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

据估计，到2050年，全球将有450万人髋部骨折。即使做了手术，也有30%的病人在一年内死亡。在幸存者中，25%的人再也不能走路，22%的人从家里搬到了养老院。康复帮助患者“达到并保持最佳功能”。然而，指导髋部骨折后有效康复的证据有限。这种不确定性可能是由于患者之间的差异。分层的方法可以根据病人的需要来调整康复，从而改善结果。髋部骨折幸存者将量身定制的治疗方法描述为康复的关键。此外，国民保健制度建议将分层方法作为医疗保健进展的核心。目的：提高髋部骨折后患者和护理人员的康复效果。在病人和护理人员的支持下，每一步的目标是：确定不同预后不良风险的患者组2。设计一项干预措施，使这些群体能够根据他们的需要进行康复治疗。急性住院干预的可行性检验在老年人创伤康复研究中与患者、护理人员和公众建立合作小组调查计划确定患者群体：我们完成了一项系统综述，并采访了20名患者和护理人员，以确定影响髋部骨折康复后不良预后风险的4个因素：年龄、性别、认知和活动能力。我们将分析国家髋部骨折数据库（NHFD）和物理治疗髋部骨折冲刺审计（PHFSA），根据这些因素的组合来估计康复后不良预后的预测准确性。分析将由伦敦国王学院的国家健康研究所（NIHR）统计小组提供支持。我们将使用结果将多因素分层分为低、中、高风险的不良预后。我们将与患者、护理人员和相关卫生专业人员讨论分类的可接受性。干预开发和测试：在患者和护理人员的支持下，我们将根据MRC框架设计和可行性测试干预措施，以开发复杂的干预措施。我们将更新髋部骨折后康复的Cochrane系统综述。我们将完成对成人虚弱的急性康复的综述。我们将使用NHFD和PHFSA来量化目前为低、中、高风险患者提供的康复服务。我们会访问专职医护人员，听取他们对这项规定的意见。这些访谈将补充已完成的患者访谈。我们将举办利益相关方研讨会，以评估患者、护理人员和专职卫生专业人员对审查、当前提供和访谈的意见，并设计一种干预措施，使低、中、高风险阶层与适合其需求的康复相匹配。干预措施将包括行为改变技术和联合保健。从低风险阶层到高风险阶层，对行为改变的重视程度将逐渐降低。我们将在急诊医院进行干预试验前获得批准以确定e1。符合条件、招募和保留的患者数量。随机化、评估和干预对患者、护理人员和相关卫生专业人员的可接受性。遵从干预并忠实于其交付。events5不利。sackley （KCL导师，英国国家卫生研究院高级研究员，授予5000万英镑用于复杂干预试验）将支持干预措施的发展。创建一个合作小组：我们将创建一个小组、网站和策略，以便在老年人创伤康复研究中与患者、护理人员和公众进行持续的合作。该小组将以KCL的中风研究患者和家属小组为蓝本，该小组自2005年以来一直保持公众参与。

BACKGROUNDGlobally, 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.AIMSWe 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 outcomes2. design an intervention which matches these groups to rehabilitation tailored to their needs3. feasibility test the intervention in acute hospital4. create a collaborative group with patients, carers, and the public in older adult trauma rehabilitation researchINVESTIGATION PLANIdentify 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 determine1. the number of eligible, recruited, and retained patients2. the acceptability of randomization, assessments, and intervention to patients, carers, and allied health professionals3. compliance with the intervention and fidelity of its delivery4. adverse events5. estimate of an effect size for a future definitive trialSackley (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.