RecommendationConsider early supported discharge as part of the Hip Fracture Programme, provided the Hip Fracture Programme multidisciplinary team remains involved, and the patient:
  • is medically stable and
  • has the mental ability to participate in continued rehabilitation and
  • is able to transfer and mobilise short distances and
  • has not yet achieved their full rehabilitation potential, as discussed with the patient, carer and family.
Relative values of different outcomesLength of hospital stay, functional outcomes and re-admission rates were considered the primary outcomes of interest. All these outcomes were used in the decision analytical model.
Trade off between clinical benefits and harmsMultidisciplinary ESD at home in selected patients reduces hospital length of stay but may result in overall prolonged rehabilitation (hospital + home) compared to hospital MDR. Selected patients were defined from the studies as medically stable, cognitively intact, able to transfer independently, and mobilise short distances.

Despite only a few low quality studies being identified the GDG consensus was that multidisciplinary ESD at home is beneficial to a specific patient group, as defined above. The evidence reviewed showed an increase in functional independence measures with ESD compared to usual care.

Our decision analysis found QALYs were 0.0456 higher in the community MDR arm of the study compared to usual care.
Economic considerationsNo cost-effectiveness studies were identified for this clinical question. An original decision analytical model was developed, which was based on the findings of an RCT included in our clinical review 58,60. The analysis showed that there is uncertainty as to whether MDR ESD at home is cost-effective compared to usual care. In particular, findings were sensitive to the length of hospital stay and length of the home-based rehabilitation programme.

However, the GDG noted that the ICER of £9533/QALYs is well below the £20,000 threshold.

It is also important to note that our model did not find community MDR to be cost saving compared to usual care. This was because patients in the community MDR branch of the model underwent rehabilitation in their own home for a relatively longer period of time than those of the other studies included in the economic evidence profile in section 8.7 in Appendix H.
Quality of evidenceThere were few studies identified, which ranged from low to high quality with often only one study per outcome. Therefore our confidence in the results is low.

Studies were undertaken in medically stable and cognitively intact patients and there were no studies that evaluated multidisciplinary ESD at home in cognitively impaired patients or patients living in care/nursing homes. This recommendation was therefore partly based on evidence and partly GDG consensus opinion.
Other considerationsPatient selection, as defined above is very important for multidisciplinary ESD at home and may represent a very small number of eligible patients.

The benefits of MDR ESD in patient with mild to moderate cognitive impairment living at home alone or with a relative/carer are unknown. MDR ESD in this context may be beneficial and should be considered.

The benefits of MDR ESD in patients living in care/nursing homes are unknown. MDR ESD in these patients, undertaken alongside the care/nursing homes may be beneficial.

Interaction with any key carer and evaluation of his/her ability and willingness to provide support and care is in all cases an essential and normative element of the decision making process in considering the appropriateness or otherwise of early supported discharge

The GDG highlighted this recommendation as a key priority for implementation.

From: 12, Multidisciplinary management

Cover of The Management of Hip Fracture in Adults
The Management of Hip Fracture in Adults [Internet].
NICE Clinical Guidelines, No. 124.
National Clinical Guideline Centre (UK).
Copyright © 2011, National Clinical Guideline Centre.

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