Growing knowledge about hip fracture in older people.

Hip fracture is a common condition associated with a high morbidity and mortality; and its human cost and economic burden are set to escalate globally. In January 2002, the Scottish Intercollegiate Guidelines Network (SIGN) updated its Guideline on the Prevention and Management of Hip Fracture in Older People [1]. This guideline attempts to provide an evidence-based template for the management of hip fracture and its local adoption and modification is encouraged. There is also a growing consensus that the management of fractures should be linked with assessment of risk factors and appropriate intervention (i.e. prevention and management of falls and osteoporosis). In this the guideline echoes recommendations of the National Service Framework in England [2] and the subsequent document ‘Adding Life to Years’ [3] in Scotland. Because of the enormity of the problem, audit is a particularly useful tool to drive clinical and organisational improvements in quality and effectiveness of care with regard to the journey of care after a hip fracture. Hip fracture could thus be seen as a ‘tracer condition’ to monitor response of the health service. Scotland is again unique within the UK in having an established and funded hip fracture audit program, documenting casemix, care process and outcome data from over 19,000 cases of hip fracture so far. This Scottish Hip Fracture Audit (SHFA) is now providing valuable information about hip fracture in 15 of the 25 orthopaedic units in Scotland [4], and demonstrates the importance of standardised approaches to data collection and intervention. It is also capable of showing the cost effectiveness and resource implications of differing local models of care. The SHFA, which arose from pioneering work in Sweden by Professor K. -G. Thörngren, is also linked with the larger European Standardised Audit of Hip Fracture in Europe study (SAHFE) [5]. While a large amount of data will continue to accrue from these initiatives, this does not detract from the need to pursue specific questions through randomised controlled trials which can, to an extent, adjust for some of the heterogeneity inherent in an elderly population. Trials on rehabilitation after a hip fracture are broadly focused on two main areas: the rehabilitation package itself (focusing mainly on the strategy of care employed and the setting in which it is delivered), and specific components of physical rehabilitation (e.g. maximal exercise, intensive therapy, neuromuscular stimulation) [6]. The main strategies of care have included early/ supported home discharge schemes and traditional in-patient rehabilitation, which may be carried out on an orthopaedic or geriatric ward. One modification of the latter is that of rehabilitation within a specialised and geographically distinct Geriatric Orthopaedic Rehabilitation Unit (GORU). A Cochrane review comparing co-ordinated multidisciplinary inpatient rehabilitation (typified by the GORU model) with usual orthopaedic care was hampered by the heterogeneity between trials but found a trend towards effectiveness in the former model [7], with further research suggested. GORUs may also be beneficial in selected groups with more disability [7, 8] and have other advantages of convenience and service organisation and delivery. The vexed question of choosing the optimal rehabilitation package for an individual patient may not be answerable by studies on this scale but may require co-ordinated multicentre approaches at best, or pooled results from studies which are similar in design. In this context the effectiveness of the package of care itself should take priority over any analysis of individual elements within the packages. The adoption of agreed outcome data sets is also a necessary part of any such exercise [8] as differing and intermediate outcome measures make it impractical to pool results. Longitudinal observational studies can also complement information obtained from large scale audits and randomised controlled trials. In the current issue, Röder et al. [9] describe a prospective longitudinal study of mentally normal patients with hip fracture who received post-operative rehabilitation in hospital (orthopaedic or geriatric units), or were discharged home. The general pattern in Röder’s study was for patients to improve in function between the time of discharge and the six-month follow-up, but they tended to plateau at this point at a level below their (self-reported) pre-fracture status. During the twelve-month period of follow-up, no between-group differences were seen for the studied outcome measures (functional ability, quality of life index and mortality). Röder’s treatment groups were not formally randomised, but similar findings are also emerging elsewhere with home-based rehabilitation programmes achieving a comparable [10, 11] and sometimes improved functional outcome [12] as compared with Age and Ageing 2003; 32: 8–9 # 2003, British Geriatrics Society