Best Practices for Elderly Hip Fracture Patients

A Systematic Overview of the Evidence

Lauren A. Beaupre, PT, PhD; C. Allyson Jones, PT, PhD; L. Duncan Saunders, MBBCh, PhD; D. William C. Johnston, MD, FRCS (C); Jeanette Buckingham, MLIS; Sumit R. Majumdar, MD, MPH

Disclosures

J Gen Intern Med. 2005;20(11):1019-1025. 

In This Article

Abstract and Introduction

Objectives: To determine evidence-based best practices for elderly hip fracture patients from the time of hospital admission to 6 months postfracture.
Data Sources: MEDLINE, Cochrane Library, CINAHL, Embase, PEDro, Ageline, NARIC, and CIRRIE databases were searched for potentially eligible articles published between 1985 and 2004.
Review Methods: Two independent reviewers determined studies appropriate for inclusion using standardized selection criteria, extracted data, evaluated internal validity, and then rated studies according to levels of evidence. Only Level 1 or 2 evidence was included in our summary of clinical recommendations.
Results: Spinal anesthesia, pressure-relieving mattresses, perioperative antibiotics, and deep vein thromboses prophylaxes had consistent evidence of benefit. Routine preoperative traction was not associated with any benefits and should be abandoned. Types of surgical management, postoperative wound drainage, and even "multidisciplinary" care, lacked sufficient evidence to determine either benefit or harm. There was little evidence to either determine best subacute rehabilitation practices or to direct ongoing medical issues (e.g., nutrition). Studies conducted during the subacute recovery period were heterogeneous in terms of treatment settings, interventions, and outcomes studied and had no clear evidence for best treatment practices.
Conclusions: The evidence for perioperative practices is relatively robust and evidence-based perioperative treatment guidelines can be easily established. Conversely, more evidence is required to better guide the care of elderly patients with hip fracture during the subacute recovery period and convalescence.

Hip fracture represents the second leading cause of hospitalization for elderly people.[1] Incidence increases substantially with age, rising from 22.5 and 23.9 per 100,000 population at age 50 to 630.2 and 1289.3 per 100,000 population by age 80, for men and women, respectively.[2,3,4,5] Following a hip fracture, patients have increased health service utilization for at least 1 year, with much of health care costs attributable to subsequent long-term care.[2,6,7,8] Identifying best practices for elderly hip fracture patients while using available health resources effectively and efficiently is relevant to both clinicians and policymakers.

Standardized care, based upon current "best evidence," constitutes 1 approach to facilitate optimal outcomes and resource use. We conducted a systematic literature review of management of this patient population, examining all practices throughout the care continuum from preoperative assessment through surgical management and subsequent rehabilitation. Because our systematic review examined a broad array of treatment practices, we included not only individual studies, but also systematic reviews of specific treatment practices where available. Some of the clinical areas investigated apply to elderly patients in general, but are still important aspects of care for hip fracture patients (e.g., pressure sore prevention); thus these components were also included in our review. Our intent was to identify those evidence-based practices that should be considered a part of routine high quality care for all hip fracture patients.

processing....