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.

WHO WILL BENEFIT FROM THIS RESEARCH?

1. Older adults after musculoskeletal trauma
2. Clinicians who deliver rehabilitation for older adults after hip fracture
3. Guidelines committees
4. Falls and Fragility Fracture Audit Programme
5. Public health commissioners

HOW WILL THEY BENEFIT FROM THIS RESEARCH?

DURING/AT END OF THE FELLOWSHIP

Older adults after musculoskeletal trauma: We will provide a platform for collaborative involvement and engagement of patients, carers, and the public in future trauma rehabilitation research. This platform will enable members to say patients are 1) recognised by including a strong patient, carer and public voice in the design and testing of new rehabilitation approaches (timescale = 2 years), 2) supported to achieve the best possible health outcomes by increasing the chance of receiving rehabilitation which best reflects patient defined goals (timescale = 4 years), and 3) inspiring the next generation of healthcare researchers (timescale = 2 years).

Clinicians who deliver rehabilitation for older adults after hip fracture: We aim to influence professional clinical practice by providing clinicians who deliver rehabilitation for older adults after hip fracture with evidence of the relationship between variation in access and delivery of rehabilitation and outcomes of that rehabilitation, for all patients, and for patients with different responses to rehabilitation (timescale = 2 years). We also aim to influence professional practice by providing clinicians with the means for robust easy to use risk stratification of patients after hip fracture to inform their planning of care delivery (timescale = 2.5 years).

Guidelines committees: The National Institute for Health and Care Excellence (NICE) Clinical Guideline 124 describes recommendations for care of patients after hip fracture. The National Osteoporosis Society develops and disseminates guidelines for care after hip fracture. These guidelines point to the need for more evidence to inform optimal rehabilitation after hip fracture. We aim to inform an update to recommendations for rehabilitation after hip fracture in both the National Institute for Health and Care Excellence (NICE) Clinical Guideline 124 and National Osteoporosis Guideline (timescale = 4 years).

International audit programmes: International audit programmes aim to audit care that patients with hip fracture receive in hospital to inform quality improvement initiatives, and ultimately patient benefit. We aim to inform rehabilitation data elements for inclusion in their national audit through engagement with the Global Fragility Fracture Network Hip Fracture Audit Database Minimum Common Dataset Advisory Group (timescale = 2 years).

Public health commissioners: Best Practice Tariffs are a set of prices and rules that help the NHS to deliver the best value care for patients. Tariffs are based on quality care indicators informed by research. We aim to improve the effectiveness of public policy in hip fracture through the introduction of hip fracture rehabilitation quality care indicators for Best Practice Tariffs (timescale = 2 years).

AFTER COMPLETION OF THE FELLOWSHIP

The fellowship will inform a definitive trial to determine the clinical- and cost- effectiveness of a stratified model of acute rehabilitation after hip fracture that is tailored to patient needs. The findings have the potential for benefit to patients, carers, clinicians, guidelines committees, Public Health England and NHS Improvement by increasing the probability of selecting the most appropriate acute rehabilitation as the first intent to improve patient- healthcare- and societal- outcomes after hip fracture (timescale = 7 years).