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Comprehensive geriatric care most effective in several subgroups of hip fracture patients
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June 2016
Comprehensive geriatric care most effective in several subgroups of hip fracture patients
Study Type:Randomized Trial
OE Level Evidence:2
Journal Level of Evidence:N/A
Who benefits from orthogeriatric treatment? Results from the Trondheim hip-fracture trial
BMC Geriatr. 2016 Feb 19;16(1):49Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
397 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.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
The Norwegian Research Council, the Central Norway Health Authority, the St. Olav Hospital Trust, the Department of Neuroscience, NTNU, the SINTEF and St. Olav Hospital Fund for Research and Innovation, and the Municipality of Trondheim
Conflicts:
None disclosed
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)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
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
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
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.
What was the principal research question?
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?
Study Characteristics
-
Population:
397 home-dwelling patients above the age of 70 were included in the study between April 2008 and April 2010. To be selected, patients were required to be able to walk 10 m prior to sustaining the hip fracture. Perioperative treatment was standardized across groups and postoperative weight-bearing was permitted in most cases. In Garden type 1 or 2 fractures, treatment was typically provided with a two-screw fixation while arthroplasty was performed for type 3 and 4 fractures.
Intervention:
Comprehensive Geriatric Care (CGC) Group: Personalized multidimensional, interdisciplinary treatment based on the individual's medical, mental, social, and functional characteristics was provided. The treatment protocol incorporated a review of drug regimen, pain relief, hydration, nutrition, and elimination and assessment of fall risk and osteoporosis. An emphasis was placed on early mobilization, rehabilitation, and discharge. (n=198; 162 completed; mean age=83.4+/-5.4; 53M/145F)
Comparison:
Orthopaedic Care (OC) Group: Treatment was provided in accordance with national and international guidelines for orthopaedic care. (n=199; 149 completed; mean age=83.2+/-6.4; 51M/148F)
Outcomes:
Outcomes included personal activities of daily living (p-ADLs) as assessed using the Barthel Index (BI), instrumental activities of daily living (i-ADLs) as assessed using the Nottingham Extended ADL Scale (NEAS), cognition as assessed by the Mini-Mental Status examination (MMSE), and mobility as assessed using the Short Physical Performance Battery (SPPB).
Methods:
RCT: Prospective: Single-Center: Post-Hoc Analysis
Time:
Assessments were made 4 and 12 months post fracture.
What were the important findings?
- 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).
What should I remember most?
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).
How will this affect the care of my patients?
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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