An Analysis of the Feasibility of Home Rehabilitation Among Elderly People With Proximal Femoral Fractures

Article Outline

• Abstract
• Methods
  • Participants
  • Baseline Evaluation and Discharge Procedure
  • Follow-Up and Outcome Variables
  • Statistical Analysis
• Results
• Discussion
  • Feasibility
  • Long-Term Institutionalization
• Conclusions
• Acknowledgment
• References
• Copyright

Abstract 

Giusti A, Barone A, Oliveri M, Pizzonia M, Razzano M, Palummeri E, Pioli G. An analysis of the feasibility of home rehabilitation among elderly people with proximal femoral fractures.

Objective

To evaluate the feasibility and predictors of success of home-based rehabilitation (HBR) in older adults after hip fracture.

Design

Prospective inception cohort study with 12 months of follow-up.

Setting

Acute and subacute care with follow-up in a community setting in Italy.

Participants

Community-dwelling older adults (N=199) aged 70 years or older, discharged from an acute orthopedic unit after repair of a nontraumatic proximal femoral fracture.

Interventions

Patients’ choice of pursuing HBR or institutional-based rehabilitation (IBR).

Main Outcome Measures

Proportion of subjects discharged home for rehabilitation. Rates of institutionalization assessed at 3, 6, and 12 months postdischarge. Mean changes of the Barthel Index from baseline and proportion of subjects who regained their prefracture levels of function at the time of follow-up in the 2 intervention groups (HBR, IBR).

Results

Ninety-nine (49.7%) patients chose HBR, and the rest (50.3%) were discharged to a rehabilitation facility. With regard to the baseline characteristics, the 2 patient groups (HBR, IBR) differed with respect to living arrangement (P≤.001), prefracture functional status in basic (Barthel Index, P=.033; Katz Index, P=.041) and instrumental activities of daily living (IADLs) (P=.041), and occurrence of delirium (P=.022). During the follow-up, the number of subjects institutionalized at 3, 6, and 12 months was 52, 26, and 22, respectively. In the multiple logistic regression model, the only significant variable affecting the choice of IBR at discharge was the absence of relatives at home (odds ratio [OR], 6.7; 95% confidence interval [CI], 3.33–13.46; P≤.001), whereas a prefracture functional impairment in more than 3 IADLs (at 12mo: OR=3.99; 95% CI, 1.57–10.18; P=.004), the absence of relatives at home (at 12mo: OR=8.81; 95% CI, 2.47–31.46; P=.001), and delay to surgery longer than 3 days (at 12 mo: OR=5.51; 95% CI, 1.28–23.81; P=.022) resulted in significant risk factors for long-term institutionalization. Compared with subjects who received traditional rehabilitation, those discharged home showed—after controlling for prefracture Barthel Index score, IADLs, cognitive status and age—a slightly lower functional decline and a higher rate of recovery during the follow-up (mean change in Barthel Index score ± standard deviation at 12mo: HBR, −11.2±24.7 vs IBR, −23.7±28.5; P=.015).

Conclusions

In an unselected population of hip-fractured older adults previously living in the community, HBR seems to be a feasible alternative to IBR in those subjects living with relatives.

Key Words:  Elderly , Hip fracture , Home care services , Rehabilitation

HIP FRACTURE IS AMONG the most common causes of acute hospitalization in the elderly and is associated with significant mortality, institutionalization, and loss of function.¹, ², ³, ⁴, ⁵, ⁶ Previous studies reported a sustained decline in physical function and walking ability in the elderly who survive the first year after hip fracture.², ³, ⁴ In addition, Braithwaite et al¹ estimated that these patients spent about 17% of their remaining life in a nursing facility, 12% of which was attributable to hip fracture. It is therefore essential to understand the factors that may influence functional decline and long-term institutionalization after hip fracture. Although the literature is varied, old age, male sex, poor prefracture physical and cognitive function, and social impairment were consistently found to be related to such negative outcomes.⁵, ⁶, ⁷, ⁸, ⁹ In particular, previous studies highlighted the importance of psychosocial factors for recovery after hip fracture and reported a positive effect of the presence of relatives on the improvement of walking ability during the follow-up.⁷, ⁸, ⁹

Despite the fact that several approaches have been proposed to prevent progression of disability and to maximize functional recovery after hip fracture, the optimal rehabilitation site is still uncertain.¹⁰, ¹¹, ¹², ¹³ In recent years, the development of home-based rehabilitation (HBR) programs in Europe, Australia, and North America have provided a supposedly safer and more cost-effective alternative to traditional rehabilitation.¹⁴, ¹⁵, ¹⁶

Considering their potential advantages, home care services seem to be underutilized in developed countries, as reported by Jarman et al,¹⁷ who observed a very low proportion of patients discharged home after hip fracture. Two recently published randomized controlled trials¹⁵, ¹⁶ (RCTs) reported that HBR and institutional-based rehabilitation (IBR) in elderly patients after hip fracture produce comparable results in terms of functional outcomes. However, these studies excluded patients with prefracture cognitive or functional impairment and those living alone at the time of hospital admission and were characterized by a relatively small sample. Because patients with premorbid cognitive decline or disability are a significant proportion of the hip-fractured elderly,¹⁸, ¹⁹ it remains uncertain whether the abovementioned conclusions correctly reflect the unbiased population, and in particular, if those patients with a higher degree of frailty may benefit from an HBR program.

The main purpose of the present study was to analyze the feasibility of an HBR program for an unselected population of older adults, originally living at home, who were hospitalized for hip fracture, to identify factors that affect the choice of the rehabilitation setting (HBR vs IBR) and to compare the effectiveness of the 2 rehabilitation programs. We also investigated some prefracture characteristics of the patients and events occurring during the hospital stay that may serve as significant predictors for long-term institutionalization after hip fracture.

Back to Article Outline

Methods 

Participants 

All hip-fractured patients consecutively admitted to the Genoa Galliera Hospital, Genoa, Italy, between November 1, 2000, and November 1, 2001, were eligible for inclusion in the study if they were at least 70 years old, were living in the community at the time of fracture, had surgical stabilization of the fracture, and were discharged alive. Patients with a fracture due to secondary causes (metastatic cancer, Paget’s disease of the bone), those living in a nursing home at the time of fracture, and those who refused to give informed consent (follow-up and in-hospital interviews) were excluded. The hospital’s ethics committee reviewed and approved the study protocol. When the subjects were too confused to understand the informed consent process, proxy consent was obtained.

Baseline Evaluation and Discharge Procedure 

Baseline data were collected through a comprehensive geriatric assessment performed by a physician within 18 hours of admission. Demographic information included age, sex, and living arrangements defined as either living alone or with spouses or other family members. Prefracture functional status (2wk before) was measured both for basic (BADLs) and instrumental activities of daily living (IADLs) using the Barthel Index (score range, 0–100) and the Katz Index (score range, 0–6) for the BADLs and the Lawton Index (score range, 0–8) for the IADLs.²⁰, ²¹, ²², ²³ Cognitive status was assessed by the Short Portable Mental Status Questionnaire (SPMSQ) (score range, 0–10).²⁴ Medical burden and severity of illness were measured using the Cumulative Illness Rating Scale (CIRS) and the Acute Physiology and Chronic Health Evaluation II scale (APACHE II) (score range, 0–71).²⁵, ²⁶ When a subject was too ill or cognitively compromised, data were obtained from a proxy. Information collected during hospital stay included medical complications, occurrence of delirium, type of fracture, and time to surgery. After surgical treatment, a geriatric-care nurse with each patient and his/her proxies developed a discharge plan, including the choice of rehabilitation setting. Patients and their proxies were given detailed information about home rehabilitation services and skilled rehabilitation facilities available in the area. The decision whether patients were discharged to a home care program or to rehabilitation facilities was made by the patients themselves and/or their families. Both HBR and IBR were provided by the health care system. The specific content and duration of the training program therapy, for both home and institutional patients, were left to the discretion of the individual therapists. Usually physical therapists provided strengthening and range-of-motion exercises and instructed their patients in gait and transfer training.

The proportion of subjects discharged home was recorded and used to assess feasibility.

Follow-Up and Outcome Variables 

A telephone follow-up interview was conducted at 3, 6, and 12 months after hospital admission to assess the functional status in BADLs and the placement of patients (home vs institution). For this purpose, a telephone questionnaire was designed using the items of the Barthel Index adapted for a telephone interview with an additional question regarding the placement of patients (place of residence at each point of follow-up). To compare the effectiveness of the 2 rehabilitation settings (HBR vs IBR), 2 estimators were taken into consideration. The first was the mean change of the Barthel Index score from baseline (prefracture functional status) at the times of follow-up. The second was the proportion of patients who regained their respective prefracture levels of functional ability, measured through the Katz Index, at 3, 6, and 12 months from discharge.

The subjects institutionalized at 3, 6, and 12 months were recorded to examine the relation between the baseline characteristics of patients and the risk of long-term institutionalization.

Statistical Analysis 

Descriptive statistics were used to identify baseline characteristics of patients treated at home and of those treated in the institution: categoric variables were expressed in percentages and continuous variables were reported as mean ± standard deviation (SD). Baseline functional, clinical, and demographic characteristics between the 2 groups were compared using unpaired t tests (for continuous variables) or chi-square tests (for categoric variables).

Bivariate and multivariate analyses were performed to identify the factors that affected the choice of rehabilitation setting and the predictors of long-term institutionalization. The dependent variable was the cumulative institutionalization, expressed as a binary value, at each time point (discharge, 3mo, 6mo, 1y). All the independent variables were expressed as categoric variables. Categories were selected on the basis of their clinical significance or distribution (25th and 75th percentiles) as follows: age (70–75y, 76–85y, >85y), sex (man, woman), Barthel Index score (0–49, 50–90, 91–100), Katz Index score (0–2, 3–4, 5–6), Lawton Index score (0–3, 4–6, 7–8), APACHE II score (0–2, 3–5, >6), SPMSQ score (0–4, 5–7, 8–10), CIRS comorbidity index subscore (1–2, 3–4, >4), CIRS severity index subscore (<1.5, 1.5–1.9, >1.9), living situation (living alone, cohabitation), time to surgery (0–3d, >3d), type of fracture (femoral neck, pertrochanteric), occurrence of delirium (yes, no), and medical complications (yes, no). First, we analyzed the bivariate association between the outcome and each of the categoric independent variables by nonparametric Mann-Whitney U test or Kruskal-Wallis test depending on the number of categories. Then, a logistic regression analysis was performed to examine the relation between the outcome and the independent variables that were significant in the bivariate analysis.

To compare the effectiveness of rehabilitation between the 2 groups the mean changes of the Barthel Index scores over the course of the study were analyzed using repeated-measures analysis of variance (ANOVA) with outcome group (HBR vs IBR) as grouping factor. The focus of the analysis was on the significance of the interaction between group and time, which tested hypotheses regarding the equality of changes over time in the 2 groups. Then the change score was calculated by subtracting the prefracture score from that at 3, 6, and 12 months. The difference in the score between groups was examined using analysis of covariance (ANCOVA) with baseline scores of the Barthel Index, Lawton Index, SPMSQ, CIRS comorbidity index, and age as covariates. The Katz Index was used to evaluate functional recovery. Patients who attained prefracture scores at each point of follow-up were considered to have gained complete recovery regardless of the prefracture level. To calculate the percentage of subjects with complete recovery, those with prefracture Katz Index scores of 0 were excluded.

All comparisons were 2-tailed and significance was set at P less than .05. Odds ratios (ORs), 95% confidence intervals (CIs), and P values were calculated using standard formulae. Statistical analysis was performed using SPSS^a for Windows.

Back to Article Outline

Results 

Between November 1, 2000, and November 1, 2001, 248 patients were admitted to the Galliera Hospital with a fracture of the proximal femur. Twelve died during hospital stay and 37 of those surviving were living in a nursing home at the time of fracture. One hundred ninety-nine subjects living at home were discharged, but 5 refused to give informed consent or dropped out during follow-up. The data refer to 194 subjects who completed the baseline assessment and the follow-up interview.

The participants averaged 83.6±6 years old, and 14.5% were men. Ninety-five (49%) patients were discharged directly home for rehabilitation, and for the rest (99 [51%]), rehabilitation was provided in an institution. At 3, 6, and 12 months, the number of surviving subjects was 178, 167, and 158, respectively, and the number of subjects institutionalized was 52 (29%), 26 (16%), and 22 (14%), respectively.

The baseline demographic, functional, and clinical characteristics of patients treated at home (HBR) and of those discharged to a rehabilitation facility (IBR) are shown in table 1. The 2 groups were similar, except for the proportion of subjects living alone at the time of fracture (home, 23.2% vs institution, 62%; P≤.001), prefracture functional status in BADLs (eg, mean Barthel Index score: HBR, 85.5±23.4 vs IBR, 82.4±22.6; P=.033), IADLs (mean Lawton Index score: HBR, 11.5±6.7 vs IBR, 9.8±6.2; P=.041), and occurrence of delirium (HBR, 29.2% vs IBR, 45%; P=.022).

Table 1. Baseline Demographics and Functional and Clinical Characteristics of the Patients by Setting of Rehabilitation Program

Variable	HBR	IBR	P
No. of subjects (%)	95(49)	99(51)	NA
Mean age ± SD (y)	82.5±6.3	83.5±6.7	.375
Male (%)	16	13	.528
Pertrochanteric fracture (%)	55	49	.356
In-hospital complications (%)⁎	55	60	.438
Delirium (%)†	29	45	.022
Pressure ulcers > stage I (%)‡	31	41	.156
Subjects living alone (%)	23	62	<.001
Mean APACHE II acute physiology scale score ± SD	8.7±3.4	8.8±2.9	.979
Mean CIRS comorbidity index score ± SD	3.4±1.6	3.5±1.7	.608
Mean Barthel Index score ± SD	85.5±23.4	82.4±22.6	.033
Mean Katz Index score ± SD	4.7±1.8	4.3±1.9	.041
Subjects with Katz Index score of 0, n (%)§	8(8.4)	7(7.0)	.333
Mean Lawton Index score ± SD	11.5±6.7	9.8±6.2	.041
Mean SPMSQ ± SD	6.9±3.0	6.5±2.5	.063

Abbreviation: NA, not applicable.

Risk factors for short- and long-term institutionalization (univariate analysis) are shown in table 2. The only factors associated with discharge to the rehabilitation facility were the living situation and the occurrence of delirium during hospital stay. At 3, 6, and 12 months, other factors became significantly related to the risk of long-term institutionalization: living alone, old age, premorbid functional status in BADLs and IADLs, delay to surgery, occurrence of delirium, and poor cognitive status.

Table 2. Univariate Analysis

Variable	Discharge		3 Months		6 Months		12 Months
	%⁎	P	%⁎	P	%⁎	P	%⁎	P
Age (y)		.271		.199		.196		.036
70–75	44.0		29.2		17.4		9.5
76–85	47.9		23.0		14.0		12.2
>86y	57.5		35.8		23.5		25.4
Sex		.510		.771		.653		.665
Male	44.8		29.0		16.6		13.6
Female	51.2		26.1		18.3		17.4
Barthel Index score†		.134		.199		.011		.005
0–49	52.9		41.2		33.3		28.6
50–90	60.6		30.9		26.3		28.8
91–100	45.0		25.5		11.0		9.3
Katz Index score†		.110		.099		.019		.003
0–2	65.6		41.4		34.6		36.0
3–4	54.5		30.8		32.1		25.0
5–6	46.5		25.2		12.7		10.6
Lawton Index score†		.100		<.001		<.001		<.001
0–3	56.6		42.3		32.8		34.4
4–6	55.3		30.2		17.1		15.4
7–8	39.7		11.1		3.2		1.6
APACHE II acute physiology scale score		.629		.372		.853		.335
0–2	48.5		31.1		17.5		15.1
3–5	52.4		25.0		20.0		20.0
>6	61.1		23.1		23.1		33.3
SPMSQ score‡		.115		.002		.003		.002
0–4	52.6		37.9		33.3		34.6
5–7	60.0		41.1		25.5		26.5
8–10	43.3		17.4		9.0		8.0
CIRS comorbidity index score‡		.950		.627		.184		.688
1–2	49.2		25.4		12.1		15.5
3–4	51.1		30.9		18.5		19.5
>5	52.2		28.9		27.0		13.3
CIRS severity index score‡		.415		.436		.248		.998
<1.5	44.4		27.9		11.6		14.0
1.5–1.9	50.9		26.2		14.4		14.3
>1.9	59.0		37.5		26.9		13.0
Social support		<.001		<.001		<.001		<.001
Living alone	72.9		44.0		27.0		25.8
Cohabitation	33.3		17.5		8.0		5.3
Time to surgery (d)		.759		.673		.254		.033
0–3	50.0		27.6		11.3		5.9
>3	52.4		30.7		18.3		18.8
Fracture type		.356		.125		.394		.372
Femoral neck	53.7		23.3		15.5		14.1
Pertrochanteric	47.1		33.7		20.4		19.3
Medical complications		.438		.227		.141		.214
Yes	52.6		32.3		21.8		20.0
No	47.1		24.1		13.2		12.7
Delirium		.022		.040		.028		.002
No	44.0		23.5		13.3		10.3
Yes	60.8		38.1		26.5		28.8

NOTE. Variables associated with the risk of being discharged to a rehabilitation facility and long-term institutionalization.

These variables, significant in bivariate analysis, were included in a logistic regression model (table 3). On the basis of bivariate analysis, only 2 categories were considered for the Barthel Index (score 91–100, score <91) and the SPMSQ (score 8–10, score <8).

Table 3. Multivariate Analysis

NOTE. Predictors of discharge to a rehabilitation facility and of long-term institutionalization.

The multivariate analysis showed that living situation was the only significant variable affecting the choice of a rehabilitation facility at discharge (OR=6.70; 95% CI, 3.33–13.46; P≤.001). The odds of being treated in an institution increased almost 7-fold for patients living alone compared with those living with relatives.

A prefracture functional impairment in IADLs and the living situation provided independent predictors of institutionalization at 3 and 6 months. These same variables together with time to surgery were significant at 1 year (see table 3).

During the follow-up, both groups showed a significant decline of functional ability (Barthel Index). Repeated-measures analysis showed that the HBR group had higher Barthel Index scores than the IBR group at follow-up (ANOVA group by time, P=.007). Barthel Index score decreased 10.8% for the HBR group from the prefracture level (85.5±23.4) to 12 months (76.2±32.1) and decreased 25.6% for the IBR group from the prefracture level (82.4±22.6) to 12 months (58.9.2±33.3). ANCOVA showed that differences in measures of the Barthel Index score by outcome group were maintained at 3, 6, and 12 months even after controlling for prefracture Barthel Index score, IADL, SPMSQ, and age (3mo, P=.017; 6mo, P=.001; 12mo, P=.015) (table 4). All covariates except age and comorbidity showed significant differences (Barthel Index prefracture scores, P=.001; SPMSQ, P=.001; IADL, P=.001; age, P=.828; CIRS comorbidity index, P=.222).

Table 4. Variations of the Barthel Index From Prefracture Levels and Rates of Subjects With Complete Recovery of Functional Ability at 3, 6, and 12 Months

Months	HBR	IBR	P⁎
Three
No. surviving subjects	89	89
Mean change Barthel Index score ± SD	−13.8±20.3	−23.6±26.4	.017
Subjects with complete recovery, n (%)†	33(40.7)	30(33.6)	.587‡
Six
No. surviving subjects	85	82
Mean change Barthel Index score ± SD	−10.4±20.4	−24.8±27.6	.001
Subjects with complete recovery, n (%)†	36(46.2)	24(31.7)	.056‡
Twelve
No. surviving subjects	81	77
Mean change Barthel Index score ± SD	−11.2±24.7	−23.7±28.5	.015
Subjects with complete recovery, n (%)†	41(54.7)	24(32.9)	.008‡

Only 15 subjects were totally dependent (Katz Index score 0) before fracture (8 in the HBR group, 7 in the IBR group). These subjects were excluded from the calculation of the proportion who achieved complete recovery after rehabilitation. The number of patients with complete recovery was higher in the HBR group during the follow-up even if the differences between the groups were highly significant only at 12 months (52.7% in HBR vs 32.9% in IBR, P=.008).

Back to Article Outline

Discussion 

Feasibility 

The present results provide support for the feasibility of HBR programs in real clinical practice. About half of the participants who were included in the present research consented to take part in the home rehabilitation program and were discharged directly home. These results are consistent with those of another work²⁷ that reported a similar rate of participation. However, most previous studies usually excluded from home rehabilitation program patients with premorbid disability, dementia, and/or postoperative delirium or medical complications, and current literature discourages home rehabilitation in these kinds of patients.¹⁵, ¹⁶, ²⁷ In the present study, we considered an unselected population of hip-fractured elderly. The large spectrum of inclusion criteria adopted allowed the enrollment of a heterogeneous sample of elderly patients. In fact, 20% of subjects discharged home were severely demented and 8% presented with a prefracture moderate to severe functional impairment in BADLs.

Nevertheless, patients in the HBR group presented with a slightly better health status, with a lower rate of in-hospital delirium and a lower degree of functional impairment in BADLs and IADLs, and a higher proportion of these patients were living at home with relatives. When we look at the factors affecting the choice of home rehabilitation, only the living situation (cohabitation) resulted as significant in a multivariate model, and no significant effect of prefracture functional status (for BADLs and IADLs) and/or delirium was found. Differences in population characteristics, exclusion criteria adopted, and study design may explain why social support appears to be less significant in other studies designed to assess the reasons for refusing home rehabilitation.²⁷, ²⁸

Subjects treated at home showed a slightly lower physical decline over the time of the follow-up and a higher rate of recovery compared with those who followed an institutional rehabilitation program. This positive effect of home rehabilitation remains significant after controlling for baseline differences in physical and cognitive status between the 2 groups, even if the lack of randomization and the skewed groups represent the main limitation of the study in terms of an assessment of the superiority of one or the other treatment.

The few existing studies on this topic suggest that HBR and IBR are comparable in terms of effectiveness, but because of the heterogeneity of the trials and the outcomes considered, there are no conclusive data.¹³, ¹⁵, ¹⁶

Our data show that even when patients with cognitive decline and premorbid disability are considered, HBR appears to be a feasible alternative in an unselected real-world population of elderly patients with hip fracture.

Long-Term Institutionalization 

Over the follow-up, a high proportion of subjects of those originally discharged to rehabilitation facilities were institutionalized. After 12 months, the percentage was 14% (22 patients) of the total surviving population. These findings are consistent with other studies¹, ⁵, ⁶ that reported a high rate of institutionalization up to 12 months postinjury in hip-fractured elderly. Cree et al⁵ reported an increased risk of institutionalization in patients with cognitive decline and advanced age but not in those with a preexisting impairment in BADLs. Other investigators⁶ found similar results. Fransen et al²⁹ reported 7-fold increased odds of being institutionalized in men compared with women of the same age. In the present study, the large spectrum of covariates made it easier to distinguish the individual effect of the variables of interest on the outcome by controlling the possible influences of the other variables. In fact, several factors were significantly associated with the risk of long-term institutionalization in bivariate analysis, whereas in a multivariate model only prefracture functional status in IADLs, living situation, and time to surgery resulted as significant independent predictors of the adverse outcome considered. Although the absence of relatives at home was a significant predictor of early institutionalization, the coexistence of living alone with a preexisting disability was decisive for long-term institutionalization. Our findings showed that in models including both BADLs and IADLs, the latter was the most relevant, probably because even an early functional decline could affect long-term poor outcomes, which indirectly supports the hypothesis that IADL impairments represent a marker of frailty.³⁰

Delay to surgery (defined as >48h) is a well-known risk factor for mortality and short- and long-term negative outcomes after hip fracture,³¹, ³², ³³ but its adverse influence on return to the community was not shown in a previous study.³⁴ In our study, this factor remains as an independent predictor for long-term institutionalization, even if it only becomes significant in the late phase of follow-up, probably because in the earlier period other factors have a greater effect.

Back to Article Outline

Conclusions 

A home rehabilitation program after hip fracture is feasible in about half of patients discharged after surgical repair and may represent an alternative to traditional rehabilitation in elderly patients living with relatives. The main limitation of this study is the lack of randomization. Nevertheless, the present study suggests that HBR is slightly more effective than IBR. Further larger RCTs are needed to examine the efficacy and evaluate the cost effectiveness of home rehabilitation programs.

Supplier

Back to Article Outline

Acknowledgment 

We are grateful to Paul Sears for his critical review of the English version of the manuscript.

Back to Article Outline

References 

1. Braithwaite RS , Col NF , Wong JB . Estimating hip fracture morbidity, mortality and costs . J Am Geriatr Soc . 2003;51:364–370
   • View In Article
   • MEDLINE
   • CrossRef
2. Magaziner J , Hawkes W , Hebel JR , et al.   Recovery from hip fracture in eight areas of function . J Gerontol A Biol Sci Med Sci . 2000;55:M498–M507
   • View In Article
   • MEDLINE
   • CrossRef
3. Magaziner J , Fredman L , Hawkes W , et al.   Changes in functional status attributable to hip fracture (a comparison of hip fracture patients to community-dwelling aged) . Am J Epidemiol . 2003;157:1023–1031
   • View In Article
   • MEDLINE
   • CrossRef
4. Norton R , Butler M , Robinson E , Lee-Joe T , Campbell AJ . Declines in physical functioning attributable to hip fracture among older people (a follow-up study of case-control participants) . Disabil Rehabil . 2000;22:345–351
   • View In Article
   • MEDLINE
   • CrossRef
5. Cree M , Soskolne CL , Belseck E , et al.   Mortality and institutionalization following hip fracture . J Am Geriatr Soc . 2000;48:283–288
   • View In Article
   • MEDLINE
6. Marottoli RA , Berkman LF , Leo-Summers L , Cooney LM . Predictors of mortality and institutionalization after hip fracture (The New Haven EPESE cohort) . Am J Public Health . 1994;84:1807–1812
   • View In Article
   • MEDLINE
   • CrossRef
7. Magaziner J , Simonsick EM , Kashner TM , Hebel JR , Kenzora JE . Predictors of functional recovery one year following hospital discharge for hip fracture (a prospective study) . J Gerontol A Biol Sci Med Sci . 1990;45:M101–M107
   • View In Article
8. Mutran EJ , Reitzes DC , Mossey J , Fernandez ME . Social support, depression, and recovery of walking ability following hip fracture surgery . J Gerontol B Psychol Sci Soc Sci . 1995;50:S354–S361
   • View In Article
   • MEDLINE
9. Cummings SR , Phillips SL , Wheat ME , et al.   Recovery of function after hip fracture. The role of social supports . J Am Geriatr Soc . 1988;36:801–806
   • View In Article
   • MEDLINE
10. Binder EF , Brown M , Sinacore DR , Steger-May K , Yarasheski KE , Schechtman KB . Effects of extended outpatient rehabilitation after hip fracture (a randomized controlled trial) . JAMA . 2004;292:837–846
    • View In Article
    • CrossRef
11. Munin MC , Seligman K , Dew MA , et al.   Effect of rehabilitation site on functional recovery after hip fracture . Arch Phys Med Rehabil . 2005;86:367–372
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (111 KB)
    • CrossRef
12. Tinetti ME , Baker DI , Gottschalk M , et al.   Home-based multicomponent rehabilitation program for older persons after hip fracture (a randomized trial) . Arch Phys Med Rehabil . 1999;80:916–922
    • View In Article
    • Abstract
    • Full-Text PDF (960 KB)
    • CrossRef
13. Cameron I , Crotty M , Currie C , et al.   Geriatric rehabilitation following fracture in older people (a systematic review) . Health Technol Assess . 2000;4(2):i–iv 1-111.
    • View In Article
    • MEDLINE
14. Coast J , Richards SH , Peters TJ , Gunnell DJ , Darlow MA , Pounsford J . Hospital at home or acute hospital care? A cost minimization analysis . BMJ . 1998;316:1802–1806
    • View In Article
    • MEDLINE
    • CrossRef
15. Crotty M , Whitehead CH , Gray S , Finucane PM . Early discharge and home rehabilitation after hip fracture achieves functional improvements (a randomized controlled trial) . Clin Rehabil . 2002;16:406–413
    • View In Article
    • MEDLINE
    • CrossRef
16. Kuisma R . A randomized, controlled comparison of home versus institutional rehabilitation of patients with hip fracture . Clin Rehabil . 2002;16:553–561
    • View In Article
    • MEDLINE
    • CrossRef
17. Jarman B , Aylin P , Bottle A . Discharge destination and length of stay (differences between US and English hospitals for people aged 65 and over) . BMJ . 2004;328:605
    • View In Article
    • CrossRef
18. Koval KJ , Chen AL , Aharonoff GB , Egol KA , Zuckerman JD . Clinical pathway for hip fractures in the elderly (the Hospital for Joint Diseases experience) . Clin Orthop Relat Res . 2004;425:72–81
    • View In Article
    • CrossRef
19. Shyu YI , Liang J , Wu CC , et al.   A pilot investigation of the short-term effects of an interdisciplinary intervention program on elderly patients with hip fracture in Taiwan . J Am Geriatr Soc . 2005;53:811–818
    • View In Article
    • MEDLINE
    • CrossRef
20. Mahoney FI , Barthel DW . Functional evaluation (the Barthel Index) . Md State Med J . 1965;14:61–65
    • View In Article
    • MEDLINE
21. Shah S , Vanclay F , Cooper B . Improving the sensitivity of the Barthel Index for stroke rehabilitation . J Clin Epidemiol . 1989;42:703–709
    • View In Article
    • MEDLINE
    • CrossRef
22. Katz S , Ford AB , Moskowitz RW , Jackson BA , Jaffe MW . Studies of illness in the aged. The index of ADL (a standardized measure of biological and psychosocial function) . JAMA . 1963;185:914–919
    • View In Article
    • MEDLINE
23. Lawton MP . Scales to measure competence in everyday activities . Psychopharmacol Bull . 1988;24:609–614
    • View In Article
    • MEDLINE
24. Pfeiffer E . A Short Portable Mental Status Questionnaire for the assessment of organic brain deficit in elderly patients . J Am Geriatr Soc . 1975;23:433–441
    • View In Article
    • MEDLINE
25. Parmelee PA , Thuras PD , Katz IR , Lawton MP . Validation of the Cumulative Illness Rating Scale in a geriatric residential population . J Am Geriatr Soc . 1995;43:130–137
    • View In Article
    • MEDLINE
26. Knaus WA , Draper EA , Wagner DP , Zimmerman JE . APACHE II (a severity of disease classification system) . Crit Care Med . 1985;13:818–829
    • View In Article
    • MEDLINE
    • CrossRef
27. Crotty M , Kittel A , Hayball N . Home rehabilitation for older adults with fractured hips (how many will take part?) . J Qual Clin Pract . 2000;20:65–68
    • View In Article
    • MEDLINE
    • CrossRef
28. Fried TR , van Doorn C , O’Leary JR , Tinetti ME , Drickamer MA . Older persons’ perceptions of home and hospital as sites of treatment for acute illness . Am J Med . 1999;107:317–323
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (90 KB)
    • CrossRef
29. Fransen M , Woodward M , Norton R , Robinson E , Butler M , Campbell AJ . Excess mortality or institutionalization after hip fracture (men are at greater risk than women) . J Am Geriatr Soc . 2002;50:685–690
    • View In Article
    • MEDLINE
    • CrossRef
30. Nourhashemi F , Andrieu S , Gillette-Guyonnet S , Vellas B , Albarede JL , Grandjean H . Instrumental activities of daily living as a potential marker of frailty (a study of 7364 community-dwelling elderly women (the EPIDOS Study)) . J Gerontol A Biol Sci Med Sci . 2001;56:M448–M453
    • View In Article
    • MEDLINE
    • CrossRef
31. Villar RN , Allen SM , Barnes SJ . Hip fractures in healthy patients (operative delay versus prognosis) . BMJ . 1986;293:1203–1204
    • View In Article
    • CrossRef
32. Davis FM , Woolner D , Frampton C , et al.   Prospective multi-center trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly . Br J Anaesth . 1987;59:1080–1088
    • View In Article
    • MEDLINE
33. Weller I , Wai EK , Jaglal S , Kreder HJ . The effect of hospital type and surgical delay on mortality after surgery for hip fracture . J Bone Joint Surg Br . 2005;87:301–305
    • View In Article
    • MEDLINE
    • CrossRef
34. Cree AK , Nade S . How to predict return to the community after fractured proximal femur in the elderly . Aust N Z J Surg . 1999;69:723–725
    • View In Article
    • MEDLINE

• a Version 12.0; SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.