Care Pathway for Sub-acute Hip Rehabilitation

Overview

The effectiveness of integrated care pathways for hip fractures in sub-acute rehabilitation settings is not known. The study objective was to assess if a hip fracture integrated care pathway at a sub-acute rehabilitation facility would result in better functional outcomes, shorter length of stay and fewer institutionalisations. A randomised controlled trial on an integrated care pathway was conducted for hip fracture patients in a sub-acute rehabilitation setting. The study supports the use of integrated care pathways in sub-acute rehabilitation settings to reduce length of stay whilst achieving the same functional gains.

Full Title of Study: “Integrated Care Pathway for Hip Fractures in a Subacute Rehabilitation Setting”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Health Services Research
    • Masking: Single (Outcomes Assessor)
  • Study Primary Completion Date: June 14, 2006

Detailed Description

All patients admitted to St Luke's Hospital, a 185-bed hospital in Singapore providing multidisciplinary stepdown care, from 8 September 2004 to 14 June 2006 for the purpose of rehabilitation after a new hip fracture were included. Patients were excluded if any of the following criteria were present: (i) Pre-morbid non-ambulatory status, (ii) nursing home residents, (iii) palliative care patients, and (iv) patients previously enlisted for the trial. Administrative staff allocated patients to either ICP or usual care according to the last digit of their National Registration Identity Card (NRIC) numbers, odd numbers to the intervention group and even numbers to the control group. Patients were then admitted to 1 of 2 intervention wards or 1 of 3 control wards. Patients were enrolled by the principal investigators only after moving into their respective wards because of work flow limitations. Those who refused consent or were excluded remained in their assigned wards and received usual care. Both intervention and control groups were under the care of multidisciplinary teams but the intervention group had structured assessments and checklists in addition to usual care while the control group had usual care alone.

Interventions

  • Other: Care Pathway
    • The intervention group had the following as part of the integrated care pathway: Medical assessment on admission for risk factors for falls. A weekly assessment of complications including pain, deep venous thrombosis, anaemia, wounds and pressure ulcers, etc. The Confusion Assessment Method and the Geriatric Depression Scale were utilized. Physiotherapy and occupational therapy guidelines with recommended milestones (set for the full, partial and non-weight bearing groups) Physiotherapy Clinical Outcome Variables Scale (PTCOVS)16 was used by the physiotherapists in the intervention group to assess the baseline mobility, to define outcome goals and to direct treatment plans. A postoperative hip precaution handout (containing information on avoiding hip prosthesis dislocation in patients with total hip replacement or hemiarthroplasty) was given to patients and their caregivers.

Arms, Groups and Cohorts

  • No Intervention: Control group
    • Usual care consisted of 2 half hourly therapy sessions per day from Monday to Friday and medical ward rounds 3 times a week. Multidisciplinary rounds were conducted every 2 weeks. Any specific goals or interventions were at the discretion of the managing team.
  • Experimental: Intervention group
    • Intervention group had structured assessments and checklists (as part of the integrated care pathway) in addition to usual care.

Clinical Trial Outcome Measures

Primary Measures

  • Montebello Rehabilitation Factor Score (MRFS)
    • Time Frame: 1 day At discharge
    • MRFS is a recognised measure of hip fracture patients’ functional outcome, calculated with the following formula, using the Modified Barthel Index (MBI) scores (which scores the degree of independence of a subject from any assistance up to a maximum score of 100)
  • Montebello Rehabilitation Factor Score (MRFS)
    • Time Frame: At 6 months
    • MRFS is a recognised measure of hip fracture patients’ functional outcome, calculated with the following formula, using the Modified Barthel Index (MBI) scores (which scores the degree of independence of a subject from any assistance up to a maximum score of 100)
  • Montebello Rehabilitation Factor Score (MRFS)
    • Time Frame: At 1 year
    • MRFS is a recognised measure of hip fracture patients’ functional outcome, calculated with the following formula, using the Modified Barthel Index (MBI) scores (which scores the degree of independence of a subject from any assistance up to a maximum score of 100)
  • Proportions of patients achieving pre-morbid ambulatory status
    • Time Frame: 1 day At discharge
    • Pre-morbid ambulatory status is a predictor for post-operative mobility
  • Proportions of patients achieving pre-morbid ambulatory status
    • Time Frame: At 6 months
    • Pre-morbid ambulatory status is a predictor for post-operative mobility
  • Proportions of patients achieving pre-morbid ambulatory status
    • Time Frame: At 1 year
    • Pre-morbid ambulatory status is a predictor for post-operative mobility
  • Length of stay in hospital
    • Time Frame: 1 day At discharge
    • Refers to the average number of days that patients spend in hospital
  • Percentage of patients admitted to nursing home
    • Time Frame: Up to 1 year after discharge
    • A form of institutional care

Secondary Measures

  • Readmissions to an acute hospital for any reason
    • Time Frame: up to 1-year post-discharge
    • An episode when a patient who had been discharged from a hospital is admitted again within a specified time interval
  • Cumulated mortality
    • Time Frame: 1 year
    • Probability or risk of individuals dying from the disease during a specified period
  • Quality of life scale—Short form 12 quality of life
    • Time Frame: 6 months and 1 year
    • Scale for short form 12 quality of life 0-100 Scale for Physical Component Summary (PCS) and Scale for Mental Component Summary (MCS), a multipurpose, generic measure of health status 0-100 Interpretation of the score : The higher score, the better

Participating in This Clinical Trial

Inclusion Criteria

  • Patients admitted to St Luke's Hospital for the purpose of rehabilitation after a new hip fracture.

Exclusion Criteria

  • Patients were excluded if any of the following criteria were present: (i) Pre-morbid non-ambulatory status, (ii) nursing home residents, (iii) palliative care patients, and (iv) patients previously enlisted for the trial.

Gender Eligibility: All

Minimum Age: N/A

Maximum Age: N/A

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • St Luke’s Hospital, Singapore
  • Collaborator
    • National University, Singapore
  • Provider of Information About this Clinical Study
    • Principal Investigator: Boon Yeow, Tan, Chief Executive Officer, Medical Director, Medical Division – St Luke’s Hospital, Singapore
  • Overall Official(s)
    • Tze Pin Ng, FAMS, PhD, Study Chair, National University, Singapore

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