Inequity in rehabilitation interventions after hip fracture: a systematic review

Abstract

Objective to determine the extent to which equity factors contributed to eligibility criteria of trials of rehabilitation interventions after hip fracture. We define equity factors as those that stratify healthcare opportunities and outcomes. Design systematic search of MEDLINE, Embase, CINHAL, PEDro, Open Grey, BASE and ClinicalTrials.gov for randomised controlled trials of rehabilitation interventions after hip fracture published between 1 January 2008 and 30 May 2018. Trials not published in English, secondary prevention or new models of service delivery (e.g. orthogeriatric care pathway) were excluded. Duplicate screening for eligibility, risk of bias (Cochrane Risk of Bias Tool) and data extraction (Cochrane’s PROGRESS-Plus framework). Results twenty-three published, eight protocol, four registered ongoing randomised controlled trials (4,449 participants) were identified. A total of 69 equity factors contributed to eligibility criteria of the 35 trials. For more than 50% of trials, potential participants were excluded based on residency in a nursing home, cognitive impairment, mobility/functional impairment, minimum age and/or non-surgical candidacy. Where reported, this equated to the exclusion of 2,383 out of 8,736 (27.3%) potential participants based on equity factors. Residency in a nursing home and cognitive impairment were the main drivers of these exclusions. Conclusion the generalisability of trial results to the underlying population of frail older adults is limited. Yet, this is the evidence base underpinning current service design. Future trials should include participants with cognitive impairment and those admitted from nursing homes. For those excluded, an evidence-informed reasoning for the exclusion should be explicitly stated. PROSPERO CRD42018085930.

<p>Geriatric Interdisciplinary Home Rehabilitation After Hip Fracture in People with Dementia – A Subgroup Analysis of a Randomized Controlled Trial</p>

“…3 Despite dementia being common among older people with hip fracture and that the population has complex care needs, 6 the condition has often been an exclusion criterion for participation in previous clinical trials. 8 There is, however, growing evidence that people with hip fracture and cognitive impairment (CI) or dementia benefit from enhanced interdisciplinary rehabilitation in hospital, 9,10 combined in-hospital and in-home rehabilitation, [11][12][13][14] and from rehabilitation in nursing homes, 15 although the optimal rehabilitation strategies remain unclear. 6 To our knowledge, no previous team-based home rehabilitation (HR) interventions after hip fracture have included people with severe CI or dementia.…”

An under-represented and underserved population in trials: methodological, structural, and systemic barriers to the inclusion of adults lacking capacity to consent

“…There is an increasing focus on using an equity lens to critically review the development and evaluation of health (and other) interventions for populations who may experience health inequities to ensure that the evidence generated is of relevance for both clinical practice and public policy making [57]. The lack of equity in trials of interventions, such as rehabilitation interventions after hip fracture, for adults who lack capacity has been identified as a result of their exclusion from trials [19] based on equity factors (e.g. PROGRESS+ factors [57]).…”

“…A recent review of studies on the NIHR portfolio found that 60% of the studies excluded learning disability groups, none of the studies investigating pneumonia or sepsis included learning disability groups despite being a key contributor to premature deaths, and only 1.4% of all studies were specifically related to learning disabilities [18]. Similar exclusions of people with cognitive impairment are seen in other areas of research such as geriatrics [7], rehabilitation interventions following hip fracture [19], perioperative medicine [20], trauma [21] and neurological research [22]. Under-recruitment to research into conditions such as dementia is one of the key challenges to advancing understanding of these conditions and improving the care and treatment of those who live with these conditions [23].…”

“…While eligibility is an essential component of trial design, arbitrary exclusion of large numbers of the clinical population restricts the pool of potential participants, affects the generalisability of the results and, as these excluded individuals are disproportionately from vulnerable populations, raises ethical concerns [22]. The lack of inclusion of adults who lack capacity in trials that are directly relevant to them should be carefully scrutinised by funders and those determining the scientific merit of proposed trials and, where they are excluded, an evidence-informed justification for their exclusion should be explicitly stated [19].…”

People living in nursing care facilities who are ambulant and fracture their hips: description of usual care and an alternative rehabilitation pathway

“…People living in nursing care facilities (NCFs) are often excluded from participating in research and clinical trials [1] which has contributed to a lack of information regarding the usual clinical care provided in NCFs to residents following their return from hospital after hip fracture surgery. This lack of information makes the development of practice guidelines difficult.…”