Rationale for the review

This realist review, along with a national UK survey of current rehabilitation practice and focus groups with patients, carers and multidisciplinary rehabilitation teams, was performed to inform the development of an enhanced rehabilitation programme following proximal femoral fracture.

Objectives and focus of the review

The main objective of this review was to identify the important components of a multidisciplinary rehabilitation programme following surgical treatment for hip fracture in older people, in particular to distil and understand the evidence relating to how successful interventions work, in which setting and context, for which outcome and in which group of patients.

Research questions

1. What community-based multidisciplinary rehabilitation programmes have been developed and what were their main aims (intended outcomes)?
2. What were the mechanisms by which community-based rehabilitation of hip fracture patients is believed to result in its intended outcomes?
3. What are the identified contexts that determine whether different mechanisms yield intended outcomes?

Given the evidence in response to questions 1–3 we also drew conclusions regarding the following questions.

1. In what circumstances are the rehabilitation programmes likely to be clinically effective and cost-effective if implemented in the NHS?
2. In what circumstances and with which combination of mechanisms and contexts are the rehabilitation programmes likely to generate unintended effects or costs?

Rationale for using realist synthesis

A realist review was undertaken to identify suitable components for an enhanced multidisciplinary rehabilitation programme following proximal femoral fracture. Such rehabilitation programmes are complex interventions because they are multifaceted and interact in complex ways with many contextual factors³⁹ (see Appendix 1). Compared with systematic reviews, realist reviews aim to build a deeper understanding of the mechanisms behind an intervention and to identify ‘what works, for whom, in what circumstances and why’.^39,40 Whereas conventional systematic reviews judge the overall effectiveness of an intervention and pay less attention to context, realist reviews attempt to explain mechanisms by which interventions produce different patterns of outcomes according to different contextual factors (see Appendix 2). The realist review was conducted by a researcher experienced in large-scale systematic reviews, traditional and network meta-analyses, large-scale database analyses and mixed-method process evaluations of policy or intervention trials, supported by team members with expertise in realist review and realist evaluation methodology.

Realist reviews use a theory-driven approach with a philosophy of realism and adopt an explanatory rather than a judgemental approach to evidence synthesis.⁴⁰ They seek to produce more transferable findings by taking into account, for example, the heterogeneous nature of rehabilitation programmes and the heterogeneous hip fracture population. The findings are then formulated into statements, the ‘programme theories’, which are propositions for how a programme is considered to produce intended outcomes. They can be generated from various sources of evidence such as the literature, discussions with experts and, as in our study, a survey of current practice (see Chapter 4) and focus groups with patients, carers and rehabilitation professionals (see Chapter 5). During the review process, these intermediate theories are tested, rejected or developed into the final programme theories to make recommendations for future practice, policy and research. We used the guidelines developed by the RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) collaboration^41,42 (see Appendix 3) to report our methods and findings.

Extending the realist review to include any economic evidence allows the consideration of behavioural economic theories relating to factors such as welfare judgements,⁴³ expected utility gains⁴⁴ and choice architecture.⁴⁵ Additional costs may be accrued when modifying the setting in which the rehabilitation takes place (e.g. home based vs. hospital based) or the delivery team responsible for the rehabilitation programme (e.g. multidisciplinary vs. a single practitioner). The intervention itself could accrue additional costs, for example through additional training required by practitioners, additional time required by practitioners to deliver the rehabilitation programme and additional technology or equipment required for the rehabilitation programme (e.g. instruction packs for exercises). However, we recognised that the literature may not be rich enough to provide understanding of all behavioural economic factors in this field.

Scoping the literature

A scoping search of the literature was carried out in MEDLINE, EMBASE and PubMed for relevant systematic reviews concerning multidisciplinary rehabilitation following hip fracture and stroke and in the frail elderly using the broad search terms ‘rehabilitation’, ‘frail’, ‘elderly’, ‘stroke’, ‘hip/femur fracture’. The reviews identified^{3,5,9,10,14,17,21–38,46–60} and their reference lists were the starting point for identifying both the implicit and the explicit theories behind the success or failure of rehabilitation programmes or their components. Existing UK and international guidelines were also searched for additional contributions to theory development.

Immersion in the literature to develop initial theory areas

Initial immersion in the rehabilitation literature sought to identify an initial list of relevant intermediate programme theories. We scanned relevant primary studies and other linked papers with a strong theoretical content identified from the reference lists of the included reviews. This process helped to map out important areas and research gaps in the literature, resulting in a list of unanswered questions under different domains related to receivers (patients), deliverers (health-care and rehabilitation teams), programmes (rehabilitation) and settings or systems (hospital, community, etc.) used to deliver such rehabilitation programmes (see Appendix 4).

Developing and refining the intermediate programme theories in interactive workshops

These lists of questions were formulated into statements (see Appendix 5) to signify how the different domains of a programme interact and might affect all of the agencies (stakeholders) involved. These intermediate programme theories were refined during discussions between members of the evaluation team and with other researchers engaged in similar realist evaluations (at two realist evaluation workshops in the School of Healthcare Sciences, Bangor University, convened by one of the senior researchers, JR-M). To keep track of these emerging programme theories a table was constructed in which the theories could be recorded, cross-referenced and commented on. Feedback from the workshops was integrated into this table.

The list of questions enabled the building of context, mechanism and outcome (CMO) configurations that formed the basis of the development of the final programme theories of how complex programmes (systems) work in certain contexts to produce intended (or unintended) outcomes. The initial list of these CMO configurations is presented in Appendix 6; again, this was refined iteratively in team meetings.

Feedback from patient/carer interviews and the health professional survey

Results from the survey of health professionals (see Chapter 4) and focus groups with patients, carers and rehabilitation professionals (see Chapter 5) were also used to refine these programme theories. These refined theories were incorporated into the review as it progressed. Findings from the health professional survey that contributed to theory development included the importance of tailoring, the importance of feedback mechanisms and variation in the delivery of rehabilitation in different areas based on the availability of staff and facilities (see Chapter 4). The focus groups with patients and their carers highlighted unmet information needs with regard to the process of recovery, the availability of services that patients are entitled to access but which they are not necessarily aware of and geographical variation in the provision of services (see Chapter 5).

Developing programme theories

As already described, the summary of findings from our initial immersion in the literature, feedback from meetings and workshops (from experts in health psychology, rehabilitation and implementation research) and the findings from the patient/carer focus groups and health professional survey were integrated into our candidate programme theories. The emergent list of intermediate working theories was used as the basis for the development of bespoke data extraction forms.

Developing bespoke data extraction forms

Two sets of bespoke data extraction forms were developed using a Microsoft Access^® database (2013; Microsoft Corporation, Redmond, WA, USA) to extract data from both comparative studies (RCTs/quasi-RCTs/non-RCTs, comparative cohort and case–control studies) and non-comparative studies (qualitative studies involving patients or health professionals, service evaluations, routinely collected database studies). The data extraction form for comparative studies (see Tables 37 and 38) was designed to collect data from each study on study characteristics (design, sample type, sample size), the intervention/programme and the control, process details (fidelity of the intervention, dosage), contextual factors in the study setting, outcomes collected and theories or mechanisms postulated by the authors to explain the results. The data extraction form for non-comparative studies (see Table 39) was designed to collect data on study characteristics, research methods, the theoretical approach, the sample type, the intervention/programme and the method of analysis as well as evidence to test the programme theories.

The forms were used in two stages to extract data from included studies and test the intermediate and final programme theories. The first set of forms was used to populate the initial themes with evidence from effective (or ineffective) components of rehabilitation programmes and how these interacted with outcomes in given contexts. These themes were then refined into statements, which led to the development of intermediate programme theories. The second set of forms was used to test these theories and adjudicate between competing theories (see Table 40).

Literature search

The literature search strategy used in the NICE guideline review of multidisciplinary rehabilitation programmes for hip fracture⁷ was adapted to encompass all of the theory areas of the first phase of the review process. No filters for study design were applied so that all study designs such as RCTs and non-RCTs and observational, economic and qualitative studies could be included. Full details of the search strategies for the major electronic databases are reported in Appendix 8.

The following databases were searched from inception to February 2013 for published, semi published and grey literature:

• MEDLINE
• MEDLINE In-Process & Other Non-Indexed Citations
• OLDMEDLINE
• EMBASE
• Cumulative Index to Nursing and Allied Health Literature
• Allied and Complementary Medicine Database
• British Nursing Index
• Health Management Information Consortium
• PsycINFO
• Cochrane Central Register of Controlled Trials
• Database of Abstracts of Reviews of Effects
• Cochrane Database of Systematic Reviews
• Health Technology Assessment database
• NHS Economic Evaluation Database
• Science Citation Index
• Social Science Citation Index
• Index to Scientific & Technical Proceedings
• Physiotherapy Evidence Database
• Biosciences Information Service
• System for Information on Grey Literature in Europe
• ProQuest Dissertations & Theses database.

Identified references were deduplicated and transferred to bibliographic software (EndNote X5; Thomson Reuters, CA, USA) to facilitate assessment for inclusion and the categorisation of relevant studies. Multiple publications arising from the same study were identified, grouped together and represented by a single reference.

Realist review involves iterative and purposive literature searching^39,41 and so citations were tracked (forwards and backwards) and internet search engines, such as Google Scholar (Google Inc., Mountain View, CA, USA), and individual publisher websites were used to identify additional evidence as the review progressed and new ideas emerged. The reference lists of previous systematic reviews and included studies were also screened to identify relevant studies. Using this method, no attempt was made to include every relevant study but materials were retrieved purposively to answer specific questions or test-specific theories. The process stopped when sufficient evidence had been collected to answer these questions or test the theories. Conversely, if a new question arose, it triggered further literature searching to answer the question posed and to determine its fit within existing theory or whether or not a new theory needed to be formulated.

Screening of references for relevance

A working definition of multidisciplinary rehabilitation to be used for screening sources of evidence (Table 1) was adapted from a review of intermediate care services;^61,62 the working definition in this review had been adapted, in turn, from Godfrey et al.⁶³

TABLE 1

Working definition of multidisciplinary rehabilitation used to screen sources of evidence

This definition was used when screening the titles and abstracts of identified studies in the EndNote library for relevance. Screening was carried out independently by separate reviewers and discrepancies were resolved after discussion. In addition, potentially relevant studies were categorised according to study type: systematic review, RCT or non-RCT, observational study, economic evaluation or qualitative study. There were no language restrictions and non-English publications were translated whenever possible using Google Translate (Google Inc., Mountain View, CA, USA) or by other research colleagues who could speak the relevant language.

Participants of interest were elderly adults with proximal hip fracture. The intervention of interest was multidisciplinary rehabilitation following proximal hip fracture. The outcomes of interest were mortality, pain, functional status, quality of life, health utility, health service use, costs and patients’ experiences.

Literature identified in the initial search was screened in two stages for both behavioural economic evidence and evidence of economic evaluation (e.g. cost analysis, cost-effectiveness analysis, cost–benefit analysis, cost–utility analysis). Screening for economic studies at the title and abstract stage was conducted by the four main reviewers. Potential economic studies identified in the initial search were then screened by two experienced health economists, who excluded studies based on the following criteria:

• clearly falls outside the definition of multidisciplinary rehabilitation for hip fracture (see Table 1)
• clearly is not an economic evaluation or comparative cost study or does not include behavioural economic theory
• does not involve services users who belong to our service user group of interest.

The detailed screening process for economic evidence and the study flow chart are presented in Chapter 3.

Conceptual categorisation of screened relevant references

Potentially relevant references were conceptually categorised as ‘rich’, ‘thick’ or ‘thin’ based on the criteria described by Ritzer⁶⁴ and Roen et al.⁶⁵ and as used in a recent review of intermediate care.⁶¹ This process made the database manageable and enabled information to be gleaned from the most appropriate studies for theory building and testing. A detailed description of the criteria used for this purpose is provided in Appendix 9.

Inclusion and exclusion of studies

Selection and appraisal of documents

After the initial screening and conceptual categorisation of the references in the EndNote library, potentially relevant studies were exported into a separate library for full document retrieval. Study inclusion criteria were applied to these retrieved documents by two reviewers independently and conflicts were resolved by discussion or after consulting a third reviewer. A list of all studies to be included was prepared for data extraction.

Data extraction

Data were extracted by one reviewer and checked for accuracy by a second. Inconsistencies or disagreements were resolved by mutual discussion and checking against the source study.

Quality assessment

Study quality was assessed using the Mixed Methods Appraisal Tool for mixed studies reviews,⁶⁸ which can be used across different study designs (qualitative studies, trials, observational studies). The purpose of appraising the ‘quality’ of studies was to assist in the judgement of the relevance and rigour of different evidence from a ‘fitness for purpose’ perspective as opposed to scoring the studies for acceptance or rejection.

Data synthesis

The data from the quantitative, comparative effectiveness and qualitative studies were synthesised separately.

The data from the effectiveness studies were exported into structured tables to show the strength and direction of the treatment effects. Outcomes reported in the included studies were broadly categorised into four domains: physical/physiological, psychological, health service utilisation and AEs. These were subcategorised further under the following headings (the outcome measure instruments used are listed in Appendices 10 and 11):

• physical/physiological
  • ADL
  • composite scores
    • favourable clinical outcome
    • functional recovery
  • exercise behaviour
  • quality of life
  • function
    • physical function
    • mobility
    • functional recovery
    • balance
  • physiological measurements/muscle strength
• psychosocial
  • patient satisfaction
  • carer satisfaction
  • cognitive function/dementia
  • depression
  • fear of falling
  • psychological morbidity
  • self-efficacy/falls efficacy
  • socialisation
  • social support
• health service use
  • physical/occupational therapy sessions
  • discharge destination/new nursing home admissions
  • falls and hospital readmissions
  • health-care utilisation
  • length of hospital stay
  • severity of illness/disease burden
• AEs
  • malnourishment
  • morbidity rate
  • mortality rate
  • pain
  • rate of (repeat) falls.

The rehabilitation settings where the programmes were delivered varied from the acute hospital setting to the community setting and were categorised as below:

• acute hospital
  • inpatient
    • specialised orthopaedic ward
    • specialised orthogeriatric ward
  • outpatient
    • general outpatient rehabilitation unit
    • specialised orthogeriatric outpatient rehabilitation unit
  • rehabilitation unit
    • general elderly rehabilitation unit
    • specialised orthogeriatric rehabilitation unit
• community
  • place of residence
  • nursing, care or residential home
  • specialised nursing home rehabilitation unit
  • community hospital
  • community rehabilitation centre.

Testing the theories with quantitative and qualitative evidence

Data from each individual study were examined in terms of the identified programme theories and the interaction between mechanisms, context and outcomes. Next, the data across the different studies were examined to detect patterns and themes for each theory in turn. Separate fields were created in the Microsoft Access database to capture these interactions as well as raw statement data from the included studies to support reviewers’ reflections. Data synthesis involved individual reflection and team discussions to question the integrity of each theory, adjudicate between competing theories, consider the same theory in comparative settings and compare the theory with actual practice. When candidate theories failed to explain the data, new theories were sought from included studies or from the wider rehabilitation literature, such as studies of rehabilitation following stroke or following inpatient admission after being unable to stand. The narrative of the review was guided by the final theories that emerged from this process. The literature analysis relating to each identified theory is presented in detail, followed by a data summary to show the relationships between data themes and the theories in the final synthesis. Extracts were taken from participant quotations (patient, carer or health professional) reported in the included qualitative studies and used as evidence to support subthemes of the main theories. This is an established method used in a recently reported review of intermediate services⁶¹ to incorporate and integrate the theoretical perspectives from qualitative evidence into quantitative evidence.

Results of the initial scoping review

The scoping search for systematic reviews and other reviews as well as guidelines relating to the rehabilitation of older frail populations identified 39 reviews, both Cochrane reviews^{9,10,27,33,37,49} and other traditional systematic reviews.^{3,5,14,17,21–26,28–32,34–36,38,46–48,50–60} The majority of the reviews were related to hip fracture rehabilitation,^{3,5,9,10,14,17,21–24,26,27,29,30,32–36,49,51–57,59,60} but a few also included rehabilitation for stroke as well as for other conditions in older frail populations needing continuous care.^{24,25,28,31,37,46–48,50,58} A few conceptually rich and theoretically sound primary studies from the reference lists of these reviews were also obtained.^69–73 The search also identified five sets of guidelines, from the UK [NICE,⁷ Scottish Intercollegiate Guidelines Network (SIGN)⁷⁴], USA,⁷⁵ Canada⁷⁶ and Australia and New Zealand.⁷⁷

Study flow diagram for the realist review

The electronic searches identified 19,646 references, with a further 24 references identified by hand searching. Deduplication resulted in 12,278 unique references that were screened for relevance by two independent reviewers. The full texts of 610 references were obtained and, after collating multiple publications, 128 studies were included in the review^{12,13,69,72,78–201} (Figure 2; see Appendix 12 for the total number of references retrieved from each electronic database).

FIGURE 2

Realist and economic review flow chart.

Study characteristics

Of the 128 primary studies included in the review, 17 were conceptually rich^{13,69,72,78–80,83,86,89,106,107,124,131,165,176,193,197} and 111 were conceptually thick^{12,81,82,84,85,87,88,90–105,108–123,125–130,132–164,166–175,177–192,194–196,198–201} (see Appendix 13). Thin sources were screened but were not included in the review for data extraction (see Appendix 14). A list of studies excluded from the review with reasons can be found in Appendix 15. Appendices 16–18 present the raw data tables describing the general characteristics of the included studies, the populations of interest, the treatment categories with characteristics of the interventions and the strengths, limitations and conclusions as presented by authors, respectively. These data are described briefly in the following sections according to the types of research methods used.

Summary of participant characteristics

The number of patients/participants included in the studies ranged from 1 to 2762. The review included a total of 22,443 patients and 97 health professionals. In total, 6282 (range 90–401) patients participated in RCTs,^{12,69,78,80,87,90–126,128–130,197,199} 276 (range 24–95) patients participated in quasi-RCTs,^83,131–133 116 (range 20–30) patients participated in non-RCTs,^79,134–137 3044 (range 1–919) patients participated in historical cohort studies,^{13,157–165,170,173,178} 7136 (range 18–946) patients participated in concurrent cohort studies,^{81,138–152,169,177,179,181,182,184,187,188,190–193,196,200,201} 1697 (range 3–764) patients participated in controlled before-and-after studies,^{85,153–156,180,186,195} 45 patients participated in mixed-method studies,^84,89 3243 (range 130–2762) patients participated in database analyses^166–168 and 521 (range 12–222) patients/health professionals participated in qualitative studies,^{72,82,86,88,127,174–176,183,185,189,198} with two studies involving health professionals (n = 97) rather than patients.^176,198 Two studies used administrative/work process data and did not include any patient data.^171,172

The majority of the studies included patients aged ≥ 65 years.^{79,80,82–86,88,90–93,95,97,99–102,105,107,109,111,113,115,116,120,121,124–127,131,135,138–148,151,153,155–157,160,162,163,165,166,175,178–180,182–184,189–191,199,201} Six studies included adults of any age with a hip fracture and undergoing rehabilitation;^{78,112,167,174,185,186} two of these included carers¹⁷⁴ or health professionals.¹⁸⁵ Eight studies included patients aged ≥ 50 years;^{87,98,103,118,173,187,188,192} 18 studies included patients aged ≥ 60 years;^{12,89,96,104,114,117,119,122,132,133,149,154,164,193–197} 19 studies included patients aged ≥ 70 years;^{69,72,79,88,106,108,110,111,116,120,131,136,143,148,150,161,180,183,184} and seven studies included patients aged ≥ 80 years.^{13,81,123,134,137,152,178} The age of the included participants could not be determined from the study reports for four studies.^{171,172,181,200} Sixteen studies included only female participants^{69,79,80,102,104,123,126,147,156,158,165,174,180,183,185,191} and one included only male participants.¹⁵⁹ The rest included participants of both genders but the majority of studies included a greater proportion of women.

The majority of studies excluded patients who had a cognitive impairment or dementia or who lacked mental capacity to give informed consent;^{12,13,69,72,78–100,102–109,111–118,120–122,124–138,140,142–151,153–156,158–169,171–181,183,185–201} 11 studies included such patients,^{101,110,119,123,139,141,152,157,170,182,184} with one study stating that such patients would be included only if suitable carers ready to participate in the study were identified.¹¹⁹ The majority of the studies included participants who were mobile and living independently in their own home or in a care home before their hip fracture.^{12,69,72,79–86,88–90,92–114,116–119,121,123,124,126–130,132–136,138,139,143,145–149,153,156–158,161,165,166,168,169,171,175–177,179,180,183–186,191,193,194,196,197,199,201} Only seven studies included patients with a medical or psychological comorbidity;^{123,139,145,157,158,184,193} the majority of studies excluded such patients, especially when exercise would have been contraindicated. Only two studies included patients who had a history of a previous fracture.^175,184

The majority of the studies were carried out in English-speaking countries and involved mainly white Caucasian populations. Three Swedish studies,^90,99,127 two Taiwanese studies,^119,196 one German study⁹³ and one Danish study⁸⁴ included only patients who could speak, read and write in these languages, with other patients excluded.

Summary of interventional studies

Forty-eight of the studies were RCTs,^{12,69,78,80,87,90–126,128–130,191,197,199} with 10 from Australia,^{87,94,95,110,112,117,118,123,125,129} nine from the USA,^{69,80,91,92,107,113,121,126,191} six from the UK,^{12,102,109,115,128,197} four each from Sweden^90,98,99,120 and Taiwan,^{95,105,119,122} two each from Canada,^108,111 Norway,^116,199 Finland,^101,114 Hong Kong^103,106 and Switzerland,^93,96 and one each from Denmark,¹⁰⁴ Belgium,⁹⁷ Italy,⁷⁸ Spain¹²⁴ and Germany.¹³⁰ Only seven studies^{69,78,80,106,107,124,197} were categorised as being conceptually rich.

Four of the studies were quasi-RCTs^83,131–133 and five were non-RCTs,^79,134–137 with two each from Canada^134,135 and the USA,^79,83 and one each from Israel,¹³¹ Japan,¹³⁷ Italy,¹³³ South Africa¹³⁶ and Taiwan.¹³² Three of these studies were categorised as being conceptually rich.^79,83,131

Thirty-two of the studies were concurrent cohort studies,^{81,138–152,169,177,179,181,182,184,187,188,190,192–194,196,200,201} with nine from the USA,^{81,142,146,147,149,181,191,192,194} four each from Italy,^{141,143,177,182} Israel^{138,148,179,201} and Sweden,^{139,187,188,193} two each from the UK,^150,200 the Netherlands,^140,144 Taiwan^190,196 and Germany,^151,152 and one each from Norway,¹⁴⁵ France¹⁸⁴ and Canada.¹⁶⁹ None of these studies was categorised as being conceptually rich.

Eight of the studies were controlled before-and-after studies,^{85,153–156,180,186,195} with two each from the USA^153,156 and the UK,^85,155 and one each from Canada,¹⁹⁵ Denmark,¹⁵⁴ Sweden¹⁸⁰ and the Netherlands.¹⁸⁶ None of these studies was categorised as being conceptually rich.

Thirteen of the studies were historical cohort studies,^{13,157–165,170,173,178} with three from the USA,^159,165,173 two from the UK,^13,158 and one each from Australia,¹⁶¹ Austria,¹⁷⁸ Canada,¹⁵⁷ Germany,¹⁶³ Israel,¹⁶² Italy,¹⁷⁰ Japan¹⁶⁴ and Sweden.¹⁶⁰ None of these studies was categorised as being conceptually rich.

Among the non-comparative interventional studies there were two mixed-method studies,^84,89 one each from the USA⁸⁹ and Denmark.⁸⁴ One study from Finland¹⁶⁶ reported a cross-sectional analysis of pre-trial data, two studies from the USA^167,168 reported a hospital database analysis and another study from the USA reported longitudinal data from a survey. One study from Australia¹⁶⁹ reported before-and-after outcome data for a cohort who underwent an intensive rehabilitation programme in the acute hospital. There were also two case report studies:^13,170 one from Italy¹⁷⁰ and one from the UK.¹³ Two mixed-method studies^84,89 and a case series⁸¹ were categorised as being conceptually rich.

Summary of non-interventional studies

Non-interventional studies did not use any intervention or treatment to affect the outcomes but were useful for their conceptual input to the theoretical framework and provided explanations for elements of the proposed theories. Two studies, one from the USA¹⁷¹ and one from Canada,¹⁷² reported service and work process restructuring. One study from Australia¹⁶¹ utilised hospital data on hip fracture patients 4 months post surgery who had been successfully rehabilitated into the community. These patients were divided into fallers or non-fallers after their rehabilitation. None of these studies was categorised as being conceptually rich.

Twelve of the studies were qualitative studies,^{72,82,86,88,127,174–176,183,185,189,198} with three each from the UK^86,176,198 and USA,^72,174,183 two from Sweden^88,127 and one each from Australia,¹⁸⁵ Canada,¹⁷⁵ China¹⁸⁹ and Taiwan.⁸² Six of these studies^{72,86,127,175,183,189} interviewed hip fracture patients after discharge about their experiences of the whole process and the rehabilitation that they went through. Two of the studies^176,198 interviewed health professionals providing rehabilitation services regarding their experiences about such provision as well as any issues encountered that might be amenable to service improvement. Three of these studies were categorised as being conceptually rich.^72,86,176

Summary of the study settings

Twenty-two of the included studies^{69,72,82,92,107,114,115,117,118,121,122,125–127,135,142,156,161,163,165,174,201} were conducted in the community after the patients had been discharged from the acute or community hospital to either their pre-fracture place of residence or a care home. Sixty-seven studies^{12,13,78–80,83,87–89,93,96–98,100–102,104,106,108,111,112,116,119,124,129,132,134,137–141,146,148,152,157–160,162,164,166–173,175–187,194,195,197,198,200} were conducted while patients were still in the acute hospital following surgery. In 39 studies the intervention started in the acute hospital but continued in the community following discharge.^{81,84–86,90,91,94,95,99,103,105,109,110,113,120,123,128,130,131,133,136,143–145,147,149–151,153–155,188–193,196,199}

Overview of the rehabilitation programmes

Appendix 17 summarises the interventions and comparators as described in the included studies.

Physical activity components of the rehabilitation programmes

Fifty-two of the included studies reported some form of physical intervention^{69,78–81,83,87,91–93,96,98,99,103,104,107–110,112–115,117,118,121,122,126,130,131,134,136,148,151,153,154,156,158,162,164,169,170,177,180–182,186,187,191,192,194,199} and seven also included a psychological component.^{78–80,91,148,180,191} Twenty studies compared intensive physical exercise with less intensive physical activity or an inactive control.^{69,78,80,83,91–93,104,107–110,113,114,117,118,122,126,130,169} Twenty-four studies compared supervised programmes with conventional programmes that either did not include supervision as part of the programme or included only minimal supervision to ensure patient safety.^{69,80,83,87,91–93,104,107–110,112–114,126,131,136,151,153,180,186,191,199} Nine studies compared specifically tailored programmes with generic rehabilitation programmes.^{69,79,80,83,99,109,113–115}

Psychological components of the rehabilitation programmes

Fourteen studies reported using a psychological intervention in isolation^{12,106,137,141,171,197,201} or as part of a comprehensive rehabilitation programme along with physical components.^{78–80,91,148,180,191} Three of these studies^141,171,191 did not report any outcome data but were utilised mainly for theory explanation.

Place of rehabilitation

Twenty-six studies compared different rehabilitation settings.^{81,97,101,103,112,120,125,128,131,133,135,143,145–147,149,151,152,154,160,161,179,188,195,200,201} Ten of these studies compared some form of community (own home or care home) rehabilitation with hospital-based rehabilitation,^{101,103,125,128,131,133,135,143,145,160} with one comparing hospital plus home rehabilitation with hospital rehabilitation only.¹³³ Eight studies^{97,112,120,146,149,151,152,200} compared hospital-based rehabilitation with usual care, no post-discharge care or rehabilitation in nursing facilities. Other studies did not compare rehabilitation settings per se but included comparisons based on patients’ characteristics, such as fallers compared with non-fallers,¹⁶¹ very old patients compared with younger patients²⁰¹ and treated in a cognitive specialised rehabilitation unit compared with treated in a non-cognitive specialised rehabilitation unit.¹⁵² One study compared the discharge practices of four hospitals after inpatient rehabilitation.¹⁴⁷

Process or system improvement

Twenty-nine studies investigated the effects of improvement or change in existing health-care rehabilitation structures.^{69,83,94,95,98,100,102,105,111,116,117,119,120,123,124,127,128,132,138–140,144,150,155,157,159,163,167,184} Seventeen studies compared the development of multidisciplinary co-ordination programmes with usual care or another existing programme.^{69,83,98,102,111,117,119,120,123,124,127,132,144,155,157,159,184} There was large variation in these programmes from different health-care systems, but common features included comprehensive geriatric assessment both pre and post surgery, assessment of patient needs and assignment of appropriate health-care staff to address those needs, regular multidisciplinary meetings to discuss progress and care pathways that continue into the community after discharge. Usual or conventional care varied greatly among the studies, ranging from simple control of post-operative symptoms¹¹⁷ to comprehensive assessment.^69,83,120

Eight studies reported on structured discharge planning from hospital to the community based on patients’ abilities, the extent of support needed and the availability of support from family or friends during the recovery period.^{94,95,100,105,128,139,140,150} Six studies compared the early discharge of patients to their own home with usual discharge,^{94,95,100,128,140,150} one study compared early discharge to a rehabilitation unit of a community hospital with early discharge home¹³⁹ and one study compared early discharge to the rehabilitation ward of a nursing home with conventional (delayed) discharge to the same ward.¹⁰⁵

Four studies reported the implementation of new ward protocols.^{116,138,163,167} One study compared a newly commissioned orthogeriatric ward with a traditional orthopaedic ward¹¹⁶ and another study compared comprehensive geriatric assessment with usual care.¹³⁸ The other two studies were non-interventional improvement reports that utilised routinely collected hospital data in their analyses.^163,167 One did not report any patient-related outcomes but was useful for theory development.¹⁶³

Summary of outcomes

Outcomes data were extracted from 70 of the included studies.^{12,69,78,80,81,83,87,90–93,95–97,100–103,105–111,114,115,117–124,130–133,135–140,143,144,146–149,151–158,160–162,167,169,184,192,195,199–201} Sixty-five of these studies reported physical or physiological outcomes,^{12,69,78,80,81,83,87,90–93,95,97,100,102,103,105–111,114,115,117–124,130–133,135–140,143,144,146–149,151–157,161,162,167,169,184,192,195,199,201} 22 reported psychological or social outcomes,^{69,80,81,83,90,95,105,106,110,115,117–119,121,130,136–138,143,151,161,169} 26 reported health service utilisation^{83,87,90,93,97,100–102,105,111,119,120,124,138,140,143,147,148,152,154,155,157,158,160,200,201} and 16 reported AEs^{93,96,97,100,101,110,111,119,124,133,137,144,148,154,155,162} as their main outcomes.

The rest of the included studies^{13,72,79,82,84–86,88,89,94,98,99,104,112,113,116,125–129,134,141,142,145,150,159,163–166,168,170–183,185–191,193,194,196–198} mainly contributed to theory building and explanation.

The directions of effect at various follow-up points are presented in structured tables in Appendix 19. The outcomes reported are discussed further when appropriate in the following discussion of the evidence for the final programme theories.

Study quality assessment

The results of the quality assessment are presented in Appendix 20.

Programme theory 1: improve patient engagement by tailoring the intervention according to individual needs and preferences

Proximal hip fracture patients presenting with a range of pre-fracture physical and mental functioning and a variety of comorbidities (C) need a rehabilitation programme that is tailored to individual needs (M) to achieve appropriate outcomes such as improved physical functioning, greater mobility, reduced disability and independent living (O).

Tailoring of rehabilitation activities involved the interplay of many factors encompassing the patient, the health-care professional and the environment in which the rehabilitation took place. The main theme revolved around making rehabilitation planning patient centred and contextualising what is important for patients so that this can be incorporated into their care plan, allowing a better chance of engaging patients in their recovery.

Summary of programme theory 1

A summary of programme theory 1 is provided in Box 1.

BOX 1

Summary of programme theory 1: improve patient engagement by tailoring the intervention according to individual needs and preferences

Programme theory 2: reducing the fear of falling and improving self-efficacy to exercise and carry out activities of daily living

Proximal hip fracture results in poor physical functioning, fear of falling, low mood and lack of self-efficacy (C), requiring improved quality and an increased amount of practice of physical exercises, ADL and psychological tasks (M) to gain mastery and control to improve confidence, mobility and physical functioning (O).

Summary of programme theory 2

A summary of programme theory 2 is provided in Box 2.

BOX 2

Summary of programme theory 2: reducing the fear of falling and improving self-efficacy to exercise and carry out ADL

Programme theory 3: co-ordination of services and sectors delivering rehabilitation

The diversity of services provided by different disciplines across sectors from a variety of funders (C) requires co-ordinated provision of multidisciplinary rehabilitation programmes (M) to deliver appropriate physical, functional and psychological interventions to patients in a timely manner (O).

Summary of programme theory 3

A summary of programme theory 3 is provided in Box 3.

BOX 3

Summary of programme theory 3: co-ordination of services and sectors delivering rehabilitation

Summary of findings

Three programme theories arose from this realist review that appeared to put patients at the heart of rehabilitative care and improve outcomes. These were:

1. tailoring the intervention according to patients’ individual needs and preferences to improve patient engagement
2. reducing fear of falling and improving self-efficacy to exercise and perform ADL through increased quality and frequency of the practice of exercises and daily tasks under supervision
3. the co-ordination of services and sectors delivering the rehabilitation.

Strengths and limitations

This was a realist rather than a systematic review of multidisciplinary rehabilitation following hip fracture aimed at synthesising evidence to develop an enhanced rehabilitation package for such patients. To our knowledge, this is the first realist review that has attempted to build an explanatory account about the effectiveness of different components of rehabilitation interventions following hip fracture in the context of what works for whom and under what circumstances.^39,40 As such, we did not attempt to summarise all of the evidence and judge whether or not rehabilitation programmes were effective, but rather we attempted to build an explanatory account of the mechanisms behind their effectiveness and to establish which components were effective in certain circumstances and contexts.

No studies were excluded based on a particular outcome and data for all reported outcomes were extracted. Particular caution needs to be exercised when the included studies have used non-validated measures or measures have been combined to give a cumulative outcome, such as combining numbers of readmissions and deaths into a single outcome designated as ‘poor outcome’.²⁶ About 35 outcomes using 152 outcome measure instruments were recorded (see Appendices 10 and 11). Such a variety of outcomes in hip fracture rehabilitation studies has been reported by the majority of reviews^3,21 explored during theory-building and scoping searches. This applies to both long-term³ and short-term¹⁴ disability arising as a result of hip fracture. This was recognised as a limitation of traditional review methods, as were the myriad of treatment strategies used and inconsistent reporting,^{9,10,23,24,47,50} which made comparisons across studies difficult and led to inconclusive results.^{3,8–10,21,23–25,28,29,47,49,50,240,241} These issues also led to difficulties in replicating intervention designs in different health-care systems as well as in drawing evidence-based conclusions about best practice.^10,24 Successfully combining a few commonly reported outcomes to estimate the long-term health outcomes of rehabilitation programmes¹⁰ could help to more accurately estimate the comorbid disease burden, which may benefit from longer-term rehabilitation and falls prevention programmes, leading to health gains and reduced costs in the long term.³

It is acknowledged that the pragmatic method of reviewing the literature and synthesising the evidence may be difficult to replicate and that another team carrying out a similar review may reach different conclusions. This review has attempted to be as inclusive as possible and incorporate evidence from multiple sources and study types, which helped to provide context to the findings of the comparative studies. The use of a specific definition of rehabilitation programmes and categorising sources of evidence according to their conceptual richness might have resulted in some relevant studies being missed or excluded. However, this was mitigated by the comprehensive electronic literature searches, complemented by manual citation tracking.

The process of identifying and formulating programme theories was challenging, particularly when some studies did not explicitly state how the intervention being tested was developed or the content and operation of services in the context of that particular intervention. This similar issue has been highlighted in a recent review of intermediate care services, which recommended that the research community provide more information about ‘how’ and ‘why’ the interventions/services being evaluated were developed and delivered.⁶²

Comparison with previous literature

As discussed in the previous section, a realist approach was used to tease out which components of rehabilitation programmes were useful and which were not,^10,23 rather than summarising overall effectiveness as in previous systematic reviews. It also addressed some of the gaps in hip fracture rehabilitation, such as the lack of interventions that enhance self-efficacy^{24,169,242,243} and address postural balance and fear of falling,^14,21,24,169 the exclusion of moderately cognitively impaired patients,^{10,16,17,24,36,57,244} the short-term provision of rehabilitation services^10,244 and the lack of reporting of carer outcomes.¹⁰

Self-efficacy to exercise has long been recognised as an important mediator for regaining confidence in daily activities and function and overcoming the fear of falling, to enable an increase in the practice of physical activities and exercise.^{14,69,72,227,245} But such potential has not been realised fully in rehabilitation interventions, especially once patients have been discharged from the acute hospital.^{157,169,242,246} Targeted information provision and education,²⁴⁶ skills enhancement,²²⁷ addressing and accommodating user needs and views²¹⁴ and social and peer support are important to improve motivation and engagement and help patients regain control and confidence after the medical and psychological crisis presented by hip fracture.²²⁷ A rehabilitation intervention model addressing both psychological and physical needs may be an answer to this dilemma, as such strategies in isolation have minimal positive effects on outcomes.^10,73,91 This has been successfully shown in the rehabilitation of patients with stroke²⁴⁷ and other conditions.^61,62,214 This review identified that mutual aid and social support,²⁴⁶ combined with the development of practical skills through supervised practice and exercise,^243,248 have the potential to improve quality of life and reduce the rates of rehospitalisation and long-term institutionalisation. This is mediated by building confidence, cognitive understanding and practical skills.

Recent drives to both improve patient outcomes following hip fracture and reduce costs through effective rehabilitation programmes have highlighted the importance of tailoring specific rehabilitation packages according to individual patient needs rather than following set programmes that do not take into account patients’ circumstances.²²⁷ Such tailoring activity involves multidisciplinary team decision-making in consultation with the patient and his or her carers about the appropriate timing and place of such activities. The timing of different interventions is important, as some intervention activities appear to produce better outcomes if introduced at certain time points and in appropriate settings. For example:

• coaching may have a minimal effect if started immediately after surgery in hospital⁹¹ but has been shown to enhance patients’ self-efficacy, skills and mastery to perform exercises independently if provided in the community soon after discharge^{36,69,72,73,244,245,249}
• occupational therapy and interventions for fear of falling in the acute hospital have a minimal effect^99,245 but appear to be effective when provided at patients’ usual place of residence,^244,245,250 probably because patients start ambulating either independently or with help and can appreciate that the occupational therapy supervision aims to make the environment safe for them to practise exercises and ADL²⁸
• supervised physical training and earlier mobilisation in rehabilitation programmes during the acute hospital stay,³⁶ and strength and progressive resistance training later in the programmes, either during or after discharge, appear to improve outcomes,^25,36,57,251 as earlier commencement of intensive physical therapy may act as a hindrance and there is a danger of patients becoming disengaged or dropping out of programmes⁹ because of the challenging nature of the tasks
• falls prevention programme training combined with supervised exercise to improve self-efficacy and regain confidence,³⁶ but only after patients have restarted walking.^5,9

Similarly, no single pathway provides the answers to all patient issues because of the complexity of comorbidities with which hip fracture patients can present.^8,29,49,240 Geriatric orthopaedic rehabilitation units are likely not to be cost-effective but can be beneficial for frailer patients to reduce complication rates, readmissions, nursing home placements and in-hospital deaths; however, they showed little effect on the rate of death post discharge, in both the short term and the long term.²⁹ Similarly, geriatric hip fracture programmes and early supported discharge can be cost-effective if offered to suitable patients, as they appear to reduce the length of hospital stay in such groups.^47,252 If they are offered to all patients without distinction, however, they will simply transfer the cost from the hospital to the community, as some patients may need prolonged care in the community.¹⁴⁰ Multidisciplinary co-ordination would play an important role in such instances to determine the appropriate skills mix of rehabilitation professionals during a patient’s inpatient rehabilitation and discharge planning^8,49,240 as well as rehabilitation beyond the acute care setting and into the community.²⁵² Such rehabilitation programmes would need to be flexible with a mix of components to respond and adapt to individual patient needs and requirements.

Implications for practice, policy and research

In the early post-operative period, patients’ needs and wishes should be used to tailor the rehabilitation package (the timing of delivery of certain components of the programme, the skills mix of rehabilitation professionals needed, the appropriate place and support element built into the programme) to allow it to produce positive outcomes and be cost-effective in the long term.

Rehabilitation programmes need to take into account the longer-term needs of patients to reduce the detrimental sequelae that follow, for example fear of falling again leading to movement restriction, reduced participation in physical activities and ADL, reduced function leading to disability and dependence and psychological issues leading to isolation and reduced quality of life.

Rehabilitation programmes should have elements of support, supervision and coaching to help patients regain lost confidence and realise the importance of the enhanced practice of physical activities and ADL for improving function and reducing disability.

Realist review methodology provides a flexible and pragmatic way of developing complex intervention such as rehabilitation programmes for hip fractures through an explanatory building exercise and teasing out individual and effective components of such programmes.

The programme theories that emerged from this realist review were combined with the findings of the survey of therapy professionals (see Chapter 4) and the patient/carer focus groups (see Chapter 5) to develop the rehabilitation package (see Chapter 6) to be tested in a feasibility study (see Chapter 7).