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

据估计，到2050年，全球将有450万人髋关节骨折。即使手术，30%的患者在一年内死亡。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“实现并保持最佳功能”。然而，有有限的证据来指导髋部骨折后的有效康复。这种不确定性可能是由于患者之间的差异。分层方法可以通过根据患者需求定制康复来改善结果。髋部骨折幸存者描述了一种量身定制的方法作为恢复的关键。此外，NHS建议将分层方法作为医疗保健进步的核心。AIMSWe旨在改善髋部骨折后患者和护理人员的康复结果。在患者和护理人员的支持下，每一步的目标是：1。确定具有不同不良结局风险的患者群体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3。在急性病医院进行干预的可行性试验4.在老年人创伤康复研究中，与患者、护理人员和公众建立一个合作小组调查计划确定患者群体：我们完成了一项系统回顾，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患者预后不良风险的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）和理疗髋部骨折冲刺审计（PHFSA），以根据这些因素的组合来估计康复后不良结局的预测准确性。分析将得到伦敦国王学院国家健康研究所（NIHR）统计组的支持。我们将根据结果将多因素分层分为低、中、高风险的不良结局。我们将与患者、护理人员和专职医疗人员讨论分类的可接受性。干预措施的开发和测试：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。我们将更新科克伦系统评价髋部骨折后康复。我们将完成一个综述急性康复成人虚弱。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。我们会访问专职医疗人员，了解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者研讨会，以评估患者，护理人员和专职医疗专业人员对审查，当前提供和采访的看法，并设计一种干预措施，将低，中，高风险阶层与适合他们需求的康复相匹配。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。我们将在急性医院进行干预试验之前获得批准，以确定1。合格、招募和保留的患者数量2。随机化、评估和干预对患者、护理人员和专职医疗人员的可接受性3。遵守干预措施并忠实地提供干预措施4。不良事件5. Sackley（KCL导师，NIHR高级研究员，复杂干预试验奖励50，000，000英镑）将支持干预开发。创建协作组：我们将创建一个小组，网站和策略，与患者，护理人员和公众在老年人创伤康复研究中持续合作。该小组将仿照KCL的中风研究患者和家庭小组，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.