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Cochrane Database of Systematic Reviews Review - Intervention

Multidisciplinary rehabilitation for older people with hip fractures

Authors' declarations of interest

Version published: 12 November 2021 Version history

https://doi.org/10.1002/14651858.CD007125.pub3
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Background

Hip fracture is a major cause of morbidity and mortality in older people, and its impact on society is substantial. After surgery, people require rehabilitation to help them recover. Multidisciplinary rehabilitation is where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. This is an update of a Cochrane Review first published in 2009.

Objectives

To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE and Embase (October 2020), and two trials registers (November 2019).

Selection criteria

We included randomised and quasi‐randomised trials of post‐surgical care using multidisciplinary rehabilitation of older people (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. The other 'critical' outcomes were health‐related quality of life, mortality, dependency in activities of daily living, mobility, and related pain.

Data collection and analysis

Pairs of review authors independently performed study selection, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome.

Main results

The 28 included trials involved 5351 older (mean ages ranged from 76.5 to 87 years), usually female, participants who had undergone hip fracture surgery. There was substantial clinical heterogeneity in the trial interventions and populations. Most trials had unclear or high risk of bias for one or more items, such as blinding‐related performance and detection biases. We summarise the findings for three comparisons below.

Inpatient rehabilitation: multidisciplinary rehabilitation versus 'usual care'
Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 20 trials.

Multidisciplinary rehabilitation probably results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow‐up (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; 13 studies, 3036 participants; moderate‐certainty evidence). Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months, this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 patients (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of multidisciplinary rehabilitation intervention showed no evidence of subgroup differences.

Multidisciplinary rehabilitation may result in fewer deaths in hospital but the confidence interval does not exclude a small increase in the number of deaths (RR 0.77, 95% CI 0.58 to 1.04; 11 studies, 2455 participants; low‐certainty evidence). A similar finding applies at 4 to 12 months' follow‐up (RR 0.91, 95% CI 0.80 to 1.05; 18 studies, 3973 participants; low‐certainty evidence). Multidisciplinary rehabilitation may result in fewer people with poorer mobility at 6 to 12 months' follow‐up (RR 0.83, 95% CI 0.71 to 0.98; 5 studies, 1085 participants; low‐certainty evidence).

Due to very low‐certainty evidence, we have little confidence in the findings for marginally better quality of life after multidisciplinary rehabilitation (1 study). The same applies to the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living at 1 to 4 months' follow‐up (measured in various ways by 11 studies), or at 6 to 12 months' follow‐up (13 studies). Long‐term hip‐related pain was not reported.

Ambulatory setting: supported discharge and multidisciplinary home rehabilitation versus 'usual care'

Three trials tested this comparison in 377 people mainly living at home. Due to very low‐certainty evidence, we have very little confidence in the findings of little to no between‐group difference in poor outcome (death or move to a higher level of care or inability to walk) at one year (3 studies); quality of life at one year (1 study); in mortality at 4 or 12 months (2 studies); in independence in personal activities of daily living (1 study); in moving permanently to a higher level of care (2 studies) or being unable to walk (2 studies). Long‐term hip‐related pain was not reported.

One trial tested this comparison in 240 nursing home residents. There is low‐certainty evidence that there may be no or minimal between‐group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or 12 months. Due to very low‐certainty evidence, we have very little confidence in the findings of no between‐group differences in dependency at 4 weeks or at 12 months, or in quality of life, inability to walk or pain at 12 months.

Authors' conclusions

In a hospital inpatient setting, there is moderate‐certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low‐certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low‐certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes, for which the evidence is of very low certainty.

The generally very low‐certainty evidence available for supported discharge and multidisciplinary home rehabilitation means that we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true.

Given the prevalent clinical emphasis on early discharge, we suggest that research is best orientated towards early supported discharge and identifying the components of multidisciplinary inpatient rehabilitation to optimise patient recovery within hospital and the components of multidisciplinary rehabilitation, including social care, subsequent to hospital discharge.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Are mixed‐speciality (multidisciplinary) teams the best way to help older people recover from hip fracture?

Key messages

‐ Compared with usual care, care provided by a team of healthcare professionals with different specialities (multidisciplinary rehabilitation teams) led by a geriatrician or other medical specialist may help more older people in hospital to recover after a hip fracture.

‐ We don’t know if multidisciplinary rehabilitation is better than usual care after hospital discharge because there is insufficient evidence.

‐ Future research should aim to identify the best treatments provided by the mix of specialties that make up multidisciplinary teams, so people can leave hospital early and be supported in the community.

How are hip fractures treated?

Hip fractures are common but serious injuries in older people. About a third of people with hip fractures die within a year of their injury. People with hip fractures may also have other conditions that slow their recovery. Many do not regain the mobility and independence they had before the fracture, and may need residential care in a nursing home afterwards.

Usual care for people with hip fracture is surgery, followed by therapy on the hospital ward to restore mobility and basic functions of daily living, such as bathing and dressing. This may involve people from other departments in the hospital. However, people with hip fractures need help with a range of activities, and may suffer mental as well as physical problems after surgery. So, a better approach to help their recovery, or ‘rehabilitation’, may be to involve a team of people with expertise from different areas, or ‘disciplines’. They develop a rehabilitation plan for each person, depending on their needs. This ‘multidisciplinary rehabilitation’ team, which is typically led by a doctor specialising in the care of older people or other medical specialist in rehabilitation, could also include other doctors, nurses, physiotherapists, dieticians, social workers and mental health specialists. Multidisciplinary rehabilitation could take place in hospital, in acute (short‐stay treatment) or rehabilitation wards, or in a person's home residence. Some types of multidisciplinary rehabilitation involve early discharge from hospital with support at home.

What did we want to find out?

We wanted to know if multidisciplinary rehabilitation helps people recover better from hip fracture than usual care. We were particularly interested in how many people had a ‘poor outcome’ at up to a year after surgery; that is, whether they died or were more dependent such that they needed to be cared for in a nursing home. We also looked at:

‐ health‐related quality of life;
‐ deaths;
‐ need for help with daily activities;
‐ mobility; and
‐ pain.

What did we do?

We searched for studies that compared multidisciplinary rehabilitation with usual care in older people after hip fracture surgery.

We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We found 28 studies with 5351 older people who’d had hip fracture surgery. They were aged on average from 76.5 to 87 years and most were women.

Main results

Multidisciplinary rehabilitation after surgery compared with usual care in hospital (20 studies):

‐ probably results in fewer cases of 'poor outcome' at 6 to 12 months than usual care. Of 1000 people with hip fracture who received usual care, 347 would have a ‘poor outcome’ between 6 and 12 months after surgery; 41 fewer people (12% of 347) would have a ‘poor outcome’ with multidisciplinary rehabilitation;

‐ may reduce the risk of death in hospital, and in the longer term for up to 1 year.

‐ may result in fewer people with poorer mobility at 6 to 12 months.

We don’t know if multidisciplinary rehabilitation improves or worsens quality of life and activities of daily living. There was no evidence on long‐term, hip‐related pain.

Multidisciplinary rehabilitation after surgery compared with usual care at home (3 studies):

We don’t know if multidisciplinary rehabilitation makes any difference to:

‐ a ‘poor outcome’ at 1 year;

‐ quality of life at 1 year;

‐ deaths at 4 or 12 months;

‐ whether people need help with daily living activities;

‐ moving into a nursing home; or

‐ mobility.

There was no evidence on long‐term, hip‐related pain.

Multidisciplinary rehabilitation after surgery compared with usual care for nursing home residents (1 study) may make no difference to:

‐ a 'poor outcome' (died or unable to walk) at 12 months; or

‐ deaths at 4 or 12 months.

We don’t know if multidisciplinary rehabilitation makes a difference to:

‐ whether people need help with daily living activities at 4 weeks or 12 months;

‐ quality of life, mobility or pain at 12 months.

What are the limitations of the evidence?

We are moderately confident in the evidence about ‘poor outcome’ for people in hospital but much less confident in all the other evidence because less was available and all the studies had weaknesses that could affect the reliability of their results. 

How up to date is this evidence?

The evidence is up to date to October 2020.

Authors' conclusions

Implications for practice

In a hospital inpatient setting, there is moderate‐certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician, results in fewer cases of 'poor outcome' (death or deterioration in residential status). There is low‐certainty evidence that multidisciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low‐certainty evidence that multidisciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. No conclusions can be drawn on other outcomes for which the evidence is of very low certainty.

The generally very low‐certainty evidence available for supported discharge and multidisciplinary home rehabilitation means we are very uncertain whether the findings of little or no difference for all outcomes between the intervention and usual care is true.

Implications for research

Future research evaluating the effectiveness of specialised inpatient rehabilitation needs to pay attention to several factors. A modest effect size, such as a 10% reduction in 'poor outcome', would be an important result for this population. To obtain definitive evidence for such a reduction, larger trials are needed. Measures of outcome should be standardised (particularly with regard to functional status) and assessed by a blinded observer. Trials should include careful monitoring of direct and indirect costs, as well as assessing cost‐effectiveness and carer burden. Components of the interventions used in trials, and details of the treatment provided to the control group, should be carefully specified. Some account should be taken of other strategies for rehabilitation, including those of early discharge and a greater emphasis on community‐based rehabilitation.

Participant characteristics, including cognitive status, should be clearly presented, and if subgroup analyses are considered, these should be a priori, sufficiently powered, and an analysis of the outcome of participants with or without evident dementia considered. Although this basic dichotomy would be instructive, further categorisation by participant characteristics would be valuable, as within the hip fracture population, there are very different groups of older people, ranging from independent older people to older people with severe frailty and cognitive impairment. Achieving an international consensus on a suitable classification, such as based on pre‐fracture dependence in personal activities of daily living or extent of frailty, that could be used in future studies would be likely to reduce the heterogeneity in study outcomes.

As the effectiveness of multidisciplinary rehabilitation overall has now been established, evaluation of its components should occur, with an emphasis on optimising cost‐effectiveness. New service models for rehabilitating people with hip fracture should be rigorously evaluated before they are implemented and become established.

As well as trial registration and making the trial protocol publicly available, it is important that trial reports conform to the requirements of the nonpharmacologic CONSORT statement (Boutron 2017). Complying with this version of CONSORT should mean that adequate descriptions of the interventions under test will be available.

For the sake of continuity, we have retained the protocol scope and title of this Cochrane Review with its emphasis on 'rehabilitation'. However, when assessing the scope of the next update for this topic area, consideration should be given to whether the scope needs refining to fit with the broader concept of 'multidisciplinary management of hip fracture'. This would be consistent with recommendations and terminology in other publications (Cameron 2000; Ranhoff 2019; Riemen 2016; Swift 2016).

Summary of findings

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Summary of findings 1. Multidisciplinary inpatient rehabilitation versus usual care

Multidisciplinary inpatient rehabilitation compared with usual care for older people with hip fracture

Patient or population: older people undergoing rehabilitation soon after surgically treated hip fracture

Settings: inpatient care – thus, before hospital discharge. Rehabilitation extended to care in the community in some trials

Intervention: multidisciplinary inpatient rehabilitation

Comparison: usual care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care

Intervention

'Poor outcome' (dead or deterioration in residential status, generally requiring institutional care)

Follow‐up: 6 to 12 months

347 per 1000a

306 per 1000
(278 to 340)

RR 0.88

(0.80 to 0.98)

3036 participants
(13 studies)

⊕⊕⊕⊝
Moderateb

Overall, 969 participants (31.9%) had a 'poor outcome'.

Quality of life: EQ‐5D (0: dead to 1: best quality)c

Follow‐up: 4 months

The mean EQ‐5D score in the usual care group was0.46

The mean EQ‐5D score was 0.08 higher in the intervention group
(0.03 to 0.1 higher)

‐

347 participants
(1 study)d

⊕⊝⊝⊝
Very lowe

The trial found a similar though slightly reduced difference at 12 months (MD 0.07, 95% CI 0.02 to 0.12; 337 participants).

The CIs of both results included the MCID of 0.08

Mortality (at discharge)

Follow‐up: up to hospital discharge

75 per 1000a

58 per 1000
(44 to 78)

RR 0.77

(0.58 to 1.04)

2455 participants
(11 studies)

⊕⊝⊝⊝
Lowf

There were 168 deaths (6.8%) in total

Mortality (end of scheduled follow‐up)

Follow‐up: 4 to 12 months

182 per 1000a

166 per 1000
(146 to 192)

RR 0.91

(0.80 to 1.05)

3973 participants
(18 studies)

⊕⊕⊝⊝
Lowf

There were 682 deaths (17.2%) in total

Greater dependence in personal activities of daily livingg
Follow‐up: 1 to 4 months

558 per 1000a

486 per 1000
(424 to 553)

RR 0.87, (0.76 to 0.99)

754 participants (4 studies)

⊕⊝⊝⊝
Very lowh

Evidence from 7 other studies:

  • Three studies providing data for the Barthel Index (in two, a Chinese version was used) found higher (better) ADL scores in the intervention group. However, the clinical importance of the results is uncertain and the difference may only be slight.

  • Four other studies, which provided incomplete or no data, reported no evidence of between‐group differences in ADL.

Greater dependence in personal activities of daily livingg
Follow‐up: 6 to 12 months

723 per 1000a

See Comment

463 per 1000
(368 to 587)

RR 0.64 (0.51 to 0.81)

238 participants
(2 studies)

⊕⊝⊝⊝
Very lowh

Evidence from 11 other studies:

  • The RRs from two other studies reporting related outcomes (incomplete recovery of ADL and mobility; non‐recovery of independent self‐care ability) favoured the intervention but the 95% CI in both cases crossed the line of no effect.

  • Four studies providing data for the Barthel Index (in two, a Chinese version was used) found higher (better) ADL scores in the intervention group. However, the clinical importance of the results is uncertain and the difference may only be slight.

  • One study reported no between‐group difference in the losses in ADL as measured by the Katz Index.

  • Four other studies, which provided incomplete or no data for analysis, reported no evidence of between‐group differences in ADL.

Greater dependency in mobility (e.g. requiring help by another person)

Follow‐up: 6 to 12 months

403 per 1000a

335 per 1000
(287 to 395)

RR 0.83
(0.71 to 0.98)

1085 participants

(5 studies)

⊕⊕⊝⊝
Lowi

Another study (193 participants) found no significant between‐group difference in mobility assessed using the Short Physical Performance Battery (SPPB) tool at 12 months.

Hip‐related pain

Follow‐up: 12 months

See Comment

‐

‐

Pain data specific to injury location were available only for a subgroup of one trial. However, we considered the results were unreliable given the major imbalance in the numbers available in the two groups.

Delirium in hospitalj

509 per 1000a

433 per 1000
(377 to 499)

RR 0.85

(0.74 to 0.98)

980 participants
(4 studies)

⊕⊕⊝⊝
Lowi

Only delirium or confusion documented as a complication was considered for this outcome.
There were 538 (45%) cases in total.

A fifth trial (199 participants) reported significantly fewer participants of the intervention had post‐operative delirium (reported P = 0.003).

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
ADL: activities of daily living; CI: confidence interval; MCID: minimal clinically important difference; MD: mean difference; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low certainty: the true effect is likely to be substantially different from the estimate of effect.

aThe estimate was the median control group risk across studies (or control group risk if just one study).
bEvidence downgraded one level for serious risk of bias.
cEQ‐5D scores are anchored at 1 (full health) and 0 (a state as bad as being dead); negative values are possible and represent health states regarded as worse than being dead. Those who have died are given a zero.
dTwo other trials, based in Taiwan, reported separate data for 8 domains of a Taiwan version of the SF‐36. The results at 12 months from 391 participants for all domains except bodily pain favoured the intervention (very low‐certainty evidence downgraded one level for serious risk of bias and two levels for very serious indirectness, reflecting the minimal care provided after hospital discharge and the unusually high scores that may reflect a difference in the population compared with elsewhere).
e Evidence downgraded one level for serious risk of bias, two levels for very serious imprecision (one study only, wide confidence interval includes no clinically important effect).
fEvidence downgraded one level for serious risk of bias and one level for serious imprecision as the confidence interval crosses the line of no effect.
gThis was reported based on a diverse set of outcome measures: featured is survivors with greater dependency in ADL scores relative to pre‐fracture ADL scores (e.g. the Barthel Index and the Katz Index).
hEvidence downgraded one level for serious risk of bias, one level for serious imprecision and one level for serious inconsistency; the last reflecting a general view of the variation of effect in the results from the group of trials reporting this outcome using different and incompatible measures.
iEvidence downgraded one level for serious risk of bias and one level for serious imprecision (wide confidence interval).
jThis outcome is listed as a critical outcome in the protocol for the Cochrane Programme Grant on hip fracture management.

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Summary of findings 2. Supported discharge and multidisciplinary home rehabilitation versus usual care: mainly for people living in their own homes (ambulatory setting)

Supported discharge and multidisciplinary home rehabilitation compared with usual care for older people, mainly living in their own homes, with hip fracture

Patient or population: older people, mainly living in the community, undergoing rehabilitation after surgically treated hip fracture

Settings: ambulatory ‐ predominantly in people's own homes

Intervention: supported discharge and multidisciplinary home rehabilitation (duration between three to four weeks)

Comparison: usual care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care

Intervention

'Poor outcome' (dead or moved to higher level of care or unable to walk)

Follow‐up: 12 months

188 per 1000a

172 per 1000
(117 to 254)

RR 0.91

(0.62 to 1.35)

377 participants
(3 studies)

⊕⊝⊝⊝
Very lowb

Overall, 78 participants (20.7%) had a 'poor outcome'

Quality of life: SF‐36 Physical Component score (0: worst to 100: best)

Follow‐up: 12 months

The mean SF‐36 PC score in the usual care group was 33.3

The mean SF‐36 PC score was 4.70 higher in the intervention group
(0.43 lower to 9.83 higher)

‐

56 participants
(1 study)

⊕⊝⊝⊝
Very lowc

No evidence of a difference was also reported for the mental component score: MD 1.5 (95% CI ‐2.88 to 5.88)

Mortality (at 4 months)

Follow‐up: 3 to 4 months

66 per 1000a

51 per 1000
(23 to 117)

RR 0.77

(0.34 to 1.76)

275 participants
(2 studies)

⊕⊝⊝⊝
Very lowb

There were 20 deaths (7.3%) in total

Mortality (end of scheduled follow‐up)

Follow‐up: 12 months

125 per 1000a

172 per 1000
(77 to 204)

RR 1.00

(0.61 to 1.63)

377 participants
(3 studies)

⊕⊝⊝⊝
Very lowb

There were 53 deaths (14.1%) in total

Independent in personal activities of daily living
Follow‐up: 12 months

368 per 1000a

241 per 1000
(152 to 380)

RR 1.06
(0.71 to 1.57)

159 participants
(1 study)

⊕⊝⊝⊝
Very lowd

Note, this is a positive outcome. Overall, 60 were independent.
Another study (93 participants) reported more favourable results for the intervention groupe

Permanent move to higher level of care (hostel, nursing home, sheltered housing)
Follow‐up: 12 months

69 per 1000a

25 per 1000
(5 to 117)

RR 0.35
(0.07 to 1.69)

168 participants
(2 studies)

⊕⊝⊝⊝
Very lowb

Overall, 8 survivors (4.8%) had moved to a higher level of care

Unable to walk

Follow‐up: 12 months

87 per 1000a

78 per 1000

(34 to 178)

RR 0.89 (0.38 to 2.04)

214 participants
(2 studies)

⊕⊝⊝⊝
Very lowb

Overall, 19 survivors (8.9%) were unable to walk

Pain (end of follow‐up)

See comment

‐

‐

‐

‐

None of the three studies reported on hip or lower‐limb pain.

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

aThe estimate was the median control group risk across studies (or control group risk if just one study).
bEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (few or very few events, wide confidence interval crossing the line of no effect).
cEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (one small study only, wide confidence interval crossing the line of no effect).
dEvidence downgraded one level for serious risk of bias, two levels for very serious imprecision (one study only, wide confidence interval crossing the line of no effect), and one level for inconsistency (this latter is hypothetical but reflects that data from another study (93 participants) were in favour of the intervention group; see below).
eThis study reported higher FIM (Functional Independence Measure: 0 to 91; independent) scores in the intervention group (median 85 versus 80, reported P = 0.001).

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Summary of findings 3. Supported discharge and multidisciplinary home rehabilitation versus usual care: people living in a nursing home setting (ambulatory setting)

Supported discharge and multidisciplinary home rehabilitation compared with usual care for older people, living in nursing homes, with hip fracture

Patient or population: older people from nursing homes undergoing rehabilitation after surgically treated hip fracture

Settings: ambulatory ‐ in nursing homes (in Australia)

Intervention: supported discharge and multidisciplinary home rehabilitation (4 week programme)

Comparison: usual care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care

Intervention

'Poor outcome' (dead or unable to walk)

Follow‐up: 12 months

662 per 1000a

689 per 1000
(576 to 821)

RR 1.04
(0.87 to 1.24)

240 participants
(1 study)

⊕⊕⊝⊝
Lowb

Overall, 162 participants (67.5%) had a 'poor outcome'

Quality of life: EQ‐5D (0: dead to 1: best quality)c

Follow‐up: 12 months

The mean EQ‐5D score in the usual care group was 0.3

The mean EQ‐5D score was 0.06 lower in the intervention group
(0.12 lower to 0.0 lower)

‐

235 participants
(1 study)

⊕⊝⊝⊝
Very lowd

The difference is unlikely to be clinically important.

Mortality (at 4 months)

Follow‐up: 3 to 4 months

281 per 1000a

295 per 1000
(197 to 439)

RR 1.05
(0.70 to 1.56)

240 participants
(1 study)

⊕⊕⊝⊝
Lowb

There were 69 deaths (28.8%) in total

Mortality (end of scheduled follow‐up)

Follow‐up: 12 months

430 per 1000a

486 per 1000
(370 to 641)

RR 1.13
(0.86 to 1.49)

240 participants
(1 study)

⊕⊕⊝⊝
Lowb

There were 110 deaths (45.8%) in total

Functional dependency: modified Barthel Index (0 to 100: total independence in personal care)
Follow‐up: 4 weeks

The mean Barthel score in the usual care group was 23.5

The mean Barthel score was 0.90 higher in the intervention group
(4.51 lower to 6.31 higher)

‐

202 participants
(1 study)

⊕⊝⊝⊝
Very lowe

Functional dependency: modified Barthel Index (0 to 100: total independence in personal care)
Follow‐up: 12 months

The mean Barthel score in the usual care group was 23.5

The mean Barthel score was 4.90 lower in the intervention group
(11.69 lower to 1.89 higher)

‐

125 participants
(1 study)

⊕⊝⊝⊝
Very lowf

Unable to walk

Follow‐up: 12 months

87 per 1000a

78 per 1000

(34 to 178)

RR 0.89 (0.38 to 2.04)

130 participants
(1 study)

⊕⊝⊝⊝
Very lowf

Overall, 52 survivors (40%) were unable to walk

Pain: PAINAD (0 to 10; severest pain)

Follow‐up: 12 months

The mean pain score in the control group was 0.06

The mean pain score was 0.01 lower in the intervention group
(0.44 lower to 0.42 higher)

‐

126 participants
(1 study)

⊕⊝⊝⊝
Very lowf

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; PAINAD: Pain Assessment In Advanced Dementia; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

aThe estimate was the control group risk for the one study testing this comparison.
bEvidence downgraded one level for serious risk of bias and one level for serious imprecision (single study results, wide confidence interval crossing the line of no effect).
cEQ‐5D scores are anchored at 1 (full health) and 0 (a state as bad as being dead); negative values are possible and represent health states regarded as worse than being dead. Those who have died are given a zero.
dEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (one study only, wide confidence interval and large numbers of deaths that scored 0). The study also reported other quality of life data for survivors at 12 months using the DEMQOL (Dementia Quality of Life) instrument (self‐reported form completed by 70 participants) and the DEMQOL‐Proxy instrument (by 126 proxies). Evidence from these measures was also rated as very low certainty, reflecting downgrading one level for serious risk of bias, two levels for imprecision (reduced sample size and wide confidence interval).
eEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (single study results, wide confidence interval crossing the line of no effect). Additionally, we would have downgraded one level for indirectness as the timing of follow‐up is too short and just at the end of the treatment period.
fEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (low numbers of participants, wide confidence interval crossing the line of no effect).

Background

This review is an update  of Handoll 2009. The scope of this review has been extended to examine different models of multidisciplinary rehabilitation.

Description of the condition

Fracture of the proximal femur, generally termed a 'hip fracture', occurs most often in frail older people and generally as a result of a simple fall from standing height or less (Norton 1997). In higher‐income countries, the mean age of people sustaining a hip fracture is around 84 years for men and 83 years for women (NICE 2011). Around two‐thirds of hip fractures occur in women (NHFD 2017). People sustaining a hip fracture frequently have many other medical and physical problems; these often hinder their recovery and add to the challenge of managing their fracture. Cognitive impairment and dementia are also major considerations, both in terms of risk of hip fracture and recovery from hip fracture. Despite generally successful surgical treatment, hip fracture poses a major threat to life, mobility and independence (Marottoli 1992). About a third of people sustaining a hip fracture die within the first year (Lyons 1997; NICE 2011), often as a direct consequence of their fracture (Parker 1991). Most of the survivors fail to regain their former levels of mobility and activity, and many become more dependent (Magaziner 2000). About 10% to 20% of the survivors will require a change to a more dependent residential status (Dyer 2016).

The burden on society from hip fracture is immense and is increasing. An estimated 1.6 million hip fractures occurred in 2000 (Johnell 2006), with predictions of numbers rising to 7.3 to 21.3 million by the year 2050; the steepest increases being expected in Asia (Odén 2015). The resources required to provide the institutional and community care for those afflicted are already enormous (Schneider 1990). The direct costs of hip fracture were found to exceed acute myocardial infarction in Italy (Piscitelli 2007). There are data suggesting trends in the incidence of hip fracture vary between countries. In some higher‐income countries, the age‐specific incidence of hip fracture is decreasing, but this is probably not the case in most other countries (Ballane 2014). In higher‐income countries, lifetime prevalence has been estimated to be one in six for white women and somewhat less than half of this for white men (Cummings 2002). Inevitably, the absolute disease burden will also increase with population aging, putting further pressure on already stretched healthcare systems. Additionally, very large costs are generated by the additional requirement for institutional care for many people.

Description of the intervention

Most people with hip fracture have surgery (Handoll 2008), after which there are a wide range of treatments that are used to assist recovery (SIGN 2002). Some of these treatments have specific goals, such as restoring mobility (see Handoll 2011 for a systematic review of mobilisation strategies) and independence in other basic daily living functions, such as bathing, dressing and continence. The focus of this review is the delivery and provision of rehabilitation, specifically using a multidisciplinary approach.

For the purpose of this review, 'rehabilitation' is defined as services provided by a multidisciplinary team with the goal of reducing disability by improving ability to complete activities; for example, walking and dressing.

Care provision after hip fracture varies substantially across the world and may be determined by economic and cultural factors (personal or societal). Many strategies have been employed for the rehabilitation of people with hip fracture. Rehabilitation is generally adapted to an individual's general health, disability status, living circumstances and preferences for types of treatment. For instance, after hip fracture, some people are fit enough to return directly home from the surgical ward – albeit, where possible, with the support of services, including home‐based rehabilitation. The majority have, or require, additional treatment in an institutional setting.

There is an increasing trend to provide treatment early in the hospital stay of people with hip fracture, to encourage mobility and self‐care (NICE 2011). Inpatient rehabilitation can be provided in an orthopaedic ward, but it may take place in a separate rehabilitation ward, to where people are transferred from the acute orthopaedic ward upon recovery from their operation. (Further consideration of the setting for inpatient care is discussed in relation to applicability of the included trials in Overall completeness and applicability of evidence.) The rehabilitation ward is an environment designed to optimise individuals’ function by practicing tasks, including mobility, self‐care and domestic activities. This is enabled by the support of staff, assistive equipment including mobility and bathing aids, and establishing daily routines such as eating meals in a dining room. Multiple health disciplines – for example, physiotherapists, occupational therapists, social workers, nurses and doctors – work with the person with hip fracture to provide a co‐ordinated rehabilitation programme. This is facilitated by formal meetings, usually weekly, and regular discussion about goals of treatment with the patient and their family.

Ideally, people are generally discharged from a hospital‐based rehabilitation programme when able to live with acceptable risk in their usual accommodation or an alternative setting. Following discharge from hospital, several different types of rehabilitation programme have been described. Early Supported Discharge (ESD) is a rehabilitation programme provided in patient's home setting. In the USA, people are often discharged to skilled nursing facilities for rehabilitation. Other types of non‐inpatient rehabilitation programme are provided in some circumstances; for example, in a day hospital or in an outpatient department.

There is no agreed taxonomy for classification of multidisciplinary rehabilitation programmes after hip fracture. These programmes have been conceptualised as 'acute rehabilitation' (meaning rehabilitation in an acute care ward following hip fracture), and 'post‐acute rehabilitation' (Sheehan 2019). The post‐acute rehabilitation programme types are complex. They may be provided in an inpatient rehabilitation ward, as an outpatient or day hospital service, at home or in long‐term care. These components vary between countries; in some countries, the inpatient rehabilitation is provided in nursing care facilities. These two major categories of programmes can be connected by transition services; see Figure 1.

Figure 1
Hip fracture rehabilitation services – programme components (extract from Sheehan 2019)

Hip fracture rehabilitation services – programme components (extract from Sheehan 2019)

A different and commonly‐used classification of these programme categories is described in Cameron 2000. This classification established the following models.

  • (Geriatric) Hip Fracture Programme (GHFP): meaning an orthogeriatric programme incorporating multidisciplinary rehabilitation as well as other components (such as peri‐operative assessment). These programmes may or may not have an ambulatory component.

  • Geriatric Orthopaedic Rehabilitation Unit (GORU): a rehabilitation ward that is exclusively for geriatric orthopaedic patients; thus, people with hip fractures or other fragility fractures. This is more common in the UK.

  • Mixed Assessment and Rehabilitation Unit (MARU): a rehabilitation ward where older patients from mixed diagnostic groups are accommodated; thus, people with hip fracture or other fragility fractures in addition to older people requiring rehabilitation for other reasons (for example, stroke). This is the more common model internationally.

  • Early Supported Discharge (ESD): as mentioned above, this is an ambulatory programme that aims to discharge people with hip fracture at an earlier stage and support them at home while continuing rehabilitation.

Sheehan 2019 has evolved a working definition of a (Geriatric) Hip Fracture Programme, which includes at least an acute rehabilitation component and a post‐acute rehabilitation component. ESD could be considered as a part of a GHFP or as a stand‐alone transitional service. GORU and MARU are categories within post‐acute inpatient rehabilitation programmes. We also identified an additional category, orthogeriatric programme, provided in the acute care setting that involves orthopaedic and geriatric collaboration and aims to improve functioning. Further details are provided in Table 1; see also Appendix 1.

Open in table viewer
Table 1. Classification of multidisciplinary rehabilitation programmes

Descriptor

Label

Description

Hip fracture programme

HFP

Fits NICE definition (NICE 2011, also 2017 version); see Appendix 1. Has components in acute care, can involve inpatient rehabilitation and encourages early supported discharge when feasible.

Orthogeriatric programme

OG

Programme is provided in the acute care setting after hip fracture and involves orthopaedic and geriatric collaboration and aims to improve functioning.

Geriatric orthopaedic rehabilitation unit

GORU

Subacute rehabilitation unit for older people with orthopaedic injuries (see Cameron 2000).

Mixed assessment and rehabilitation unit

MARU

Subacute rehabilitation unit for older people with range of diagnoses. Can be called geriatric evaluation and management unit (GEM) in some countries (see Cameron 2000).

Early supported discharge

ESD

Fits NICE definition and aims to assist selected older people return home after hip fracture. Can be to own home or residential aged care facility (RACF).

However, in some cases, there may be more of a focus on enhancing support rather than achieving early or accelerated discharge.

Home‐based rehabilitation

HBR

Home‐based rehabilitation after hip fracture without direct link to hospital services

Outpatient rehabilitation

OPR

Outpatient rehabilitation after hip fracture without direct link to hospital services

The Cameron 2000 classification has also been included in subsequent National Institute for Health and Care Excellence (NICE) Guidelines in the UK (NICE 2011), and also adopted, in part, in the Cochrane Programme Grant on the management of hip fracture. This project, aligned with the NICE Guidelines, specifically focuses on the Hip Fracture Programme, with consideration also of designated Hip Fracture Units, and Early Supported Discharge as part of multidisciplinary care.

In summary, the primary intervention tested in this review is specialised multidisciplinary rehabilitation supervised by a geriatrician, rehabilitation physician or other appropriate physician, with usual care, for older people with hip fracture, in either an inpatient rehabilitation setting, an ambulatory rehabilitation setting, or both. The comparator (control) intervention is usual care. In early studies, this was care in the orthopaedic surgical ward. However, in some more recent studies, it is an alternative rehabilitation programme that usually starts later, and is less intensive and co‐ordinated (Halbert 2007). All of these interventions are complex organisational interventions. Emerging models for multidisciplinary rehabilitation for older people with hip fracture have prompted secondary additions to our approach in terms of the different models, and with direct comparisons of different models of multidisciplinary rehabilitation.

How the intervention might work

The primary goal for the person with hip fracture is return to an optimal level of functioning (WHO 2020). To achieve this, specific goals are set, and the therapeutic input required to achieve these is dependent on the co‐ordinated skills of multiple health professionals. While the process has been described and documented by the World Health Organization (WHO), stroke researchers have most clearly described the components of rehabilitation that are potentially associated with effectiveness (Stroke Collaboration 2013). In this review, we aim to establish the effectiveness and cost‐effectiveness of multidisciplinary rehabilitation overall, rather than attempt to evaluate its components. However, we have now expanded our scope to include comparisons of different models of multidisciplinary rehabilitation.

Why it is important to do this review

This review is required because of the very large number of older people who sustain hip fractures, and the substantial impact – both on the individual and to society – of these fractures. It is, therefore, highly important that the effectiveness of the various strategies employed for the rehabilitation of people with these fractures is assessed. Since the previous review (Handoll 2009), there has been a continuation of the international trend to reduction of acute hospital length of stay, with the continuing development of rehabilitation programmes that operate in other settings. We have again included outpatient or 'ambulatory' rehabilitation, to ensure continuing relevance of the review. Additionally, the evolving models of multidisciplinary rehabilitation for hip fracture merit a reframing of the evidence to inform specific consideration of these models.

Objectives

To assess the effects of multidisciplinary rehabilitation, in either inpatient or ambulatory care settings, for older people with hip fracture.

Methods

Criteria for considering studies for this review

Types of studies

We included randomised trials of post‐surgical care comparing specialised multidisciplinary rehabilitation with conventional care. Trials that used a quasi‐randomisation technique (e.g. allocation by date of birth or days of the week) were also eligible for inclusion.

Types of participants

We included older people with any type of fracture of the proximal femur that had been surgically fixed prior to entry into the care programme. We did not define specific age limits, but as anticipated, most participants were aged 65 years and over. We included younger participants (< 65 years), as the number of these was relatively small, and there appeared to be adequate randomisation, with unbiased distribution of this younger population between the intervention and control groups. We excluded trials of proximal femoral fracture confined to younger populations (e.g. age < 60 years) or to people with multiple trauma, including hip fracture. We also planned to exclude trials focused on the rehabilitation of people with metastatic disease or those focused on people with high‐energy fractures, such as from motor vehicle crashes. We included mixed population trials, provided the number of participants in any of these categories (i.e. people under 60 years of age, with multiple trauma, metastatic disease, or with high‐energy fractures) was relatively small, with an unbiased distribution between the intervention and control groups; or separate data were available for the target population of this review.

Types of interventions

For this review, the type of intervention under scrutiny is treatment in a multidisciplinary rehabilitation programme (where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician, as opposed to 'usual' care (control group)). Such a programme would aim to improve the functioning of the person with hip fracture. The programme needed to have been provided in an inpatient or ambulatory setting (or both). Here, ambulatory setting covers home (including nursing homes), outpatient department and day hospital locations. 'Usual care' for the control group refers to the usual orthopaedic or medical care, or potentially a rehabilitation programme of lesser intensity, or with different components, to the intervention under study. We further classified the interventions as presented in Table 1.

Revisions to this aspect of the scope of the current version of this review are detailed below.

  • We relaxed the criteria for multidisciplinary care to explore the inclusion of trials that did not fulfil our more stringent criterion for supervision by a geriatrician or rehabilitation physician, but otherwise featured a strong component of physician involvement, often at the assessment stage. Where possible, we categorised the interventions according to the models stated in the Description of the intervention. We allowed for combined categories; for instance, a geriatric hip fracture programme set within a hip fracture unit.

  • We included comparisons of different models of multidisciplinary rehabilitation. For example, HFP versus GORU. In selecting the control intervention, we used the less specific or intensive intervention.

  • We set out a pro forma to examine 'usual care'; this included consideration of whether it and care common to both groups were representative of current management; such as early surgery and early mobilisation.

Types of outcome measures

For this update, we restructured the types of outcome measures into three categories: a) 'critical' or main outcomes for presentation, where appropriate, in the summary of findings tables; b) other 'important' clinical outcomes; and c) economic or resource outcomes. The selection of outcomes was in keeping with those identified via the Cochrane Programme Grant on the management of hip fracture (see Appendix 2). We describe these changes in the Differences between protocol and review section. The previous set of outcomes used in Handoll 2009 is shown in Appendix 3.

Another key shift in our reporting is the greater emphasis on interim outcomes at around four months. This change reflects the finding that quality of life and 'poor outcome' (death or deterioration in residential status) at four months are likely to be consistent with those at 12 months (Griffin 2015). We continued to examine the effects of combining mortality data with measures of greater dependency in activities of daily living and mobility.

The following listing, including the differentiation between 'critical' and 'important' outcomes, is orientated at inpatient rehabilitation trials. We made some adjustments, such as to the timing, for trials conducted in the ambulatory setting. Whilst we did not set out variations in the selection of outcomes for different scenarios (e.g. different patient populations or models of rehabilitation model) beforehand, we discussed the rationale for any changes we made without view of the results and thereby avoided selective reporting bias.

Main or 'critical' outcomes

We selected the following main or 'critical' outcomes for presentation in the summary of findings tables and other summary sections of the review.

  • 'Poor outcome', defined as death or deterioration of functional status leading to increased dependency in the community or admission to institutional care. Timing between 4 and 12 months.

  • Health‐related quality of life scores (e.g. SF‐36 or EQ‐5D, two widely‐used health questionnaires). Preference was given to trial data at around four months' follow‐up, but the choice depended on data availability, reporting of mortality and whether death‐adjusted estimates were provided (Parsons 2018).

  • Mortality (all‐cause); at short‐term (around 4 months, but 'at discharge' data were also accepted) and long‐term (around 12 months).

  • Dependency in activities of daily living, primarily based on requiring the assistance of another person, but also based on measures such as the Barthel Index and Functional Independence Measure (FIM); at short‐term (around 4 months) and long‐term (around 12 months).

  • Mobility; we selected measures in the following order, according to availability: non‐return to former mobility or indoor/outdoor walking status with emphasis on requiring assistance from another person; mean mobility score; self‐reported walking score. Timing between 4 and 12 months.

  • Pain: verbal (numerical) rating or visual analogue score (VAS). Similar considerations on timing as above.

Other important clinical outcomes

The following list covers other important outcomes presented in this review. These include data for the main outcomes that were collected at different time points or where additional to those used above (thus, where multiple outcome measures are used for the same outcome: e.g. SF‐36 and EQ‐5D are presented in the same trial; or multiple measures of mobility are presented).

  • 'Poor outcome' at hospital discharge.

  • Level of care and extent of support required or provided on discharge (inpatient or from rehabilitation programme).

  • Residential status at between 4 and 12 months.

  • Medical complications / sequelae: pneumonia; thromboembolism (symptomatic deep vein thrombosis or pulmonary embolism); pressure injury (ulcer, sore); urinary tract infection; delirium.

  • Readmission.

  • Carer burden and stress.

Subsequent changes on conduct of review update

For the subgroup of trials testing ambulatory rehabilitation only, we also included number of fallers (number of people who fell), number of fall‐related hospital admissions and new fractures.

We decided not to report on 'Level of care and extent of support required or provided on discharge (inpatient or from rehabilitation programme)' as this was too variable in timing, often linked with the interventions themselves and potentially confounded data since it could be influenced by participant, care facility and social care circumstances.

Since delirium was identified as a critical outcome in the protocol for the Cochrane Programme Grant on hip fracture management, we specifically reported on this adverse event, including in the summary of findings table for inpatient rehabilitation.

Economic outcomes

We summarised cost‐analyses reported by the included trials. We reviewed each trial report for costs and resource data that would enable economic evaluation. Data for the following outcomes were routinely collected.

  • Length of hospital stay.

  • Overall length of stay in secondary care.

  • Subsequent admission rates to, and days spent in, institutional care.

Search methods for identification of studies

Electronic searches

For this update, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process & Other Non‐Indexed Citations and Embase. We did not apply any language restrictions.

The searches up to January 2016 were carried out in two stages. The first search was run from 2009 (the date of the last published search) to August 2013. A second, top‐up search was then run up to 25 January 2016. We also searched ClinicalTrials.gov (January 2016) and the WHO International Clinical Trials Registry Platform (February 2016) for ongoing and recently completed trials. The search was then extended to 25 February 2019. However, the search for CENTRAL was run without a lower date limit to check for trials that might have been excluded on title and abstract alone that were eligible for inclusion under the revised scope. We also extended our search of ClinicalTrials.gov (24 April 2019) and the WHO International Clinical Trials Registry Platform (27 April 2019) for ongoing and recently completed trials. Subsequently, the search was updated to 21 November 2019 (from 1 January 2019) and for CENTRAL, MEDLINE and Embase to 15 October 2020.

The topic‐specific MEDLINE search was combined with the sensitivity‐maximising version of the Cochrane Highly Sensitive Search Strategy for identifying randomised trials (Lefebvre 2011). In Embase, a more precise randomised controlled trial (RCT) filter was used for the second‐stage search. This filter was developed for retrieving RCTs in Embase to add to CENTRAL. Search strategies up to January 2016 for CENTRAL, MEDLINE, Embase and the trial registers are shown in Appendix 4. Those for the extended search up to February 2019 are shown in Appendix 5; the same strategies were used for the search updates on 21 November 2019 and 15 October 2020. Details of previous search strategies are published in the first version of this review (Handoll 2009).

Notably, in the first search of the second stage, we searched our previous set of excluded studies for those that met our revised scope, in terms of a lower intensity or level of organisation of multidisciplinary care and comparisons of different models of multidisciplinary rehabilitation.

Searching other resources

For completeness, other searches from the 2009 version of the review are presented in Appendix 6. When screening the CENTRAL search up to 2000, we checked through a non‐Cochrane Review on rehabilitation following fractures in older people (Cameron 2000). We also screened records of hip fracture rehabilitation trials identified up to November 2018 as part of work on the Cochrane Programme Grant on the management of hip fracture. We checked through the reference lists of all trials and the four systematic reviews we identified in our search (Moyet 2018; Nordstrom 2018; Wang 2015; Wu 2018).

Data collection and analysis

A summary of key changes in this version and the previous version (Handoll 2009), and the published protocol (Cameron 2008), is presented in Differences between protocol and review.

Selection of studies

For the search up to January 2016, initial screening was conducted by pairs of review authors (IC, HH, JM, CP). Subsequently, all five review authors (thus, including TF), independently assessed potentially eligible trials identified via the search for inclusion using a pre‐piloted form. Any disagreement was resolved through discussion. It was not found necessary to seek further information about study methods and interventions from trialists to determine eligibility.

For the search update to February 2019 for the revised review scope, three review authors (IC, HH, JM) conducted initial independent screening. One review author (HH) processed the results of this screening and prepared the documentation for study selection, which was independently performed by the same three review authors. All disagreement was resolved through discussion.

For the search update to October 2020 for the revised review scope, one review author (HH) conducted initial screening. The same review author processed the results of this screening and prepared the documentation for study selection, which was independently performed by HH and IC. All disagreement was resolved through discussion.

Data extraction and management

Using a pre‐piloted data extraction form, pairs of review authors independently extracted trial details and data for the trials not already included in Handoll 2009. Two review authors (always including HH and IC) performed data extraction for all trials, and checked this against data extraction forms provided by the other authors and, where appropriate, the data presented in Cameron 2000, Cameron 2001, Halbert 2007 and Handoll 2009. We sought key additional information from trialists, including the method of randomisation. There was no need to extract results from graphs in trial reports, although this would have been considered where data were not otherwise available. Decisions for data aggregation for calculating 'poor outcome', the designated primary outcome of this review, from mortality and functional data (typically relating to greater dependency) presented in individual trials were made by consensus (IC, HH and JM).

We collected results for the final follow‐up time available, as well as at intermediate assessments, at discharge and at around four months.

We collected the following information and data for each study for presentation in the Characteristics of included studies, for use in risk of bias assessment and assessment of indirectness (applicability), and for summarising elsewhere in the review. We noted where key information was not available.

  • Study characteristics: study design; study dates (period of recruitment); setting(s) including hospital type (teaching/university, trauma centre, general), number of centres, country/countries; sample size calculation and primary outcome; length of follow‐up and interim follow‐ups; funding and declaration/conflict of interest.

  • Population characteristics: participant inclusion and exclusion criteria; the number of recruited participants, overall and by study arm; baseline demographics (e.g. gender, age, types of fracture, American Society of Anesthesiology (ASA) physical status, cognitive impairment, mixed populations (multi‐trauma, other fractures or injuries, other diagnoses)); surgical treatment.

  • Interventions and usual care: full details of the interventions including components, timing, physical location/environments and staff profiles, including for categorisation of rehabilitation model purposes; full details of common care, including major confounders such as time of surgery and mobilisation policy (early mobilisation as opposed to extended bed rest).

  • Details of outcomes and outcome measurement.

  • Economic and health resource information.

Assessment of risk of bias in included studies

Pairs of review authors independently assessed risk of bias, without masking of the source and authorship of the trial reports, for the new trials included in this update. One review author (HH or IC) checked consistency in assessment at data entry. We used the tool outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2008, hereafter referred to as the Cochrane Handbook). This tool incorporates assessment of randomisation (sequence generation and allocation concealment), blinding (of participants, treatment providers and outcome assessors), completeness of outcome data, selection of outcomes reported and other sources of bias. We considered 'hard' outcomes (e.g. death, admission to institutional care, readmission to hospital) and other outcomes (e.g. functional status) separately in our assessment of blinding and completeness of outcome data. We assessed three additional sources of bias: selection bias resulting from imbalances in key baseline characteristics (e.g. cognitive function, prior care); performance bias, such as resulting from lack of comparability in the experience of care providers; and ascertainment bias, such as differences in timing of follow‐up assessment.

Measures of treatment effect

We present quantitative data reported in individual trial reports for outcomes listed in the inclusion criteria in the text and the analyses, using risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences (MDs) with 95% CIs for continuous outcomes. We used final scores in preference to change scores. We would have used standard mean differences where pooling final scores for continuous outcomes measured using comparable but different scores.

Unit of analysis issues

Although we would have included cluster‐randomised trials, the unit of randomisation in all the included trials was the individual participant. We were alert to other potential unit of analyses issues, such as the re‐inclusion of participants incurring a second hip fracture in the recruitment period (around 10% of survivors sustain bilateral hip fractures within a year), repeated observation from more than one time‐point, and multiple observations for the same outcome (e.g. multiple medical complications). For the sole multi‐arm trial, we presented the data for the two intervention groups separately in the analyses and split up the numbers in the control group in order to avoid double counting.

Dealing with missing data

We approached trial authors for missing or unclear data. Where appropriate, we have performed intention‐to‐treat analyses to include all people randomised to the intervention groups. As planned, we have investigated the effect of dropouts and exclusions by conducting worst and best scenario analyses. We were alert to the potential mislabelling or non‐identification of standard errors and standard deviations. Unless missing standard deviations could be derived from confidence intervals or standard errors, we did not assume values in order to present these in the analyses.

Assessment of heterogeneity

We assessed heterogeneity by visual inspection of the forest plot (analysis) along with consideration of the Chi2 test for heterogeneity and the I2 statistic (Higgins 2003). We based our interpretation of the I2 statistic results on those suggested by Higgins 2011 (Section 9.5.2):

  • 0% to 40%: might not be important;

  • 30% to 60%: may represent moderate heterogeneity;

  • 50% to 90%: may represent substantial heterogeneity;

  • 75% to 100%: considerable (very substantial) heterogeneity.

Assessment of reporting biases

We attempted to reduce the impact of reporting bias by conducting an extensive literature search that included inspection of 'grey literature' and pursuit of trials listed in clinical trial registers. Where there were more than 10 trials in a forest plot, we generated funnel plots to visually examine the potential for publication bias.

Data synthesis

Where appropriate, we pooled results of comparable studies using both fixed‐effect and random‐effects models. We decided on the choice of the model reported by careful consideration of the extent of heterogeneity and whether it could be explained, in addition to other factors, such as the number and size of included studies. We used 95% CIs throughout. We considered not pooling data where there was considerable heterogeneity (I2 statistic value of greater than 75%) that could not be explained by the diversity of methodological or clinical features amongst trials. Where it was inappropriate to pool data, we have presented trial data in the analyses or tables for illustrative purposes and report these in the text. In the absence of cluster‐randomised trials, we found it unnecessary to use the generic inverse variance to pool data (Deeks 2005).

The primary analysis is based on the rehabilitation setting: inpatient or ambulatory. We specified a priori that, unless predominantly delivered in an ambulant setting, care spanning over both settings or combinations of inpatient and ambulant settings would be initially included in the inpatient category.

Subgroup analysis and investigation of heterogeneity

Our primary analysis is by setting: inpatient and ambulatory. As an exploratory analysis, we pooled the data from both settings; however, we restricted data from the ambulatory setting to supported discharge and home‐based rehabilitation. In our protocol, we stated that our planned subgroup analyses, which could have been based on the primary setting or the combined setting data, would be by the stage of rehabilitation; participant cognitive function (one measure of this would be the ability versus inability to give individual consent); and pre‐injury residence or dependency status (own home/independent; dependent/nursing home or institutional care). We also stated that presentation in separate subgroups would be considered where there is a fundamental difference in intervention, including types of service provision. Based on our development of the classification for multidisciplinary rehabilitation, we established more transparent categories for subgroup analysis by types of intervention. In the event, we only conducted formal subgroup analyses based on different models of the intervention. We have also presented data stratified by risk of selection bias.

We investigated whether the results of subgroups were significantly different by inspecting the overlap of CIs and performing the test for subgroup differences available in Review Manager 5 (Review Manager 2014).

Sensitivity analysis

Where possible, we planned to do sensitivity analyses examining various aspects of trial and review methodology. As previously, these included checking the effects of missing data, and whether there was selection bias due to major imbalances in participant characteristics in the comparison groups. We considered this second aspect in the context of judgements for selection bias for random sequence generation and allocation concealment. For this update, we also conducted sensitivity analyses to explore the differences between using random‐effects and fixed‐effect models for pooling for the main outcomes with pooled data from five or more trials. We also planned to examine the effects of excluding studies testing interventions that are not currently available worldwide or whose other care is not generally representative of current management, or both.

Summary of findings and assessment of the certainty of the evidence

We used the GRADE approach to assess the certainty of the evidence related to all outcomes listed in the Types of outcome measures (Schünemann 2011). The four levels of evidence certainty are 'high', 'moderate', 'low' or 'very low'. Certainty may be downgraded due to study limitations (risk of bias), imprecision, inconsistency, indirectness or publication bias.

We prepared three summary of findings tables, including for our main comparison of inpatient rehabilitation, and presented the results for each of the critical outcomes listed in Types of outcome measures. The outcomes presented in the summary of findings tables were context‐specific. We added another row for delirium for inpatient rehabilitation, as this was identified as a critical outcome for the Cochrane Programme Grant on the management of hip fracture, in anticipation of informing the update of the NICE guidelines. One review author (HH) produced the summary of findings tables generated in Review Manager 5 (Review Manager 2014). These tables, including the GRADE assessments, were discussed with a second review author (IC), and then shared with the other review authors.

Results

Description of studies

Results of the search

We conducted the search for this updated review (2021) in two main phases. The full search for the first phase, prior to the change in the scope of the review, was from April 2009 to January 2016. Detailed results of this phase are provided in Appendix 7, and the study flow is summarised in Figure 2. Overall, after the first phase, there were 19 included studies, 29 excluded studies, 4 ongoing trials and one study awaiting classification. 

Figure 2
Study flow diagram for the first phase of the search update 2009 to January 2016 (former scope)

Study flow diagram for the first phase of the search update 2009 to January 2016 (former scope)

We used the same search strategy, updated to February 2019, for the second phase. Although we felt it unlikely that we had missed any studies, we searched the CENTRAL search from database inception. We also added in all 29 studies previously excluded on the basis of the 2016 selection criteria to facilitate a systematic application of the revised selection criteria. We provide detailed results of this second phase in Appendix 7, and the study flow is summarised in Figure 3. This includes the results of search extensions to 21 November 2019 and then 15 October 2020; with one further report found in January 2021 that confirmed exclusion of a study. The second phase resulted in nine newly included studies, four of which had been previously excluded in Handoll 2009. For completeness, the 'Results of the search' section from Handoll 2009 is copied in Appendix 8.

Figure 3
Study flow diagram for the second phase of the search updates up to February/March 2019, November 2019 and October 2020 (revised scope)

Study flow diagram for the second phase of the search updates up to February/March 2019, November 2019 and October 2020 (revised scope)

Overall, the search update resulted in 15 newly included studies and 13 additional articles pertaining to four studies already included in Handoll 2009. The 15 newly included trials are: Ashe 2019; Baroni 2019; Chong 2013; Crotty 2019; Jette 1987 (previously excluded); Karlsson 2016 (was Gustafson 2009, previously in 'studies awaiting classification' (SAC); Marcantonio 2001 (previously excluded); Prestmo 2015; Sanchez Ferrin 1999 (previously excluded); Shyu 2013a; Singh 2012; Tseng 2019; Uy 2008 (previously in SAC); Watne 2014; and Ziden 2008 (previously in SAC).

Overall, after completing the searches, there are now 28 included studies, 47 excluded studies and 7 studies awaiting classification.

Included studies

Individual trial details of the methods, participants, interventions and outcome measurements for the 28 included trials are presented in the Characteristics of included studies. Appendix 9 summarises the participant characteristics and our assessment of the representativeness of study populations. Appendix 10 summarises early treatment, such as timing and type of surgery, set into the context of the setting and timing of the studies, and our assessment of the representativeness in terms of current practice.

Design

Except for Shyu 2013a, which had three intervention groups, the included trials randomised individual patients into one of two intervention groups. Two trials used quasi‐randomised methods (Chong 2013; Jette 1987).

Sample sizes

The 28 included trials involved a total of 5351 randomised participants, the great majority of whom had undergone surgery for hip fracture. Sample size at randomisation ranged from 11 participants recruited into Uy 2008, to 397 into Prestmo 2015.

Setting

The 28 trials took place in one of 11 countries: Australia (6 trials); Canada (2); Finland (1); Italy (1); Norway (2); Singapore (1); Spain (2); Sweden (4); Taiwan (3); UK (4); and USA (2). The majority were single‐centre trials in terms of recruitment, with the exception of Ashe 2019, Crotty 2003, Crotty 2019 and Singh 2012. Recruitment start dates ranged from 1983 (Jette 1987), to 2012 (Crotty 2019); no information was available for Kennie 1988, and Marcantonio 2001.

Care was provided in an inpatient setting – thus, before hospital discharge – for both intervention groups in 21 trials. Care in the intervention group continued for three to four months, with home visits by a geriatric nurse as part of the intervention, for the three trials conducted in Taiwan (Shyu 2008; Shyu 2013a; Tseng 2019). In three other trials, care was mixed hospital and community care but the community component applied only to the intervention group as follows:  in Crotty 2003, the intervention group participants were discharged from acute care within 48 hours of randomisation; in Karlsson 2016, the intervention involved early discharge and home rehabilitation; and in Ziden 2008, where home rehabilitation was provided after early supported discharge from hospital. Care was provided in the community in four trials: Ashe 2019 at outpatients; Crotty 2019 at nursing homes; Ryan 2006 at home; and Singh 2012 at outpatients and home.

Participants

The mean age of trial participants ranged from 76.5 years in Shyu 2013a to 87 years in Crotty 2019, where all participants were from nursing homes. All but four trials set a lower age limit for trial entry: this ranged from 50 in Cameron 1993 to 70 in five trials (Crotty 2019; Karlsson 2016; Naglie 2002; Prestmo 2015; Stenvall 2007a). Twelve trials set 65 as the lowest age for participation. Four trials included only women (Fordham 1986; Gilchrist 1988; Kennie 1988; Uy 2008). The proportion of men in the remaining trials varied from 17% in Cameron 1993, to 37% in Ashe 2019.

Seven trials explicitly or implicitly excluded people with dementia or cognitive impairment (Ashe 2019; Crotty 2003; Fordham 1986; Galvard 1995; Ryan 2006; Swanson 1998; Ziden 2008). Three trials explicitly excluded people with severe cognitive impairment (Shyu 2008; Shyu 2013a; Tseng 2019); however, a third of the participants of Shyu 2008 had mild cognitive impairment. Jette 1987 did not report on this characteristic. Of the 11 trials documenting dementia prior to the fracture or baseline, the proportion of the trial population with dementia ranged from 5% in Singh 2012, to 77.5% in Crotty 2019. The other six trials documenting cognitive impairment reported this in different ways: 48% of the study population of Cameron 1993 were cognitively impaired; 55% of the study population of Gilchrist 1988 had reduced cognitive scores indicating some cognitive impairment; 47% of Kennie 1988 and 40% of Marcantonio 2001 had mild or greater cognitive impairment; 26% of Naglie 2002 had mild to moderate cognitive impairment but the numbers with more severe impairment were not provided. All 11 participants of Uy 2008 had moderate or severe cognitive impairment.

In Tseng 2019, all 176 participants had diabetes mellitus, the treatment of which was a specific focus of the intervention.

There was no selection based on pre‐fracture residence in 14 trials (Baroni 2019; Cameron 1993; Fordham 1986; Gilchrist 1988; Jette 1987; Karlsson 2016; Kennie 1988; Marcantonio 2001; Naglie 2002; Sanchez Ferrin 1999; Singh 2012; Stenvall 2007a; Vidan 2005; Watne 2014). Two of these studies excluded people whose fracture had occurred in hospital (Kennie 1988; Stenvall 2007a). Twelve trials included only people living in the community (Ashe 2019; Chong 2013; Crotty 2003; Galvard 1995; Huusko 2002; Prestmo 2015; Ryan 2006; Swanson 1998; Shyu 2008; Shyu 2013a; Tseng 2019; Ziden 2008), and except for Prestmo 2015 and Swanson 1998, exclusively in their own home. Crotty 2019 and Uy 2008 included only people who were living in nursing homes before their fracture.

Interventions

All trials, except Chong 2013, compared multidisciplinary rehabilitation (intervention) with a control group ('usual care'). Chong 2013 compared two types of multidisciplinary rehabilitation. The nature of multidisciplinary rehabilitation varied considerably in the included trials. Similarly, there was variation in 'usual care', where described. In 21 trials, multidisciplinary rehabilitation was provided primarily in an inpatient setting. Ambulatory multidisciplinary rehabilitation was tested in seven trials. Table 2 summarises the interventions, split by setting, and usual care for the 28 included trials. Further details of the interventions tested in the individual trials are provided in Characteristics of included studies.

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Table 2. Interventions tested in the included studies

Study ID

Setting

Country; trial start

Intervention

Control

Comments

Inpatient rehabilitation

Baroni 2019

Hospital

Italy; 2012

Orthogeriatric programme

Orthopaedic care; referral to geriatrician as required

Cameron 1993

Hospital

Australia; 1989

Hip fracture programme

Usual care (56% had multidisciplinary rehabilitation)

Intervention emphasised accelerated rehabilitation

Chong 2013

Hospital

Singapore; 2004

Mixed assessment and rehabilitation unit plus structured assessments and checklists

Mixed assessment and rehabilitation unit

Comparison of two types of multidisciplinary rehabilitation

Fordham 1986

Hospital

UK; 1984

Geriatric orthopaedic rehabilitation unit

Orthopaedic management (geriatrician available for advice) including decision to transfer to orthopaedic rehabilitation unit.

Galvard 1995

Hospital

Sweden; 1988

Geriatric orthopaedic rehabilitation unit

Usual orthopaedic care

Gilchrist 1988

Hospital

UK; 1984

Geriatric orthopaedic rehabilitation unit

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

Huusko 2002

Hospital

Finland; 1994

Orthogeriatric programme

Discharge to local community hospitals, treatment by general practitioners

Jette 1987

Hospital

USA; 1984

Orthogeriatric programme

Usual care: 'standard rehabilitation'

Kennie 1988

Hospital

UK; before 1986

Geriatric orthopaedic rehabilitation unit

Routine orthopaedic care in orthopaedic admission ward

Marcantonio 2001

Hospital

USA; before 1999

Orthogeriatric programme

Orthopaedics team management, including internal medicine or geriatrics consultations on a reactive basis.

The geriatrician input mainly related to reducing delirium

Naglie 2002

Hospital

Canada; 1993

Orthogeriatric programme

Usual care on orthopaedic units which included access to geriatric consultation

Prestmo 2015

Hospital

Norway; 2008

Hip fracture programme

Usual orthopaedic care provided in an orthopaedic ward. Assessment by geriatrician by request only

Sanchez Ferrin 1999

Hospital

Spain; 1996

Mixed assessment and rehabilitation unit (single session of geriatric review)

Usual care under Orthopaedics and Traumatic Surgery Service; consultations to other specialists as required

Low level of geriatrician involvement with emphasis on treating co‐morbidity

Shyu 2008

Hospital

Taiwan; 2001

Hip fracture programme, included home visits

Usual care on trauma or orthopaedic ward. Some consultations of other disciplines

No care provided after discharge at approximately one week in control group

Shyu 2013a

Hospital

Taiwan; 2005

Hip fracture programme (+ home visits): 2 groups
1. HFP + health‐maintenance interventions to manage depressive symptoms and malnutrition and prevent falls
2. HFP

Usual care by orthopaedists.

No care provided after discharge at approximately one week in control group

Separate analysis of the two HFP groups not done in this review

Stenvall 2007a

Hospital

Sweden; 2000

Geriatric orthopaedic rehabilitation unit

Usual care on specialist orthopaedic ward

Intervention included an assessment at 4 months by geriatric team

Swanson 1998

Hospital

Australia; 1994

Hip fracture programme

Standard orthopaedic management, geriatrician on referral

Intervention, which included accelerated rehabilitation programme, was based in an orthopaedic ward

Tseng 2019

Hospital and community (intervention group)

Taiwan; 2010

Hip fracture programme, included home visits

Usual care under orthopaedics, with consultations to internal medicine as required

Trial and intervention focused on diabetes‐specific care.

No care provided after discharge, around 4 to 5 days after surgery, in control group

Uy 2008

Hospital

Australia; 2001

Hip fracture programme

Usual care: discharge back to the nursing home soon after surgery

All nursing home residents

Vidan 2005

Hospital

Spain; 1997

Orthogeriatric programme

Usual orthopaedic care, counselling from different specialists

Watne 2014

Hospital

Norway; 2009

Hip fracture programme

Usual care on orthopaedic ward, relevant specialists were seen on request

Ambulatory rehabilitation

Ashe 2019

Community

(outpatients and home)

Canada; 2011

Outpatient rehabilitation

Usual post‐op rehabilitation

Intervention focused on falls and fracture risk

Crotty 2003

Hospital and community (intervention group)

Australia; 1998

Early supported discharge, included home‐based interdisciplinary rehabilitation

Usual or 'conventional' care, involving routine interdisciplinary hospital care and rehabilitation in hospital.

The extra multidisciplinary rehabilitation component is the home‐based interdisciplinary rehabilitation

Crotty 2019

Community (nursing home / care facility)

Australia; 2012

Early supported discharge to residential aged care facility (nursing home)

Usual care according to usual practice in the nursing home

All nursing home residents.
A detailed description of usual care is available.

Karlsson 2016

Hospital and community (intervention group)

Sweden; 2008

Early supported discharge (continuation of rehabilitation in patient's home)

Same inpatient geriatric care and rehabilitation

The extra multidisciplinary rehabilitation component is the home‐based interdisciplinary rehabilitation

Ryan 2006

Community (at home)

UK; 2000

Home‐based rehabilitation: intensive

Home‐based rehabilitation: less intensive

Comparision of two intensities of multidisciplinary rehabilitation

Singh 2012

Community (outpatients and home)

Australia; 2003

Hip fracture programme (included home visits)

Standard care included orthogeriatric care, rehabilitation service, other medical and allied health consultation as required

Intervention extended to multidisciplinary treatment of frailty

Ziden 2008

Hospital and community (intervention group: home)

Sweden; 2004

Supported discharge, included home rehabilitation ward and home visits

Usual care in geriatric ward with no structured rehabilitation after discharge

Geriatrician management applied to both groups
Inpatient rehabilitation

The types of multidisciplinary rehabilitation programmes, where compared to usual care in an inpatient setting, fell into four categories, as defined in Table 1.

Three trials were distinct from the other 17 trials. In Marcantonio 2001, geriatrician input was mainly related to reducing delirium; in Sanchez Ferrin 1999, geriatrician involvement was low level and focused on treating co‐morbidity; and in Tseng 2019, the intervention was focused on diabetes‐specific care.

Usual care also varied between studies and was not well described in several, especially the older trials. Perusal of Appendix 10 shows the lack of information available for key aspects of early treatment. Of particular note is the minimal nature of usual care provided in three trials conducted in Taiwan, where care ceased after hospital discharge at around one week (Shyu 2008; Shyu 2013a; Tseng 2019).

Two multidisciplinary care interventions were tested versus usual care in Shyu 2013a. Although we present the data for these separately in the analyses, we considered the addition of health‐maintenance interventions to one intervention group did not make the intervention a distinctly different multidisciplinary care programme.

In contrast, we considered the addition of an 'integrated care pathway' to one of the two multidisciplinary rehabilitation interventions tested in Chong 2013 did result in two markedly different types of multidisciplinary rehabilitation. Both interventions were in a mixed assessment and rehabilitation unit setting.

Ambulatory rehabilitation

The multidisciplinary rehabilitation intervention was predominantly in the community in seven trials.

Of four trials testing supported discharge and home rehabilitation, all or the majority of participants in three trials received rehabilitation in their own homes (Crotty 2003; Karlsson 2016; Ziden 2008), whereas the intervention was provided in a nursing home setting for all participants of Crotty 2019. The interventions are summarised below.

  • Crotty 2003 compared accelerated discharge from hospital, within 48 hours of randomisation, and home‐based interdisciplinary rehabilitation with usual care involving routine interdisciplinary hospital care and rehabilitation in hospital. The rehabilitation programme at the patient's home focused on early resumption of self‐care and domestic activities. The average duration of home rehabilitation was three weeks (20.3 days).

  • Crotty 2019 compared a four‐week ambulatory geriatric multidisciplinary rehabilitation programme delivered in a nursing home setting with usual care, where treatment was provided according to usual practice in the nursing home.

  • Karlsson 2016 compared early discharge from hospital with extended multidisciplinary home rehabilitation versus usual care involving routine interdisciplinary hospital care and rehabilitation in hospital. The median duration of the home rehabilitation was three weeks (21 days).

  • Ziden 2008 compared home rehabilitation with conventional rehabilitation. Both groups were admitted to rehabilitation wards, but the home rehabilitation group had supported discharge and a three‐week home rehabilitation programme that emphasised self‐efficacy for independent functioning.

Ryan 2006 compared intensive (six visits per week) with less intensive (three or fewer visits per week) multidisciplinary rehabilitation in the participant's own home.

Multidisciplinary rehabilitation was totally or mainly provided at an outpatient clinic in two trials (Ashe 2019; Singh 2012). However, these trials tested otherwise very different interventions. Ashe 2019 compared a post‐discharge geriatrician‐led multidisciplinary clinic, held at 3 to 12 months post fracture, with referral for further rehabilitation as necessary, versus usual care. Singh 2012 compared 12 months of geriatrician‐led multidisciplinary care,  which included high‐intensity weight‐lifting exercise, in an outpatient hospital programme and targeted treatment of frailty at outpatients and home versus usual rehabilitation care.

Outcomes

Only 'poor outcome', our primary outcome, is considered here. We defined this a priori as death or deterioration of functional status leading to increased dependency in the community or admission to institutional care. Where data were available, 'poor outcome' was presented for long‐term follow‐up (between 4 and 12 months) and at hospital discharge. The definitions of deterioration in residential status varied. For some trials, it was based on the requirement for institutional care; in others, the non‐return to home or independent living. Using this definition, deterioration was not measured in the two trials that focused on people from nursing homes who returned to nursing homes (Crotty 2019; Uy 2008). In Crotty 2019, deterioration of functional status was recast in terms of the inability to walk. The same applied to another ambulatory rehabilitation trial, Karlsson 2016, as data on change of residence were unavailable. The definition of poor outcome for individual trials is provided as footnotes in the analyses.

Funding and financial conflicts of interest

Twenty‐one trials acknowledged external funding, and one study acknowledged external support, from public funding bodies or foundations. Six trials did not mention funding (Baroni 2019; Chong 2013; Galvard 1995; Gilchrist 1988; Sanchez Ferrin 1999; Uy 2008). Eleven trials provided explicit statements of no financial conflicts of interest, and 15 trials did not provide statements. Of the two remaining trials, Crotty 2019 stated there was no "relevant conflict", whilst acknowledging funding from industry for other research, and Singh 2012 reported independence from funding organisations and sponsors.

Excluded studies

We list the reasons for exclusion of 47 studies in the Characteristics of excluded studies. The primary reasons for exclusion were: not randomised treatment allocation (15 trials); not multidisciplinary rehabilitation (26 trials); and mixed population without separate data for people with hip fracture (6 trials). Extra consideration of the study design was needed for four of the 15 studies excluded because treatment allocation was not randomised (Boyer 1986; Gonzalez‐Montalvo 2010; Lahtinen 2015; NCT03430193). The first three reported some randomised or quasi‐randomised aspect to their trial but the actual study design, as described in the reasons for exclusion, precluded actual or appropriate random allocation to the treatment groups. The trial registration document for NCT03430193 implied random allocation, but the published protocol and two reports purporting to be about the trial contradicted this implication; they also included major inconsistencies in relation to other details. We excluded Boyer 1986, a mixed population trial, also because of the lack of extractable data on people with hip fracture. Several of the trials ineligible for this review (because they were not testing multidisciplinary rehabilitation) appear in other published Cochrane Reviews on hip fracture rehabilitation: Crotty 2010 includes five excluded trials (Allegrante 2001; Hagsten 2004; Huang 2005; Krichbaum 2007; Tinetti 1999), and Handoll 2011includes Binder 2004. The pending update of Handoll 2011 is likely to include two other trials aimed at improving mobility: Edgren 2015 and Suwanpasu 2013.

Studies awaiting classification

Details of the seven trials in this category are presented in the Characteristics of studies awaiting classification. As detailed in this table, we are unsure of the status of Baroni 2016 (inpatient comparison with a target of 150 participants), or its link with Baroni 2019, despite receiving responses from the contact trialist. We require clarification on the interventions for the four primarily inpatient trials that are insufficiently reported, either in trial registration documentation (NCT01934946, reported sample size of 130 participants; NCT03894709, intended sample size of 304 older people with hip fracture and cognitive impairments, plus their carers), or conference abstracts (Hammond 2017, involved 282 people with hip fracture and cognitive impairment; Wu 2019, involved 157 older people with hip fracture). We also require clarification on the intervention tested in NCT04207788 (intended sample size of 108 participants), which appeared to be mainly delivered in the home setting. Lastly, we require separate data for 335 people with hip fracture for Parsons 2019, which included 403 participants in hospital because of injury.

Risk of bias in included studies

We present a summary of our assessments of the risk of bias associated with various aspects of study design and conduct in Figure 4.

Figure 4
Summary of review authors' assessments (+ = low; ? = unclear; ‐ = high risk of bias) for aspects of study conduct for individual trials

Summary of review authors' assessments (+ = low; ? = unclear; ‐ = high risk of bias) for aspects of study conduct for individual trials

Allocation

We considered 15 trials at low risk of bias for randomisation sequence generation and allocation concealment. Insufficient information on sequence generation prevented judgement of this aspect for four trials (Fordham 1986; Gilchrist 1988; Vidan 2005; Ziden 2008); and on allocation concealment for nine trials (Baroni 2019; Galvard 1995; Gilchrist 1988; Marcantonio 2001; Sanchez Ferrin 1999; Shyu 2008; Shyu 2013a; Swanson 1998; Ziden 2008). Two trials used quasi‐randomised methods and were deemed at high risk of selection bias (Chong 2013; Jette 1987). For the other trials, there were no serious concerns regarding risk of selection bias from inappropriate methods of treatment allocation.

Blinding

Blinded assessors for at least some outcomes were reported for 11 trials (Ashe 2019; Chong 2013; Crotty 2003; Marcantonio 2001; Naglie 2002; Prestmo 2015; Ryan 2006; Stenvall 2007a; Uy 2008; Vidan 2005; Watne 2014). However, the success of this blinding was rarely ascertained, and was found not to be successful in "5‐10% of the cases" in Watne 2014, where the research nurses were unblinded because of information from the trial participants or their relatives. Trial participants were stated to be blinded to treatment allocation in Shyu 2008, Shyu 2013a and Tseng 2019, but we considered this was incompatible with informed consent for Tseng 2019. Despite lack of blinding, many trials clearly applied systematic methods for data collection and often also had independent assessors. We considered the outcomes of death, residence and readmission to be less influenced by lack of blinding than other outcomes, such as function and quality of life measures.

For the first set of outcomes, we considered 12 trials at low risk for these biases, mainly reflecting blinded assessment or systematic assessment of independently‐collected medical record data, and we judged only one trial, Baroni 2019, at high risk. For functional and other related outcomes, all three trials considered at low risk for these biases appeared to have successful blinded assessment (Ryan 2006; Sanchez Ferrin 1999; Vidan 2005). High risk of bias, mainly reflecting lack of, or unsuccessful, blinding, was judged likely for 10 trials (Ashe 2019; Crotty 2019; Fordham 1986; Jette 1987; Karlsson 2016; Kennie 1988; Marcantonio 2001; Tseng 2019; Watne 2014; Ziden 2008). Baroni 2019 did not report on functional outcomes.

Incomplete outcome data

Participant flow information was generally available, although sometimes only after contact with the trial investigators. There were some concerns for attrition bias for 'hard outcomes' such as mortality, residence and readmission data for nine trials (Baroni 2019; Fordham 1986; Huusko 2002; Jette 1987; Prestmo 2015; Sanchez Ferrin 1999; Shyu 2008; Uy 2008; Ziden 2008). We considered two of these trials to be at high risk of attrition bias for 'hard outcomes': Huusko 2002, where there were post‐randomisation exclusions and data excluded from participants without initial mental scores; and Ziden 2008, where over half of the participants were excluded post‐randomisation. We judged the other 19 trials to be at low risk of attrition bias for these outcomes. In contrast, only four trials were at low risk for functional outcomes (Naglie 2002; Stenvall 2007a; Swanson 1998; Vidan 2005), and nine trials at high risk of bias (Chong 2013; Crotty 2019; Fordham 1986; Galvard 1995; Huusko 2002; Marcantonio 2001; Uy 2008; Watne 2014; Ziden 2008). Large losses to follow‐up, imbalanced loss to follow‐up, missing data, data discrepancies indicating missing data or a combination of these were reasons for most of these assessments. The limitations in the functional outcomes data due to the small sample size was the basis for a high risk of bias in Uy 2008. Baroni 2019 did not report on these outcomes.

Selective reporting

The study protocol and trial registration were available for Prestmo 2015 and Watne 2014, both of which we assessed as low risk for selective reporting bias. The two other trials we assessed as low risk are: Crotty 2019, where all outcomes listed at trial registration were reported; and Fordham 1986, where the comprehensiveness of the reporting for this trial made it very unlikely that selective reporting had occurred. We judged 10 trials to be at high risk of selective reporting bias because of missing outcomes and incomplete reporting (Ashe 2019; Baroni 2019; Huusko 2002; Jette 1987; Karlsson 2016; Marcantonio 2001; Shyu 2008; Shyu 2013a; Singh 2012; Tseng 2019). For the remaining trials, which we assessed as having an unclear risk of reporting bias, it seemed likely that the published report included all expected outcomes, including those that were pre‐specified, but no protocol or trial registration document was available to check this.

Other potential sources of bias

Other biases that we considered pertained to selection bias from major imbalances in baseline characteristics, performance bias in terms of important differences in care provision outside of that of the trial interventions, and detection bias resulting from difference in follow‐up procedures. Contamination bias – resulting from the inadvertent application of the intervention being evaluated to people in the control group, potentially leading to reduced differences between the intervention and control groups – was also considered as part of performance bias.

Eight trials had major imbalances at baseline that could have influenced trial findings. In Kennie 1988 and Stenvall 2007a, these imbalances are likely to have favoured the intervention group, whereas the converse was likely in four other trials (Galvard 1995; Huusko 2002; Karlsson 2016; Ryan 2006). It is harder to judge for Ziden 2008, which anyway did not provide the baseline characteristics for over half of the randomised participants. Uy 2008, the other trial at high risk, had too small a sample size for randomisation to be effective, and the imbalances were relatively large in the type of hip fracture and prior use of walking aid.

Insufficient information on care programmes, especially in the control group and on clinicians' experience, prevented judgement on the risks from performance bias. However, we did consider there was a high risk of bias in five trials. In Crotty 2019, there were very likely to be differences in practice between the nursing homes, as well as contamination resulting from shared staff. In Fordham 1986, this was mainly in consequence of the location of the two study sites and arrangements for geriatrician cover. In Galvard 1995, the geriatric hospital had no prior experience with people with hip fracture. In Jette 1987, there was a strong suggestion of contamination between experimental and control groups, with staff coming from the same department. Finally, in Ryan 2006, there was risk of compensatory care provision in the less intensive group. Some contamination bias, resulting from shared care facilities or staff, or both, also seemed likely in 10 trials (Baroni 2019; Chong 2013; Crotty 2019; Fordham 1986, Gilchrist 1988, Jette 1987; Karlsson 2016; Ryan 2006; Sanchez Ferrin 1999; Vidan 2005). Notably, Naglie 2002 purposefully minimised the risk of contamination bias by ensuring "interdisciplinary care and usual care were provided by different staff on different wards", but still provided insufficient information to make a judgement on this item.

Active and systematic methods of follow‐up seemed to preclude detection bias in all but four trials: in Ashe 2019, the start of follow‐up was 25 days later in the control group, a difference that may or may not be important; in Galvard 1995, the imbalance in the follow‐up of functional outcomes may have reflected different research environments at the two study sites; in Jette 1987, there was insufficient information to be certain of comparability; and in Karlsson 2016, data collection differed in the two groups.

Effects of interventions

See: Summary of findings 1 Multidisciplinary inpatient rehabilitation versus usual care; Summary of findings 2 Supported discharge and multidisciplinary home rehabilitation versus usual care: mainly for people living in their own homes (ambulatory setting); Summary of findings 3 Supported discharge and multidisciplinary home rehabilitation versus usual care: people living in a nursing home setting (ambulatory setting)

In the following, all results are presented using the fixed‐effect model. We performed sensitivity analysis to check whether there were important changes to the results if the random‐effects model was used instead for pooling. The results from the latter, for key outcomes with data from five or more trials, are presented in Appendix 11; these show that none differed importantly from the results presented below.

Inpatient multidisciplinary rehabilitation versus usual care

Main outcomes
Poor outcome

We combined the outcomes of death or deterioration in residential status (generally, the requirement for institutional care) to give the overall outcome measure of 'poor outcome', which was assessed at the conclusion of follow‐up (6 to 12 months) and at hospital discharge. At final follow‐up, there is moderate‐certainty evidence, downgraded by one level for serious risk of bias, of a lower risk of a poor outcome at long‐term follow‐up in the intervention group (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.80 to 0.98; I2 = 0%; 13 studies, 3036 participants; Analysis 1.1; Figure 5). The 13 trials are listed by recruitment start dates, where available. As found in the previous version of our review, this demonstrates that Kennie 1988 remains an outlier: its removal does not substantively change the findings: RR 0.91, 95% CI 0.82 to 1.01; analysis not shown.

Figure 5
Multidisciplinary inpatient rehabilitation versus usual care: 'Poor outcome' (long‐term follow‐up at 6 or 12 months)

Multidisciplinary inpatient rehabilitation versus usual care: 'Poor outcome' (long‐term follow‐up at 6 or 12 months)

An exploratory subgroup analysis by type of intervention (GORU, HFP, MARU, orthogeriatric (OG) programme) showed no evidence of subgroup differences (test for interaction: P = 0.25; I2 = 26.4%); see Analysis 1.2. Removal of the three trials conducted in Taiwan, where no clinical care was provided after discharge at approximately one week in the 'usual care' group, does not substantively change the findings: RR 0.87, 95% CI 0.79 to 0.97; 2399 participants; analysis not shown. Another sensitivity analysis, based on perceived risk of selection bias (Analysis 1.3), showed no evidence of a difference between the results for trials subgrouped by risk of selection bias (low versus unclear or high risk), which included that linked to probably serious imbalances in participant characteristics (test for interaction: P = 0.316). Evidence is missing from Jette 1987 and Marcantonio 2001. Jette 1987 reported no significant between‐group difference in survival, nor, separately reported, in the "eventual discharge disposition" but did not supply data: at 12 months, 22 had died and 26% of the survivors were not living at home. Marcantonio 2001 reported that 28 (22%) overall had died or were in a new nursing home placement at six months; there was no report of the distribution of this outcome in the two groups.

Poor outcome at hospital discharge was based on mortality in hospital and discharge location. This outcome is more vulnerable to issues related to indirectness and bias, such as differences in discharge policies and supply of alternative accommodation (as in Galvard 1995). It is notable that there are data for this outcome from three GORU trials, Fordham 1986, Galvard 1995 and Gilchrist 1988, that did not provide data for long‐term 'poor outcome'. There is very low‐certainty evidence, downgraded one level for serious risk of bias, one level for serious indirectness and one level for serious imprecision reflecting the reduced quantity of data available, of a lower risk of a poor outcome in the intervention group (RR 0.87, 95% CI 0.76 to 1.00; ; I2 = 24%; 8 studies, 1537 participants; Analysis 1.4). Jette 1987 reported no significant between‐group difference in hospital deaths or in residential status at discharge without reporting separate treatment group data; overall, 40 (53%) had a poor outcome at discharge, either death (4 participants) or discharged to a rehabilitation hospital (28 participants) or newly to a nursing home (8 participants).

Mortality

Mortality data were reported for all 20 trials; however, these were not split by treatment group for Jette 1987 or Marcantonio 2001. Although favouring the intervention, pooled results do not confirm a difference between the two groups at end of follow‐up at 4 to 12 months (RR 0.91, 95% CI 0.80 to 1.05; I2 = 0%; 18 studies, 3973 participants; low‐quality evidence downgraded one level for serious risk of bias and one level for serious imprecision as the confidence interval crosses the line of no effect; Analysis 1.5). The results for Cameron 1993 were for the four‐month follow‐up period, the main trial follow‐up period. The inclusion of 12‐month mortality figures for Cameron 1993 did not alter the above finding (RR 0.90, 95% CI 0.79 to 1.03; Analysis 1.6). Jette 1987 reported no significant between‐group difference in mortality at 12 months; overall there were 22 (29%) deaths. Marcantonio 2001 reported only an overall mortality at six months of 15 (12%). Note, the results for Swanson 1998 are 12‐month mortality data provided by the lead trialist, rather than the six months' post‐discharge figures extrapolated from the main trial report. An exploratory subgroup analysis by type of intervention (GORU, HFP, MARU, OG programme) showed no evidence of subgroup differences (test for interaction: P = 0.78; I2 = 0%); see Analysis 1.7.

Hospital mortality also favoured the intervention group, but again the pooled results do not confirm a difference between the two groups (RR 0.77, 95% CI 0.58 to 1.04; I2 = 11%; 11 studies, 2455 participants; low‐certainty evidence downgraded one level for serious risk of bias and one level for serious imprecision as the wide confidence interval crosses the line of no effect; Analysis 1.8). Jette 1987 reported no significant between‐group difference in hospital mortality; overall there were 4 (5.3%) deaths.

Health‐related quality of life

Three trials reported on HRQoL (Prestmo 2015; Shyu 2008; Shyu 2013a). Prestmo 2015 found very low‐certainty evidence, downgraded one level for risk of bias and two levels for imprecision as there are insufficient data from just one study, of potentially better quality of life measured using the EQ‐5D (‐0.59 to 1.00: best quality) in the intervention group at both four months (mean difference (MD) 0.08, 95% CI 0.03 to 0.13; 347 participants) and 12 months (MD 0.07, 95% CI 0.02 to 0.12; 337 participants); see Analysis 1.9). The confidence interval of both results included the minimally clinical important difference (MCID) of 0.8; this value is consistent with that used in hip fracture trial literature (Griffin 2018).

The results at 1, 3, 6 and 12 months for the SF‐36 Taiwan version for Shyu 2008 were reported in a later publication (Shyu 2010). As shown in Analysis 1.10, the intervention group had higher scores for all eight domains at 12 months. Pooled data (391 participants) with Shyu 2013a retained this pattern except for bodily pain, where there was no difference between the two groups. In particular, there were marked and clinically important differences favouring multidisciplinary rehabilitation between the two groups in physical domains, especially physical functioning (MD 13.20, 95% CI 6.99 to 19.41) and role limitations due to physical health problems (MD 27.98, 95% CI 19.54 to 36.42; Analysis 1.10). Relative to other populations, the mean scores in the intervention group for several domains, especially the two role limitations categories, are much higher than the norms found in other populations (Walters 2001). We rated this very low‐certainty evidence, downgraded one level for serious risk of bias and two levels for very serious indirectness, reflecting the minimal care provided after hospital discharge in these trials and the unusually high scores that may reflect a difference in the population compared with elsewhere).

Kennie 1988, which reported incomplete data at one year for 65 participants, reported no between‐group difference (P = 0.85) in the 'Life Satisfaction Index' (Neugarten 1961), which was slightly modified by the trial investigators in an unrevealed way for use in a Scottish population.

Functional status: dependency in activities of daily living (ADL), primarily based on requiring assistance of another person

Measures of physical functioning and dependency varied considerably between studies, and data pooling was very limited. The numbers of participants for whom measurements were taken were unclear in several trials, and data were often incomplete. Notably, separate group data were not reported for Jette 1987, and Gilchrist 1988 provided no data on function. In Handoll 2009, we presented long‐term (usually one year) results and also framed mobility outcomes in terms of dependency and reported these together with dependency in ADL. We also combined binary data of poor functional result in survivors with final mortality data to check whether this showed any anomalies (i.e. a group may have fewer deaths but more survivors in poorer health). In this update, we reorganised the ADL outcomes into two categories: a) binary data of non‐recovery or greater dependency in ADL; or b) continuous data for measures of ADL such as the Barthel Index. We report these at short‐term follow‐up (1 to 4 months) for survivors and at longer‐term follow‐up (between 6 to 12 months) for survivors and, where practical, for all participants, including those who had died. Mobility outcomes are presented separately. We have not presented data for ADL at hospital discharge or instrumental ADL in the following.

Binary data for non‐recovery of previous ADL or greater dependency for short‐term follow‐up are presented in Analysis 1.11, and for the converse outcome, regain of previous ADL at short‐term follow‐up, in Analysis 1.12. Binary data for non‐recovery of previous ADL or greater dependency for long‐term follow‐up are presented in Analysis 1.13. Where final value means and SD data are available for the Barthel Index and modifications of this measure, these are presented in Analysis 1.14. Non‐parametric data are shown in Analysis 1.15. Change scores for the Katz Index presented in Sanchez Ferrin 1999 are shown in Analysis 1.16. Separate results for participants who were from nursing homes are presented in Analysis 1.17. Other ADL data are presented narratively below.

Short‐term follow‐up (1 to 4 months)

Pooled data from four trials for greater dependency in ADL favoured the intervention (194/382 versus 218/372; RR 0.87, 95% CI 0.76 to 0.99; I2 = 0%; 754 participants; Analysis 1.11). Analysis 1.12 shows the same findings but recast as a positive outcome as presented in these trials in terms of the regain of former ADL (RR 1.18, 95% CI 1.01 to 1.38). Analysis 1.14 shows that Barthel Index (0 to 20; best outcome) scores at four months also favoured the intervention group for Prestmo 2015 (MD 1.01, 95% CI 0.21 to 1.81; 333 participants) as did the pooled results from two studies for the Chinese Barthel Index (0 to 100; best outcome) at three months (MD 7.57, 95% CI 2.87 to 12.27; I2 = 52%; 285 participants). The clinical importance of these differences is unknown and may only be slight. Watne 2014 (242 participants) found no evidence of a difference in Barthel scores at four months (reported P = 0.8); Analysis 1.15. Three other studies also reported no evidence of between‐group differences. Huusko 2002 (220 survivors) reported the median change from baseline to three months in the Katz Index (0 to "8"; high score means better functional status) was 0 in both groups (reported P value = 0.5). Jette 1987 (maximum 75 participants) reported there were no significant between‐group differences at three months in activities in daily living either in terms of basic activities, instrumental activities, social/role function or emotional function. Naglie 2002 (257 participants) found no between‐group difference in Barthel scores (0 to 100; best function) at three months: 62.0 versus 62.4.
Taken overall, we are very uncertain whether the intervention improves or makes no difference to short‐term function compared with 'usual care'. This is because we rated the available evidence as very low‐certainty, being downgraded one level for serious risk of bias, one level for imprecision and one level for inconsistency; the last reflecting a general view of the variation in the results from the 11 trials reporting this outcome.

We did not use data collected at hospital discharge by Fordham 1986 (binary data for single item ADLs, such as ability to dress the lower half of the body) and Sanchez Ferrin 1999 (same level based on Katz score as before fracture) given the variation in length of follow‐up. Nor did we use the data from Uy 2008: results for the 10 participants followed up in this trial are reported separately below as they were all from nursing homes.

Long‐term follow‐up (usually 12 months)

Reflecting the differences in the derivation in the reported measures, the results for greater dependency in ADL are presented in separate subgroupings in Analysis 1.13. Two trials (238 participants) found the risk of greater dependency based on the survivors' pre‐fracture Katz index was lower in the intervention group (RR 0.64, 95% CI 0.51 to 0.81). While the risk ratio favoured the intervention group, the 95% CIs crossed the line of no effect for Vidan 2005 (252 participants), which defined this outcome on the incomplete recovery of ADL and mobility (RR 0.88, 95% CI 0.71 to 1.09); and the data for Shyu 2013a (269 participants), which defined this outcome on the non‐recovery of independent self‐care ability (RR 0.85, 95% CI 0.64 to 1.14). For each outcome, the result for survivors, combined with mortality data, did not show an anomalous situation where the direction of effect differed between the result for the function in the survivors and the combined outcome (Analysis 1.13). Thus, there was no evidence that where more had died in one group (here, the usual care group) that this had resulted in the survivors in that group having better function overall in contrast to the survivors in the other group (here, the MDR group), which still included those who were frailer and who may not have survived if they had been in the first group.

Analysis 1.14 shows that Barthel Index (0 to 20; best outcome) scores at 12 months favoured the intervention group for Prestmo 2015 (MD 1.13, 95% CI 0.31 to 1.95; 300 participants); data from this trial also appear in Analysis 1.13. The pooled results from two studies at 12 months for the Chinese Barthel Index (0 to 100; best outcome: MD 4.04, 95% CI ‐1.42 to 9.51; I2 = 0%; 293 participants) and the results from Swanson 1998 (60 participants) at six months for a modified Barthel Index (0 to 100; best outcome: MD 6.30, 95% CI ‐0.53 to 13.13) favoured the intervention group but the 95% CIs crossed the line of no effect. The clinical importance of all these differences is unknown and may only be slight. Watne 2014 (242 participants) found no evidence of a difference in Barthel scores at 12 months (reported P = 0.44); Analysis 1.15. Naglie 2002 (241 participants) found no between‐group difference in Barthel scores (0 to 100; best function) at six months: 65.0 versus 65.7.

Sanchez Ferrin 1999 reported no between‐group difference in the losses in ADL as measured by the Katz Index at six months (Analysis 1.16). Huusko 2002 (193 survivors) reported the median change from baseline to one year in the Katz Index (0 to "8"; high score means better functional status) was 0 in both groups (reported P value = 0.5). Jette 1987 (maximum 75 participants) reported there were no significant between‐group differences at 6 or 12 months in activities in daily living either in terms of basic activities, instrumental activities, social/role function or emotional function.

Taken overall, we are very uncertain whether the intervention improves or makes no difference to long‐term function compared with 'usual care'. This is because we rated the available evidence as very low‐certainty, being downgraded one level for serious risk of bias, one level for imprecision and one level for inconsistency; the last reflecting a general view of the variation in the results from the 13 trials reporting this outcome.

Nursing home participants

Analysis 1.17 shows the non‐parametric data for the Barthel Index for participants from nursing homes who were returned back to nursing homes from Uy 2008 (10 participants at 1 and 4 months) and a subgroup from Watne 2014 (73 participants at 4 months, 54 at 12 months). Very little can be made of these data, given the very few and unbalanced number of participants in the two groups of Uy 2008, the different measures used and probable lack of between‐group differences in Watne 2014. The main observation is that these scores are much and expectedly lower than in the overall population of Watne 2014 and those reported in other trials in Analysis 1.14.

Mobility

Data on different aspects of mobility were available in several trials. However, we kept a primary focus on mobility outcomes indicating the need for help from another person at longer‐term follow‐up. Thus, we do not include data on gait speeds or data at hospital discharge, such as those from Fordham 1986, which reported on the numbers able to stand and the numbers able to walk 5 to 10 steps at this stage. We also do not include data from a subgroup of participants (26% of those randomised) in Galvard 1995, which reported all but one participant attending the clinic could walk indoors at one year (38/38 versus 59/60). As well as binary data for greater dependency in walking, we also report on mobility assessed using the Short Physical Performance Battery (SPPB) tool (0 to 12: best mobility).

Pooled data from five trials for greater dependency in mobility measured at 6 or 12 months favoured the intervention (194/382 versus 218/372; RR 0.83, 95% CI 0.71 to 0.98; I2 = 0%; 1085 participants; low‐certainty evidence, downgraded one level for serious risk of bias and one level for imprecision as the 95% CI is wide; Analysis 1.18). Naglie 2002 found no difference in function in terms of transfers. For both outcomes, the result for survivors combined with mortality data did not show an anomalous situation where the direction of effect differed between the result for the function in the survivors and the combined outcome.

SPPB data were available for Prestmo 2015, which found in favour of the intervention at both 4 and 12 months (Analysis 1.19); and for Watne 2014, which reported results for a different population that included nursing home residents. Watne 2014 reported there was no significant between‐group difference at the same follow‐up times (Analysis 1.20). As reported by Prestmo 2015, 1.0 point in the SPPB score is regarded as a substantial meaningful change, and 0.5 points is a small meaningful change. Hence the best estimate and 95% CI reported at 12 months follow‐up for this trial includes a clinically meaningful difference (MD 0.69, 95% CI 0.09 to 1.29; 284 participants). Overall, there is very low‐certainty evidence on whether the intervention improves or makes no difference to mobility assessed using the SPPB compared with 'usual care'. Based on the results from two trials, we downgraded the evidence one level for serious risk of bias, one level for imprecision and one level for inconsistency; although the latter could not be quantified statistically.

Pain

Pain data specific to the injury location were available only for Galvard 1995. However, the results for hip pain when walking, sitting and supine were available for a subgroup of participants at one year (38 (21% of 182 in the intervention group) versus 60 (31% of 196 in the control group). We judged these data were not reliable because of the differences in the participant numbers in the two subgroups.

Other outcomes
Poor outcome at hospital discharge

This is reported above, under 'poor outcome'; Analysis 1.4.

Level of care and extent of support required or provided on discharge (inpatient or from rehabilitation programme)

As explained in Types of outcome measures, we decided not to report on this outcome.

Residential status between 4 to 12 months

Fewer survivors of the intervention group were in institutional, mainly nursing home, care between 6 to 12 months (RR 0.90, 95% CI 0.76 to 1.06; I2 = 6%; 14 studies, 2497 participants; low‐certainty evidence downgraded one level for serious risk of bias and one level for serious imprecision as the confidence interval crosses the line of no effect; Analysis 1.21).

Medical complications (morbidity)

In general, there was variation between the trials in the definition, detection and reporting of medical complications, and ensuring these were distinct from underlying morbidity. The available data for in‐hospital medical complications from five studies (Marcantonio 2001; Sanchez Ferrin 1999; Swanson 1998; Vidan 2005; Watne 2014), or complications during 12 months' follow‐up (Huusko 2002), are presented in Analysis 1.22.

Of note is that delirium in hospital was the sole complication reported on by Marcantonio 2001. Cognitive function and delirium were a key focus of Watne 2014. Pooled results from four trials for this complication were in favour of the intervention group (199/483 versus 239/497; RR 0.85, 95% CI 0.74 to 0.98; 980 participants; low‐certainty evidence downgraded one level for serious risk of bias and one level for serious imprecision (wide confidence interval)). Stenvall 2007a (199 participants) reported significantly fewer participants of the intervention group had post‐operative delirium (reported P = 0.003).

Of the more frequent individual complications for which data were available for analysis, there was very low‐certainty evidence of fewer pressure injuries (RR 0.50, 95% CI 0.35 to 0.70; I2 = 32%; 3 studies, 854 participants) and urinary tract infections (RR 0.61, 95% CI 0.42 to 0.88; I2 = 0%; 2 studies, 535 participants) in the intervention group. The very low‐certainty evidence for participants experiencing any medical complication means that we are uncertain of the finding potentially favouring the intervention (RR 0.91, 95% CI 0.79 to 1.04; I2 = 68%; 3 studies, 891 participants; evidence downgraded one level for serious risk of bias, one level for imprecision (CI crossed the line of no effect) and one level for inconsistency (substantial heterogeneity)).

Accounts of these outcomes by other trials are detailed as follows. Cameron 1993 reported that there were no medical complications that could be directly attributed to the intervention. Huusko 2002 reported there was no difference between the two groups in the numbers of people with "some type of" complication during follow‐up. Prestmo 2015 reported that they had "noted no differences in fracture‐related or other complications during the index stay (data not shown)". Identification of new medical disorders was part of the intervention of Gilchrist 1988, who from an inspection of post‐discharge case records with a full set of investigation results, reported significantly fewer cases of untreated medical conditions in the intervention group (5/88 versus 33/69). Kennie 1988 reported there was no difference between the two groups in the "number of overall illnesses post‐discharge". The active prevention, identification and treatment of medical disorders was part of the intervention in Stenvall 2007a, where significantly fewer participants of the intervention were reported with post‐operative delirium (reported P = 0.003), urinary tract infection (P = 0.005) or pressure ulcers (P = 0.01). Vidan 2005 attributed the reduced overall incidence of medical complications in the intervention group (70 versus 100) to the early identification and daily patient care.

We did not use the total complications data for Baroni 2019 because these were internally inconsistent in the report. Jette 1987 (75 participants), which gave overall population data only on medical complications, reported that "half were confused after surgery", 24 developed urinary tract infection, 19 had heart rhythm disturbances, 14 had pneumonia, 11 had depression, and 5 had congestive heart failure.

Re‐operation (unplanned return to operating theatre) or substantive treatment for an adverse effect

Two studies, Vidan 2005 and Watne 2014, reporting the number of participants incurring a surgical complication, found no evidence of a between‐group difference (RR 0.88, 95% CI 0.54 to 1.42; 2 studies, 638 participants). We did not find data on re‐operations.

Hospital readmission

There was low‐certainty evidence, downgraded one level for serious risk of bias and one level for serious indirectness as duration of follow‐up was mixed and inadequately short in several trials and the reasons for readmission were generally not detailed, of little to no between‐group difference in hospital readmission during follow‐up (RR 0.97, 95% CI 0.84 to 1.12; I2 = 23%; 11 studies, 2538 participants; Analysis 1.23). Swanson 1998 explicitly reported that no readmission was related to the original admission. One intervention group participant who remained in hospital was included in the numerator for Swanson 1998. A similar pattern in the results applied when mortality data (these were deaths in hospital except for Cameron 1993, where results were for mortality at four months) were added to readmission data (RR 0.91, 95% CI 0.78 to 1.05; 8 studies, 1975 participants; Analysis 1.24).

Carer burden

Two studies reported data relating to carer burden (Cameron 1993; Kennie 1988). A separate report of Cameron 1993 found that carer burden prior to fracture was the strongest predictor of subsequent burden, and that carers of people in nursing homes and people with greater cognitive and physical disability were more burdened. Cameron 1993 found that the intervention did not significantly impact on carer burden. In the 12‐month follow‐up of Kennie 1988, no difference in carer burden was reported between the intervention and control groups. Without supporting data or indication of how outcome was assessed, Huusko 2002 reported no differences between the two groups in home nursing, food service or help from others. No extra data were available for carer burden in relation to the mental health of family carers for Shyu 2013a.

Economic outcomes
Length of stay in hospital and hospital readmission

The reported lengths of stay (the majority of studies considered total length of stay), which usually included initial treatment in the orthopaedic unit and subsequent stay in the rehabilitation setting, varied considerably. For example, the range of mean values in the control groups was from 8.7 days in Baroni 2019 to 56 days in Kennie 1988. Lengths of stay in Huusko 2002 were calculated from the day of surgery to the day of discharge, lasting at least two weeks. Where data were presented showing the distribution of lengths of stay, it was clear that they were not normally distributed but, for completeness, we present the available data for 12 studies, ordered by recruitment start dates, in Analysis 1.25. We did not pool these data, given the clearly considerable heterogeneity. Analysis 1.25 shows a mixed picture, where length of stay in the intervention group is clearly shorter in four trials (Cameron 1993; Kennie 1988; Stenvall 2007a; Swanson 1998), and longer in three trials (Galvard 1995; Naglie 2002; Prestmo 2015). There is no evidence of a between‐group difference for the remaining five trials (Baroni 2019; Gilchrist 1988; Sanchez Ferrin 1999; Shyu 2008; Tseng 2019). Of interest is that lengths of stay tend to be shorter over time. However, the data from two trials conducted in Taiwan, where hospital stays are generally short anyway, may exaggerate this impression.

Incomplete data for initial hospital stay are available for six trials. Standard deviations were not available for Fordham 1986 (mean length of stay GORU: 56 days; control: 44 days; no difference reported); and data were presented as medians in Huusko 2002 (median 34 versus 42 days, reported P = 0.05), Vidan 2005 (median 16 versus 18 days, reported P = 0.06); and Watne 2014 (median stay in allocated ward 11 versus 8 days; reported P = 0.001). The length of stay was shorter in both groups in the 102 participants who were returned to their nursing homes (median stay in allocated ward 8 versus 4 days; reported P = 0.001). The distribution of length of stay data in Fordham 1986 also showed more participants of the intervention group (10 versus 4) stayed over 91 days. Jette 1987 reported an overall length of hospital stay of 21 days with no significant difference between the two groups. No between‐group difference in length of stay in the acute hospital setting was reported for Marcantonio 2001 (median 5 days in both groups). Vidan 2005 reported two outliers whose stay was over 100 days.

The total number of days in hospital per participant was 80 in each group of Huusko 2002. There was also no difference in mean stay over six months in institutional care (either acute or rehabilitation hospital or nursing home) in Naglie 2002, which was reported to be 110 days for both groups. Mean hospital stay in Stenvall 2007a over one year was shorter in the intervention group (37.0 versus 51.4 days; reported P = 0.051). Shyu 2013a reported only that the mean hospital stay ranged from 7.93 to 8.47 days in the three groups.

Cost analysis

Five trials reported the results from a cost analysis (Cameron 1993; Fordham 1986; Galvard 1995; Huusko 2002; Prestmo 2015). Cameron 1993, who reported cost outcomes in a separate paper, found that costs (defined as cost per recovered patient) were significantly reduced in the intervention group (10,600 versus 12,800 Australian dollars (AUD)). Costs assessed were direct costs due to treatment and aftercare, up to four months after the fracture. Fordham 1986 concluded that the cost of care per participant (2714 versus 2618 pounds sterling (GBP) at 1985 prices) was slightly greater in the intervention group due to costs generated by travel to the unit. Galvard 1995 reported increased costs for the intervention group (84,537 versus 94,026 Swedish krona at 1989 prices). Though the total direct cost per participant during the first year in the intervention group was estimated at 2000 euros more (1999 prices: 17,900 versus 15,900 euros), Huusko 2002 considered that the costs did not differ remarkably, and furthermore suggested that the costs in the control group were underestimated. Prestmo 2015 noted higher mean index stay (in hospital) costs per participant in the intervention group (2010 prices in euros: 11,868 versus 9537; MD 2331, 95% CI 1483 to 3178; reported P < 0.001). However, after costing for hospital costs after discharge, rehabilitation stay, nursing home stay, and other primary health and care services, Prestmo 2015 reported no significant between‐group difference in the total cost per participant at 12 months (2010 prices in euros: 54,332 versus 59,486; MD ‐5154 favouring the intervention, 95% CI ‐13,311 to 3007; reported P = 0.22). When considered together with the higher QALY (quality‐adjusted life years) results in the intervention group (0.49 versus 0.42; MD 0.07, 95% CI 0.01 to 0.13; reported P = 0.019), Prestmo 2015 reported that the intervention had a 99% probability of being cost‐effective compared with usual care.

Gilchrist 1988 noted that no additional funding had been allocated for the intervention in their trial. An estimate of the cost benefit of the orthopaedic‐geriatrician liaison unit responsible for delivering the intervention in Swanson 1998 was given in the abstract of conference proceedings (Day 1997), but did not appear in the final report.

Subgroup analysis by participant characteristics

Subgroup analyses by participant characteristics were available for Huusko 2002, Marcantonio 2001 and Watne 2014. As argued in Handoll 2009, we considered the data relating to dementia (normal cognition, suspected mild dementia, suspected moderate dementia, suspected severe dementia) presented in a previous report of Huusko 2002 were too compromised to use. Marcantonio 2001 only reported data for delirium split by dementia status. Subgroup data were reported for participants with dementia and those from nursing homes in Watne 2014. As shown in Analysis 1.26, there was no evidence of subgroup differences for mortality at 12 months (test for subgroup differences: Chi² = 0.00, degrees of freedom (df) = 1 (P = 0.99), I² = 0%). Similar findings applied to long‐term mortality when subgrouped by residential status (analysis not shown).

Comparison of different types of inpatient multidisciplinary rehabilitation

Multidisciplinary rehabilitation was provided in both groups of Chong 2013, a quasi‐RCT, which tested the addition of an 'integrated care pathway'. There was no evidence of a difference between the two groups at 12 months in 'poor outcome', defined as dead or with reduced mobility (44/76 versus 35/62; RR 1.03, 95% CI 0.77 to 1.37; very low‐certainty evidence downgraded two levels for very serious risk of bias, particularly selection bias, and one level for serious imprecision; Analysis 2.1). The very low‐certainty evidence means we are also uncertain of the findings of little difference in mortality, inability to walk as before or any nursing home stay post‐discharge (Analysis 2.1). Chong 2013 found no differences between the two groups in the physical or mental component summary scores for SF‐12 quality of life measured at 12 months (Analysis 2.2; very low‐certainty evidence). Similarly, Chong 2013 reported no differences in the changes in the modified Barthel Index over time (Analysis 2.3; very low‐certainty evidence). Overall numbers of participants readmitted to hospital by 12 months were not reported; however, the available data for set times did not show evidence of a difference between the two groups (Analysis 2.4; very low‐certainty evidence). The median length of hospital stay was reported to be significantly lower in the intervention group: 35 days versus 48 days; reported P = 0.009).
 

Ambulatory rehabilitation versus usual care

Seven trials tested rehabilitation in the community setting (Ashe 2019; Crotty 2003; Crotty 2019; Karlsson 2016; Ryan 2006; Singh 2012; Ziden 2008). We pooled data from three of the seven trials in this category as they tested sufficiently similar interventions in comparable settings (Crotty 2003; Karlsson 2016; Ziden 2008); the other four are considered in turn.

Supported discharge and multidisciplinary home rehabilitation versus usual care

While four trials tested this intervention, we pooled data from only three trials (Crotty 2003; Karlsson 2016; Ziden 2008). This is mainly because all participants from Crotty 2019 were from nursing homes, and the multidisciplinary intervention and usual care in the nursing home setting was substantively different from those of the other three trials. Typically, the home rehabilitation lasted between three to four weeks.

Intervention solely or mainly aimed at people living in their own homes

Main outcomes

The available data for poor outcome, mortality, transfer to a higher level of care and inability to walk at three to four months follow‐up are shown in Analysis 3.1, and at 12 months' follow‐up in Analysis 3.2. The very low‐certainty evidence, downgraded one level for serious risk of bias and two levels for very serious imprecision (few events, wide confidence intervals crossing the line of no effect) means we are uncertain of the findings of little or no between‐group difference in poor outcome at three months (RR 1.22, 95% CI 0.63 to 2.39; 1 study, 209 participants) or at one year (38/190 versus 40/187; RR 0.91, 95% CI 0.62 to 1.35; I2 = 0%; 3 studies, 377 participants). The same conclusion of uncertainty of the findings of little to no between‐group difference applies to mortality at three or four months (RR 0.77, 95% CI 0.34 to 1.76; I2 = 0%; 2 studies, 275 participants), and mortality at one year (27/190 versus 26/187; RR 1.00, 95% CI 0.61 to 1.63; I2 = 0%; 3 studies, 377 participants). Based on very few events, there is very low‐certainty evidence of little or no between‐group differences in the inability to walk at three months (RR 2.47, 95% CI 0.68 to 9.02; 1 study, 183 participants) or at 12 months (RR 0.89, 95% CI 0.38 to 2.04; I2 = 14%; 2 studies, 214 participants); or in the move to a higher level of care by 12 months (RR 0.35, 95% CI 0.07 to 1.69; I2 = 0%; 2 studies, 168 participants).

While Crotty 2003 and Ziden 2008 excluded people with dementia, 50% of the participants had dementia in Karlsson 2016. For illustrative purposes only, subgroup analysis split according to whether participants had dementia or not in Karlsson 2016 are shown for poor outcome and mortality at 12 months in Analysis 3.3 and Analysis 3.4. There was no statistically significant differences between the results for participants with or without dementia for either poor outcome (test for subgroup differences (interaction): P = 0.72) or mortality (test for interaction: P = 0.16).

Only Crotty 2003, reporting results for 56 of 66 randomised participants, provided usable data on quality of life: see Analysis 3.5. There is very low‐certainty evidence, downgraded one level for serious risk of bias and two levels for very serious imprecision, of little between‐group difference in quality of life at 12 months assessed using the SF‐36 scores (0 to 100; best quality of life) split by the physical (MD 4.70, 95% CI ‐0.43 to 9.83) and mental (MD 1.50, 95% CI ‐2.88 to 5.88) components. Quality of life was incompletely reported in Ziden 2008, which selectively reported on two domains, physical function and bodily pain, of the eight domains of the SF‐36: these were found to favour the intervention group at 6 and 12 months. We considered these results unreliable when taken out of context in this way. Quality of life assessed via the EQ‐5D data are listed in the trial registration document but not yet reported for Karlsson 2016.

We present further data, from Karlsson 2016 and Ziden 2008, linked with assessment of dependency, in Analysis 3.6 ('Independence in personal activities of daily living (PADL) and outdoor walking', at 3 and 12 months), Analysis 3.7 ('Function (ADL): Barthel index'; non‐parametric data at 3 and 12 months), and Analysis 3.8 ('Daily activities scores at 1 year'; non‐parametric data for FIM (Functional Independence Measure) and FAI (Frenchay Activity Index)). Not presented are findings at four months' follow‐up for Crotty 2003, which found statistically significant differences favouring the intervention group for the modified Barthel Index (median 97.0 versus 94.0; clinical importance not established). The evidence for all these outcomes is very low‐certainty evidence, downgraded one level for serious risk of bias and two levels for very serious imprecision. Thus, we are uncertain of the findings of minimal between‐group difference in independent functioning and mobility, and the Barthel Index findings by Karlsson 2016; the findings in favour of the intervention group for both daily activities scores found by Ziden 2008; and the findings for the modified Barthel Index reported by Crotty 2003.

None of the trials reported on hip or lower‐limb pain.

Other outcomes

All the evidence for the other outcomes is rated at very low certainty, downgraded one or two levels for serious or very serious risk of bias and two levels for very serious imprecision, reflecting few events, small sample sizes and wide confidence intervals.

Ziden 2008 reported all participants were alive at discharge. Six participants in the intervention group did not participate in the home rehabilitation programme: three were discharged to a short‐term nursing home and three to another acute clinic. In the control group, deviation from 'usual care' comprised nine participants discharged to short‐term nursing home care, eight who received community home rehabilitation and four who visited outpatient physiotherapists.

Karlsson 2016 found no evidence of a between‐group difference in the numbers of people incurring a medical complication or who had delirium recorded after hospital discharge (Analysis 3.9).

There was no evidence of a difference in the numbers of participants who were readmitted to hospital within 4 or 12 months (RR 1.20, 95% CI 0.83 to 1.74; I2 = 0%; 2 studies, 265 participants; Analysis 3.10). Thirteen participants, roughly spread between the two groups, had a reoperation in Karlsson 2016; see Analysis 3.10.

Fall and further fracture data from Crotty 2003 (up to 4 months) and Karlsson 2016 (from discharge to 12 months) are presented in Analysis 3.11. There is very low‐certainty evidence of little to no difference between the two groups for these outcomes.

Crotty 2003, reporting on care burden, as rated by the Caregiver Strain Index (CSI: 0 to 12: worst stress), found a one‐point difference in medians at four months (1.0 versus 2.0; maximum number of carers: 21 versus 18) and a three‐point difference at one year (median CSI 1.0 versus 4.0; reported P = 0.02) in favour of the home rehabilitation group.

Economic outcomes

Consistent with a policy of accelerated discharge, participants in the home‐based rehabilitation groups of Crotty 2003 and Karlsson 2016 had shorter stays in hospital. This was by six days in both Crotty 2003 (MD ‐6.50 days, 95% CI ‐11.30 to ‐1.70 days; Analysis 3.12) and Karlsson 2016 (median 17 days (interquartile range (IQR) 12 to 26) versus 23 days (IQR 17 to 32)). Although the mean length of hospital stay was over a day shorter in the home‐based rehabilitation group of Ziden 2008, the data do not confirm a between‐group difference (MD ‐1.60 days, 95% ‐4.59 to 1.39; Analysis 3.12). In all three trials, overall duration of rehabilitation in the intervention group would have been longer, as shown by data from Crotty 2003 (MD 14.00 days, 95% CI 7.84 to 20.16 days). Therapists visited participants of the home‐based group an average of 13.6 times in Crotty 2003, 14.2 times in Karlsson 2016, and 4.9 times in Ziden 2008.

In a separate publication reporting results at one month follow‐up, Ziden 2008 observed that the home rehabilitation group spent 376 fewer days within institutional care (short‐term nursing homes and geriatric clinics) than the usual care group.

Crotty 2003 found there were no statistically significant differences in carer time, GP visits or use of community services at four months.

Intervention for people living in a nursing home setting

Crotty 2019 compared a four‐week ambulatory geriatric multidisciplinary rehabilitation programme delivered in a nursing home with usual care, where treatment was provided according to usual practice in the nursing home. The 240 previously mobile people from 76 nursing homes (nursing care facilities) with hip fracture were discharged from acute hospital at about a week after their injury; most were unable to transfer or were confined to bed at the time of transfer. Follow‐up was reported at four weeks, at the end of the intervention, and one year. The lead trial investigator provided additional mortality data at four months.

Main outcomes

There is low‐certainty evidence, downgraded one level for serious risk of performance bias and one for serious imprecision, of no or minimal between‐group differences at 12 months in 'poor outcome', defined as dead or unable to walk (82/119 versus 80/121; RR 1.04, 95% CI 0.87 to 1.24), mortality (58/119 versus 52/121; RR 1.13, 95% CI 0.86 to 1.49), or survivors who were unable to walk (24/61 versus 28/69; RR 0.97, 95% CI 0.64 to 1.48); see Analysis 4.1. At four weeks, there was very low‐certainty evidence of fewer deaths in the intervention (10 versus 22; RR 0.46, 95% CI 0.23 to 0.93). However, this difference was gradually lost, and there was low‐certainty evidence of no or very little between‐group difference by four months (35 versus 34 deaths; RR 1.05, 95% CI 0.70 to 1.56); see Analysis 4.2.

The large loss to follow‐up, predominantly from death at one year, means that the certainty of evidence is very low for quality of life, dependency, mobility and pain data for survivors at one year. Thus, we are very uncertain of the findings of a very slightly better self‐reported quality of life in the intervention group when measured via the DEMQOL (12 to 112; best QoL) (MD 7.40, 95% CI 2.38 to 12.42; 70 participants) and, conversely, of very little between‐group difference in favour of the control group when measured via the DEMQOL‐Proxy (31 to 124; best QoL) (MD ‐3.20, 95% CI ‐6.94 to 0.54; 126 participants); see Analysis 4.3. The data for the EQ‐5D are more complete, as these include deaths, which were set at zero. While the data show a small quantitative difference in favour of the control group (MD ‐0.06, 95% CI ‐0.12 to ‐0.00; 235 participants; Analysis 4.4), the difference is unlikely to be clinically important (Walters 2005).

We are uncertain of the findings of minimal between‐group difference in functional dependency assessed using the modified Barthel Index (0 to 100: total independence in personal care) at four weeks (MD 0.90, 95% CI ‐4.51 to 6.31; 202 participants) or at one year (MD ‐4.90, 95% CI ‐11.69 to 1.89; 125 participants); see Analysis 4.5. Mobility, measured using the Nursing Home Life‐Space Diameter (0 bed/chair‐bound to 50 leaving the facility daily), was slightly higher at one month in the intervention group, but it is unknown whether this small difference is clinically important (MD 1.90, 95% CI 0.56 to 3.24; 203 participants; Analysis 4.6). There was no evidence of a between‐group difference in this outcome at one year (MD 0.30, 95% CI ‐1.40 to 2.00; 126 participants; Analysis 4.6).

There was no evidence of a between‐group difference in pain, assessed using the Pain Assessment In Advanced Dementia scale (0 to 10; severest pain) at four weeks or at one year; see Analysis 4.7.

Other outcomes

There is very low‐certainty evidence of a greater number of people in the intervention group who fell in the first four weeks (Analysis 4.8). The numbers of fall‐related hospital admissions (27 in all) and of hip fractures (4 in all) were too small to draw conclusions (Analysis 4.8).

Economic analysis

The mean per participant 12‐month Australian Medicare costs at 2015/16 unit prices were AUD 2076 higher in the intervention group than in the control arm, but these differences were reported not to be statistically significant (reported 95% CI AUD ‐220 to 4360); see Analysis 4.9. Crotty 2019 based their cost‐effectiveness analysis on the DEMQOL data at one year; notably these were statistically in favour of the intervention group, unlike those for DEMQOL‐Proxy or EQ‐5D data. The incremental cost‐effectiveness ratio (ICER) was reported at AUD 328,685 per QALY gained (95% CI 82,654 to 75,007,056). Crotty 2019 noted that, given that this ICER is substantially greater than the implicit cost‐effectiveness threshold of AUD 50,000 per QALY gained currently applied by regulatory bodies in Australia, the intervention would not be considered cost‐effective.

Intensive compared with less intensive multidisciplinary home rehabilitation

Ryan 2006 compared intensive with less intensive home‐based multidisciplinary rehabilitation, lasting a maximum of 12 weeks, in a subgroup of 71 people who had been recently discharged from hospital after hip fracture surgery. (The other subgroup included in Ryan 2006 comprised 89 people recovering from stroke.) The evidence for all reported outcomes for the hip fracture subgroup is of very low certainty, downgraded one level for risk of bias and two levels for serious imprecision. There is no evidence of differences between the two groups of hip fracture participants in any of the measured outcomes. The data for 'poor outcome' (mortality or institutional care at 12 months), mortality and institutional care are presented in Analysis 5.1. The findings for quality of life measured using the EQ‐5D, dependence assessed via the Barthel Index, and activity assessed via the Frenchay Activities Index at 3 and 12 months are shown in Analysis 5.2. Of note in terms of the population, is that the median values of the Barthel Index were at the top end of the range at three months, having been 16 and 17 at baseline in the two groups. Mobility and pain were not reported. Intensification of intervention was based on at least doubling the number of contacts made by the multidisciplinary team per week. This aim was not achieved, although statistically significantly more visits were made to the intervention group (see Analysis 5.3: mean difference 6.50 visits; 95% CI 3.01 to 9.99).

Multidisciplinary care, including progressive resistance training for one year, versus usual care

Singh 2012 randomised 124 participants to 12 months of geriatrician‐led multidisciplinary care, including high‐intensity weight‐lifting exercise, in an outpatients hospital programme and targeted treatment of frailty at outpatients and home, or usual rehabilitation care. Follow‐up was 12 months after the fracture – thus, at the end of the intervention. All results were very low‐certainty evidence, downgraded one level for risk of bias and two levels for imprecision, reflecting low numbers of events and wide confidence intervals.

The available data for poor outcome, mortality and nursing home admission at 12 months are shown in Analysis 3.1. At 12 months, fewer intervention group participants had a poor outcome (dead or in institutional care) than in the control group (7/62 versus 16/62; RR 0.44, 95% CI 0.19 to 0.99); had died (4/62 versus 8/62); or were in institutional care (5/62 versus 12/62).

Basic activities of daily living (ADLs) measured using the Katz ADL Index (0 to 12; higher scores = greater dependency) were marginally better in the intervention group at 12 months (mean 0.5 versus 1.0); the reported adjusted mean difference also favoured the intervention group (MD ‐0.09, 95% CI ‐1.9 to 0.2; reported P = 0.06).

Singh 2012 (99 participants) reported assistive device use was "significantly lower at 12 months (P < 0.02) in the intervention group" but did not provide details of the continuous measure used.

Singh 2012 found no evidence of a difference between the two groups in ALSAR: Assessment of Living Skills And Resources scores; either relating to skills or to resource availability (scores 0 to 22; lower scores = better outcome); data for 99 participants; Analysis 6.2.

Post‐discharge multidisciplinary clinic, with referral for further rehabilitation as necessary, versus usual care

Ashe 2019 compared a post‐discharge geriatrician‐led multidisciplinary clinic, with referral for further rehabilitation as necessary, with usual care, in 53 community‐dwelling older adults who were on average 32.5 weeks (range 3 to 12 months) post‐fracture. Currently, only very limited outcome data on physical activity and sedentary behaviour are available for this study (Zusman 2019); none of the reported outcomes feature in those presented in this review. We received confirmation that no participants died or moved to residential care during the study, although data were missing for one participant in the intervention group (Analysis 7.1).

Care in both settings

As per our protocol, we pooled the data from both settings as an exploratory analysis. However, we restricted the data from the ambulatory setting to supported discharge and own‐home‐based rehabilitation. Inclusion of data from Crotty 2003, Karlsson 2016 and Ziden 2008, where the care in the intervention group was predominantly at the participant's own home, made very little difference (RR 0.89, 95% CI 0.80 to 0.98; I2 = 0%; 16 studies, 3413 participants; Analysis 8.1) to the results for 'poor outcome' at long‐term follow‐up. (Those for inpatient rehabilitation only are: RR 0.88, 95% CI 0.80 to 0.98; 13 studies, 3036 participants.) Of note is that the exploratory subgroup analysis by type of intervention (GORU, HFP, MARU, OG programme; and supported discharge and home‐based rehabilitation) showed no evidence of subgroup differences (test for interaction: P = 0.39; I2 = 2.5%). Similar observations apply to pooled data for mortality at the end of scheduled follow‐up (RR 0.92, 95% CI 0.81 to 1.05; I2 = 0%; 21 studies, 4350 participants; Analysis 8.2) compared with inpatient data only (RR 0.91, 95% CI 0.80 to 1.05; I2 = 0%; 18 studies, 3973 participants; Analysis 1.5).

Discussion

Summary of main results

This updated review includes 28 trials involving a total of 5351 randomised participants, almost all of whom had undergone surgery for hip fracture. Four trials included women only, and women were in the majority for the other 24 trials. The mean age of trial participants ranged from 76.5 years to 87 years. Care was provided in an inpatient setting – thus, before hospital discharge – for both intervention groups in 21 trials. Care was provided predominantly or exclusively in the community (ambulatory rehabilitation) for the other seven trials. One of the 21 inpatient trials compared two different types of multidisciplinary rehabilitation.

Inpatient multidisciplinary rehabilitation versus usual care

The evidence for this comparison in this setting, which was tested by 20 trials, is summarised in summary of findings Table 1.

  • There is moderate‐certainty evidence (data from 13 studies) that multidisciplinary rehabilitation in an inpatient setting results in fewer cases of 'poor outcome' (death or deterioration in residential status, generally requiring institutional care) at 6 to 12 months' follow‐up. Based on an illustrative risk of 347 people with hip fracture with poor outcome in 1000 people followed up between 6 and 12 months (data based on the median control group risk data from the 13 studies), this equates to 41 (95% CI 7 to 69) fewer people with poor outcome after multidisciplinary rehabilitation. Expressed in terms of numbers needed to treat for an additional harmful outcome (NNTH), 25 people (95% CI 15 to 100) would need to be treated to avoid one 'poor outcome'. Subgroup analysis by type of intervention showed no evidence of subgroup differences. The very low‐certainty evidence means we have very little confidence in findings from one trial of a marginally better quality of life in the multidisciplinary rehabilitation group. Of note, however, is that the Hip Fracture Programme was tested in eight of these studies, including three of the four recently completed studies.

  • There is low‐certainty evidence (data from 11 studies) that multidisciplinary rehabilitation in an inpatient setting may result in fewer deaths in hospital but could also result in slightly more. Based on an illustrative risk of 75 people with hip fracture dying in hospital in 1000 people followed up until hospital discharge (data based on the median control group risk data from the 11 studies), this equates to 17 fewer (95% CI 31 fewer to 3 more) people dying in the multidisciplinary rehabilitation group.

  • There is low‐certainty evidence (data from 18 studies) that multidisciplinary rehabilitation in an inpatient setting may result in fewer deaths at 4 to 12 months' follow‐up but could also result in slightly more. Based on an illustrative risk of 182 people with hip fracture dying in hospital in 1000 people followed up (data based on the median control group risk data from the 18 studies), this equates to 16 fewer (95% CI 36 fewer to 10 more) people dying in the multidisciplinary rehabilitation group. Subgroup analysis by type of intervention showed no evidence of subgroup differences.

  • The evidence based on a variety of measures in 11 trials for assessing greater dependence in personal activities of daily living at one to four months' follow‐up was of very low certainty. This means we have very little confidence in the mixed findings of some or no difference from multidisciplinary rehabilitation on dependence in activities of daily living in survivors.

  • A similar conclusion applied for evidence from 13 studies on greater dependence in personal activities of daily living at 6 to 12 months' follow‐up.

  • There is low‐certainty evidence (data from 5 studies) that multidisciplinary rehabilitation in an inpatient setting may result in less decline in mobility in survivors at 6 to 12 months' follow‐up. Based on an illustrative risk of 403 people with hip fracture with greater dependency in mobility in 1000 people followed up between 6 and 12 months (data based on the median control group risk data from the 5 studies), this equates to 68 (95% CI 8 to 116) fewer people with poorer mobility after multidisciplinary rehabilitation.

  • There was no evidence on long‐term hip‐related pain.

  • We included delirium in hospital, when delirium or confusion was documented as a complication, as an extra critical outcome given the growing awareness of the importance of delirium in this setting. There is low‐certainty evidence (data from 4 studies) that multidisciplinary rehabilitation in an inpatient setting may result in fewer cases of delirium in hospital.

Comparison of different types of inpatient multidisciplinary rehabilitation

The only study comparing different types of inpatient multidisciplinary rehabilitation tested the effects of adding an 'integrated care pathway' to multidisciplinary rehabilitation. This quasi‐RCT of 162 participants provided very low‐certainty evidence, which means we have very little confidence in findings of little to no between‐group differences in 'poor outcome', mortality, inability to walk as before or any nursing home stay post‐discharge, quality of life, and dependency.

Ambulatory rehabilitation

We reported on four comparisons – one of which was split according to participants' former residence – tested in seven trials. Five of these trials were newly included in this update. The comparisons are considered below.

Supported discharge and multidisciplinary home rehabilitation versus usual care
Intervention solely or mainly aimed at people living in their own homes

The evidence for this comparison in this setting, which was tested by three trials, is summarised in summary of findings Table 2. The very low‐certainty evidence, where the wide confidence intervals crossed the line of no effect, means that we have very little confidence in the findings of little to no between‐group difference in 'poor outcome' (mortality or move to a higher level of care or inability to walk) at one year (3 studies, 377 participants); in quality of life at one year (1 study, 56 participants); in mortality at four months (2 studies, 275 participants) or at 12 months (2 studies, 214 participants); in being independent in personal activities of daily living (data presented for 1 study, 159 participants); in a permanent move to a higher level of care (2 studies, 168 participants); or being unable to walk (2 studies, 214 participants). None of the trials reported on hip or lower‐limb pain.

Intervention for people living in a nursing home setting

The evidence for this comparison in this setting, which was tested by one trial of 240 participants, is summarised in summary of findings Table 2. There is low‐certainty evidence that there may be no or minimal between‐group differences at 12 months in 'poor outcome' defined as dead or unable to walk; or in mortality at 4 months or at 12 months. The very low‐certainty evidence for the remaining outcomes reflected the large loss to follow‐up, predominantly from death. This means we have very little confidence in the findings of no between‐group differences in quality of life at 12 months (125 participants); dependency at 4 weeks (202 participants) or at 12 months (125 participants); inability to walk at 12 months (130 participants); or pain at 12 months (126 participants).

Intensive with less intensive multidisciplinary home rehabilitation

An intervention that aimed to double the number of weekly contacts at the patient's home from a multidisciplinary rehabilitation team was tested by one trial that included 71 participants recently discharged from hospital after hip fracture surgery. The very low‐certainty evidence available for this comparison means that we have very little confidence in the lack of between‐group differences in 'poor outcome', mortality, quality of life, and dependency in activities of daily living at one year follow‐up. Mobility and pain were not reported. Of note is that the aimed doubling of the number of contacts in the intervention group was not achieved.

Multidisciplinary care, including progressive resistance training for one year, versus usual care

This was tested in one trial that included 124 participants. The very low‐certainty evidence, where the wide confidence intervals typically crossed the line of no effect, means that we have very little confidence in the findings that marginally favoured the intervention for 'poor outcome', death, or survivors in institutional care, basic activities of daily living or use of assistive devices. Quality of life and pain were not reported.

Post‐discharge multidisciplinary clinic, with referral for further rehabilitation as necessary, versus usual care

This intervention, which started between 3 and 12 months post‐fracture, was tested in one trial of 53 community‐dwelling older adults. Aside from receiving confirmation that no participants died or moved to residential care during the study, there are as yet no data available on outcomes relevant to this review.

Overall completeness and applicability of evidence

Completeness of the evidence

The review now includes 28 trials involving a total of 5351 randomised participants. Focusing on the three main comparisons presented in the summary of findings tables:

  • of the 20 trials that compared multidisciplinary rehabilitation versus usual care in the inpatient setting, data for 'poor outcome' at final follow‐up were available for only 13 trials and 72% of participants (3036/4214). Data were most complete for long‐term mortality (18 trials, 3973 participants); only available for three trials for quality of life measures; and not available for long‐term hip pain. Dependence in activities of daily living was reported for 11 trials up to 4 months, and 13 trials at long‐term follow‐up. However, the variety and incompatibility of measures, as well as incomplete data for dependence in activities of daily living, substantially reduced the potential for pooling.

  • of the three ambulatory rehabilitation trials, involving 377 participants, that compared supported discharge and multidisciplinary rehabilitation versus usual care for home dwellers, complete data were available for 'poor outcome' (although a different definition of this outcome was accepted for one trial), and long‐term mortality. Only one of these trials, reporting data for 56 participants, reported on quality of life. Again, no data were available for hip pain.

  • data were available for all main outcomes for the other ambulatory rehabilitation trial that tested a similar intervention, but in a nursing home setting. However, there was a large loss to follow‐up, predominantly from death, in this trial.

Applicability of the evidence

The characteristics of multidisciplinary rehabilitation and 'usual care' varied considerably in the 28 included trials, and all findings need to be viewed in the context of the clinical heterogeneity of the trial interventions, trial populations and outcome measurement. Our observation in Handoll 2009, that the included trials are "a disparate group", still applies. Nonetheless, all study populations fit with the general characteristics, in terms of age and gender, of the typical population of older people with hip fracture, and the interventions are consistent with the broad conceptual basis of multidisciplinary rehabilitation, where rehabilitation is delivered by a multidisciplinary team, supervised by a geriatrician, rehabilitation physician or other appropriate physician. In the following, we consider applicability in terms of participants, interventions and outcomes.

COVID‐19 pandemic

All included trials were conducted before the onset of the COVID‐19 pandemic. In our view, the basic characteristics in terms of population, interventions and outcomes remain as before. However, the typical population for hip fracture is the one most vulnerable to the serious consequences of COVID‐19, as illustrated by Hall and colleagues’ finding that COVID‐19 was independently associated with a threefold increased 30‐day mortality rate for this population in Scotland (Hall 2021). Hall 2021 noted that length of stay was the only modifiable risk factor for infection, highlighting "the importance of high‐quality and timely care in this patient group". In some countries, where COVID‐19 has largely been contained, care of this vulnerable population is essentially as before but in others, the impact of COVID‐19 on health and social care systems has been immense, and inevitably has impacted and will continue to impact the access to appropriate care for these individuals. It has been estimated that existing rehabilitation services in 60% to 70% of countries have been disrupted due to the COVID‐19 pandemic (WHO 2020).

Populations

To aid consideration of the representativeness of the study populations, we prepared a table featuring key characteristics; see Appendix 9. In our judgement of the representativeness (see 'Target population'), we considered this applied to all studies except Jette 1987, where there was not enough information to be certain. However, for many studies, the population represented a key subgroup. For example, all participants of Tseng 2019 had diabetes, and all participants in Crotty 2019 and Uy 2008 were nursing home residents. Being able to walk, return to living at home, having adequate cognition (absence of dementia), or one or more of these, also defined key subpopulations, particularly for some ambulatory rehabilitation trials. The typical living situation for older people also varies between countries, and we noted in Appendix 9 the possibility of more home dwellers in Italy (Baroni 2019) than in some other countries (e.g. the UK). The same observation applies to the studies based in Taiwan (Shyu 2008; Shyu 2013a; Tseng 2019), where we also emphasised that "Taiwan differs substantially in case mix, culture and social organisation from 'Western' societies".

Interventions

When revising our protocol for this update, we set out a plan to collect data on the key components of the multidisciplinary rehabilitation tested in the included trials, in order to examine and summarise these in terms of common components. To this end, we developed a pro forma, with a primary focus on team members and treatment components, and piloted the pro forma on six studies. Our pilot showed that this was a substantial project, which was not essential for the review and, moreover, could seriously impede the review's completion. Additionally, the pilot and consideration of other trials indicated that under‐reporting of the intervention and control groups, especially in older trials, was a serious problem, as well as the clinical heterogeneity in the trial settings. The under‐reporting is also illustrated in Appendix 10, which summarises the information on key items of early treatment of hip fractures, with a particular focus on assessing how representative these are in current practice.

More recent trials have provided more detailed accounts of the interventions and standard care. Notable are Prestmo 2015, where the development and delivery of patient treatment for the 'Trondheim Hip Fracture Trial' are reported in Saltvedt 2012; and Crotty 2019, where the usual care provided in nursing homes was described in Killington 2020.

Whilst we have provided a classification of different types of multidisciplinary rehabilitation programmes, the subgroup analyses do not show differences in outcomes by type of programme, and the overall analyses do not show evidence of important heterogeneity.

Inpatient care is provided in the hospital setting in the included trials. However, models of treatment have been developed whereby the intervention can be provided in a variety of settings. These can range from a ward providing acute hospital treatment and early rehabilitation (for example, the Trondheim Hip Fracture Trial) to an area in a care home where specialised rehabilitation is provided (for example, this is common in the Netherlands). The pressure to reduce length of stay in the acute setting is likely to influence this trend. Future iterations of this review will need to address these and other developments to the intervention.

Outcomes

The issues relating to applicability of outcomes revolve mainly round availability and data incompleteness. This particularly applied to quality of life and functional outcomes. However, poor definitions of outcome measurement, presentation of data for components – rather than overall results – of tools, such as the SF‐36, and use of modified or non‐validated scales also hamper assessment of applicability. Of note is that non‐return to pre‐fracture function or mobility can also be problematic as it is susceptible to measurement error at baseline from recall or at time of assessment. There is scope for standardisation for activities of daily living; some have proposed use of the Barthel Index rather than the Katz Index on account of the former's better score distribution (Liem 2013). Overall, the ability to investigate specific outcomes (such as mobility) that are relevant to older people is very limited, due to the lack of inclusion of suitable measures in the trials.

Certainty of the evidence

We have reported our judgements on the GRADE certainty of evidence in our accounts for all comparisons in Effects of interventions and restated these in the summary of findings tables for three comparisons. The gradings ranged from 'moderate certainty', where we are moderately confident in the effect estimate, for one outcome alone ('poor outcome'; summary of findings Table 1), through to 'very low certainty', where we have very little confidence in the effect estimate, for the majority of outcomes.

We downgraded all evidence one level for study limitations that could or would result in serious risk of bias. Although most trials appeared well designed – an impression sometimes enhanced upon gaining additional information from trial investigators – all were at unclear or at high risk of bias for some domains, notably blinding‐related and incomplete data domains, and possible confounding related to potential or known imbalances in key baseline characteristics (e.g. cases with dementia in Huusko 2002; a younger treatment group with higher cognitive function in Kennie 1988). Some questions remained unanswered on conduct of some trials, including those relating to performance and contamination biases.

We downgraded the evidence for most outcomes either one or two levels for serious or very serious imprecision. This was typically because of insufficient data, such as few events, wide confidence intervals, or both.

We rarely downgraded for serious inconsistency. Notably, where pooling was performed, the I2 values were very low and indicated unimportant heterogeneity at most. In assessing the mixed outcome measurement evidence for dependency in activities in daily living for the first comparison, we downgraded the evidence one level for serious inconsistency based on a general view of the variation of effect in the results from the group of trials reporting this outcome (summary of findings Table 1).

We downgraded for indirectness in a very few cases. For example, we judged 'poor outcome' at hospital discharge was vulnerable to issues related to indirectness and bias, such as differences in discharge policies and supply of alternative accommodation, that hindered applicability of the results.

We did not downgrade for publication bias. Inspection of funnel plots for 'poor outcome' (13 trials) and mortality at 4 to 12 months for our first comparison did not indicate publication bias (plots not shown). Data for other comparisons were not available to assess this.

Potential biases in the review process

Given the sustained effort over the years in searching for trials in this area, and the continued involvement of one author (IC) and his colleagues in primary research, we think it is unlikely that we have overlooked fully published trials in this relatively slow‐moving research area. It is hard to ascertain whether we have missed unpublished trials, including any in non‐English reports. The need to obtain clarification on the trial status of Baroni 2019 (included), Baroni 2016 (in Studies awaiting classification), and multiple publications, including abstracts, over several years for several trials illustrates how problematic the literature in this area can be.

Whilst we consider that we have included and excluded trials appropriately, it was sometimes hard to decide whether (included) trials evaluated multidisciplinary rehabilitation or not. To some extent, consideration of what we would accept as a legitimate intervention when adjusting the scope of our review for this update (as described in Differences between protocol and review) made this easier. This was mainly because we relaxed our criteria regarding the role of the geriatrician or rehabilitation physician, and accepted that whilst there should be a strong component of physician involvement, often relating to assessment, it did not have to continue subsequently. This resulted in the inclusion of Sanchez Ferrin 1999, which was excluded in the previous version of our review (Handoll 2009). We protected against bias related to inappropriate study selection decisions through independent study selection by two review authors and arbitration where required.

Despite the clear heterogeneity of trial comparisons, populations, outcome assessment and some aspects of trial quality, we pooled data for several 'hard' outcomes provided by the trials comparing multidisciplinary rehabilitation with usual care in the inpatient setting. This activity in itself is not a potential bias in the review process, but we acknowledge that it does hamper interpretation and considerations of external validity. Sensitivity analyses did not show important differences in findings. Whilst performed in a limited and exploratory way for different types of multidisciplinary rehabilitation, we acknowledge there were insufficient data for this and for the examination of the effects of clinical heterogeneity through subgroup analysis.

In this version of the review, we have extended our focus to various measures of function and independence, that we had acknowledged had received less attention than merited (Handoll 2009). Nonetheless, as anticipated, the data for the various validated measures of function in use are generally missing or incomplete and, where available, only limited pooling was possible and appropriate. Whilst unlikely to be a source of bias, we took care in our selection of which measures to summarise for outcomes, such as extent of dependence in activities of daily, measured in a variety of ways, and took into account the evidence and claims from all trials reporting an outcome.

A strength of the review is the often successful acquisition of extra data and details from trial investigators. This can add to the complexity of the data extraction and checking processes, and lead to disparities between the published and subsequently provided data. In this review, this process has reinforced the perception of the inherent dangers of reporting percentages without the data from which they are derived.

Agreements and disagreements with other studies or reviews

This review stems from Handoll 2009, which in turn stemmed from Cameron 2001, of which the fourth update appeared in Issue 2, 2003 of the Cochrane Library. We noted in Handoll 2009 that, despite the accumulation of evidence, our conclusions had remained consistent with those of Cameron 2001; namely: "While there is no conclusive evidence of the effectiveness of multidisciplinary inpatient rehabilitation following hip fracture surgery in older people, there is a trend towards effectiveness in all main outcomes." Our current review has been expanded in scope, with some re‐evaluation of the inclusion criteria and updating of review methods, including the incorporation of GRADE for assessing the certainty of the evidence. The addition of data for 'poor outcome' from five, and for long‐term mortality from seven, of the nine newly included studies with 'usual care' controls conducted in the inpatient setting, has strengthened the evidence, such that we are now 'moderately confident' that multidisciplinary rehabilitation reduces the risk of 'poor outcome'. Also of note is the relative increase in the number of trials of ambulatory rehabilitation from two to seven.

In Handoll 2009, we referred to an earlier systematic review by Halbert 2007, which had concluded that people who received multidisciplinary rehabilitation were at lower risk of a poor outcome, defined as death or admission to a nursing home at discharge from rehabilitation. Our observation at the time, in terms of the timing of outcome measurement, still holds: "Our review focused on long‐term outcome, which ranged between four months and one year, but crucially was less susceptible to differences in discharge policies or practicalities between intervention groups in individual trials." We noted also that while Halbert 2007 had pooled data from Crotty 2003 with those from the inpatient rehabilitation trials, we had received feedback at the protocol stage for our review that had persuaded us that we should only pool from different settings in an exploratory way. Our exploratory analysis for this review update showed that adding data from the three ambulatory rehabilitation trials, including Crotty 2003, which tested supported discharge and own‐home‐based rehabilitation, to those of the inpatient rehabilitation trials made almost no difference for either poor outcome or long‐term mortality.

We note here two recent reviews: Moyet 2018 and Nordstrom 2018. Moyet 2018, which investigated orthogeriatric models of care, included 18 studies of mixed designs; the four included RCTs are also included in our review (Gilchrist 1988; Huusko 2002; Vidan 2005; Watne 2014). Nordstrom 2018 conducted a meta‐analysis of the effects of rehabilitation by geriatric interdisciplinary teams for people with hip fracture, and reported that the intervention "increases physical function and mobility significantly compared with conventional care" but that discharge "to one’s own home and survival are not influenced". Nordstrom 2018 included seven studies, of which six are included in our review (Huusko 2002; Naglie 2002; Prestmo 2015; Stenvall 2007a; Vidan 2005; Ziden 2008). The other study, a quasi‐RCT, was excluded from our review because of compromised methods (Gonzalez‐Montalvo 2010). Ziden 2008 was considered to be conducted in an ambulatory setting in our review.

We found insufficient data to perform viable subgroup analysis of 'poor outcome' or mortality, according to participant cognitive function. A related Cochrane Review on enhanced rehabilitation and care models for adults with dementia following hip fracture surgery was updated in 2020 (Smith 2020). This reported evidence from a total of 555 participants with dementia or cognitive impairment included in seven trials investigating models of care for all older people following hip fracture. Six of these trials (where different, study IDs in Smith 2020 are in brackets) are included in our review: Huusko 2002 (Huusko 2000); Marcantonio 2001; Shyu 2008 (Shyu 2012); Stenvall 2007a (Stenvall 2012); Uy 2008; Watne 2014 (Wyller 2012). Smith 2020 found low‐certainty evidence that "some of the models of enhanced rehabilitation and care used in the included trials may show benefits over usual care for preventing delirium and reducing length of stay for people with dementia who have been treated for hip fracture". The certainty for all other results was very low. Smith 2020 proposed that determining "the optimal strategies to improve outcomes for this growing population of patients should be a research priority".

Hip fracture rehabilitation services – programme components (extract from Sheehan 2019)

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Figure 1

Hip fracture rehabilitation services – programme components (extract from Sheehan 2019)

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Study flow diagram for the first phase of the search update 2009 to January 2016 (former scope)

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Figure 2

Study flow diagram for the first phase of the search update 2009 to January 2016 (former scope)

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Study flow diagram for the second phase of the search updates up to February/March 2019, November 2019 and October 2020 (revised scope)

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Figure 3

Study flow diagram for the second phase of the search updates up to February/March 2019, November 2019 and October 2020 (revised scope)

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Summary of review authors' assessments (+ = low; ? = unclear; ‐ = high risk of bias) for aspects of study conduct for individual trials

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Figure 4

Summary of review authors' assessments (+ = low; ? = unclear; ‐ = high risk of bias) for aspects of study conduct for individual trials

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Multidisciplinary inpatient rehabilitation versus usual care: 'Poor outcome' (long‐term follow‐up at 6 or 12 months)

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Figure 5

Multidisciplinary inpatient rehabilitation versus usual care: 'Poor outcome' (long‐term follow‐up at 6 or 12 months)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 1: 'Poor outcome' (long‐term follow‐up at 6 or 12 months)

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Analysis 1.1

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 1: 'Poor outcome' (long‐term follow‐up at 6 or 12 months)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 2: 'Poor outcome' (long‐term follow‐up): subgrouped by intervention type

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Analysis 1.2

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 2: 'Poor outcome' (long‐term follow‐up): subgrouped by intervention type

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 3: 'Poor outcome' (long‐term follow‐up) by selection bias

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Analysis 1.3

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 3: 'Poor outcome' (long‐term follow‐up) by selection bias

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 4: 'Poor outcome' (at discharge)

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Analysis 1.4

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 4: 'Poor outcome' (at discharge)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 5: Mortality (end of scheduled follow‐up: 4 to 12 months)

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Analysis 1.5

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 5: Mortality (end of scheduled follow‐up: 4 to 12 months)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 6: Mortality (end of scheduled follow‐up) ‐ with 12 month data for Cameron 1993

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Analysis 1.6

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 6: Mortality (end of scheduled follow‐up) ‐ with 12 month data for Cameron 1993

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 7: Mortality (end of scheduled follow‐up): subgrouped by intervention type

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Analysis 1.7

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 7: Mortality (end of scheduled follow‐up): subgrouped by intervention type

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 8: Mortality (at discharge)

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Analysis 1.8

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 8: Mortality (at discharge)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 9: Quality of life: EQ‐5D (‐0.594: worse than death, 0: dead to 1: best quality)

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Analysis 1.9

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 9: Quality of life: EQ‐5D (‐0.594: worse than death, 0: dead to 1: best quality)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 10: Quality of life: SF‐36 (Taiwan version) (each domain: 0 to 100; best quality) at 1 year

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Analysis 1.10

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 10: Quality of life: SF‐36 (Taiwan version) (each domain: 0 to 100; best quality) at 1 year

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 11: Greater dependency in ADL up to 4 months

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Analysis 1.11

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 11: Greater dependency in ADL up to 4 months

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 12: Regain in former level of ADL independence in the short term (up to 4 months)

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Analysis 1.12

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 12: Regain in former level of ADL independence in the short term (up to 4 months)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 13: Greater dependency in ADL in the long term (6 to 12 months)

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Analysis 1.13

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 13: Greater dependency in ADL in the long term (6 to 12 months)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 14: ADL: Barthel scores (higher scores = greater independence)

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Analysis 1.14

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 14: ADL: Barthel scores (higher scores = greater independence)

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ADL: Barthel Index (0 to 20; best outcome)

Study

Scale and timing

MDR (Median (N))

MDR (IQR)

Usual care (Median (N))

Usual care (IQR)

P‐value

Watne 2014

At 4 months

17 (121)

IQR: 10 to 20

16 (121)

IQR: 12 to 20

0.80

At 12 months

17 (98)

IQR: 9.5 to 19

16 (95)

IQR: 11 to 19

0.44

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Analysis 1.15

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 15: ADL: Barthel Index (0 to 20; best outcome)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 16: Loss in activities of daily living at 6 months (Katz index; 6 maximum)

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Analysis 1.16

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 16: Loss in activities of daily living at 6 months (Katz index; 6 maximum)

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ADL: Barthel Index (participants who were from nursing homes)

Study

Scale and timing

MDR (Median (N))

MDR (Range or IQR)

Usual care (Median (N))

Usual care (Range or IQR)

Uy 2008

Index (0 to 100; best outcome)

at 1 month

37 (3)

Range: 10 to 88

14 (7)

Range: 5 to 60

Index (0 to 100; best outcome)

at 4 months

68 (3)

Range: 0 to 88

28 (7)

Range: 0 to 82

Watne 2014

Index (0 to 20; best outcome)

at 4 months

8 (35)

IQR: 4 to 13

11 (38)

IQR: 5.5 to 14

Index (0 to 20; best outcome)

at 12 months

8 (26)

IQR: 4 to 11.5

9 (28)

IQR: 4 to 14

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Analysis 1.17

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 17: ADL: Barthel Index (participants who were from nursing homes)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 18: Greater dependency in mobility

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Analysis 1.18

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 18: Greater dependency in mobility

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 19: Mobility: Short Physical Performance Battery (0 to 12: best mobility)

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Analysis 1.19

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 19: Mobility: Short Physical Performance Battery (0 to 12: best mobility)

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Mobility: Short Physical Performance Battery (0 to 12: best mobility)

Study

Scale and timing

MDR (Median (N))

MDR (IQR)

Usual care (Median (N))

Usual care (IQR)

P‐value

Watne 2014

At 4 months

4 (121)

IQR: 1 to 8

3 (121)

IQR: 1 to 6

0.13

At 12 months

3 (98)

IQR: 1 to 7

3 (95)

IQR: 1 to 6

0.14

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Analysis 1.20

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 20: Mobility: Short Physical Performance Battery (0 to 12: best mobility)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 21: Institutional care at 6 to 12 months (survivors)

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Analysis 1.21

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 21: Institutional care at 6 to 12 months (survivors)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 22: Complications

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Analysis 1.22

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 22: Complications

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 23: Readmitted to hospital during follow‐up

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Analysis 1.23

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 23: Readmitted to hospital during follow‐up

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 24: Dead or readmitted to hospital during follow‐up

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Analysis 1.24

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 24: Dead or readmitted to hospital during follow‐up

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 25: Length of hospital stay (days)

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Analysis 1.25

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 25: Length of hospital stay (days)

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Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 26: Subgroup analysis ‐ death at 12 months

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Analysis 1.26

Comparison 1: Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care, Outcome 26: Subgroup analysis ‐ death at 12 months

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Comparison 2: Inpatient setting: multidisciplinary rehabilitation (MDR) with an integrated care pathway versus MDR alone, Outcome 1: Poor outcome, dead, couldn't walk as before, or nursing home stay post discharge (12 months)

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Analysis 2.1

Comparison 2: Inpatient setting: multidisciplinary rehabilitation (MDR) with an integrated care pathway versus MDR alone, Outcome 1: Poor outcome, dead, couldn't walk as before, or nursing home stay post discharge (12 months)

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Comparison 2: Inpatient setting: multidisciplinary rehabilitation (MDR) with an integrated care pathway versus MDR alone, Outcome 2: SF‐12 scores at 12 months (0: worst to 100: best)

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Analysis 2.2

Comparison 2: Inpatient setting: multidisciplinary rehabilitation (MDR) with an integrated care pathway versus MDR alone, Outcome 2: SF‐12 scores at 12 months (0: worst to 100: best)

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Modified Barthel Index (0: worst to 100: best): "changes over time"

Study

Care pathway: Mean (SD)

MDR alone: Mean (SD)

P value

At discharge (N = 149)

Chong 2013

22.2 (17.5)

23.9 (19.7)

0.58

At 6 month follow‐up (N = 129)

Chong 2013

32.6 (21.3)

27.7 (20.6)

0.18

At 12 month follow‐up (N = 121)

Chong 2013

33.4 (22.9)

31.8 (19.5)

0.68

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Analysis 2.3

Comparison 2: Inpatient setting: multidisciplinary rehabilitation (MDR) with an integrated care pathway versus MDR alone, Outcome 3: Modified Barthel Index (0: worst to 100: best): "changes over time"

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Comparison 2: Inpatient setting: multidisciplinary rehabilitation (MDR) with an integrated care pathway versus MDR alone, Outcome 4: Hospital readmission (at set times)

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Analysis 2.4

Comparison 2: Inpatient setting: multidisciplinary rehabilitation (MDR) with an integrated care pathway versus MDR alone, Outcome 4: Hospital readmission (at set times)

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 1: 'Poor outcome', mortality, and unable to walk (3 or 4 months)

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Analysis 3.1

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 1: 'Poor outcome', mortality, and unable to walk (3 or 4 months)

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 2: 'Poor outcome', mortality, institutional care and unable to walk (12 months)

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Analysis 3.2

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 2: 'Poor outcome', mortality, institutional care and unable to walk (12 months)

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 3: Subgroup analysis: poor outcome (dead or non‐recovery of indoor walking ability) at 1 year, subgrouped by dementia status

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Analysis 3.3

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 3: Subgroup analysis: poor outcome (dead or non‐recovery of indoor walking ability) at 1 year, subgrouped by dementia status

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 4: Subgroup analysis: mortality at 1 year, subgrouped by dementia status

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Analysis 3.4

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 4: Subgroup analysis: mortality at 1 year, subgrouped by dementia status

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 5: SF‐36 scores at 12 months (0: worst to 100: best)

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Analysis 3.5

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 5: SF‐36 scores at 12 months (0: worst to 100: best)

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 6: Independence in personal activities of daily living (PADL) and outdoor walking

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Analysis 3.6

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 6: Independence in personal activities of daily living (PADL) and outdoor walking

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Function (ADL): Barthel Index (0 to 20: total independence in personal care)

Study

Scale and timing

MDR (Median (N))

MDR ( IQR)

Usual care (Median (N))

Usual care (IQR)

Karlsson 2016

At 3 months

15 (95)

IQR: 8 to 20

16 (89)

IQR: 11 to 19

At 12 months

17 (80)

IQR: 8 to 20

17 (79)

IQR: 9 to 19

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Analysis 3.7

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 7: Function (ADL): Barthel Index (0 to 20: total independence in personal care)

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Daily activities scores at 1 year

Study

Home rehabilitation (N = 45)

Usual care (N = 48)

Reported P value

FIM (Functional Independence Measure: 0 to 91; independent)

Ziden 2008

Median = 85
Range: 46 to 91

Median = 80
Range: 29 to 91

P = 0.001

FAI (Frenchay Activity Index: 0 to 45; best activity)

Ziden 2008

Median = 27
Range: 0 to 40

Median = 20
Range: 0 to 42

P = 0.028

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Analysis 3.8

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 8: Daily activities scores at 1 year

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 9: Complications (discharge to 12 months)

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Analysis 3.9

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 9: Complications (discharge to 12 months)

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 10: Readmission to hospital and reoperation

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Analysis 3.10

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 10: Readmission to hospital and reoperation

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 11: Falls outcomes

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Analysis 3.11

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 11: Falls outcomes

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Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 12: Lengths of hospital or rehabilitation stays (days)

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Analysis 3.12

Comparison 3: Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation, Outcome 12: Lengths of hospital or rehabilitation stays (days)

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Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 1: 'Poor outcome', mortality, and unable to walk (12 months)

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Analysis 4.1

Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 1: 'Poor outcome', mortality, and unable to walk (12 months)

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Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 2: All cause mortality

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Analysis 4.2

Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 2: All cause mortality

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Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 3: Quality of life at 12 months: DEMQOL & DEMQOL‐Proxy

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Analysis 4.3

Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 3: Quality of life at 12 months: DEMQOL & DEMQOL‐Proxy

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Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 4: EQ‐5D quality of life index at 12 months (0 dead to 1 best quality)

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Analysis 4.4

Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 4: EQ‐5D quality of life index at 12 months (0 dead to 1 best quality)

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Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 5: Modified Barthel Index (0 to 100: total independence in personal care)

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Analysis 4.5

Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 5: Modified Barthel Index (0 to 100: total independence in personal care)

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Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 6: Nursing Home Life‐Space Diameter (0 to 50; leaves facility daily)

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Analysis 4.6

Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 6: Nursing Home Life‐Space Diameter (0 to 50; leaves facility daily)

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Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 7: Pain: PAINAD (0 to 10; severe pain)

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Analysis 4.7

Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 7: Pain: PAINAD (0 to 10; severe pain)

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Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 8: Fall outcomes (adverse events)

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Analysis 4.8

Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 8: Fall outcomes (adverse events)

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Mean costs per patients (in AU $): base case analysis

Study

Costs

MDR: mean (SD)

Usual care: mean (SD)

Mean difference

Bootstrapped 95% CI

Crotty 2019

Medical Benefits Schedule fees

1570 (114)

1743 (142)

‐173

‐534 to 166

Pharmaceutical Benefits Schedule

1164 (210)

983 (111)

180

‐214 to 787

Inpatient costs (AR‐DRGs)

2945 (762)

3174 (829)

‐229

‐2479 to 1683

Intervention costs

2298 (76)

‐

2298

‐

Total

5900 (855)

7977 (825)

2076

‐220 to 4360

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Analysis 4.9

Comparison 4: Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes, Outcome 9: Mean costs per patients (in AU $): base case analysis

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Comparison 5: Ambulatory setting: intensive versus less intensive community rehabilitation, Outcome 1: 'Poor outcome', mortality and institutional care (12 months)

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Analysis 5.1

Comparison 5: Ambulatory setting: intensive versus less intensive community rehabilitation, Outcome 1: 'Poor outcome', mortality and institutional care (12 months)

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Quality of life, dependence and activities scores at 3 and 12 months

Study

Timing

Intensive (Median (N))

Intensive (IQR)

Less intensive (Median (N))

Less intensive (IQR)

Reported P value

Quality of life: EQ‐5D (0: dead to 1: best quality)

Ryan 2006

3 months

0.62 (30)

0.52 to 0.77

0.67 (28)

0.59 to 0.79

0.3

12 months

0.7 (30)

0.59 to 0.8

0.7 (28)

0.62 to 0.74

0.67

Barthel Index (0 to 20: independent)

Ryan 2006

3 months

20 (30)

19 to 20

20 (28)

19 to 20

0.83

12 months

20 (30)

19 to 20

20 (28)

19 to 20

0.18 (probably 0.81)

Frenchay Activities Index (0 to 45: best activity)

Ryan 2006

3 months

19 (30)

14 to 23

19 (28)

14 to 24

0.82

12 months

22 (30)

16.5 to 29.5

21 (28)

13 to 26

0.27

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Analysis 5.2

Comparison 5: Ambulatory setting: intensive versus less intensive community rehabilitation, Outcome 2: Quality of life, dependence and activities scores at 3 and 12 months

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Comparison 5: Ambulatory setting: intensive versus less intensive community rehabilitation, Outcome 3: Number of contacts over 12 weeks (for participants with hip fracture or stroke)

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Analysis 5.3

Comparison 5: Ambulatory setting: intensive versus less intensive community rehabilitation, Outcome 3: Number of contacts over 12 weeks (for participants with hip fracture or stroke)

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Comparison 6: Ambulatory setting: extended multidisciplinary ambulatory rehabilitation versus usual care, Outcome 1: 'Poor outcome', mortality and institutional care (12 months)

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Analysis 6.1

Comparison 6: Ambulatory setting: extended multidisciplinary ambulatory rehabilitation versus usual care, Outcome 1: 'Poor outcome', mortality and institutional care (12 months)

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Comparison 6: Ambulatory setting: extended multidisciplinary ambulatory rehabilitation versus usual care, Outcome 2: ALSAR: Assessment of Living Skills And Resources

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Analysis 6.2

Comparison 6: Ambulatory setting: extended multidisciplinary ambulatory rehabilitation versus usual care, Outcome 2: ALSAR: Assessment of Living Skills And Resources

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Comparison 7: Outpatient multidisciplinary clinic between 3 to 12 months post fracture versus usual care, Outcome 1: Mortality and institutional care

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Analysis 7.1

Comparison 7: Outpatient multidisciplinary clinic between 3 to 12 months post fracture versus usual care, Outcome 1: Mortality and institutional care

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Comparison 8: Exploratory analysis: inpatient and supported discharge (home‐based) settings, Outcome 1: 'Poor outcome' (long‐term follow‐up): subgrouped by intervention type

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Analysis 8.1

Comparison 8: Exploratory analysis: inpatient and supported discharge (home‐based) settings, Outcome 1: 'Poor outcome' (long‐term follow‐up): subgrouped by intervention type

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Comparison 8: Exploratory analysis: inpatient and supported discharge (home‐based) settings, Outcome 2: Mortality (end of scheduled follow‐up): subgrouped by intervention type

Figures and Tables -
Analysis 8.2

Comparison 8: Exploratory analysis: inpatient and supported discharge (home‐based) settings, Outcome 2: Mortality (end of scheduled follow‐up): subgrouped by intervention type

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Summary of findings 1. Multidisciplinary inpatient rehabilitation versus usual care

Multidisciplinary inpatient rehabilitation compared with usual care for older people with hip fracture

Patient or population: older people undergoing rehabilitation soon after surgically treated hip fracture

Settings: inpatient care – thus, before hospital discharge. Rehabilitation extended to care in the community in some trials

Intervention: multidisciplinary inpatient rehabilitation

Comparison: usual care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care

Intervention

'Poor outcome' (dead or deterioration in residential status, generally requiring institutional care)

Follow‐up: 6 to 12 months

347 per 1000a

306 per 1000
(278 to 340)

RR 0.88

(0.80 to 0.98)

3036 participants
(13 studies)

⊕⊕⊕⊝
Moderateb

Overall, 969 participants (31.9%) had a 'poor outcome'.

Quality of life: EQ‐5D (0: dead to 1: best quality)c

Follow‐up: 4 months

The mean EQ‐5D score in the usual care group was0.46

The mean EQ‐5D score was 0.08 higher in the intervention group
(0.03 to 0.1 higher)

‐

347 participants
(1 study)d

⊕⊝⊝⊝
Very lowe

The trial found a similar though slightly reduced difference at 12 months (MD 0.07, 95% CI 0.02 to 0.12; 337 participants).

The CIs of both results included the MCID of 0.08

Mortality (at discharge)

Follow‐up: up to hospital discharge

75 per 1000a

58 per 1000
(44 to 78)

RR 0.77

(0.58 to 1.04)

2455 participants
(11 studies)

⊕⊝⊝⊝
Lowf

There were 168 deaths (6.8%) in total

Mortality (end of scheduled follow‐up)

Follow‐up: 4 to 12 months

182 per 1000a

166 per 1000
(146 to 192)

RR 0.91

(0.80 to 1.05)

3973 participants
(18 studies)

⊕⊕⊝⊝
Lowf

There were 682 deaths (17.2%) in total

Greater dependence in personal activities of daily livingg
Follow‐up: 1 to 4 months

558 per 1000a

486 per 1000
(424 to 553)

RR 0.87, (0.76 to 0.99)

754 participants (4 studies)

⊕⊝⊝⊝
Very lowh

Evidence from 7 other studies:

  • Three studies providing data for the Barthel Index (in two, a Chinese version was used) found higher (better) ADL scores in the intervention group. However, the clinical importance of the results is uncertain and the difference may only be slight.

  • Four other studies, which provided incomplete or no data, reported no evidence of between‐group differences in ADL.

Greater dependence in personal activities of daily livingg
Follow‐up: 6 to 12 months

723 per 1000a

See Comment

463 per 1000
(368 to 587)

RR 0.64 (0.51 to 0.81)

238 participants
(2 studies)

⊕⊝⊝⊝
Very lowh

Evidence from 11 other studies:

  • The RRs from two other studies reporting related outcomes (incomplete recovery of ADL and mobility; non‐recovery of independent self‐care ability) favoured the intervention but the 95% CI in both cases crossed the line of no effect.

  • Four studies providing data for the Barthel Index (in two, a Chinese version was used) found higher (better) ADL scores in the intervention group. However, the clinical importance of the results is uncertain and the difference may only be slight.

  • One study reported no between‐group difference in the losses in ADL as measured by the Katz Index.

  • Four other studies, which provided incomplete or no data for analysis, reported no evidence of between‐group differences in ADL.

Greater dependency in mobility (e.g. requiring help by another person)

Follow‐up: 6 to 12 months

403 per 1000a

335 per 1000
(287 to 395)

RR 0.83
(0.71 to 0.98)

1085 participants

(5 studies)

⊕⊕⊝⊝
Lowi

Another study (193 participants) found no significant between‐group difference in mobility assessed using the Short Physical Performance Battery (SPPB) tool at 12 months.

Hip‐related pain

Follow‐up: 12 months

See Comment

‐

‐

Pain data specific to injury location were available only for a subgroup of one trial. However, we considered the results were unreliable given the major imbalance in the numbers available in the two groups.

Delirium in hospitalj

509 per 1000a

433 per 1000
(377 to 499)

RR 0.85

(0.74 to 0.98)

980 participants
(4 studies)

⊕⊕⊝⊝
Lowi

Only delirium or confusion documented as a complication was considered for this outcome.
There were 538 (45%) cases in total.

A fifth trial (199 participants) reported significantly fewer participants of the intervention had post‐operative delirium (reported P = 0.003).

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
ADL: activities of daily living; CI: confidence interval; MCID: minimal clinically important difference; MD: mean difference; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low certainty: the true effect is likely to be substantially different from the estimate of effect.

aThe estimate was the median control group risk across studies (or control group risk if just one study).
bEvidence downgraded one level for serious risk of bias.
cEQ‐5D scores are anchored at 1 (full health) and 0 (a state as bad as being dead); negative values are possible and represent health states regarded as worse than being dead. Those who have died are given a zero.
dTwo other trials, based in Taiwan, reported separate data for 8 domains of a Taiwan version of the SF‐36. The results at 12 months from 391 participants for all domains except bodily pain favoured the intervention (very low‐certainty evidence downgraded one level for serious risk of bias and two levels for very serious indirectness, reflecting the minimal care provided after hospital discharge and the unusually high scores that may reflect a difference in the population compared with elsewhere).
e Evidence downgraded one level for serious risk of bias, two levels for very serious imprecision (one study only, wide confidence interval includes no clinically important effect).
fEvidence downgraded one level for serious risk of bias and one level for serious imprecision as the confidence interval crosses the line of no effect.
gThis was reported based on a diverse set of outcome measures: featured is survivors with greater dependency in ADL scores relative to pre‐fracture ADL scores (e.g. the Barthel Index and the Katz Index).
hEvidence downgraded one level for serious risk of bias, one level for serious imprecision and one level for serious inconsistency; the last reflecting a general view of the variation of effect in the results from the group of trials reporting this outcome using different and incompatible measures.
iEvidence downgraded one level for serious risk of bias and one level for serious imprecision (wide confidence interval).
jThis outcome is listed as a critical outcome in the protocol for the Cochrane Programme Grant on hip fracture management.

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Summary of findings 1. Multidisciplinary inpatient rehabilitation versus usual care
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Summary of findings 2. Supported discharge and multidisciplinary home rehabilitation versus usual care: mainly for people living in their own homes (ambulatory setting)

Supported discharge and multidisciplinary home rehabilitation compared with usual care for older people, mainly living in their own homes, with hip fracture

Patient or population: older people, mainly living in the community, undergoing rehabilitation after surgically treated hip fracture

Settings: ambulatory ‐ predominantly in people's own homes

Intervention: supported discharge and multidisciplinary home rehabilitation (duration between three to four weeks)

Comparison: usual care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care

Intervention

'Poor outcome' (dead or moved to higher level of care or unable to walk)

Follow‐up: 12 months

188 per 1000a

172 per 1000
(117 to 254)

RR 0.91

(0.62 to 1.35)

377 participants
(3 studies)

⊕⊝⊝⊝
Very lowb

Overall, 78 participants (20.7%) had a 'poor outcome'

Quality of life: SF‐36 Physical Component score (0: worst to 100: best)

Follow‐up: 12 months

The mean SF‐36 PC score in the usual care group was 33.3

The mean SF‐36 PC score was 4.70 higher in the intervention group
(0.43 lower to 9.83 higher)

‐

56 participants
(1 study)

⊕⊝⊝⊝
Very lowc

No evidence of a difference was also reported for the mental component score: MD 1.5 (95% CI ‐2.88 to 5.88)

Mortality (at 4 months)

Follow‐up: 3 to 4 months

66 per 1000a

51 per 1000
(23 to 117)

RR 0.77

(0.34 to 1.76)

275 participants
(2 studies)

⊕⊝⊝⊝
Very lowb

There were 20 deaths (7.3%) in total

Mortality (end of scheduled follow‐up)

Follow‐up: 12 months

125 per 1000a

172 per 1000
(77 to 204)

RR 1.00

(0.61 to 1.63)

377 participants
(3 studies)

⊕⊝⊝⊝
Very lowb

There were 53 deaths (14.1%) in total

Independent in personal activities of daily living
Follow‐up: 12 months

368 per 1000a

241 per 1000
(152 to 380)

RR 1.06
(0.71 to 1.57)

159 participants
(1 study)

⊕⊝⊝⊝
Very lowd

Note, this is a positive outcome. Overall, 60 were independent.
Another study (93 participants) reported more favourable results for the intervention groupe

Permanent move to higher level of care (hostel, nursing home, sheltered housing)
Follow‐up: 12 months

69 per 1000a

25 per 1000
(5 to 117)

RR 0.35
(0.07 to 1.69)

168 participants
(2 studies)

⊕⊝⊝⊝
Very lowb

Overall, 8 survivors (4.8%) had moved to a higher level of care

Unable to walk

Follow‐up: 12 months

87 per 1000a

78 per 1000

(34 to 178)

RR 0.89 (0.38 to 2.04)

214 participants
(2 studies)

⊕⊝⊝⊝
Very lowb

Overall, 19 survivors (8.9%) were unable to walk

Pain (end of follow‐up)

See comment

‐

‐

‐

‐

None of the three studies reported on hip or lower‐limb pain.

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

aThe estimate was the median control group risk across studies (or control group risk if just one study).
bEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (few or very few events, wide confidence interval crossing the line of no effect).
cEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (one small study only, wide confidence interval crossing the line of no effect).
dEvidence downgraded one level for serious risk of bias, two levels for very serious imprecision (one study only, wide confidence interval crossing the line of no effect), and one level for inconsistency (this latter is hypothetical but reflects that data from another study (93 participants) were in favour of the intervention group; see below).
eThis study reported higher FIM (Functional Independence Measure: 0 to 91; independent) scores in the intervention group (median 85 versus 80, reported P = 0.001).

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Summary of findings 2. Supported discharge and multidisciplinary home rehabilitation versus usual care: mainly for people living in their own homes (ambulatory setting)
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Summary of findings 3. Supported discharge and multidisciplinary home rehabilitation versus usual care: people living in a nursing home setting (ambulatory setting)

Supported discharge and multidisciplinary home rehabilitation compared with usual care for older people, living in nursing homes, with hip fracture

Patient or population: older people from nursing homes undergoing rehabilitation after surgically treated hip fracture

Settings: ambulatory ‐ in nursing homes (in Australia)

Intervention: supported discharge and multidisciplinary home rehabilitation (4 week programme)

Comparison: usual care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care

Intervention

'Poor outcome' (dead or unable to walk)

Follow‐up: 12 months

662 per 1000a

689 per 1000
(576 to 821)

RR 1.04
(0.87 to 1.24)

240 participants
(1 study)

⊕⊕⊝⊝
Lowb

Overall, 162 participants (67.5%) had a 'poor outcome'

Quality of life: EQ‐5D (0: dead to 1: best quality)c

Follow‐up: 12 months

The mean EQ‐5D score in the usual care group was 0.3

The mean EQ‐5D score was 0.06 lower in the intervention group
(0.12 lower to 0.0 lower)

‐

235 participants
(1 study)

⊕⊝⊝⊝
Very lowd

The difference is unlikely to be clinically important.

Mortality (at 4 months)

Follow‐up: 3 to 4 months

281 per 1000a

295 per 1000
(197 to 439)

RR 1.05
(0.70 to 1.56)

240 participants
(1 study)

⊕⊕⊝⊝
Lowb

There were 69 deaths (28.8%) in total

Mortality (end of scheduled follow‐up)

Follow‐up: 12 months

430 per 1000a

486 per 1000
(370 to 641)

RR 1.13
(0.86 to 1.49)

240 participants
(1 study)

⊕⊕⊝⊝
Lowb

There were 110 deaths (45.8%) in total

Functional dependency: modified Barthel Index (0 to 100: total independence in personal care)
Follow‐up: 4 weeks

The mean Barthel score in the usual care group was 23.5

The mean Barthel score was 0.90 higher in the intervention group
(4.51 lower to 6.31 higher)

‐

202 participants
(1 study)

⊕⊝⊝⊝
Very lowe

Functional dependency: modified Barthel Index (0 to 100: total independence in personal care)
Follow‐up: 12 months

The mean Barthel score in the usual care group was 23.5

The mean Barthel score was 4.90 lower in the intervention group
(11.69 lower to 1.89 higher)

‐

125 participants
(1 study)

⊕⊝⊝⊝
Very lowf

Unable to walk

Follow‐up: 12 months

87 per 1000a

78 per 1000

(34 to 178)

RR 0.89 (0.38 to 2.04)

130 participants
(1 study)

⊕⊝⊝⊝
Very lowf

Overall, 52 survivors (40%) were unable to walk

Pain: PAINAD (0 to 10; severest pain)

Follow‐up: 12 months

The mean pain score in the control group was 0.06

The mean pain score was 0.01 lower in the intervention group
(0.44 lower to 0.42 higher)

‐

126 participants
(1 study)

⊕⊝⊝⊝
Very lowf

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; PAINAD: Pain Assessment In Advanced Dementia; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

aThe estimate was the control group risk for the one study testing this comparison.
bEvidence downgraded one level for serious risk of bias and one level for serious imprecision (single study results, wide confidence interval crossing the line of no effect).
cEQ‐5D scores are anchored at 1 (full health) and 0 (a state as bad as being dead); negative values are possible and represent health states regarded as worse than being dead. Those who have died are given a zero.
dEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (one study only, wide confidence interval and large numbers of deaths that scored 0). The study also reported other quality of life data for survivors at 12 months using the DEMQOL (Dementia Quality of Life) instrument (self‐reported form completed by 70 participants) and the DEMQOL‐Proxy instrument (by 126 proxies). Evidence from these measures was also rated as very low certainty, reflecting downgrading one level for serious risk of bias, two levels for imprecision (reduced sample size and wide confidence interval).
eEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (single study results, wide confidence interval crossing the line of no effect). Additionally, we would have downgraded one level for indirectness as the timing of follow‐up is too short and just at the end of the treatment period.
fEvidence downgraded one level for serious risk of bias and two levels for very serious imprecision (low numbers of participants, wide confidence interval crossing the line of no effect).

Figures and Tables -
Summary of findings 3. Supported discharge and multidisciplinary home rehabilitation versus usual care: people living in a nursing home setting (ambulatory setting)
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Table 1. Classification of multidisciplinary rehabilitation programmes

Descriptor

Label

Description

Hip fracture programme

HFP

Fits NICE definition (NICE 2011, also 2017 version); see Appendix 1. Has components in acute care, can involve inpatient rehabilitation and encourages early supported discharge when feasible.

Orthogeriatric programme

OG

Programme is provided in the acute care setting after hip fracture and involves orthopaedic and geriatric collaboration and aims to improve functioning.

Geriatric orthopaedic rehabilitation unit

GORU

Subacute rehabilitation unit for older people with orthopaedic injuries (see Cameron 2000).

Mixed assessment and rehabilitation unit

MARU

Subacute rehabilitation unit for older people with range of diagnoses. Can be called geriatric evaluation and management unit (GEM) in some countries (see Cameron 2000).

Early supported discharge

ESD

Fits NICE definition and aims to assist selected older people return home after hip fracture. Can be to own home or residential aged care facility (RACF).

However, in some cases, there may be more of a focus on enhancing support rather than achieving early or accelerated discharge.

Home‐based rehabilitation

HBR

Home‐based rehabilitation after hip fracture without direct link to hospital services

Outpatient rehabilitation

OPR

Outpatient rehabilitation after hip fracture without direct link to hospital services
Figures and Tables -
Table 1. Classification of multidisciplinary rehabilitation programmes
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Table 2. Interventions tested in the included studies

Study ID

Setting

Country; trial start

Intervention

Control

Comments

Inpatient rehabilitation

Baroni 2019

Hospital

Italy; 2012

Orthogeriatric programme

Orthopaedic care; referral to geriatrician as required

Cameron 1993

Hospital

Australia; 1989

Hip fracture programme

Usual care (56% had multidisciplinary rehabilitation)

Intervention emphasised accelerated rehabilitation

Chong 2013

Hospital

Singapore; 2004

Mixed assessment and rehabilitation unit plus structured assessments and checklists

Mixed assessment and rehabilitation unit

Comparison of two types of multidisciplinary rehabilitation

Fordham 1986

Hospital

UK; 1984

Geriatric orthopaedic rehabilitation unit

Orthopaedic management (geriatrician available for advice) including decision to transfer to orthopaedic rehabilitation unit.

Galvard 1995

Hospital

Sweden; 1988

Geriatric orthopaedic rehabilitation unit

Usual orthopaedic care

Gilchrist 1988

Hospital

UK; 1984

Geriatric orthopaedic rehabilitation unit

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

Huusko 2002

Hospital

Finland; 1994

Orthogeriatric programme

Discharge to local community hospitals, treatment by general practitioners

Jette 1987

Hospital

USA; 1984

Orthogeriatric programme

Usual care: 'standard rehabilitation'

Kennie 1988

Hospital

UK; before 1986

Geriatric orthopaedic rehabilitation unit

Routine orthopaedic care in orthopaedic admission ward

Marcantonio 2001

Hospital

USA; before 1999

Orthogeriatric programme

Orthopaedics team management, including internal medicine or geriatrics consultations on a reactive basis.

The geriatrician input mainly related to reducing delirium

Naglie 2002

Hospital

Canada; 1993

Orthogeriatric programme

Usual care on orthopaedic units which included access to geriatric consultation

Prestmo 2015

Hospital

Norway; 2008

Hip fracture programme

Usual orthopaedic care provided in an orthopaedic ward. Assessment by geriatrician by request only

Sanchez Ferrin 1999

Hospital

Spain; 1996

Mixed assessment and rehabilitation unit (single session of geriatric review)

Usual care under Orthopaedics and Traumatic Surgery Service; consultations to other specialists as required

Low level of geriatrician involvement with emphasis on treating co‐morbidity

Shyu 2008

Hospital

Taiwan; 2001

Hip fracture programme, included home visits

Usual care on trauma or orthopaedic ward. Some consultations of other disciplines

No care provided after discharge at approximately one week in control group

Shyu 2013a

Hospital

Taiwan; 2005

Hip fracture programme (+ home visits): 2 groups
1. HFP + health‐maintenance interventions to manage depressive symptoms and malnutrition and prevent falls
2. HFP

Usual care by orthopaedists.

No care provided after discharge at approximately one week in control group

Separate analysis of the two HFP groups not done in this review

Stenvall 2007a

Hospital

Sweden; 2000

Geriatric orthopaedic rehabilitation unit

Usual care on specialist orthopaedic ward

Intervention included an assessment at 4 months by geriatric team

Swanson 1998

Hospital

Australia; 1994

Hip fracture programme

Standard orthopaedic management, geriatrician on referral

Intervention, which included accelerated rehabilitation programme, was based in an orthopaedic ward

Tseng 2019

Hospital and community (intervention group)

Taiwan; 2010

Hip fracture programme, included home visits

Usual care under orthopaedics, with consultations to internal medicine as required

Trial and intervention focused on diabetes‐specific care.

No care provided after discharge, around 4 to 5 days after surgery, in control group

Uy 2008

Hospital

Australia; 2001

Hip fracture programme

Usual care: discharge back to the nursing home soon after surgery

All nursing home residents

Vidan 2005

Hospital

Spain; 1997

Orthogeriatric programme

Usual orthopaedic care, counselling from different specialists

Watne 2014

Hospital

Norway; 2009

Hip fracture programme

Usual care on orthopaedic ward, relevant specialists were seen on request

Ambulatory rehabilitation

Ashe 2019

Community

(outpatients and home)

Canada; 2011

Outpatient rehabilitation

Usual post‐op rehabilitation

Intervention focused on falls and fracture risk

Crotty 2003

Hospital and community (intervention group)

Australia; 1998

Early supported discharge, included home‐based interdisciplinary rehabilitation

Usual or 'conventional' care, involving routine interdisciplinary hospital care and rehabilitation in hospital.

The extra multidisciplinary rehabilitation component is the home‐based interdisciplinary rehabilitation

Crotty 2019

Community (nursing home / care facility)

Australia; 2012

Early supported discharge to residential aged care facility (nursing home)

Usual care according to usual practice in the nursing home

All nursing home residents.
A detailed description of usual care is available.

Karlsson 2016

Hospital and community (intervention group)

Sweden; 2008

Early supported discharge (continuation of rehabilitation in patient's home)

Same inpatient geriatric care and rehabilitation

The extra multidisciplinary rehabilitation component is the home‐based interdisciplinary rehabilitation

Ryan 2006

Community (at home)

UK; 2000

Home‐based rehabilitation: intensive

Home‐based rehabilitation: less intensive

Comparision of two intensities of multidisciplinary rehabilitation

Singh 2012

Community (outpatients and home)

Australia; 2003

Hip fracture programme (included home visits)

Standard care included orthogeriatric care, rehabilitation service, other medical and allied health consultation as required

Intervention extended to multidisciplinary treatment of frailty

Ziden 2008

Hospital and community (intervention group: home)

Sweden; 2004

Supported discharge, included home rehabilitation ward and home visits

Usual care in geriatric ward with no structured rehabilitation after discharge

Geriatrician management applied to both groups
Figures and Tables -
Table 2. Interventions tested in the included studies
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Comparison 1. Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 'Poor outcome' (long‐term follow‐up at 6 or 12 months) Show forest plot

13

3036

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.80, 0.98]

1.2 'Poor outcome' (long‐term follow‐up): subgrouped by intervention type Show forest plot

13

3036

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.80, 0.98]

1.2.1 Geriatric orthopaedic rehabilitation unit

2

307

Risk Ratio (M‐H, Fixed, 95% CI)

0.68 [0.51, 0.91]

1.2.2 Hip fracture programme

7

1685

Risk Ratio (M‐H, Fixed, 95% CI)

0.89 [0.77, 1.02]

1.2.3 Mixed assessment and rehabilitation unit

1

203

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.67, 1.31]

1.2.4 Orthogeriatric programme

3

841

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.79, 1.17]

1.3 'Poor outcome' (long‐term follow‐up) by selection bias Show forest plot

13

3036

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.80, 0.98]

1.3.1 Low risk of selection bias

6

1751

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.78, 1.00]

1.3.2 Unclear or high risk of selection bias

7

1285

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.74, 1.05]

1.4 'Poor outcome' (at discharge) Show forest plot

8

1537

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.76, 1.00]

1.5 Mortality (end of scheduled follow‐up: 4 to 12 months) Show forest plot

18

3973

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.80, 1.05]

1.6 Mortality (end of scheduled follow‐up) ‐ with 12 month data for Cameron 1993 Show forest plot

18

3973

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.79, 1.03]

1.7 Mortality (end of scheduled follow‐up): subgrouped by intervention type Show forest plot

18

3973

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.80, 1.05]

1.7.1 Geriatric Orthopaedic Rehabilitation Unit

5

1008

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.75, 1.22]

1.7.2 Hip fracture programme

8

1698

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.77, 1.19]

1.7.3 MARU

1

206

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.44, 1.23]

1.7.4 Orthogeriatric programme

4

1061

Risk Ratio (M‐H, Fixed, 95% CI)

0.86 [0.66, 1.14]

1.8 Mortality (at discharge) Show forest plot

11

2455

Risk Ratio (M‐H, Fixed, 95% CI)

0.77 [0.58, 1.04]

1.9 Quality of life: EQ‐5D (‐0.594: worse than death, 0: dead to 1: best quality) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.9.1 At 4 months

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.9.2 At 12 months

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.10 Quality of life: SF‐36 (Taiwan version) (each domain: 0 to 100; best quality) at 1 year Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.10.1 Bodily pain

2

391

Mean Difference (IV, Fixed, 95% CI)

0.11 [‐4.49, 4.70]

1.10.2 General health perceptions

2

391

Mean Difference (IV, Fixed, 95% CI)

5.03 [‐0.44, 10.50]

1.10.3 Vitality

2

391

Mean Difference (IV, Fixed, 95% CI)

6.41 [2.13, 10.69]

1.10.4 Social functioning

2

391

Mean Difference (IV, Fixed, 95% CI)

6.52 [1.10, 11.94]

1.10.5 Role limitations because of emotional problems

2

391

Mean Difference (IV, Fixed, 95% CI)

3.93 [‐1.44, 9.30]

1.10.6 General mental health

2

391

Mean Difference (IV, Fixed, 95% CI)

6.80 [2.45, 11.15]

1.10.7 Physical functioning

2

391

Mean Difference (IV, Fixed, 95% CI)

13.20 [6.99, 19.41]

1.10.8 Role limitations because of physical health problems

2

391

Mean Difference (IV, Fixed, 95% CI)

27.98 [19.54, 36.42]

1.11 Greater dependency in ADL up to 4 months Show forest plot

4

754

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.76, 0.99]

1.12 Regain in former level of ADL independence in the short term (up to 4 months) Show forest plot

4

754

Risk Ratio (M‐H, Fixed, 95% CI)

1.18 [1.01, 1.38]

1.13 Greater dependency in ADL in the long term (6 to 12 months) Show forest plot

4

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.13.1 More dependent at 1 year

2

238

Risk Ratio (M‐H, Fixed, 95% CI)

0.64 [0.51, 0.81]

1.13.2 More dependent or dead at 1 year

2

300

Risk Ratio (M‐H, Fixed, 95% CI)

0.71 [0.60, 0.84]

1.13.3 Incomplete recovery of ADL and mobility at 1 year

1

252

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.71, 1.09]

1.13.4 Incomplete recovery of ADL and mobility, or dead at 1 year

1

319

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.75, 1.04]

1.13.5 Non‐recovery of independent self‐care ability at 1 year

1

269

Risk Ratio (M‐H, Fixed, 95% CI)

0.85 [0.64, 1.14]

1.13.6 Non‐recovery of independent self‐care ability or dead at 1 year

1

282

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.65, 1.34]

1.14 ADL: Barthel scores (higher scores = greater independence) Show forest plot

4

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.14.1 Barthel Index (0 to 20) at 4 months

1

333

Mean Difference (IV, Fixed, 95% CI)

1.01 [0.21, 1.81]

1.14.2 Chinese Barthel Index (0 to 100) at 3 months

2

285

Mean Difference (IV, Fixed, 95% CI)

7.57 [2.87, 12.27]

1.14.3 Barthel Index (0 to 20) at 12 months

1

300

Mean Difference (IV, Fixed, 95% CI)

1.13 [0.31, 1.95]

1.14.4 Chinese Barthel Index (0 to 100) at 12 months

2

293

Mean Difference (IV, Fixed, 95% CI)

4.04 [‐1.42, 9.51]

1.14.5 Modified Barthel Index (0 to 100) at 6 months

1

60

Mean Difference (IV, Fixed, 95% CI)

6.30 [‐0.53, 13.13]

1.15 ADL: Barthel Index (0 to 20; best outcome) Show forest plot

1

Other data

No numeric data

1.16 Loss in activities of daily living at 6 months (Katz index; 6 maximum) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.17 ADL: Barthel Index (participants who were from nursing homes) Show forest plot

2

Other data

No numeric data

1.18 Greater dependency in mobility Show forest plot

5

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.18.1 Non‐recovery/decline in walking at long‐term follow‐up

5

1085

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.71, 0.98]

1.18.2 Non‐recovery in walking or dead at long‐term follow‐up

5

1276

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.72, 0.92]

1.18.3 Decline in transfers (bed to chair etc) at long‐term follow‐up

1

241

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.69, 1.34]

1.18.4 Decline in transfers or dead at long‐term follow‐up

1

279

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.72, 1.21]

1.19 Mobility: Short Physical Performance Battery (0 to 12: best mobility) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.19.1 At 4 months

1

325

Mean Difference (IV, Fixed, 95% CI)

0.74 [0.19, 1.29]

1.19.2 At 12 months

1

284

Mean Difference (IV, Fixed, 95% CI)

0.69 [0.09, 1.29]

1.20 Mobility: Short Physical Performance Battery (0 to 12: best mobility) Show forest plot

1

Other data

No numeric data

1.21 Institutional care at 6 to 12 months (survivors) Show forest plot

13

2497

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.76, 1.06]

1.22 Complications Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.22.1 confusion, delirium in hospital

4

980

Risk Ratio (M‐H, Fixed, 95% CI)

0.85 [0.74, 0.98]

1.22.2 heart failure, cardiac complications

2

648

Risk Ratio (M‐H, Fixed, 95% CI)

1.46 [0.89, 2.39]

1.22.3 cardiac insufficiency

1

206

Risk Ratio (M‐H, Fixed, 95% CI)

0.25 [0.05, 1.15]

1.22.4 chest infection, cardiac problem, bedsore

1

71

Risk Ratio (M‐H, Fixed, 95% CI)

0.40 [0.17, 0.94]

1.22.5 pressure injuries (sores, ulcers)

3

854

Risk Ratio (M‐H, Fixed, 95% CI)

0.50 [0.35, 0.70]

1.22.6 pneumonia, pulmonary complications

2

648

Risk Ratio (M‐H, Fixed, 95% CI)

1.46 [0.83, 2.57]

1.22.7 respiratory infection

1

206

Risk Ratio (M‐H, Fixed, 95% CI)

1.33 [0.48, 3.71]

1.22.8 urinary tract infection

2

535

Risk Ratio (M‐H, Fixed, 95% CI)

0.61 [0.42, 0.88]

1.22.9 stroke, emboli, cerebral complications

2

400

Risk Ratio (M‐H, Fixed, 95% CI)

3.99 [0.70, 22.79]

1.22.10 thrombo‐embolic complications

1

329

Risk Ratio (M‐H, Fixed, 95% CI)

5.09 [0.25, 105.24]

1.22.11 renal failure

1

329

Risk Ratio (M‐H, Fixed, 95% CI)

3.06 [0.63, 14.92]

1.22.12 ionic anomalities

1

206

Risk Ratio (M‐H, Fixed, 95% CI)

0.17 [0.02, 1.36]

1.22.13 gastrointestinal complications

1

329

Risk Ratio (M‐H, Fixed, 95% CI)

1.27 [0.35, 4.66]

1.22.14 dehydration

1

206

Risk Ratio (M‐H, Fixed, 95% CI)

0.57 [0.17, 1.89]

1.22.15 any medical complication

3

891

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.79, 1.04]

1.22.16 any surgical complications

2

638

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.54, 1.42]

1.23 Readmitted to hospital during follow‐up Show forest plot

11

2538

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.84, 1.12]

1.24 Dead or readmitted to hospital during follow‐up Show forest plot

8

1975

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.78, 1.05]

1.25 Length of hospital stay (days) Show forest plot

12

Mean Difference (IV, Random, 95% CI)

Totals not selected

1.26 Subgroup analysis ‐ death at 12 months Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.26.1 With dementia

1

162

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [0.75, 1.60]

1.26.2 Without dementia

1

167

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.53, 2.26]
Figures and Tables -
Comparison 1. Inpatient setting: multidisciplinary rehabilitation (MDR) versus usual care
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Comparison 2. Inpatient setting: multidisciplinary rehabilitation (MDR) with an integrated care pathway versus MDR alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 Poor outcome, dead, couldn't walk as before, or nursing home stay post discharge (12 months) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.1.1 Poor outcome (death or reduced mobility)

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.1.2 Death

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.1.3 Unable to walk as before

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.1.4 Any nursing home stay post discharge

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.2 SF‐12 scores at 12 months (0: worst to 100: best) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2.2.1 Physical component summary scores

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2.2.2 Mental component summary scores

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2.3 Modified Barthel Index (0: worst to 100: best): "changes over time" Show forest plot

1

Other data

No numeric data

2.3.1 At discharge (N = 149)

1

Other data

No numeric data

2.3.2 At 6 month follow‐up (N = 129)

1

Other data

No numeric data

2.3.3 At 12 month follow‐up (N = 121)

1

Other data

No numeric data

2.4 Hospital readmission (at set times) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.4.1 At discharge

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.4.2 Within 3 months

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.4.3 Within 1 year

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 2. Inpatient setting: multidisciplinary rehabilitation (MDR) with an integrated care pathway versus MDR alone
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Comparison 3. Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

3.1 'Poor outcome', mortality, and unable to walk (3 or 4 months) Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.1.1 Poor outcome (dead or unable to walk)

1

209

Risk Ratio (M‐H, Fixed, 95% CI)

1.22 [0.63, 2.39]

3.1.2 Mortality

2

275

Risk Ratio (M‐H, Fixed, 95% CI)

0.77 [0.34, 1.76]

3.1.3 Unable to walk

1

183

Risk Ratio (M‐H, Fixed, 95% CI)

2.47 [0.68, 9.02]

3.2 'Poor outcome', mortality, institutional care and unable to walk (12 months) Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.2.1 Poor outcome (dead or higher level of care / unable to walk)

3

377

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.62, 1.35]

3.2.2 Mortality

3

377

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.61, 1.63]

3.2.3 Moved to higher level of care

2

168

Risk Ratio (M‐H, Fixed, 95% CI)

0.35 [0.07, 1.69]

3.2.4 Unable to walk

2

214

Risk Ratio (M‐H, Fixed, 95% CI)

0.89 [0.38, 2.04]

3.3 Subgroup analysis: poor outcome (dead or non‐recovery of indoor walking ability) at 1 year, subgrouped by dementia status Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.3.1 Had dementia

1

103

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.81, 1.28]

3.3.2 Didn't have dementia

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.48, 1.70]

3.4 Subgroup analysis: mortality at 1 year, subgrouped by dementia status Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.4.1 Had dementia

1

103

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.45, 1.66]

3.4.2 Didn't have dementia

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

2.43 [0.66, 8.87]

3.5 SF‐36 scores at 12 months (0: worst to 100: best) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.5.1 Physical component summary scores

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.5.2 Mental component summary scores

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.6 Independence in personal activities of daily living (PADL) and outdoor walking Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.6.1 Independent PADL at 3 months

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.6.2 Independent PADL at 12 months

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.6.3 Independent outdoor walking at 3 months

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.6.4 Independent outdoor walking at 12 months

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.7 Function (ADL): Barthel Index (0 to 20: total independence in personal care) Show forest plot

1

Other data

No numeric data

3.8 Daily activities scores at 1 year Show forest plot

1

Other data

No numeric data

3.8.1 FIM (Functional Independence Measure: 0 to 91; independent)

1

Other data

No numeric data

3.8.2 FAI (Frenchay Activity Index: 0 to 45; best activity)

1

Other data

No numeric data

3.9 Complications (discharge to 12 months) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.9.1 Had complication post discharge

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.9.2 Had delirium recorded post discharge

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.10 Readmission to hospital and reoperation Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.10.1 Readmission to hospital

2

265

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [0.83, 1.74]

3.10.2 Reoperation

1

199

Risk Ratio (M‐H, Fixed, 95% CI)

1.40 [0.48, 4.14]

3.11 Falls outcomes Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.11.1 Number of fallers

2

263

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [0.80, 1.50]

3.11.2 Falls requiring hospitalisation

1

64

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.06, 14.38]

3.11.3 Additional fracture

1

199

Risk Ratio (M‐H, Fixed, 95% CI)

1.90 [0.75, 4.80]

3.12 Lengths of hospital or rehabilitation stays (days) Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.12.1 Length of hospital stay

2

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.12.2 Length of rehabilitation (hospital + home)

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 3. Ambulatory setting: supported discharge and multidisciplinary home‐based rehabilitation versus usual inpatient rehabilitation
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Comparison 4. Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

4.1 'Poor outcome', mortality, and unable to walk (12 months) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.1.1 Poor outcome (dead or unable to walk)

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.1.2 Mortality

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.1.3 Unable to walk

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.2 All cause mortality Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.2.1 At 4 weeks

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.2.2 At 4 months

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.2.3 At 12 months

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.3 Quality of life at 12 months: DEMQOL & DEMQOL‐Proxy Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.3.1 DEMQOL score (12 to 112; best QOL)

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.3.2 DEMQOL‐Proxy score (31 to 124; best QOL)

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.4 EQ‐5D quality of life index at 12 months (0 dead to 1 best quality) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.5 Modified Barthel Index (0 to 100: total independence in personal care) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.5.1 At 4 weeks

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.5.2 At 12 months

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.6 Nursing Home Life‐Space Diameter (0 to 50; leaves facility daily) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.6.1 At 4 weeks

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.6.2 At 12 months

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.7 Pain: PAINAD (0 to 10; severe pain) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.7.1 At 4 weeks

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.7.2 At 12 months

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.8 Fall outcomes (adverse events) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.8.1 Number of fallers at 4 weeks

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.8.2 Number of hospital admissions for falls

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.8.3 Number of hip fractures

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4.9 Mean costs per patients (in AU $): base case analysis Show forest plot

1

Other data

No numeric data
Figures and Tables -
Comparison 4. Ambulatory setting: outreach multidisciplinary rehabilitation versus usual care in nursing homes
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Comparison 5. Ambulatory setting: intensive versus less intensive community rehabilitation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

5.1 'Poor outcome', mortality and institutional care (12 months) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5.1.1 Poor outcome (dead or in institutional care)

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5.1.2 Mortality

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5.1.3 Institutional care

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5.2 Quality of life, dependence and activities scores at 3 and 12 months Show forest plot

1

Other data

No numeric data

5.2.1 Quality of life: EQ‐5D (0: dead to 1: best quality)

1

Other data

No numeric data

5.2.2 Barthel Index (0 to 20: independent)

1

Other data

No numeric data

5.2.3 Frenchay Activities Index (0 to 45: best activity)

1

Other data

No numeric data

5.3 Number of contacts over 12 weeks (for participants with hip fracture or stroke) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 5. Ambulatory setting: intensive versus less intensive community rehabilitation
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Comparison 6. Ambulatory setting: extended multidisciplinary ambulatory rehabilitation versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

6.1 'Poor outcome', mortality and institutional care (12 months) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

6.1.1 Poor outcome (dead or in institutional care)

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

6.1.2 Mortality

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

6.1.3 Institutional care

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

6.2 ALSAR: Assessment of Living Skills And Resources Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

6.2.1 Skills score (0 to 22; lower score = better ADL skills)

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

6.2.2 Resources score (0 to 22; lower score = more resources available)

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 6. Ambulatory setting: extended multidisciplinary ambulatory rehabilitation versus usual care
Navigate to table in Review
Comparison 7. Outpatient multidisciplinary clinic between 3 to 12 months post fracture versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

7.1 Mortality and institutional care Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

7.1.1 Mortality at 12 months

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

7.1.2 Institutional care at 12 months

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 7. Outpatient multidisciplinary clinic between 3 to 12 months post fracture versus usual care
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Comparison 8. Exploratory analysis: inpatient and supported discharge (home‐based) settings

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

8.1 'Poor outcome' (long‐term follow‐up): subgrouped by intervention type Show forest plot

16

3413

Risk Ratio (M‐H, Fixed, 95% CI)

0.89 [0.80, 0.98]

8.1.1 Geriatric orthopaedic rehabilitation unit

2

307

Risk Ratio (M‐H, Fixed, 95% CI)

0.68 [0.51, 0.91]

8.1.2 Hip fracture programme

7

1685

Risk Ratio (M‐H, Fixed, 95% CI)

0.89 [0.77, 1.02]

8.1.3 Mixed assessment and rehabilitation unit

1

203

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.67, 1.31]

8.1.4 Orthogeriatric programme

3

841

Risk Ratio (M‐H, Fixed, 95% CI)

0.97 [0.79, 1.17]

8.1.5 Supported discharge and home rehabilitation

3

377

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.62, 1.35]

8.2 Mortality (end of scheduled follow‐up): subgrouped by intervention type Show forest plot

21

4350

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.81, 1.05]

8.2.1 Geriatric Orthopaedic Rehabilitation Unit

5

1008

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.75, 1.22]

8.2.2 Hip fracture programme

8

1698

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.77, 1.19]

8.2.3 MARU

1

206

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.44, 1.23]

8.2.4 Orthogeriatric programme

4

1061

Risk Ratio (M‐H, Fixed, 95% CI)

0.86 [0.66, 1.14]

8.2.5 Supported discharge and home rehabilitation

3

377

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.61, 1.63]
Figures and Tables -
Comparison 8. Exploratory analysis: inpatient and supported discharge (home‐based) settings
Navigate to table in Review