The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 63:92-97 (2008)
© 2008 The Gerontological Society of America
Interdisciplinary Intervention for Hip Fracture in Older Taiwanese: Benefits Last for 1 Year
Yea-Ing L. Shyu,
Jersey Liang,
Chi-Chuan Wu,
Juin-Yih Su,
Huey-Shinn Cheng,
Shih-Wei Chou,
Min-Chi Chen and
Ching-Tzu Yang
1 School of Nursing, 2 Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor.
3 Traumatological Division, Department of Orthopedics, and Departments of 4 Trauma & Emergency Surgery, 5 Internal Medicine, and 6 Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
7 Department of Public Health & Biostatistics Consulting Center, and 8 Graduate Institute of Nursing, Chang Gung University, Taoyuan, Taiwan.
Address correspondence to Yea-Ing L. Shyu, PhD, School of Nursing, Chang Gung University, 259 Wen-Hua 1st Road, Kwei-Shan, Taoyuan 333, Taiwan. E-mail: yeaing{at}mail.cgu.edu.tw
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Abstract
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Background. Little is known about the effects of interventions for elderly patients with hip fracture in Asian countries, particularly beyond the short term.
Methods. Outcomes (service utilization, clinical outcomes, self-care ability, and depressive symptoms) were assessed at 1, 3, 6, and 12 months after discharge. Self-care ability (ability to perform activities of daily living [ADLs]), was measured by the Chinese Barthel Index. Depressive symptoms were measured by the Chinese Geriatric Depression Scale, short form.
Results. The experimental group (n = 80) had a significantly better ADL trajectory than the control group (n = 82) during the 1st year after discharge (p =.002). More participants in the experimental group than in the control group recovered their previous walking ability both at 6 months (81% vs 58%, respectively) and 12 months (84% vs 66%, respectively) after discharge. Overall, the odds ratio for the experimental group recovering their previous walking ability was 2.72 (p <.001) compared to the control group. The experimental group had significantly fewer depressive symptoms than the control group during the 1st year following discharge (p =.004).
Conclusion. An interdisciplinary intervention for hip fracture with a discharge support component benefited elderly persons with hip fracture by improving both self-care ability and walking ability, and by decreasing depressive symptoms during the 1st year after hospital discharge.
Key Words: Depressive symptoms • Hip fracture • Interdisciplinary intervention • Self-care ability • Walking ability
WITH an increasing aging population (1), Taiwan and many other countries (2) face the major and growing health care problem of hip fracture. Hip fracture leads to an excess mortality of 5%–20%, a morbidity that severely restricts patients, and huge economic costs to society (3,4).
Elderly patients with hip fracture have been shown to benefit from postoperative rehabilitation, early discharge planning programs, and transitional care programs (5,6). However, the majority of these studies analyzed data from Western developed countries, and few examined the longitudinal effects of interventions more than twice within the 1st year after discharge. Less is known about the effects of interventions for elderly patients with hip fracture in Asian countries, particularly beyond the short term. Taiwan differs substantially from Western developed countries in its health care system, clinical practice, case mix, culture, and social organization. These differences make it necessary to validate studies based on Western populations on the effects of intervention programs for elders with hip fracture in Taiwan.
Our previous randomized experimental study examined the short-term effects of an interdisciplinary intervention program for elders with hip fracture (7). That program consisted of geriatric consultation, continuous rehabilitation, and discharge planning. The intervention program was found to benefit elders with hip fractures in Taiwan by improving their clinical outcomes and self-care abilities and by decreasing depressive symptoms within 3 months after discharge. The purpose of this article is to report the long-term effects of this intervention program up to 1 year after patient discharge. We hypothesized that the benefits of the interdisciplinary intervention program would continue to improve throughout the 1st year postdischarge.
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METHODS
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Participants
Inclusion criteria for participants were (i) age 60 years or older, (ii) admitted to hospital for an accidental single-side hip fracture, (iii) receiving hip arthroplasty or internal fixation, (iv) able to perform full range of motion against gravity and against some or full resistance and had a prefracture Chinese Barthel Index (CBI) score >70, and (v) living in northern Taiwan. Patients were excluded if they were (i) severely cognitively impaired, making them unable to follow orders (score <10 on the Chinese Mini-Mental State Examination) (8) or (ii) terminally ill.
Participants (N = 162; 80 in the experimental group, 82 in the control group) were recruited from September 2001 to November 2003 and followed for 1 year (Figure 1). For our previous study (7), a sample size of 65 participants in each group was required to provide a power of.80 and 
of.05 for a median effect size of.50 (9) in terms of activities of daily living (ADL) improvement from postsurgical discharge to 3 months later. This effect represents a 7-point difference in a score on the 100-point CBI. In other words, the experimental group recovered around 1 ADL item more than the control group during first 3 months after discharge. Patients in the experimental and control groups reported similar prefracture ADLs when they were hospitalized for surgery. Thus, any ADL improvement between groups during the first 3 months would likely represent an intervention effect. We assumed that the intervention program might be most effective during the first 3 months due to greater recovery in this period (4). To allow for potential dropouts, we therefore aimed to recruit around 80 participants in each group.
Intervention Program
Current routine care of hip-fractured elders in Taiwan usually does not include continuity of care, geriatric assessment, and a well-organized interdisciplinary approach. As shown in the appendix, our interdisciplinary intervention program included geriatric consultation services, a rehabilitation program, and discharge-planning services.
Outcome Variables
The primary response variable was self-care ability, which was measured by the CBI as ability to perform ADLs, that is, eating, transferring, grooming, toileting, bathing, walking, climbing stairs, dressing, and bowel and bladder control (10). The CBI, with scores ranging from 0 to 100, has been shown to have satisfactory reliability and validity for assessing frail elders in Taiwan (10).
Clinical outcomes included recovery of walking ability, occurrence of falls, and mortality. Occurrence of falls and mortality were assessed by self-report of patients and family caregivers. Recovery of walking ability was rated during face-to-face interviews using the walking ability item in the CBI (10) and by comparing it with prefracture walking ability (rated at admission using the same item). Walking ability was rated from 0 to 15, with the following categories: 0 (immobile or <50 yards), 5 (wheelchair independent, including corners, >50 yards), 10 (walks with verbal or physical help of one person, >50 yards), and 15 (independent, but may use any aid, e.g., a cane, >50 yards). Service utilization variables included emergency room visits, hospital readmission, and institutionalization. Depressive symptoms were assessed using the Chinese version of the Geriatric Depression Scale, short form (GDS-s) (11,12). The maximum GDS-s score is 15; higher scores indicate more severe depressive symptoms. Reliability (internal consistency) and construct validity of the GDS-s have been established among Taiwanese elderly people (12).
Procedures
Human participant approval was obtained from the study hospital before collecting data. Participants were recruited from the emergency room by research assistants who screened the admission list twice a day. Those persons who agreed to participate were randomly assigned to either an experimental or control group at the time of admission. The randomization was conducted using flip of a coin by a neutral third party who was not involved in delivering the intervention or assessing outcomes. Participants in the experimental group then received routine hospital care plus the intervention program, whereas participants in the control group received only routine hospital care plus regular social contact provided by a research nurse at the same time that the experimental group received the intervention. All participants were assessed at 1, 3, 6, and 12 months after discharge for clinical outcomes, service utilization outcomes, self-care ability, and depressive symptoms. The participants were blinded, but the evaluators were not.
Statistical Analysis
Differences in baseline characteristics including prefracture self-care ability between the experimental and control groups were assessed by two-sample t tests or chi-square tests. To evaluate the effects of the interdisciplinary intervention and to account for correlations in repeated observations over time, a generalized estimating equation (GEE) approach was used. For a given outcome variable, the GEE model includes the following predictors: treatment (1 = experimental group, 0 = control group) and three dummy variables representing the timing of measurements at 3, 6, and 12 months after discharge (1 = measurements at 3, 6, and 12 months, 0 = measurement at 1st month). GEE analyses were carried out using SAS Win 8.0 (SAS Institute, Cary, NC).
All analyses were undertaken using the intention-to-treat approach (13). Missing data due to attrition (e.g., loss to follow-up and refusal to participate) after randomization were assigned by multiple imputation (14,15). For instance, we imputed missing data on ADLs for those who dropped out or refused to participate after randomization using baseline data (e.g., age, gender, education, functional status before fracture, functional status at discharge, and repeated observations of ADLs, if available).
For those who died during the trial, no imputation was made after death except for one participant in the experimental group who died before the 1st month assessment after discharge. The rationale for this decision was based on the principle of intent to treat, which holds that all randomized participants should be included in the analysis (13). In addition, the imputed value can be regarded as the outcome shortly before death. Meanwhile, it should be noted that the GEE allows partial information to be used because those who died can still contribute to the estimation of parameters before death. To impute three complete data sets and analyze each data set, we used NORM software (16). Estimates were then averaged across the three imputations to derive a single estimate.
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RESULTS
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Baseline Participant Characteristics
Of the 162 participants in the final sample, most (68.5%) were female, with an average age of 78.16 years (standard deviation [SD] = 7.76). Around half (51.9%) were married, half (48.8%) were illiterate, 63% received internal fixation, and 37% received arthroplasty. Participants' CBI score before fracture was 96.08 (SD = 6.47), representing moderate independence in ADLs, and 84.6% could walk independently. The experimental and control groups did not differ significantly in gender, age, marital status, education, type of surgery, prefracture self-care ability, walking ability, and length of hospital stay (Table 1).
Outcome Comparisons
Outcomes for the experimental and control groups were compared by GEE analysis (Table 2). Regression coefficients for these comparisons are listed in Table 3.
The intervention significantly affected self-care ability. Participants in the experimental group were significantly better at performing ADLs than the control group (β = 8.12, p <.01, Table 3). Relative to the control group, the experimental group improved approximately 10 points on CBI, or 1 to 2 ADLs, more during the first 3 months after discharge, and improved around 5 or 6 points, or 1 ADL, more than the control group from the 6th to the 12th month after discharge (Table 2). In addition, the experimental group had a significantly better ADL performance trajectory than the control group (Figure 2). For both the experimental and control groups, ADL performance was significantly better at the 3rd, 6th, and 12th month after discharge than at the 1st month (Table 3, Figure 2).
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Figure 2. Longitudinal changes in self-care ability for experimental and control groups during 1st year postdischarge. CBI = Chinese Barthel Index
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The intervention significantly enhanced recovery of walking ability in the experimental group (β = 1.00, p <.001, Table 3). As shown in Figure 3, more participants in the experimental group than in the control group recovered their previous walking ability at both 6 months (81% vs 58%, respectively) and 12 months (84% vs 60%, respectively) after discharge. Overall, the odds ratio for the experimental group recovering their previous walking ability was 2.72 (CI, 11.53–4.84; p <.001) compared to the control group (data not shown in Tables 2 and 3). Relative to the 1st month after discharge, the percentages of walking ability recovered at the 3rd, 6th, and 12th months after discharge were significantly better (Table 3).
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Figure 3. Longitudinal changes in walking ability for experimental and control groups during 1st year postdischarge
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The occurrence of falls did not change significantly over the year following discharge (Table 3). Although the experimental group had a lower occurrence of falls than the control group at all times after discharge (Table 2), this difference was not significant (β =.45, p >.05, Table 3).
Depressive symptoms decreased significantly over the 12 months following discharge (Table 3). In addition, participants in the experimental group had significantly fewer depressive symptoms than those in the control group (β = –1.32, p <.01, Table 3). The trajectory of depressive symptoms for the experimental group was consistently lower than that of the control group (Table 2, Figure 4).
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Figure 4. Longitudinal changes in depressive symptoms for experimental and control groups during 1st year postdischarge. GDS = Geriatric Depression Scale
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The intervention did not significantly affect emergency room visits, hospital readmissions, mortality, and institutionalization (Table 3). For mortality, because very few deaths occurred during the first 3 months after discharge, deaths within the 1st month and from the 1st to the 3rd month were combined and treated as the mortality baseline (Table 3). For institutionalization, because very few participants were institutionalized, measures of time were omitted as covariates in predicting institutionalization.
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DISCUSSION
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This study's results show that the benefits of a multidisciplinary program to treat hip fracture in Taiwanese elders can be maintained for up to 1 year after discharge, in agreement with previous studies conducted in Western developed countries (5,6). Elderly persons who received our interdisciplinary intervention program had significantly better walking ability, better self-care ability, and fewer depressive symptoms than those who received routine care during the 1st year after discharge. Our results also provide quantitative estimates for the trajectories of treatment effects.
The intervention developed and examined in this study closely resembles two multidisciplinary approaches for elders with hip fracture: geriatric hip-fracture programs (GHFPs) and early supported discharge (ESD) (17). GHFPs are usually implemented within an existing acute orthopedic unit, in which a geriatrician participates and influences care and which has multidisciplinary expertise to provide acute care and rehabilitation. ESD involves early identification and transfer of selected patients to their home from orthopedic units with expertise in discharge planning, community care, and rehabilitation. The multidisciplinary approach of GHFPs and ESD programs has been found to effectively increase the rate of return home and reduce length of hospital stay (17). However, the impact of these two approaches on mobility and ADLs could not be assessed due to insufficient data. Similar to our study findings, these two approaches have not shown any clear effect on readmission, mortality, or morbidity rates (17). A more recent study found that postoperative interdisciplinary care of inpatients reduced mortality and medical complications, but did not significantly affect long-term recovery in elderly patients with hip fracture (18). A community-based multidisciplinary rehabilitation program also had no beneficial effects for elders with hip fracture (19).
In contrast to these studies, our interdisciplinary intervention benefited elders with hip fracture by improving mobility and self-care ability and by decreasing depressive symptoms. These effects might be due to our intervention containing components of both GHFP and ESD. Including these components might maximize treatment effects (20). At the same time, patient selection might influence the intervention outcomes (20). Self-care ability has been found to influence depressive symptoms (21) and emotionally and/or mentally related health outcomes (22). Thus, improving self-care ability might indirectly improve depressive symptoms.
Because national health insurance was implemented in Taiwan in 1995, patients have free choice of health care providers and enhanced accessibility to health services. However, the current health care system has fragmented subacute and long-term care services and poorly coordinates health care (23), creating barriers for elders to recover from hip fracture, especially after hospital discharge. This health care environment might have increased the difference between the experimental and control groups in our study.
Our intervention did not significantly affect hospital readmission or mortality rates, similar to previous reports (17,24). Our nonsignificant findings might be due to the small number of rehospitalized and institutionalized patients, as well as the small number of patients who died within a year. A systematic review of nine trials found no effects of multidisciplinary approaches to care of elders with femoral fracture on outcomes of death or requiring institutional care (24).
Our criteria for selecting participants excluded elders with severe cognitive impairment and weak muscle power. Thus, our sample may have had better functional ability than the general population of elders with hip fracture in Taiwan. The effect of this intervention program can therefore only be generalized to hip-fractured elders without severe cognitive impairment and with adequate muscle power in their extremities. A limitation of our study was its single-blinded design in which the personnel delivering the intervention and assessing the outcomes were not blinded. However, these personnel were purposely assigned different research duties to minimize any potential bias. It is worth noting that, although some participants were lost to follow-up in the study period, intention-to-treat and on-protocol analyses had similar results. In conclusion, despite this study's limitations, our interdisciplinary intervention with both GHFP and discharge-support components appeared to benefit elderly persons with hip fracture in Taiwan. The results of this study may provide a reference for health care providers in countries using similar programs with Chinese/Taiwanese immigrant populations.
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Acknowledgments
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This work was supported by grants from the National Health Research Institute, Taiwan (NHRI-EX92-9023PL).
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Footnotes
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Decision Editor: Luigi Ferrucci, MD, PhD
Received May 12, 2006
Accepted June 1, 2007
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References
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- Manpower Planning Department, Council for Economic Planning and Development, Executive Yuan (Republic of China)., Projections of the Population of the Taiwan Area, Republic of China 1995 to 2036. Taipei, Taiwan: Manpower Planning Department, Council for Economic Planning and Development, Executive Yuan (Republic of China); 1996.
- Liou MJ, Tsai JS, Lin JD. Hip fracture: an increasing geriatric problem in Taiwan. Age Ageing. 2002;31:483-490.[Free Full Text]
- Randell AG, Nguyen TV, Bhalerao N, Silverman SL, Sambrook PN, Eisman JA. Deterioration in quality of life following hip fracture: a prospective study. Osteoporos Int. 2000;11:460-466.[Medline]
- Shyu YI, Chen MC, Liang J, Wu CC, Su JY. Predictors of functional recovery for hip fractured elders at twelve months following hospital discharge: a prospective study on a Taiwanese sample. Osteoporos Int. 2004;15:475-482.[Medline]
- Adunsky A, Lusky A, Arad M, Heruti RJ. A comparative study of rehabilitation outcomes of elderly hip fracture patients: the advantage of a comprehensive orthogeriatric approach. J Gerontol Biol Sci Med Sci. 2003;58A:542-547.[Medline]
- 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.[Abstract/Free Full Text]
- Shyu YIL, 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.[Medline]
- Yip PK, Shyu YI, Liu SI, et al. The multidisciplinary project of dementia study in northern Taiwan (DSNT) background and methodology. Acta Neurol Taiwan. 1997;6:210-216.
- Kraemer HC, Kupfer DJ. Size of treatment effects and their importance to clinical research and practice. Biol Psychiatry. 2005;59:990-996.[Medline]
- Chen YJ, Dai YT, Yang CT, Wang TJ, Teng YH. A Review and Proposal on Patient Classification in Long-Term Care System. Taipei, Taiwan: Department of Health, Republic of China; 1995.
- Burke WJ, Roccaforte WH, Wengel SP. The short form of the Geriatric Depression Scale: a comparison with the 30-item form. J Geriatr Psychiatry Neurol. 1991;4:173-178.[Abstract/Free Full Text]
- Liu CY, Lu CH, Yu S, Yang YY. Correlations between scores on Chinese versions of long and short forms of the Geriatric Depression Scale among elderly Chinese. Psychol Rep. 1998;82:211-214.[Medline]
- Hollis S, Campbell F. What is meant by intention to treat analysis? Survey of published randomised controlled trials. BMJ. 1999;319:670-674.[Abstract/Free Full Text]
- Little RJA, Rubin DR. Statistical Analysis with Missing Data. New York: Wiley; 1987.
- Rubin DB. Multiple Imputation for Nonresponse in Surveys. New York: Wiley; 1987.
- Schafer JL. Analysis of Incomplete Multivariate Data. London: Chapman & Hall; 1997.
- Cameron ID. Coordinated multidisciplinary rehabilitation after hip fracture. Disabil Rehabil. 2005;27:1081-1090.[Medline]
- Vidan M, Serra JA, Moreno C, Riquelme G, Ortiz J. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005;53:1476-1482.[Medline]
- Ryan T, Enderby P, Rigby AS. A randomized controlled trial to evaluate intensity of community-based rehabilitation provision following stroke or hip fracture in old age. Clin Rehabil. 2006;20:123-131.[Abstract/Free Full Text]
- Cameron ID, Crotty M, Currie C, et al. Geriatric rehabilitation following fractures in older people: a systematic review. Health Technol Assess. 2000;4:1-121 Available at: http://www.ncchta.org/execsumm/summ402.htm. Last accessed October 8, 2006.[Medline]
- Lieberman D, Galinsky D, Fried V, Grinshpun Y, Mytlis N, Tylis R. Geriatric Depression Screening Scale(GDS) in patients hospitalized for physical rehabilitation. Int J Geriatr Psychiatry. 1999;14:549-555.[Medline]
- Shyu YIL, Chen MC, Liang J, Lu JF, Wu CC, Su JY. Changes of quality of life among elderly patients with hip fracture in Taiwan. Osteoporos Int. 2004;15:95-102.[Medline]
- Chuang KY, Wu SC, Dai YT, Ma AS. Post-hospital care of stroke patients in Taipei: use of services and policy implications. Health Policy. 2006; doi: 10.1016/j.healthpol.2006.07.008.
- Cameron ID, Handoll HH, Finnegan TP, Madhok R, Langhorne P. Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures. Cochrane Database Syst Rev. 2001;(3):CD000106.
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Abstract
Methods
