Feasibility of a Follow‐Up Hip Fracture Clinic

To the Editor: Hip fractures are potentially catastrophic events for older adults and significantly affect survival and independence.1 A multidisciplinary approach is recommended to optimize recovery and functional status.2 Many such strategies focus on the immediate postoperative period before discharge,3 but care gaps persist.4 Recognizing the importance of multidisciplinary care in promoting mobility in older adults after hip fracture, a novel postdischarge clinic was designed to improve recovery from hip fracture. A feasibility study was conducted to discern recruitment and retention rates, assess the appropriateness of outcome measures, and identify challenges for a larger randomized study.5 The study was also designed to characterize recovery of mobility in a sample of older adults in the 12 months after hip fracture. The study took place at two academic hospitals in Vancouver, Canada. Community-dwelling adults aged 65 and older with a recent history (≤3 months) of hip fracture were included. People who were unable to walk 10 m before the hip fracture (self-reported), were diagnosed with dementia, or were living in a residential care facility before hip fracture or after discharge were excluded. Participants were not randomized; all received usual orthopedic postoperative treatment for the hip fracture plus a geriatrician-led postfracture follow-up clinic described in the protocol.5 The primary objective was to determine recruitment and retention rates. Participants were assessed at approximately 3, 6, and 12 months after hip fracture. The Short Physical Performance Battery (SPPB)6 was used to assess standing balance, gait speed, and sit to stand performance. Gait speed was calculated as meters per second based on a 3-m walk. Health was assessed using the visual analog scale of the EuroQol 5 Dimensions (EQ5D-5L).7 Chart reviews from the follow-up clinic were conducted to describe the intervention (e.g., health professional visits). Means and standard deviations were reported for the SPPB and self-reported health. From December 2010 to May 2011, 110 charts were screened. Only 37% (41/110) of individuals were eligible. Nine enrolled, a 22% (9/41) recruitment rate. The most frequent reasons for noneligibility were younger than 65 (21%, n = 23), not community dwelling before or after the fracture (15%, n = 17), and dementia (14.5%, n = 16). The top reasons for nonparticipation were unable to contact (25%, n = 8), language barrier (22%, n = 7), and no explanation (19%, n = 6). Participant mean age was 78.8 ± 10.7 (range 66–94) years, and an average of 101.8 ± 18.2 days elapsed between fracture repair and study enrollment. All participants saw a geriatrician and at least one other health professional (e.g., physiotherapist, occupational therapist); all received an exercise program. Seven (77.8%) participants completed the final assessment; one died before the 6-month assessment, and one experienced an unrelated health complication that prevented the final SPPB assessment (Table 1). The objective was to determine the feasibility of the multidisciplinary intervention to enhance mobility recovery of older adults after hip fracture. The most striking finding related to recruitment was that 37% of individuals hospitalized in two major hospitals were ineligible for the study in part because of prior dementia and residing in residential care. The study sought to identify participants who would be able to attend and participate in an outpatient clinic with some regularity and had considered these two exclusions as barriers to participation. Also notable was the low (22%) enrollment of eligible individuals approached during their acute hospitalization. The inclusion criteria and recruitment sites were therefore revisited to include another hospital and to enroll individuals up to 12 months after their fracture. Once participants were enrolled, retention was high. Mobility, the primary outcome for the main study, increased according to performance-based measures. Improvements in mobility were clinically significant, with the greatest change seen in gait speed,8 although most participants would still be considered to be “limited community ambulators.”9 An unexpected finding was the decrease in participants' self-reported health at 12 months. This may have occurred because study participants were not back to their prefracture status. This will be explored further with qualitative interviews within the larger study. This was a small select sample and thus may not be generalizable to all older adults with hip fracture, but the process information gained from this feasibility study was an invaluable opportunity before starting the larger trial. Furthermore, the intention was not to generate definitive answers with respect to the effect of the intervention on mobility; although participants improved mobility over the year, without a control group, it is not known whether these changes would occur naturally. These results await clarification in the full study protocol. We extend sincere thanks to the study participants for their generosity with their time. We gratefully acknowledge financial support from Canadian Institutes of Health Research (CIHR) Grant FRN 99051 and career award support for Dr. Ashe from CIHR and the Michael Smith Foundation for Health Research. Conflict of Interest: Wendy Cook, Penelope Brasher, Meghan Donaldson, Pierre Guy, and Maureen Ashe received funding from CIHR to conduct this study. Author Contributions: Ashe, Cook, Brasher, Guy: study concept and design. Schiller, McAllister, Hanson, Macri: acquisition of subjects and data. All authors: analysis and interpretation of data, preparation of manuscript. Sponsor's Role: The sponsors had no role in the study design, analysis or preparation of this manuscript.

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