Comprehensive geriatric care most effective in several subgroups of hip fracture patients .
This report has been verified
by one or more authors of the
original publication.
OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2016;4(12):41 BMC Geriatr. 2016 Feb 19;16(1):49397 hip fractures patients from the Trondheim Hip Fracture Trial were included in this post-hoc analysis. Patients were randomized to receive either comprehensive geriatric care or traditional orthopaedic care post treatment. The present analysis was conducted in order to determine if the benefits observed with comprehensive geriatric treatment seen in the Trondheim trial held true when analyses based on several subgroups were conducted (age, gender, type of fracture, and prefracture functional capacity). The findings of this publication displayed that the benefits of comprehensive geriatric care are sustained in each subgroup in at least one of the following: Barthel Index scores, the Nottingham Extended ADL Scale scores, Mini-Mental Status examination scores, and Short Physical Performance Battery scores.However, the subgroup analyses indicated that comprehensive geriatric care was found to be most beneficial in patient subgroups that were 70-79, female, had intra-capsular fractures, or had greater prefracture activities of daily living.
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Sim = 1
Incerto = 0,5
Não relevante = 0
Não = 0
A Avaliação dos Critérios de Relato avalia a transparência com que os autores relatam as caraterísticas metodológicas e do ensaio na publicação. A avaliação está dividida em cinco categorias que são apresentadas de seguida.
3/4
Randomization
2/4
Outcome Measurements
4/4
Inclusion / Exclusion
2/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
O Índice de Fragilidade é uma ferramenta que auxilia na interpretação de achados significativos, fornecendo uma medida de força para um resultado. O Índice de Fragilidade representa o número de eventos consecutivos que precisam de ser adicionados a um resultado dicotómico para que o resultado deixe de ser significativo. Um número pequeno representa um resultado mais fraco e um número grande representa um resultado mais forte.
Porque é que este estudo era necessário agora?
Hip fractures often result in reduced functional status and increased mortality, morbidity, and dependence on caregivers and family members. Additionally, when experienced at an older age, an individual’s ability to regain basic mobility is severely hindered. A previous study, The Trondheim Hip Fracture Trial, reported clinically relevant outcomes when a comprehensive geriatric care (CGC) program that incorporated both geriatric and orthopaedic practices was implemented throughout the patients' hospital stay. Although an overall benefit in comparison to traditional orthopaedic care (OC) was seen, outcomes specific to several identifiable subgroups were not reported, thus, the present study was published.
Qual era a principal questão de investigação?
Did the benefits seen in the Trondheim Hip Fracture Trial with comprehensive geriatric care as compared with traditional orthopaedic care differ when assessed based on patient age, gender, type of fracture, or pre-fracture function?
- The results of the subgroup analyses carried out in this study found that patients <80 years old, patients who were female, patients with intracapsular fractures, and patients with pre-fracture NEAS scores of 45 or greater demonstrated the greatest effect from the comprehensive geriatric care intervention.
- In patients aged 70-79, comprehensive geriatric care yielded significantly greater SPPB, Barthel Index, and NEAS scores in comparison to traditional orthopaedic care at 4 months (p=0.017, p=0.008, and p<0.0001 respectively), and significantly greater NEAS and MMSE scores at 12 months (p=0.008 and p=0.035 respectively).
- In females, CGC resulted in significantly greater improvements in SPPB, BI, and NEAS scores at both 4 and 12 months (all p<0.05) while MMSE scores were comparable (p>0.05 at 4 and 12 months). While in males, CGC and OC reported similar improvements in all outcomes at both 4 and 12 months (all p>0.05) except MMSE scores at 12 months (p=0.027)
- In patients with intra-capsular fractures, CGC yielded significantly improved outcomes in terms of SPPB, BI, and NEAS scores at 4 months (p=0.001, p=0.001, and p=0.0001 respectively) while MMSE scores were comparable in comparison to OC (p=0.05). These results were consistent at 12 months as well (SPPB: p=0.0003; BI: p=0.0004; NEAS: p=0.0004; MMSE: p=0.12).
- In patients with extra-capsular fractures, similar improvements with CGC and OC were seen in all outcomes at 4 months (all p>0.05) while at 12 months outcomes significantly favoured CGC in NEAS scores (p=0.045; all other p>0.05).
- In patients with a pre-fracture NEAS score of 45 or greater, SPPB and NEAS scores were significantly in favour of CGC as compared to OC at 4 months (p=0.005 and p<0.0001 respectively) while at 12 months, results significantly favoured the CGC group in all outcomes (all p<0.05).
De que é que me devo lembrar mais?
When comparing comprehensive geriatric care to traditional orthopaedic care in patients who sustained hip fracture, the comprehensive geriatric care yielded beneficial effects in several subgroups pertaining to age, gender, location of fracture, and functional capacity prior to fracture in terms of mobility, cognition, and ability to carry out instrumental and personal activities of daily living. Contrary to the hypothesis of this study, patients who were the least vulnerable appeared to experience the greatest effect from the comprehensive program (patients who were younger with higher prefracture activities of daily living).
Como é que isto afectará o tratamento dos meus doentes?
The results from this study indicate that comprehensive geriatric care appears to be an effective protocol that can be implemented in patients with a wide range of demographic and fracture characteristics. The subgroup analyses indicated that comprehensive geriatric care was found to be most beneficial in patient subgroups that were 70-79, female, had intra-capsular fractures, and had greater prefracture activities of daily living. Further trials should investigate interventions in patients with extra-capsular fractures and patients who are already in functional decline prior to fracture.
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