment during these patients acute inpatient stay.

4. Is there a suitable guideline already available that could be adapted? (not necessarily by SIGN)

Three guidelines and a quality standard were identified published between 2012 and 2018. The guidelines were from the UK, and the US and covered surgical timing, comorbidities affecting surgery delays, transitional care, including early supported discharge, and barriers to successful transition

5. Is there adequate literature to make an evidence-based decision about appropriate practice? (is effective intervention proven and would it reduce mortality or morbidity)

There is a body of evidence that would cover some, but not all, aspects of the key questions

6. Would the proposed practice change result in sufficient change in outcomes (health status, provider and consumer satisfaction and cost) to justify the effort?

Yes, potential outcomes are:

Access to treatment in ED Reduction in time to theatre Reduced length of stay Reduced infection Improved numbers of patients returning to own residence home within 30 days

with appropriate support Improved functional outcomes Reduced readmission rate within 14 days Reduced morbidity and mortality Improved patient and relative/carer experience

How big is the gap? Not clear. Data is being collected against national standards.

How much effort will it take to close the gap? Not clear


7. Is there a perceived need for the guideline, as indicated by a network of relevant stakeholders?

Yes, through the Scottish Hip Fracture Audit and Advisory Group

8. Is there a reasonable likelihood that NHSScotland could implement the change?

Yes, through:

Scottish hip Fracture Audit Scottish Standards of care for Hip Fracture Patients 2016 Local NHS Multidisciplinary Meetings for the care of patients with Hip Fractures.

9. Does the proposer have any conflicts of interest? If so how will these be managed?

No

10. Outcome Go forward to the next stage of topic selection

Reject Standards from a national working group have been developed and data is being collected. This proposal is on hold until there are data to direct where there is variation in practice.

YES 13/09/2018


Annex 1 Scope of recent evidence

Topic: Hip fracture – delays and obstacles to treatment and destination.

Resources searched: 2000-2017

GIN - 0

National Guidelines Clearinghouse - 2

NICE - 1 guideline, 1 quality standard

Cochrane Library - 295, 14 tangentially relevant

CRD databases

includes DARE (till 2014 only) – 262 results, 16 relevant

HTA – 59 results, 8 relevant

NHS EED (till 2014 only) – 197 results, 9 relevant (most too old for inclusion)

INAHTA is the same as UKHTA - 0

Medline for SRS 2014-2017 – 290 results, 23 relevant

HMIC – 270 results, 73 relevant

CENTRAL for RCTs – numbers only, all hip fracture - 3452

Dates searched: 16/3/17

Guidelines

American Academy of orthopedic surgeons. American Academy of Orthopaedic Surgeons clinical practice guideline on management of hip fractures in the elderly. 2014;

Surgical Timing

Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. Strength of Recommendation: Moderate ***

Hartford Institute for geriatric Nursing. Transitional care. In: Evidence-based geriatric nursing protocols for best practice. 2012;

Critical Elements of Successful Transitions


Team approach and preferably nurse led (advanced practice nurse [APN] or specialized nurse) (Coleman et al., 2006; Naylor & Keating, 2008 [Level V])

Active and early family involvement across transitions (Almborg et al., 2009 [Level IV]; Bauer et al., 2009 [Level V]; Naylor & Keating, 2008 [Level V])

Proactive patient roles and self-advocacy (Coleman et al., 2006 [Level II])

High-quality and individualized patient and family discharge instructions (Clark et al., 2005 [Level IV])

Apply interventions for improving comprehension among patients with low health literacy and impaired cognitive function (Chugh et al., 2009 [Level V]), such as the National Patient Safety Foundation's "Ask Me 3" campaign available at: http://www.npsf.org/askme3/ External Web Site Policy.

Patient and informal caregiver empowerment through education

Commence interventions well before discharge (Bauer et al., 2009 [Level V]).

Coleman identified elements of effective and successful transitions as follows (Coleman, Boult, & American Geriatrics Society Health Care Systems Committee, 2003 [Level VI]):

Communication between the sending and receiving clinicians regarding a common plan of care

A summary of care provided by the sending institution (to the next care interface providers)

The patient's goals and preferences (including advance directives)

An updated list of problems, baseline physical and cognitive functional status, medications, and allergies

Contact information for the patient's caregiver(s) and primary care practitioner

Preparation of the patient and caregiver for what to expect at the next site of care

Reconciliation of the patient's medication prescribed before the initial transfer with the current regimen

A follow-up plan for how outstanding tests and follow-up appointments will be completed

An explicit discussion with the patient and caregiver regarding warning symptoms or signs to monitor that may indicate that the condition has worsened and the name and phone number of who to contact if this occurs

Barriers to Successful Transitions

Coleman identified barriers to effective care transitions at three levels: the delivery system, the clinician, and the patient (Coleman, Boult, & American Geriatrics Society Health Care Systems Committee, 2003 [Level VI]).

The Delivery System Barriers


The lack of formal relationships between care settings represents a barrier to cross-site communication and collaboration.

Lack of financial incentives promoting transitional care and accountability in fee-for-service Medicare. Although such incentives exist in Medicare managed care, most plans do not fully address care integration.

The different financing and contractual relationships that facilities have with various pharmaceutical companies impede effective transitions. As patients are transferred across settings, each facility has incentives to prescribe or substitute medications according to its own medication formulary. This constant changing of medications creates confusion for the patient, caregiver, and receiving clinicians.

Neither fee-for-service nor managed care Medicare has implemented quality or performance indicators designed to assess the effectiveness of transitional care.

The lack of information systems designed to facilitate the timely transfer of essential information.

The Clinician Barriers

The growing reliance on designated institution-based physicians (i.e., "hospitalists") and productivity pressures have made it difficult for primary care physicians to follow their patients when they require hospitalization or short-term rehabilitation.

Nursing staff shortages have forced an increasing number of acute hospitals to divert patients to other facilities where a completely new set of clinicians, who often do not have timely access to the patient's prior medical records, manages them. Skilled nursing facility (SNF) staff are also overwhelmed and do not have the time or initiative to request necessary information.

Clinicians do not verbally communicate patient information to one another across care settings.

The Patient Barriers

Lack of advocacy or outcry from patients for improving transitional care until they or a family member is confronted with the problem firsthand.

Older patients and their caregivers often are not well prepared or equipped to optimize the care they will receive in the next setting.

They may have unrealistic expectations about the content or duration of the next phase of care and may not feel empowered to express their preferences or provide input for their care plan.

Patients may not feel comfortable expressing their concern that the primary factor that led to their disease exacerbation was not adequately addressed.

NICE. Hip Fracture CG124.

1.2.1 Perform surgery on the day of, or the day after, admission.

1.2.2 Identify and treat correctable comorbidities immediately so that surgery is not delayed by:

anaemia


anticoagulation

volume depletion

electrolyte imbalance

uncontrolled diabetes

uncontrolled heart failure

correctable cardiac arrhythmia or ischaemia

acute chest infection

exacerbation of chronic chest conditions.

1.5 Planning the theatre team

1.5.1 Schedule hip fracture surgery on a planned trauma list.

1.5.2 Consultants or senior staff should supervise trainee and junior members of the anaesthesia, surgical and theatre teams when they carry out hip fracture procedures.

1.8.4 Consider early supported discharge as part of the Hip Fracture Programme, provided the Hip Fracture Programme multidisciplinary team remains involved, and the patient:

is medically stable and

has the mental ability to participate in continued rehabilitation and

is able to transfer and mobilise short distances and

has not yet achieved their full rehabilitation potential, as discussed with the patient, carer and family.

1.8.5 Only consider intermediate care (continued rehabilitation in a community hospital or residential care unit) if all of the following criteria are met:

intermediate care is included in the Hip Fracture Programme and

the Hip Fracture Programme team retains the clinical lead, including patient selection, agreement of length of stay and ongoing objectives for intermediate care and

the Hip Fracture Programme team retains the managerial lead, ensuring that intermediate care is not resourced as a substitute for an effective acute hospital Programme.

1.8.6 Patients admitted from care or nursing homes should not be excluded from rehabilitation programmes in the community or hospital, or as part of an early supported discharge programme.

NICE. Hip Fracture in adults - QS16. 2016;

Quality measures


Structure

a) Evidence of local arrangements to ensure that people with hip fracture have surgery on a planned trauma list.

Data source: Local data collection.

b) Evidence of local arrangements to ensure that people with hip fracture have surgery on the day of, or the day after, admission.


Process

a) Proportion of operations for hip fracture that are performed on a planned trauma list.

Numerator – the number in the denominator that are performed on a planned trauma list.

Denominator – the number of operations for hip fracture.

Data source: Local data collection. The National Hip Fracture Database records the time of the operation in relation to the admission.

b) Proportion of operations for hip fracture that are performed on the day of, or the day after, admission.

Numerator – the number in the denominator that are performed on the day of, or the day after, admission.

Denominator – the number of operations for hip fracture.

Data source: Local data collection. The NHS Digital Compendium of Clinical and Health Indicators records emergency hospital admissions and timely surgery: fractured proximal femur. The National Hip Fracture Database records the time of the operation in relation to the admission.

Outcome

a) Postoperative complications for people with hip fracture.


b) Length of hospital stay for people with hip fracture.


c) Mortality for people having hip fracture surgery.


Health Technology Assessments

Abou-Setta AM, Beaupre LA, Jones CA, Rashiq S, Hamm MP, Sadowski CA, et al. Pain management interventions for hip fracture (Structured abstract). Health Technology Assessment Database. 2011; 4. [cited: url: http://www.effectivehealthcare.ahrq.gov/ehc/products/95/678/CER30__FinalReview_20110517.pdf


Objectives. To review and synthesize the evidence on pain management interventions in nonpathological hip fracture patients following low-energy trauma. Outcomes include pain management (short and long term), mortality, functional status, pain medication use, mental status, health-related quality of life, quality of sleep, ability to participate in rehabilitation, return to pre-fracture living arrangements, health services utilization, and adverse effects.

Data Sources. Comprehensive literature searches were conducted in 25 electronic databases from 1990 to present. Searches of the grey literature, trial registries, and reference lists of previous systematic reviews and included studies were conducted to identify additional studies.

Methods. Study selection, quality assessment, data extraction, and grading of the evidence were conducted independently and in duplicate. Discrepancies were resolved by consensus or thirdparty adjudication. Meta-analyses were conducted where data were available and deemed appropriate.

Results. In total, 83 studies were included (69 trials, 14 cohort studies). Most participants were females older than 75 with no cognitive impairment. The methodological quality of cohort studies was generally moderate; most trials were at high or unclear risk of bias. Included studies were grouped into eight intervention categories: systemic analgesia, anesthesia, complementary and alternative medicine, multimodal pain management, nerve blocks, neurostimulation, rehabilitation, and traction. Most studies examined peri- and postoperative pain management, albeit from few perspectives such as reported pain, mortality, and adverse effects. Long-term pain was not reported, and other outcomes were reported infrequently. Nerve blockade was effective for relief of acute pain; however, most studies were limited to either assessing acute pain or use of additional analgesia and did not report on how nerve blockades may affect rehabilitation such as ambulation or mobility if the blockade has both sensory and motor effects. Acupressure, relaxation therapy, and transcutaneous electrical neurostimulation may be associated with potentially clinically meaningful reductions in pain, but further evidence is warranted before any firm conclusions are reached. While the strength of evidence is insufficient to make firm conclusions, postoperative physical therapy may improve pain control, andintravenous parecoxib, a systemic analgesic not available in North America, may be a possible alternative to traditional intramuscular injections of opiates and older nonsteroidal anti-inflammatory drugs (NSAIDs). Preoperative traction and spinal anesthesia (with or without additional agents) did not consistently reduce pain or complications in any demonstrable way compared with standard care. Although most studies reported on adverse effects, they were short term and not adequately powered to identify significant differences. None of the included studies exclusively examined participants from institutional settings or with cognitive impairment, which reduces the generalizability of results to the overall hip fracture patient population.

Conclusion. For most interventions in this review there were sparse data available, which precludes firm conclusions for any single approach or for the optimal overall pain management following hip fracture.

Brener S. Optimal timing of hip fracture surgery: a rapid review (Structured abstract). Health Technology Assessment Database. 2013; 4. [cited: url: http://www.hqontario.ca/Portals/0/Documents/evidence/rapid-reviews/hip-fracture-surgery-optimal-timing-130419-en.pdf

This rapid review identified 6 systematic reviews, none of which directly compared outcomes for hip fracture patients receiving surgery within 24 hours versus 24 to 48 hours. However, findings were consistent among the reviews for the outcomes of interest:

· Shorter wait time for surgery is associated with decreased risk of mortality.


· No statistically or clinically meaningful differences were observed in hospital length of stay among patients who received surgery earlier versus delayed.

Evidence available at this time does not give us the precision to determine if surgery performed within 24 hours results in significantly different outcomes than surgery between 24 and 48 hours. Given that the current median wait time for hip fracture surgery in Ontario is 26 hours and 78% of patients receive surgery within 48 hours of admission, (3) the evidence supports Ontario’s current standard of care and the benchmark of surgery within 48 hours.

Brener S. Optimal timing to begin an active rehabilitation program after a hip fracture: a rapid review (Structured abstract). Health Technology Assessment Database. 2013; 4. [cited: url: http://www.hqontario.ca/Portals/0/Documents/evidence/rapid-reviews/hip-fracture-rehabilitation-program-130419-en.pdf

There is insufficient evidence to indicate the optimal time to an active rehabilitation program after hip fracture surgery.

Cameron I, Crotty M, Currie C, Finnegan T, Gillespie L, Gillespie W, et al. Geriatric rehabilitation following fractures in older people: a systematic review (Structured abstract). Health Technology Assessment Database. 2000; 4. [cited: url: https://njl-admin.nihr.ac.uk/document/download/2004155

Results

Forty-one comparative studies (of which 14 were randomised trials) and seven audit studies were included. The comparative studies were classified into seven groups on the basis of the experimental intervention being investigated:

• geriatric orthopaedic rehabilitation unit (GORU) – seven studies

• geriatric hip fracture programme (GHFP) – five studies

• early supported discharge (ESD) programme – six studies

• introduction of clinical pathways for treatment of hip fracture – three studies

• impact of the introduction of prospective payment systems (PPSs) – six studies

• miscellaneous hospital programmes – four studies

• specific types of therapy, nursing or medical care – 10 studies.

These studies were heterogeneous. Striking variation was found in the reporting of outcomes, the details of the ‘control’ interventions, and the case mix; this limited pooling of data. The very limited data that were available suggest that:

• GHFP, ESD and clinical pathways reduce total length of stay in hospital

• there is no evidence that length of stay in a GORU is less than in a conventional orthopaedic unit

• length of stay may be reduced by the introduction of a PPS • readmission rate after ESD shows a statistically non-significant increase

• significantly higher rates of return to previous residential status are achieved by GHFP and by ESD


• PPSs have led to increased use of nursing homes in the USA

• there is no evidence that any of the programmes evaluated, nor the introduction of PPSs, are associated with changes in mortality

• there are insufficient data to assess the impact of any programme on level of function, morbidity, quality of life or impact on carers

• from a health and social services perspective, GHFP and ESD are likely to be cost-saving. The economic implications of GORU are less clear. Cost-saving associated with these programmes is achieved largely through the increased rate of return to previous residential status.

Conclusions

Geriatric service interventions after hip fracture are complex: their form and outcomes are strongly influenced by local conditions. Comparative studies comparing different treatments and strategies are of poor to moderate quality, allowing only tentative conclusions. As an overall strategy for rehabilitation after hip and other lower limb fractures, GORUs are unlikely to be costeffective, but some frailer patients may benefit in respect of reduced readmission rates and need for nursing home placement. GHFPs and ESD are probably cost-effective, since they appear to shorten the average length of hospital stay, and are associated with significantly increased rates of return to previous residential status. These programmes are not mutually exclusive; an optimal GHFP is likely to involve several elements. As ESD is suitable only for a subset of less disabled patients, an alternative programme for more disabled patients is needed; this is likely to require transfer following surgery, initially to an inpatient setting which might be provided in a GORU or a mixed assessment and rehabilitation unit (MARU). No direct comparison of GORUs and MARUs has been published. Both comparisons of packages of care (such as the GORU or MARU) and comparison of individual elements in these packages may require further research. The adoption of an agreed outcome data set for audit and research would be justified.

Dent THS. Pre-operative delay after femoral fracture (Structured abstract). Health Technology Assessment Database. 2002; 4. [cited: url: http://onlinelibrary.wiley.com/o/cochrane/clhta/articles/HTA-32004000042/frame.html

Ghazipura M. Community versus inpatient rehabilitation in hip fracture patients: a rapid review (Structured abstract). Health Technology Assessment Database. 2013; 4. [cited: url: http://www.hqontario.ca/Portals/0/Documents/evidence/rapid-reviews/hip-fracture-community-130423-en.pdf

On the basis of one SR evaluating the effectiveness of inpatient rehabilitation in comparison with community-based rehabilitation among hip fracture patients, the following conclusions were reached:

· High-quality evidence shows the total FIM improved among patients receiving communitybased rehabilitation versus inpatient rehabilitation;

· Low-quality evidence indicates the total MBI is not significantly different among patients receiving community-based rehabilitation than among those receiving inpatient rehabilitation;

· Moderate-quality evidence indicates patients receiving community-based multidisciplinary rehabilitation have longer stays in rehabilitation (hospital + home) than those receiving inpatient rehabilitation.


The results primarily reflect cognitively intact and medically stable adults older than 65 with high prefracture mobility and independence and might not represent the effectiveness of community versus inpatient rehabilitation among less mobile and more dependent adults.

Judge A, Javaid MK, Leal J, Hawley S, Drew S, Sheard S, et al. Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England (Structured abstract). Health Technology Assessment Database. 2016; 4. [cited: url: https://www.ncbi.nlm.nih.gov/books/NBK385615/

Headline

The study found that in hip fracture patients, orthogeriatrician and nurse-led fracture liaison services are associated with reductions in mortality rates and are cost-effective, with the orthogeriatrician model being the more cost-effective. There was no evidence of reduction in second hip fracture, which could be attributable to a lack of treatment adherence and monitoring.

Abstract

Background:

Professional bodies have produced comprehensive guidance about the management of hip fracture. They recommend orthogeriatric services focusing on achieving optimal recovery, and fracture liaison services (FLSs) focusing on secondary fracture prevention. Despite such guidelines being in place, there is significant variation in how services are structured and organised between hospitals.

Objectives:

To establish the clinical effectiveness and cost-effectiveness of changes to the delivery of secondary fracture prevention services, and to identify barriers and facilitators to changes.

Design:

A service evaluation to identify each hospital’s current models of care and changes in service delivery. A qualitative study to identify barriers and facilitators to change. Health economics analysis to establish NHS costs and cost-effectiveness. A natural experimental study to determine clinical effectiveness of changes to a hospital’s model of care.

Setting:

Eleven acute hospitals in a region of England.

Participants:

Qualitative study – 43 health professionals working in fracture prevention services in secondary care.

Interventions:

Changes made to secondary fracture prevention services at each hospital between 2003 and 2012.

Main outcome measures:

The primary outcome is secondary hip fracture. Secondary outcomes include mortality, non-hip fragility fracture and the overall rate of hip fracture.

Data sources:


Clinical effectiveness/cost-effectiveness analyses – primary hip fracture patients identified from (1) Hospital Episode Statistics (2003–13, n = 33,152); and (2) Clinical Practice Research Datalink (1999–2013, n = 11,243).

Results:

Service evaluation – there was significant variation in the organisation of secondary fracture prevention services, including staffing levels, type of service model (consultant vs. nurse led) and underlying processes. Qualitative – fracture prevention co-ordinators gave multidisciplinary health professionals capacity to work together, but communication with general practitioners was challenging. The intervention was easily integrated into practice but some participants felt that implementation was undermined by under-resourced services. Making business cases for a service was particularly challenging. Natural experiment – the impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.65 to 0.82] and HR 0.81 (95% CI 0.75 to 0.87), respectively. Thirty-day and 1-year mortality were likewise reduced following the introduction or expansion of a FLS: HR 0.80 (95% CI 0.71 to 0.91) and HR 0.84 (95% CI 0.77 to 0.93), respectively. There was no significant impact on time to secondary hip fracture. Health economics – the annual cost in the year of hip fracture was estimated at £10,964 (95% CI £10,767 to £11,161) higher than the previous year. The annual cost associated with all incident hip fractures in the UK among those aged ≥ 50 years (n = 79,243) was estimated at £1215M. At a £30,000 per quality-adjusted life-year threshold, the most cost-effective model was introducing an orthogeriatrician.

Conclusion:

In hip fracture patients, orthogeriatrician and nurse-led FLS models are associated with reductions in mortality rates and are cost-effective, the orthogeriatrician model being the most cost-effective. There was no evidence for a reduction in second hip fracture. Qualitative data suggest that weaknesses lie in treatment adherence/monitoring, a possible reason for the lack of effectiveness on second hip fracture outcome. The effectiveness on non-hip fracture outcomes remains unanswered.

Future work:

Reliable estimates of health state utility values for patients with hip and non-hip fractures are required to reduce uncertainty in health economic models. A clinical trial is needed to assess the clinical effectiveness and cost-effectiveness of a FLS for non-hip fracture patients.

Nikitovic M. Intensity of rehabilitation after hip fracture: a rapid review (Structured abstract). Health Technology Assessment Database. 2013; 4. [cited: url: http://www.hqontario.ca/Portals/0/Documents/evidence/rapid-reviews/hip-fracture-rehabilitation-130423-en.pdf

No systematic reviews, meta-analyses, health technology assessments, or randomized controlled trials (RCTs) were identified that directly evaluated the evidence for increased intensity of rehabilitation on activities of daily living (ADL) after hip fracture.

Cochrane reviews

Atchabahian A, Schwartz G, Hall Charles B, Lajam Claudette M,Andreae Michael H. Regional analgesia for improvement of long-term functional outcome after elective large joint replacement.


Cochrane Database of Systematic Reviews. 2015; 8. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010278.pub2/abstract

Background: Regional analgesia is more effective than conventional analgesia for controlling pain and may facilitate rehabilitation after large joint replacement in the short term. It remains unclear if regional anaesthesia improves functional outcomes after joint replacement beyond three months after surgery.Objectives: To assess the effects of regional anaesthesia and analgesia on long-term functional outcomes 3, 6 and 12 months after elective major joint (knee, shoulder and hip) replacement surgery.Search methods: We performed an electronic search of several databases (CENTRAL, MEDLINE, EMBASE, CINAHL), and handsearched reference lists and conference abstracts. We updated our search in June 2015.Selection criteria: We included randomized controlled trials (RCTs) comparing regional analgesia versus conventional analgesia in patients undergoing total shoulder, hip or knee replacement. We included studies that reported a functional outcome with a follow-up of at least three months after surgery.Data collection and analysis: We used standard methodological procedures expected by Cochrane. We contacted study authors for additional information.Main results: We included six studies with 350 participants followed for at least three months. All of these studies enrolled participants undergoing total knee replacement. Studies were at least partially blinded. Three studies had a high risk of performance bias and one a high risk of attrition bias, but the risk of bias was otherwise unclear or low.Only one study assessed joint function using a global score. Due to heterogeneity in outcome and reporting, we could only pool three out of six RCTs, with range of motion assessed at three months after surgery used as a surrogate for joint function. All studies had a high risk of detection bias. Using the random-effects model, there was no statistically significant difference between the experimental and control groups (mean difference 3.99 degrees, 95% confidence interval (CI) ? 2.23 to 10.21; P value = 0.21, 3 studies, 140 participants, very low quality evidence).We did not perform further analyses because immediate adverse effects were not part of the explicit outcomes of any of these typically small studies, and long-term adverse events after regional anaesthesia are rare.None of the included studies elicited or reported long-term adverse effects like persistent nerve damage.Authors' conclusions: More high-quality studies are needed to establish the effects of regional analgesia on function after major joint replacement, as well as on the risk of adverse events (falls).

Brunskill Susan J, Millette Sarah L, Shokoohi A, Pulford EC, Doree C, Murphy Michael F, et al. Red blood cell transfusion for people undergoing hip fracture surgery. Cochrane Database of Systematic Reviews. 2015; 4. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009699.pub2/abstract

Background: The incidence of hip fracture is increasing and it is more common with increasing age. Surgery is used for almost all hip fractures. Blood loss occurs as a consequence of both the fracture and the surgery and thus red blood cell transfusion is frequently used. However, red blood cell transfusion is not without risks. Therefore, it is important to identify the evidence for the effective and safe use of red blood cell transfusion in people with hip fracture.Objectives: To assess the effects (benefits and harms) of red blood cell transfusion in people undergoing surgery for hip fracture.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (31 October 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014, Issue 10), MEDLINE (January 1946 to 20 November 2014), EMBASE (January 1974 to 20 November 2014), CINAHL (January 1982 to 20 November 2014), British Nursing Index Database (January 1992 to 20 November 2014), the Systematic Review Initiative's Transfusion Evidence Library, PubMed for e-publications, various other databases and ongoing trial registers.Selection criteria: Randomised controlled trials comparing red blood cell transfusion versus no transfusion or an alternative to transfusion, different transfusion protocols or different transfusion thresholds in people undergoing surgery for hip fracture.Data collection and analysis: Three review authors independently assessed each study's risk of


bias and extracted data using a study-specific form. We pooled data where there was homogeneity in the trial comparisons and the timing of outcome measurement. We used GRADE criteria to assess the quality (low, moderate or high) of the evidence for each outcome.Main results: We included six trials (2722 participants): all compared two thresholds for red blood cell transfusion: a 'liberal' strategy to maintain a haemoglobin concentration of usually 10 g/dL versus a more 'restrictive' strategy based on symptoms of anaemia or a lower haemoglobin concentration, usually 8 g/dL. The exact nature of the transfusion interventions, types of surgery and participants varied between trials. The mean age of participants ranged from 81 to 87 years and approximately 24% of participants were men. The largest trial enrolled 2016 participants, over 60% of whom had a history of cardiovascular disease. The percentage of participants receiving a red blood cell transfusion ranged from 74% to 100% in the liberal transfusion threshold group and from 11% to 45% in the restrictive transfusion threshold group. There were no results available for the smallest trial (18 participants). All studies were at some risk of bias, in particular performance bias relating to the absence of blinding of personnel. We judged the evidence for all outcomes, except myocardial infarction, was low quality reflecting risk of bias primarily from imbalances in protocol violations in the largest trial and imprecision, often because of insufficient events. Thus, further research is likely to have an important impact on these results.There was no evidence of a difference between a liberal versus restricted threshold transfusion in mortality, at 30 days post hip fracture surgery (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.67 to 1.26; five trials; 2683 participants; low quality evidence) or at 60 days post surgery (RR 1.08, 95% CI 0.80 to 1.44; three trials; 2283 participants; low quality evidence). Assuming an illustrative baseline risk of 50 deaths per 1000 participants in the restricted threshold group at 30 days, these data equate to four fewer (95% CI 17 fewer to 14 more) deaths per 1000 in the liberal threshold group at 30 days.There was no evidence of a difference between a liberal versus restricted threshold transfusion in functional recovery at 60 days, assessed in terms of the inability to walk 10 feet (3 m) without human assistance (RR 1.00, 95% CI 0.87 to 1.15; two trials; 2083 participants; low quality evidence).There was low quality evidence of no difference between the tra sfusion thresholds in postoperative morbidity for the following complications: thromboembolism (RR 1.15 favouring a restrictive threshold, 95% CI 0.56 to 2.37; four trials; 2416 participants), stroke (RR 2.40 favouring a restrictive threshold, 95% CI 0.85 to 6.79; four trials; 2416 participants), wound infection (RR 1.61 favouring a restrictive threshold, 95% CI 0.77 to 3.35; three trials; 2332 participants), respiratory infection (pneumonia) (RR 1.35 favouring a restrictive threshold, 95% CI 0.95 to 1.92; four trials; 2416 participants) and new diagnosis of congestive heart failure (RR 0.77 favouring a liberal threshold, 95% CI 0.48 to 1.23; three trials; 2332 participants). There was very low quality evidence of a lower risk of myocardial infarction in the liberal compared with the restrictive transfusion threshold group (RR 0.59, 95% CI 0.36 to 0.96; three trials; 2217 participants). Assuming an illustrative baseline risk of myocardial infarction of 24 per 1000 participants in the restricted threshold group, this result was compatible with between one and 15 fewer myocardial infarctions in the liberal threshold group.Authors' conclusions: We found low quality evidence of no difference in mortality, functional recovery or postoperative morbidity between 'liberal' versus 'restrictive' thresholds for red blood cell transfusion in people undergoing surgery for hip fracture. Although further research may change the estimates of effect, the currently available evidence does not support the use of liberal red blood cell transfusion thresholds based on a 10 g/dL haemoglobin trigger in preference to more restrictive transfusion thresholds based on lower haemoglobin levels or symptoms of anaemia in these people. Future research needs to address the effectiveness of red blood cell transfusions at different time points in the surgical pathway, whether pre-operative, peri-operative or postoperative. In particular, such research would need to consider people who are symptomatic or haemodynamically unstable who were excluded from most of these trials.


Crotty M, Unroe K, Cameron Ian D, Miller M, Ramirez G,Couzner L. Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people. Cochrane Database of Systematic Reviews. 2010; 1. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007624.pub3/abstract

Background: Social and psychological factors such as fear of falling, self-efficacy and coping strategies are thought to be important in the recovery from hip fracture in older people.Objectives: To evaluate the effects of interventions aimed at improving physical and psychosocial functioning after hip fracture.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 4), MEDLINE and EMBASE (to December 2008), other databases and reference lists of related articles.Selection criteria: Randomised and quasi-randomised trials of rehabilitation interventions applied in inpatient or ambulatory settings to improve physical or psychosocial functioning in older adults with hip fracture. Primary outcomes were physical and psychosocial function and 'poor outcome' (composite of mortality, failure to return to independent living and/or readmission).Data collection and analysis: Two authors independently selected trials based on pre-defined inclusion criteria, extracted data and assessed risk of bias. Disagreements were moderated by a third author.Main results: Nine small heterogeneous trials (involving 1400 participants) were included. The trials had differing interventions, including 'usual care' comparators, providers, settings and outcome assessment. Although most trials appeared well conducted, poor reporting hindered assessment of their risk of bias.Three trials testing interventions (reorientation measures, intensive occupational therapy, cognitive behavioural therapy) delivered in inpatient settings found no significant differences in outcomes. Two trials tested specialist-nurse led care, which was predominantly post-discharge but included discharge planning in one trial: this trial found some benefits at three months but the other trial found no differences at 12 months. Coaching (educational and motivational interventions) was examined in two very different trials: one trial found no effect on function at six months; and the other showed coaching improved self-efficacy expectations at six months, although not when combined with exercise. Two trials testing interventions (home rehabilitation; group learning program) started several weeks after hip fracture found no significant differences in outcomes at 12 months.Authors' conclusions: Some outcomes may be amenable to psychosocial treatments; however, there is insufficient evidence to recommend practice changes. Further research on interventions described in this review is required, including attention to timing, duration, setting and administering discipline(s), as well as treatment across care settings. To facilitate future evaluations, a core outcome set, including patient-reported outcomes such as quality of life and compliance, should be established for hip fracture trials.

Farooqi V, van den Berg Maayken EL, Cameron Ian D,Crotty M. Anabolic steroids for rehabilitation after hip fracture in older people. Cochrane Database of Systematic Reviews. 2014; 10. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008887.pub2/abstract

Background: Hip fracture occurs predominantly in older people, many of whom are frail and undernourished. After hip fracture surgery and rehabilitation, most patients experience a decline in mobility and function. Anabolic steroids, the synthetic derivatives of the male hormone testosterone, have been used in combination with exercise to improve muscle mass and strength in athletes. They may have similar effects in older people who are recovering from hip fracture.Objectives: To examine the effects (primarily in terms of functional outcome and adverse events) of anabolic steroids after surgical treatment of hip fracture in older people.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (10 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013 Issue 8), MEDLINE (1946 to August Week 4 2013), EMBASE (1974 to 2013 Week 36), trial registers, conference proceedings, and reference lists of relevant articles. The search was run in September 2013.Selection criteria: Randomised controlled trials


of anabolic steroids given after hip fracture surgery, in inpatient or outpatient settings, to improve physical functioning in older patients with hip fracture.Data collection and analysis: Two review authors independently selected trials (based on predefined inclusion criteria), extracted data and assessed each study's risk of bias. A third review author moderated disagreements. Only very limited pooling of data was possible. The primary outcomes were function (for example, independence in mobility and activities of daily living) and adverse events, including mortality.Main results: We screened 1290 records and found only three trials involving 154 female participants, all of whom were aged above 65 years and had had hip fracture surgery. All studies had methodological shortcomings that placed them at high or unclear risk of bias. Because of this high risk of bias, imprecise results and likelihood of publication bias, we judged the quality of the evidence for all primary outcomes to be very low.These trials tested two comparisons. One trial had three groups and contributed data to both comparisons. None of the trials reported on patient acceptability of the intervention.Two very different trials compared anabolic steroid versus control (no anabolic steroid or placebo). One trial compared anabolic steroid injections (given weekly until discharge from hospital or four weeks, whichever came first) versus placebo injections in 29 "frail elderly females". This found very low quality evidence of little difference between the two groups in the numbers discharged to a higher level of care or dead (one person in the control group died) (8/15 versus 10/14; risk ratio (RR) 0.75, 95% confidence interval (CI) 0.42 to 1.33; P = 0.32), time to independent mobilisation or individual adverse events. The second trial compared anabolic steroid injections (every three weeks for six months) and daily protein supplementation versus daily protein supplementation alone in 40 "lean elderly women" who were followed up for one year after surgery. This trial provided very low quality evidence that anabolic steroid may result in less dependency, assessed in terms of being either dependent in at least two functions or dead (one person in the control group died) at six and 12 months, but the result was also compatible with no difference or an increase in dependency (dependent in at least two levels of function or dead at 12 months: 1/17 versus 5/19; RR 0.22, 95% CI 0.03 to 1.73; P = 0.15). The trial found no evidence of between-group differences in individual adverse events.Two trials compared anabolic steroids combined with another nutritional intervention ('steroid plus') versus control (no 'steroid plus'). One trial compared anabolic steroid injections every three weeks for 12 months in combination with daily supplement of vitamin D and calcium versus calcium only in 63 women who were living independently at home. The other trial compared anabolic steroid injection every three weeks for six months and daily protein supplementation versus control in 40 "lean elderly women". Both trials found some evidence of better function in the steroid plus group. One trial reported greater independence, higher Harris hip scores and gait speeds in the steroid plus group at 12 months. The second trial found fewer participants in the anabolic steroid group were either dependent in at least two functions, including bathing, or dead at six and 12 months (one person in the control group died) (1/17 versus 7/18; RR 0.15, 95% CI 0.02 to 1.10; P = 0.06). Pooled mortality data (2/51 versus 3/51) from the two trials showed no evidence of a difference between the two groups at one year. Similarly, there was no evidence of between-group differences in individual adverse events. Three participants in the steroid group of one trial reported side effects of hoarseness and increased facial hair. The other trial reported better quality of life in the steroid plus group.Authors' conclusions: The available evidence is insufficient to draw conclusions on the effects, primarily in terms of functional outcome and adverse events, of anabolic steroids, either separately or in combination with nutritional supplements, after surgical treatment of hip fracture in older people. Given that the available data points to the potential for more promising outcomes with a combined anabolic steroid and nutritional supplement intervention, we suggest that future research should focus on evaluating this combination.

Forster R,Stewart M. Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair. Cochrane Database of Systematic Reviews. 2016; 3. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004179.pub2/abstract


Background: The optimal duration of thromboprophylaxis after total hip or knee replacement, or hip fracture repair remains controversial. It is common practice to administer prophylaxis using low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) until discharge from hospital, usually seven to 14 days after surgery. International guidelines recommend extending thromboprophylaxis for up to 35 days following major orthopaedic surgery but the recommendation is weak due to moderate quality evidence. In addition, recent oral anticoagulants that exert effect by direct inhibition of thrombin or activated factor X lack the need for monitoring and have few known drug interactions. Interest in this topic remains high.Objectives: To assess the effects of extended-duration anticoagulant thromboprophylaxis for the prevention of venous thromboembolism (VTE) in people undergoing elective hip or knee replacement surgery, or hip fracture repair.Search methods: The Cochrane Vascular Information Specialist searched the Specialised Register (last searched May 2015) and CENTRAL (2015, Issue 4). Clinical trials databases were searched for ongoing or unpublished studies.Selection criteria: Randomised controlled trials assessing extended-duration thromboprophylaxis (five to seven weeks) using accepted prophylactic doses of LMWH, UFH, vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC) compared with short-duration thromboprophylaxis (seven to 14 days) followed by placebo, no treatment or similar extended-duration thromboprophylaxis with LMWH, UFH, VKA or DOACs in participants undergoing hip or knee replacement or hip fracture repair.Data collection and analysis: We independently selected trials and extracted data. Disagreements were resolved by discussion. We performed fixed-effect model meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs). We used a random-effects model when there was heterogeneity.Main results: We included 16 studies (24,930 participants); six compared heparin with placebo, one compared VKA with placebo, two compared DOAC with placebo, one compared VKA with heparin, five compared DOAC with heparin and one compared anticoagulants chosen at investigators' discretion with placebo. Three trials included participants undergoing knee replacement. No studies assessed hip fracture repair.Trials were generally of good methodological quality. The main reason for unclear risk of bias was insufficient reporting. The quality of evidence according to GRADE was generally moderate, as some comparisons included a single study, low number of events or heterogeneity between studies leading to wide CIs.We showed no difference between extended-duration heparin and placebo in symptomatic VTE (OR 0.59, 95% CI 0.35 to 1.01; 2329 participants; 5 studies; high quality evidence), symptomatic deep vein thrombosis (DVT) (OR 0.73, 95% CI 0.39 to 1.38; 2019 participants; 4 studies; moderate quality evidence), symptomatic pulmonary embolism (PE) (OR 0.61, 95% CI 0.16 to 2.33; 1595 participants; 3 studies; low quality evidence) and major bleeding (OR 0.59, 95% CI 0.14 to 2.46; 2500 participants; 5 studies; moderate quality evidence). Minor bleeding was increased in the heparin group (OR 2.01, 95% CI 1.43 to 2.81; 2500 participants; 5 studies; high quality evidence). Clinically relevant non-major bleeding was not reported.We showed no difference between extended-duration VKA and placebo (one study, 360 participants) for symptomatic VTE (OR 0.10, 95% CI 0.01 to 1.94; moderate quality evidence), symptomatic DVT (OR 0.13, 95% CI 0.01 to 2.62; moderate quality evidence), symptomatic PE (OR 0.32, 95% CI 0.01 to 7.84; moderate quality evidence) and major bleeding (OR 2.89, 95% CI 0.12 to 71.31; low quality evidence). Clinically relevant non-major bleeding and minor bleeding were not reported.Extended-duration DOAC showed reduced symptomatic VTE (OR 0.20, 95% CI 0.06 to 0.68; 2419 participants; 1 study; moderate quality evidence) and symptomatic DVT (OR 0.18, 95% CI 0.04 to 0.81; 2459 participants; 2 studies; high qual ty evidence) compared to placebo. No differences were found for symptomatic PE (OR 0.25, 95% CI 0.03 to 2.25; 1733 participants; 1 study; low quality evidence), major bleeding (OR 1.00, 95% CI 0.06 to 16.02; 2457 participants; 1 study; low quality evidence), clinically relevant non-major bleeding (OR 1.22, 95% CI 0.76 to 1.95; 2457 participants; 1 study; moderate quality evidence) and minor bleeding (OR 1.18, 95% CI 0.74 to 1.88; 2457 participants; 1 study; moderate quality evidence).We showed no difference between extended-duration anticoagulants chosen at investigators' discretion and placebo (one study, 557 participants, low quality evidence) for symptomatic VTE (OR 0.50, 95% CI 0.09 to 2.74), symptomatic DVT (OR 0.33, 95% CI 0.03 to 3.21), symptomatic PE (OR 1.00, 95% CI 0.06 to 16.13), and major bleeding (OR 5.05, 95% CI


0.24 to 105.76). Clinically relevant non-major bleeding and minor bleeding were not reported.We showed no difference between extended-duration VKA and heparin (one study, low quality evidence) for symptomatic VTE (OR 1.64, 95% CI 0.85 to 3.16; 1279 participants), symptomatic DVT (OR 1.36, 95% CI 0.69 to 2.68; 1279 participants), symptomatic PE (OR 9.16, 95% CI 0.49 to 170.42; 1279 participants), major bleeding (OR 3.87, 95% CI 1.91 to 7.85; 1272 participants) and minor bleeding (OR 1.33, 95% CI 0.64 to 2.76; 1279 participants). Clinically relevant non-major bleeding was not reported.We showed no difference between extended-duration DOAC and heparin for symptomatic VTE (OR 0.70, 95% CI 0.28 to 1.70; 15,977 participants; 5 studies; low quality evidence), symptomatic DVT (OR 0.60, 95% CI 0.11 to 3.27; 15,977 participants; 5 studies; low quality evidence), symptomatic PE (OR 0.91, 95% CI 0.43 to 1.94; 14,731 participants; 5 studies; moderate quality evidence), major bleeding (OR 1.11, 95% CI 0.79 to 1.54; 16,199 participants; 5 studies; high quality evidence), clinically relevant non-major bleeding (OR 1.08, 95% CI 0.90 to 1.28; 15,241 participants; 4 studies; high quality evidence) and minor bleeding (OR 0.95, 95% CI 0.82 to 1.10; 11,766 participants; 4 studies; high quality evidence).Authors' conclusions: Moderate quality evidence suggests extended-duration anticoagulants to prevent VTE should be considered for people undergoing hip replacement surgery, although the benefit should be weighed against the increased risk of minor bleeding. Further studies are needed to better understand the association between VTE and extended-duration oral anticoagulants in relation to knee replacement and hip fracture repair, as well as outcomes such as distal and proximal DVT, reoperation, wound infection and healing.

Gillespie William J,Walenkamp Geert HIM. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database of Systematic Reviews. 2010; 3. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000244.pub2/abstract

Background: Surgical site infection and other hospital-acquired infections cause significant morbidity after internal fixation of fractures. The administration of antibiotics may reduce the frequency of infections.Objectives: To determine whether the prophylactic administration of antibiotics in people undergoing surgical management of hip or other closed long bone fractures reduces the incidence of surgical site and other hospital-acquired infections.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to November 2009), EMBASE (1988 to December 2009), other electronic databases including the WHO International Clinical Trials Registry Platform (December 2009), conferences proceedings and reference lists of articles.Selection criteria: Randomised or quasi-randomised controlled trials comparing any regimen of systemic antibiotic prophylaxis administered at the time of surgery, compared with no prophylaxis, placebo, or a regimen of different duration, in people with a hip fracture undergoing surgery for internal fixation or prosthetic replacement, or with any closed long bone fracture undergoing internal fixation. All trials needed to report surgical site infection.Data collection and analysis: Two authors independently screened papers for inclusion, assessed risk of bias and extracted data. Pooled data are presented graphically.Main results: Data from 8447 participants in 23 studies were included in the analyses. In people undergoing surgery for closed fracture fixation, single dose antibiotic prophylaxis significantly reduced deep surgical site infection (risk ratio 0.40, 95% CI 0.24 to 0.67), superficial surgical site infections, urinary infections, and respiratory tract infections. Multiple dose prophylaxis had an effect of similar size on deep surgical site infection (risk ratio 0.35, 95% CI 0.19 to 0.62), but significant effects on urinary and respiratory infections were not confirmed. Although the risk of bias in many studies as reported was unclear, sensitivity analysis showed that removal from the meta-analyses of studies at high risk of bias did not alter the conclusions. Economic modelling using data from one large trial indicated that single dose prophylaxis with ceftriaxone is a cost-effective intervention. Data for the incidence of adverse effects were very limited, but as expected they appeared to be more common in those receiving


antibiotics, compared with placebo or no prophylaxis.Authors' conclusions: Antibiotic prophylaxis should be offered to those undergoing surgery for closed fracture fixation.

Guay J, Parker Martyn J, Gajendragadkar Pushpaj R,Kopp S. Anaesthesia for hip fracture surgery in adults. Cochrane Database of Systematic Reviews. 2016; 2. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000521.pub3/abstract

Background: The majority of people with hip fracture are treated surgically, requiring anaesthesia.Objectives: The main focus of this review is the comparison of regional versus general anaesthesia for hip (proximal femoral) fracture repair in adults. We did not consider supplementary regional blocks in this review as they have been studied in another review.Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2014, Issue 3), MEDLINE (Ovid SP, 2003 to March 2014) and EMBASE (Ovid SP, 2003 to March 2014).Selection criteria: We included randomized trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The main outcomes were mortality, pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, deep vein thrombosis and return of patient to their own home.Data collection and analysis: Two reviewers independently assessed trial quality and extracted data. We analysed data with fixed-effect (I2 < 25%) or random-effects models. We assessed the quality of the evidence according to the criteria developed by the GRADE working group.Main results: In total, we included 31 studies (with 3231 participants) in our review. Of those 31 studies, 28 (2976 participants) provided data for the meta-analyses. For the 28 studies, 24 were used for the comparison of neuraxial block versus general anaesthesia. Based on 11 studies that included 2152 participants, we did not find a difference between the two anaesthetic techniques for mortality at one month: risk ratio (RR) 0.78, 95% confidence interval (CI) 0.57 to 1.06; I2 = 24% (fixed-effect model). Based on six studies that included 761 participants, we did not find a difference in the risk of pneumonia: RR 0.77, 95% CI 0.45 to 1.31; I2 = 0%. Based on four studies that included 559 participants, we did not find a difference in the risk of myocardial infarction: RR 0.89, 95% CI 0.22 to 3.65; I2 = 0%. Based on six studies that included 729 participants, we did not find a difference in the risk of cerebrovascular accident: RR 1.48, 95% CI 0.46 to 4.83; I2 = 0%. Based on six studies that included 624 participants, we did not find a difference in the risk of acute confusional state: RR 0.85, 95% CI 0.51 to 1.40; I2 = 49%. Based on laboratory tests, the risk of deep vein thrombosis was decreased when no specific precautions or just early mobilization was used: RR 0.57, 95% CI 0.41 to 0.78; I2 = 0%; (number needed to treat for an additional beneficial outcome (NNTB) = 3, 95% CI 2 to 7, based on a basal risk of 76%) but not when low molecular weight heparin was administered: RR 0.98, 95% CI 0.52 to 1.84; I2 for heterogeneity between the two subgroups = 58%. For neuraxial blocks compared to general anaesthesia, we rated the quality of evidence as very low for mortality (at 0 to 30 days), pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, decreased rate of deep venous thrombosis in the absence of potent thromboprophylaxis, and return of patient to their own home. The number of studies comparing other anaesthetic techniques was limited.Authors' conclusions: We did not find a difference between the two techniques, except for deep venous thrombosis in the absence of potent thromboprophylaxis. The studies included a wide variety of clinical practices. The number of participants included in the review is insufficient to eliminate a difference between the two techniques in the majority of outcomes studied. Therefore, large randomized trials reflecting actual clinical practice are required before drawing final conclusions.


Handoll Helen HG, Cameron Ian D, Mak Jenson CS,Finnegan Terence P. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database of Systematic Reviews. 2009; 4. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007125.pub2/abstract

Background: Hip fracture is a major cause of morbidity and mortality in older people and its impact on society is substantial.Objectives: To examine the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older patients with hip fracture.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2009), The Cochrane Library (2009, Issue 2), MEDLINE and EMBASE (both to April 2009).Selection criteria: Randomised and quasi-randomised trials of post-surgical care using multidisciplinary rehabilitation of older patients (aged 65 years or over) with hip fracture. The primary outcome, 'poor outcome' was a composite of mortality and decline in residential status at long-term (generally one year) follow-up.Data collection and analysis: Trial selection was by consensus. Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.Main results: The 13 included trials involved 2498 older, usually female, patients who had undergone hip fracture surgery. Though generally well conducted, some trials were at risk of bias such as from imbalances in key baseline characteristics.There was substantial clinical heterogeneity in the trial interventions and populations. Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 11 trials. Pooled results showed no statistically significant difference between intervention and control groups for poor outcome (risk ratio 0.89; 95% confidence interval 0.78 to 1.01), mortality (risk ratio 0.90, 95% confidence interval 0.76 to 1.07) or hospital readmission. Individual trials found better results, often short-term only, in the intervention group for activities of daily living and mobility. There was considerable heterogeneity in length of stay and cost data. Three trials reporting carer burden showed no evidence of detrimental effect from the intervention. Overall, the evidence indicates that multidisciplinary rehabilitation is not harmful.The trial comparing primarily home-based multidisciplinary rehabilitation with usual inpatient care found marginally improved function and a clinically significantly lower burden for carers in the intervention group. Participants of this group had shorter hospital stays, but longer periods of rehabilitation. One trial found no significant effect from doubling the number of weekly contacts at the patient's home from a multidisciplinary rehabilitation team.Authors' conclusions: While there was a tendency to a better overall result in patients receiving multidisciplinary inpatient rehabilitation, these results were not statistically significant.Future trials of multidisciplinary rehabilitation should aim to establish both effectiveness and cost effectiveness of multidisciplinary rehabilitation overall, rather than evaluate its components.

Handoll Helen HG, Sherrington C,Mak Jenson CS. Interventions for improving mobility after hip fracture surgery in adults. Cochrane Database of Systematic Reviews. 2011; 3. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001704.pub4/abstract

Background: Hip fracture mainly occurs in older people. Strategies to improve mobility include gait retraining, various forms of exercise and muscle stimulation.Objectives: To evaluate the effects of different interventions for improving mobility after hip fracture surgery in adults.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE and other databases, and reference lists of articles, up to April 2010.Selection criteria: All randomised or quasi-randomised trials comparing different mobilisation strategies after hip fracture surgery.Data collection and analysis: The authors independently selected trials, assessed risk of bias and extracted data. There was no data pooling.Main results: The 19 included trials (involving 1589 older adults) were small, often with methodological flaws. Just two pairs of trials tested similar interventions.Twelve trials evaluated mobilisation strategies started soon after hip fracture surgery. Single trials found improved mobility from, respectively, a two-week weight-bearing programme, a quadriceps muscle strengthening exercise programme and electrical stimulation aimed at alleviating pain. Single trials found no significant improvement in mobility from, respectively, a treadmill


gait retraining programme, 12 weeks of resistance training, and 16 weeks of weight-bearing exercise. One trial testing ambulation started within 48 hours of surgery found contradictory results. One historic trial found no significant difference in unfavourable outcomes for weight bearing started at two versus 12 weeks. Of two trials evaluating more intensive physiotherapy regimens, one found no difference in recovery, the other reported a higher level of drop-out in the more intensive group. Two trials tested electrical stimulation of the quadriceps: one found no benefit and poor tolerance of the intervention; the other found improved mobility and good tolerance.Seven trials evaluated strategies started after hospital discharge. Started soon after discharge, two trials found improved outcome after 12 weeks of intensive physical training and a home-based physical therapy programme respectively. Begun after completion of standard physical therapy, one trial found improved outcome after six months of intensive physical training, one trial found increased activity levels from a one year exercise programme, and one trial found no significant effects of home-based resistance or aerobic training. One trial found improved outcome after home-based exercises started around 22 weeks from injury. One trial found home-based weight-bearing exercises starting at seven months produced no significant improvement in mobility.Authors' conclusions: There is insufficient evidence from randomised trials to establish the best strategies for enhancing mobility after hip fracture surgery.

Lewis Sharon R, Butler Andrew R, Brammar A, Nicholson A,Smith Andrew F. Perioperative fluid volume optimization following proximal femoral fracture. Cochrane Database of Systematic Reviews. 2016; 3. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003004.pub4/abstract

Background: Proximal femoral fracture (PFF) is a common orthopaedic emergency that affects mainly elderly people at high risk of complications. Advanced methods for managing fluid therapy during treatment for PFF are available, but their role in reducing risk is unclear.Objectives: To compare the safety and effectiveness of the following methods of perioperative fluid optimization in adult participants undergoing surgical repair of hip fracture: advanced invasive haemodynamic monitoring, such as transoesophageal Doppler and pulse contour analysis; a protocol using standard measures, such as blood pressure, urine output and central venous pressure; and usual care.Comparisons of fluid types (e.g. crystalloid vs colloid) and other methods of optimizing oxygen delivery, such as blood product therapies and pharmacological treatment with inotropes and vasoactive drugs, are considered in other reviews.Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 9); MEDLINE (October 2012 to September 2015); and EMBASE (October 2012 to September 2015) without language restrictions. We ran forward and backward citation searches on identified trials. We searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform for unpublished trials. This is an updated version of a review published originally in 2004 and updated first in 2013 and again in 2015. Original searches were performed in October 2003 and October 2012.Selection criteria: We included randomized controlled trials (RCTs) in adult participants undergoing surgical treatment for PFF that compared any two of advanced haemodynamic monitoring, protocols using standard measures or usual care, irrespective of blinding, language or publication status.Data collection and analysis: Two review authors assessed the impact of fluid optimization interventions on outcomes of mortality, length of hospital stay, time to medical fitness, whether participants were able to return to pre-fracture accommodation at six months, participant mobility at six months and adverse events in-hospital. We pooled data using risk ratio (RR) or mean difference (MD) for dichotomous or continuous data, respectively, on the basis of random-effects models.Main results: We included in this updated review five RCTs with a total of 403 participants, and we added two new trials identified during the 2015 search. One of the included studies was found to have a high risk of bias; no trial featured all pre-specified outcomes. We found two trials for which data are awaited for classification and one ongoing trial.Three studies compared advanced haemodynamic


monitoring with a protocol using standard measures; three compared advanced haemodynamic monitoring with usual care; and one compared a protocol using standard measures with usual care. Meta-analyses for the two advanced haemodynamic monitoring comparisons are consistent with both increased and decreased risk of mortality (RR Mantel-Haenszel (M-H) random-effects 0.41, 95% confidence interval (CI) 0.14 to 1.20; 280 participants; RR M-H random-effects 0.45, 95% CI 0.07 to 2.95; 213 participants, respectively). The study comparing a protocol with usual care found no difference between groups for this outcome.Three studies comparing advanced haemodynamic monitoring with usual care reported data for length of stay and time to medical fitness. There was no statistically significant difference between groups for these outcomes in the two studies that we were able to combine (MD IV fixed 0.63, 95% CI -1.70 to 2.96); MD IV fixed 0.01, 95% CI -1.74 to 1.71, respectively) and no statistically significant difference in the third study. One study reported reduced time to medical fitness when comparing advanced haemodynamic monitoring with a protocol, and when comparing protocol monitoring with usual care.The number of participants with one or more complications showed no statistically significant differences in each of the two advanced haemodynamic monitoring comparisons (RR M-H rando -effects 0.83, 95% CI 0.59 to 1.17; 280 participants; RR M-H random-effects 0.72, 95% CI 0.40 to 1.31; 173 participants, respectively), nor any differences in the protocol and usual care comparison.Only one study reported the number of participants able to return to normal accommodation after discharge with no statistically significant difference between groups.There were few studies with a small number of participants, and by using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach, we judged the quality of the outcome evidence as low. We had included one study with a high risk of bias, but upon applying GRADE, we downgraded the quality of this outcome evidence to very low.Authors' conclusions: Five studies including a total of 403 participants provided no evidence that fluid optimization strategies improve outcomes for participants undergoing surgery for PFF. Further research powered to test some of these outcomes is ongoing.

Parker Martyn J, Griffiths R,Appadu B. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database of Systematic Reviews. 2002; 1. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001159/abstract

Background: Various nerve blocks using local anaesthetic agents have been used in order to reduce pain after hip fracture, and subsequent surgery.Objectives: To determine the effects of nerve blocks (inserted either pre-operatively, operatively or post-operatively) that may be used to relieve pain after a hip fracture.Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 2), MEDLINE (1966 to May Week 2 2008), EMBASE (1988 to 2008 Week 21), CINAHL (1982 to May Week 4 2008) and reference lists of relevant articles.Selection criteria: Randomised and quasi-randomised trials involving the use of nerve blocks as part of the care of a hip fracture patient.Data collection and analysis: Two review authors independently assessed trials for inclusion, trial quality by use of a nine item scale and extracted data. Wherever appropriate, results of outcome measures were pooled.Main results: Seventeen randomised or quasi-randomised trials involving 888, mainly elderly and female, participants were included. Nine trials related to insertion of a nerve block pre-operatively and eight to peri-operative insertion.Nerve blocks resulted in statistically significant reductions in reported pain levels and in the quantity of parenteral or oral analgesia administered to control pain from the fracture or during surgery. There were few reported complications, none major, associated with nerve blocks. The limited data for other outcomes, such as medical complications and mortality, showed a general lack of differences between nerve block and control group participants. There were no notable adverse reactions or complications from the nerve blocks.Authors' conclusions: Because of the small number of participants included in this review,


limitations in the measurement and reporting of outcomes and the differing types of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant clinical benefit when compared with other analgesic methods as part of the treatment of a hip fracture. They do, however, reduce the degree of pain experienced by the patient from the hip fracture and subsequent surgery. Further randomised trials with larger numbers of participants and full reporting of clinical outcomes would be justified.

Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, et al. Hospital at home early discharge. Cochrane Database of Systematic Reviews. 2009; 1. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000356.pub3/abstract

Background: 'Early discharge hospital at home' is a service that provides active treatment by health care professionals in the patient's home for a condition that otherwise would require acute hospital in-patient care. If hospital at home were not available then the patient would remain in an acute hospital ward.Objectives: To determine, in the context of a systematic review and meta-analysis, the effectiveness and cost of managing patients with early discharge hospital at home compared with in-patient hospital care.Search methods: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register , MEDLINE (1950 to 2008), EMBASE (1980 to 2008), CINAHL (1982 to 2008) and EconLit through to January 2008. We checked the reference lists of articles identified for potentially relevant articles.Selection criteria: Randomised controlled trials recruiting patients aged 18 years and over. Studies comparing early discharge hospital at home with acute hospital in-patient care. Evaluations of obstetric, paediatric and mental health hospital at home schemes are excluded from this review. Data collection and analysis: Two authors independently extracted data and assessed study quality. Our statistical analyses were done on an intention-to-treat basis. We requested individual patient data (IPD) from trialists, and relied on published data when we did not receive trial data sets or the IPD did not include the relevant outcomes. For the IPD meta-analysis, where at least one event was reported in both study groups in a trial, Cox regression models were used to calculate the log hazard ratio and its standard error for mortality and readmission separately for each data set. The calculated log hazard ratios were combined using fixed-effect inverse variance meta-analysis.Main results: Twenty-six trials were included in this review [n = 3967]; 21 were eligible for the IPD meta-analysis and 13 of the 21 trials contributed data [1899/2872; 66%]. For patients recovering from a stroke and elderly patients with a mix of conditions there was insufficient evidence of a difference in mortality between groups (adjusted HR 0.79, 95% CI 0.32 to 1.91; N = 494; and adjusted HR 1.06, 95% CI 0.69 to 1.61; N = 978). Readmission rates were significantly increased for elderly patients with a mix of conditions allocated to hospital at home (adjusted HR 1.57; 95% CI 1.10 to 2.24; N = 705). For patients recovering from a stroke and elderly patients with a mix of conditions respectively, significantly fewer people allocated to hospital at home were in residential care at follow-up (RR 0.63; 95% CI 0.40 to 0.98; N = 4 trials; RR 0.69, 95% CI 0.48 to 0.99; N =3 trials). Patients reported increased satisfaction with early discharge hospital at home. There was insufficient evidence of a difference for readmission between groups in trials recruiting patients recovering from surgery. Evidence on cost savings was mixed.Authors' conclusions: Despite increasing interest in the potential of early discharge hospital at home services as a cheaper alternative to in-patient care, this review provides insufficient objective evidence of economic benefit or improved health outcomes.

Smith Toby O, Hameed Yasir A, Cross Jane L, Henderson C, Sahota O,Fox C. Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery. Cochrane Database of Systematic Reviews. 2015; 6. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010569.pub2/abstract


Background: Hip fracture is a major fall-related injury which causes significant problems for individuals, their family and carers. Over 40% of people with hip fracture have dementia or cognitive impairment, and their outcomes after surgery are poorer than those without dementia. It is not clear which care and rehabilitation interventions achieve the best outcomes for these people.Objectives: (a) To assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared to usual care.(b) To assess the effectiveness for people with dementia of models of care including enhanced rehabilitation strategies which are designed for all older people, regardless of cognitive status, following hip fracture surgery compared to usual care.Search methods: We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register, up to and including week 1 June 2014 using the terms hip OR fracture OR surgery OR operation OR femur OR femoral.Selection criteria: We include randomised and quasi-randomised controlled clinical trials (RCTs) evaluating the effectiveness for people with dementia of any model of enhanced care and rehabilitation following hip fracture surgery compared to usual care.Data collection and analysis: Two review authors working independently selected studies for inclusion and extracted data. We assessed the risk of bias of included studies. We synthesised data only if we considered studies sufficiently homogeneous in terms of participants, interventions and outcomes. We used the GRADE approach to rate the overall quality of evidence for each outcome.Main results: We included five trials with a total of 316 participants. Four trials evaluated models of enhanced interdisciplinary rehabilitation and care, two of these for inpatients only and two for inpatients and at home after discharge. All were compared with usual rehabilitation and care in the trial settings. The fifth trial compared outcomes of geriatrician-led care in hospital to conventional care led by the orthopaedic team. All papers analysed subgroups of people with dementia/cognitive impairment from larger RCTs of older people following hip fracture. Trial follow-up periods ranged from acute hospital discharge to 24 months post-discharge.We considered all of the studies to be at high risk of bias in more than one domain. As subgroups of larger studies, the analyses lacked power to detect differences between the intervention groups. Further, there were some important differences in the baseline characteristics of the participants in experimental and control groups. Using the GRADE approach, we downgraded the quality of the evidence for all outcomes to 'low' or 'very low'.No study assessed our primary outcome (cognitive function) nor other important dementia-related outcomes including behaviour and quality of life. The effect estimates for most comparisons were very imprecise, so it was not possible to draw firm conclusions from the data. There was low-quality evidence that enhanced care and rehabilitation in hospital led to lower rates of some complications and that enhanced care provided across hospital and home settings reduced the chance of being in institutional care at three months post-discharge (Odds Ratio (OR) 0.46, 95% confidence interval (CI) 0.22 to 0.95, 2 trials, n = 184), but this effect was more uncertain at 12 months (OR 0.90, 95% CI 0.40 to 2.03, 2 trials, n = 177). The effect of enhanced care and rehabilitation in hospital and at home on functional outcomes was very uncertain because the quality of evidence was very low from one small trial. Results on functional outcomes from other trials were inconclusive. The effect of geriatrician-led compared to orthopaedic-led management on the cumulative incidence of delirium was very uncertain (OR 0.73, 95% CI 0.22 to 2.38, 1 trial, n = 126, very low-quality evidence).Authors' conclusions: There is currently insufficient evidence to draw conclusion about how effective the models of enhanced rehabilitation and care after hip fracture used in these trials are for people with dementia above active usual care. The current evidence base derives from a small number of studies with quality limitations. This should be addressed as a research priority to determine the optimal strategies to improve outcomes for this growing population of patients.

Ward D, Drahota A, Gal D, Severs M,Dean Taraneh P. Care home versus hospital and own home environments for rehabilitation of older people. Cochrane Database of Systematic Reviews. 2008; 4. [cited: url: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003164.pub2/abstract


Background: Rehabilitation for older people has acquired an increasingly important profile for both policy-makers and service providers within health and social care agencies. This has generated an increased interest in the use of alternative care environments including care home environments. Yet, there appears to be limited evidence on which to base decisions.This review is the first update of the Cochrane review which was published in 2003.Objectives: To compare the effects of care home environments (e.g. nursing home, residential care home and nursing facilities) versus hospital environments and own home environments in the rehabilitation of older people.Search methods: We searched the Cochrane Effective Practice and Organisation of Care Specialised Register and Pending Folder, MEDLINE (1950 to March Week 3 2007), EMBASE (1980 to 2007 Week 13), CINAHL (1982 to March, Week 4, 2007), other databases and reference lists of relevant review articles were additionally reviewed. Date of most recent search: March 2007.Selection criteria: Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) that compared rehabilitation outcomes for persons 60 years or older who received rehabilitation whilst residing in a care home with those who received rehabilitation in hospital or own home environments.Data collection and analysis: Two review authors independently assessed trial quality and extracted data.Main results: In this update, 8365 references were retrieved. Of these, 339 abstracts were independently assessed by 2 review authors, and 56 studies and 5 review articles were subsequently obtained. Full text papers were independently assessed by two or three review authors and none of these met inclusion criteria.Authors' conclusions: There is insufficient evidence to compare the effects of care home environments versus hospital environments or own home environments on older persons rehabilitation outcomes. Although the authors acknowledge that absence of effect is not no effect. There are three main reasons; the first is that the description and specification of the environment is often not clear; secondly, the components of the rehabilitation system within the given environments are not adequately specified and; thirdly, when the components are clearly specified they demonstrate that the control and intervention sites are not comparable with respect to the methodological criteria specified by Cochrane EPOC group. The combined effect of these factors resulted in the comparability between intervention and control groups being very weak.

Other Systematic reviews

1 Abou-Setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP, Sadowski CA, et al. Comparative effectiveness of pain management interventions for hip fracture: a systematic review (Structured abstract). Annals of Internal Medicine 2011; 155: 234-45.

2 Ali AM, Gibbons CE. Predictors of 30-day hospital readmission after hip fracture: a systematic review. Injury 2017;48(2):243-52.

3 Auais MA, Eilayyan O, Mayo NE. Extended exercise rehabilitation after hip fracture improves patients' physical function: a systematic review and meta-analysis (Provisional abstract). Physical Therapy 2012; 92: 1437-51.

4 Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials (Structured abstract). Bmj 2010; 340:c1718:

5 Diong J, Allen N, Sherrington C. Structured exercise improves mobility after hip fracture: a meta-analysis with meta-regression. British Journal of Sports Medicine 2016;50(6):346-55.

6 Doleman B, Moppett IK. Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and meta-regression. Injury 2015;46(6):954-62.


7 Donohue K, Hoevenaars R, McEachern J, Zeman E, Mehta S. Home-based multidisciplinary rehabilitation following hip fracture surgery: what is the evidence? (Provisional abstract). Rehabilitation Research and Practice 2013; 875968.

8 Fox MT, Persaud M, Maimets I, Brooks D, O'Brien K, Tregunno D. Effectiveness of early discharge planning in acutely ill or injured hospitalized older adults: a systematic review and meta-analysis (Structured abstract). BMC Geriatrics 2013; 13: 70.

9 Gandhi RR, Overton TL, Haut ER, Lau B, Vallier HA, Rohs T, et al. Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma. The Journal of Trauma and Acute Care Surgery 2014;77(5):787-95.

10 Gregg EW, Pereira MA, Caspersen CJ. Physical activity, falls, and fractures among older adults: a review of the epidemiologic evidence (Structured abstract). Journal of the American Geriatrics Society 2000; 48: 883-93.

11 Halbert J, Crotty M, Whitehead C, Cameron I, Kurrle S, Graham S, et al. Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: a systematic review (Structured abstract). Journal of Rehabilitation Medicine 2007; 39: 507-12.

12 Hartmann FV, Novaes MR, de Carvalho MR. Femoral nerve block versus intravenous fentanyl in adult patients with hip fractures - a systematic review. Brazilian Journal of Anesthesiology 2017;67(1):67-71.

13 Hawley S, Javaid MK, Prieto-Alhambra D, Lippett J, Sheard S, Arden NK, et al. Clinical effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study. Age & Ageing 2016;45(2):236-42.

14 Katsoulis M, Benetou V, Karapetyan T, Feskanich D, Grodstein F, Pettersson-Kymmer U, et al. Excess mortality after hip fracture in elderly persons from Europe and the USA: the CHANCES project. Journal of Internal Medicine 2017;281(3):300-10.

15 Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients (Structured abstract). Injury 2009; 40: 692-7.

16 Kuske S, Moschinski K, Andrich S, Stephan A, Gnass I, Sirsch E, et al. Drug-based pain management in people with dementia after hip or pelvic fractures: a systematic review protocol. Systematic Reviews 2016;5(1):113.

17 Leigheb F, Vanhaecht K, Sermeus W, Lodewijckx C, Deneckere S, Boonen S, et al. The effect of care pathways for hip fractures: a systematic review (Structured abstract). Calcified Tissue International 2012; 91: 1-14.

18 Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatrics 2016;16(1):157.

19 McFarlane RA, Isbel ST, Jamieson MI. Factors determining eligibility and access to subacute rehabilitation for elderly people with dementia and hip fracture. Dementia 2015;19:19.

20 Mehta SP, Roy JS. Systematic review of home physiotherapy after hip fracture surgery (Provisional abstract). Journal of Rehabilitation Medicine 2011; 43: 477-80.


21 Moja L, Piatti A, Pecoraro V, Ricci C, Virgili G, Salanti G, et al. Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes - a meta-analysis and meta-regression of over 190,000 patients (Structured abstract). Plos One 2012; 7:

22 Muir SW, Yohannes AM. The impact of cognitive impairment on rehabilitation outcomes in elderly patients admitted with a femoral neck fracture: a systematic review (Structured abstract). Journal of Geriatric Physical Therapy 2009; 32: 24-32.

23 Nazrun AS, Tzar MN, Mokhtar SA, Mohamed IN. A systematic review of the outcomes of osteoporotic fracture patients after hospital discharge: morbidity, subsequent fractures, and mortality. Therapeutics & Clinical Risk Management 2014;10:937-48.

24 Neuman MD, Archan S, Karlawish JH, Schwartz JS, Fleisher LA. The relationship between short-term mortality and quality of care for hip fracture: a meta-analysis of clinical pathways for hip fracture (Structured abstract). Journal of the American Geriatrics Society 2009; 57: 2046-54.

25 Peeters CM, Visser E, Van de Ree CL, Gosens T, Den Oudsten BL, De Vries J. Quality of life after hip fracture in the elderly: A systematic literature review. Injury 2016;47(7):1369-82.

26 Potter LJ, Doleman B, Moppett IK. A systematic review of pre-operative anaemia and blood transfusion in patients with fractured hips. Anaesthesia 2015;70(4):483-500.

27 Rasmussen B, Uhrenfeldt L. Establishing well-being after hip fracture: a systematic review and meta-synthesis. Disability & Rehabilitation 2016;38(26):2515-29.

28 Resnick B, Beaupre L, McGilton KS, Galik E, Liu W, Neuman MD, et al. Rehabilitation Interventions for Older Individuals With Cognitive Impairment Post-Hip Fracture: A Systematic Review. Journal of the American Medical Directors Association 2016;17(3):200-5.

29 Riddell M, Ospina M, Holroyd-Leduc JM. Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review. CJEM Canadian Journal of Emergency Medical Care 2016;18(4):245-52.

30 Ritcey B, Pageau P, Woo MY, Perry JJ. Regional Nerve Blocks For Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM Canadian Journal of Emergency Medical Care 2016;18(1):37-47.

31 Saletti-Cuesta L, Tutton E, Langstaff D, Willett K. Understanding informal carers' experiences of caring for older people with a hip fracture: a systematic review of qualitative studies. Disability & Rehabilitation 2016:1-11.

32 Swart E, Vasudeva E, Makhni EC, Macaulay W, Bozic KJ. Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis. Clinical Orthopaedics & Related Research 2016;474(1):222-33.

33 Swart E, Vasudeva E, Makhni EC, Macaulay W, Bozic KJ. Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis. Clinical Orthopaedics & Related Research 2016;474(1):222-33.

34 Toussant EM, Kohia M. A critical review of literature regarding the effectiveness of physical therapy management of hip fracture in elderly persons (Structured abstract). Journals of Gerontology Series A - Biological Sciences and Medical Sciences 2005; 60: 1285-91.


35 van Wyk PM, Chu CH, Babineau J, Puts M, Brooks D, Saragosa M, et al. Community-based rehabilitation post hospital discharge interventions for older adults with cognitive impairment following a hip fracture: a systematic review protocol. JMIR Research Protocols 2014;3(3):e47.

36 Wang H, Li C, Zhang Y, Jia Y, Zhu Y, Sun R, et al. The influence of inpatient comprehensive geriatric care on elderly patients with hip fractures: a meta-analysis of randomized controlled trials. International journal of clinical and experimental medicine 2015;8(11):19815-30.

37 Xu JT, Wang XJ. Meta-analysis of studies on mortality of early surgery vs delayed surgery for patients with femoral neck fractures (Provisional abstract). China Journal of Orthopaedics and Traumatology 2011; 24: 500-3.

38 Zuo D, Jin C, Shan M, Zhou L, Li Y. A comparison of general versus regional anesthesia for hip fracture surgery: a meta-analysis. International journal of clinical and experimental medicine 2015;8(11):20295-301.

Medline search for RCTs

3452