Development of a stratified model of care for acute rehabilitation after hip fracture

BACKGROUND Globally, an estimated 4.5 million people will fracture their hip in 2050. Even with surgery, 30% of patients die within a year. Among survivors, 25% never walk again and 22% change from living at home to a nursing home. Rehabilitation assists patients 'to achieve and maintain optimal functioning'. Yet, there is limited evidence to guide effective rehabilitation after hip fracture. This uncertainty may be due to between patient differences. A stratified approach could improve outcomes by tailoring rehabilitation to patient needs. Hip fracture survivors describe a tailored approach as key to recovery. Further, the NHS recommends a stratified approach as central to healthcare progress. AIMS We aim to improve patient and carer outcomes of rehabilitation after hip fracture. Supported by patients and carers at each step, the objectives are to: 1. identify patient groups with different risk of poor outcomes 2. design an intervention which matches these groups to rehabilitation tailored to their needs 3. feasibility test the intervention in acute hospital 4. create a collaborative group with patients, carers, and the public in older adult trauma rehabilitation research INVESTIGATION PLAN Identify patient groups: We completed a systematic review and interviewed 20 patients and carers to identify 4 factors that influence patients risk of poor outcome after rehabilitation for hip fracture- age, sex, cognition, and mobility. We will analyse of National Hip Fracture Database (NHFD) and Physiotherapy Hip Fracture Sprint Audit (PHFSA) to estimate the prediction accuracy of poor outcome following rehabilitation according to combinations of these factors. Analyses will be supported by the National Institute for Health Research (NIHR) Statistics Group at Kings College London. We will use results to classify multifactorial strata as low-, medium-, or high- risk of poor outcome. We will discuss classification acceptability with patient, carers, and allied health professionals. Intervention development and testing: Supported by patients and carers, we will design and feasibility test the intervention per the MRC framework for the development of complex interventions. We will update the Cochrane systematic review of rehabilitation after hip fracture. We will complete an overview of reviews on acute rehabilitation for adults with frailty. We will use NHFD and PHFSA to quantify current rehabilitation provision for patients classified as low-, medium-, and high- risk. We will interview allied health professionals to obtain their views on this provision. These interviews will complement completed patient interviews. We will hold stakeholder workshops to assess patient, carer, and allied health professional views on reviews, current provision, and interviews, and to design an intervention which matches low-, medium-, and high- risk strata to rehabilitation tailored to their needs. The intervention will include behaviour change techniques and allied health care. There will be a decreasing emphasis on behaviour change from low- to high- risk strata. We will obtain approvals prior to intervention testing in acute hospital to determine 1. the number of eligible, recruited, and retained patients 2. the acceptability of randomization, assessments, and intervention to patients, carers, and allied health professionals 3. compliance with the intervention and fidelity of its delivery 4. adverse events 5. estimate of an effect size for a future definitive trial Sackley (KCL mentor, NIHR Senior Investigator, £50,000,000 awarded for complex intervention trials) will support intervention development. Create a collaborative group: We will create a group, website, and strategy for sustained collaboration with patients, carers, and the public in older adult trauma rehabilitation research. The group will be modeled on the Stroke Research Patient and Family Group at KCL which has sustained public engagement since 2005.