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¶**¶¶ ¶¶***
From *the Division of General Internal Medicine and Clinical Epidemiology, University Health Network and Mount Sinai Hospital, Toronto, Ont.; the Geriatrics Program, Toronto Rehabilitation Institute, Toronto, Ont.; the Clinical Epidemiology and Health Care Research Program (University Health Network Unit), University of Toronto, Toronto, Ont.; the Department of Medicine, University of Toronto, Toronto, Ont.; ¶the Department of Health Administration, University of Toronto, Toronto, Ont.; **the Department of Medicine, Boston University, Boston, Mass. (current affiliation); the Division of Orthopedic Surgery, University Health Network, Toronto, Ont.; the Department of Surgery, University of Toronto, Toronto, Ont.; the Department of Public Health Sciences, University of Toronto, Toronto, Ont.; ¶¶the Loeb Research Unit, Ottawa Hospital, Ottawa, Ont. (current affiliation); and ***the Department of Surgery, University of Ottawa, Ottawa, Ont. (current affiliation)
Correspondence to: Dr. Gary Naglie, Toronto General Hospital, Rm. EN G-233, 200 Elizabeth St., Toronto ON M5G 2C4; fax 416 595-5826; gary.naglie{at}uhn.on.ca
Background: Hip fractures in elderly people are associated with impaired function and ambulation and high rates of death and admission to institutions. Interventions designed to improve the outcomes of hip fracture (e.g., mobility and discharge to own home) that have incorporated interdisciplinary care have had mixed results. We compared the effectiveness of postoperative interdisciplinary care with that of usual care for elderly patients with hip fracture.
Methods: The study population consisted of 279 patients at least 70 years of age from the community and from nursing homes who underwent surgical repair of hip fracture at a university-affiliated acute care hospital. The subjects were randomly assigned to receive postoperative interdisciplinary care (n = 141) or usual care (n = 138) during their hospital stay. Interdisciplinary care included routine assessment and care by an internist-geriatrician, physiotherapist, occupational therapist, social worker and clinical nurse specialist, as well as twice-weekly interdisciplinary rounds to set goals for the patients and to monitor their progress. The primary outcome measure was the proportion of patients alive with no decline in ambulation or transfers in and out of a chair or bed and no change in place of residence at 6 months after surgery.
Results: At 6 months, 56 patients (39.7%) in the interdisciplinary care group and 47 (34.1%) in the usual care group were alive and had no decline from baseline in terms of ambulation, chair and bed transfers or place of residence (difference 5.6%, 95% confidence interval –5.6% to 17.0%). Multiple logistic regression analysis with adjustment for baseline factors showed no significant difference between treatment groups for the primary outcome measure at 3 months (p = 0.44) or at 6 months (p = 0.67). The initial length of stay in hospital was longer for patients receiving interdisciplinary care: 29.2 (standard deviation [SD] 22.6) v. 20.9 (SD 18.8) days (p < 0.001). However, the mean number of days spent in an institution (including hospital, inpatient rehabilitation and nursing home) over the 6-month follow-up period was similar in the 2 groups (p = 0.84). A subgroup analysis suggested a trend to benefit from interdisciplinary care in patients with mild to moderate cognitive impairment.
Interpretation: Postoperative inpatient interdisciplinary care did not result in significantly better 3- or 6-month outcomes in elderly patients with hip fracture.
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