The medical consultant's role in caring for patients with hip fracture.
BACKGROUND
Hip fractures are an important cause of death and functional dependence in the United States.


OBJECTIVE
To review the evidence for clinical decisions that medical consultants make for patients with hip fracture and to develop recommendations for care.


METHODS
Published reports of clinical studies were found by searching MEDLINE and selected bibliographies.


METHODS
Studies were included if data were presented on clinical interventions to improve care of conditions typically encountered by medical consultants in the care of patients with hip fracture. Such conditions include timing of surgery, infection prophylaxis, thromboembolic prophylaxis, postoperative nutritional management, urinary tract management, prevention and management of delirium, application and timing of rehabilitation services, and prevention of subsequent falls. Meta-analyses; randomized, controlled trials; or other controlled studies were included if possible. If no such trials were identified, the best evidence from studies with other designs was included.


METHODS
Interventions were selected on the basis of their efficacy or potential efficacy in improving functional outcome. Trials with positive and negative results were compared for differences in intervention and strength of study methods.


RESULTS
Strong evidence supports medical recommendations for decisions about timing and duration of prophylactic antibiotics, selection of thromboembolic prophylaxis, urinary tract and nutritional management, and rehabilitative services. Many case series support early surgical repair, although patients who would benefit from delay and further medical work-up have not been well identified. Evidence for decisions about assessment of subsequent risk for fall and risk for and management of delirium is based largely on data from patients without hip fracture but is probably applicable. Future research should target optimal duration of thromboembolic prophylaxis, cost-effectiveness of low-molecular-weight heparin compared with that of other thromboembolic prophylactic regimens, management of delirium, rehabilitative services, and efficacy of assessment of risk for later falls.


CONCLUSIONS
The data suggest that evidence-based medical care can improve hip fracture outcomes. The medical consultant has a key role in providing this care and managing the preoperative conditions and postoperative complications that may affect optimal functional recovery.
Morrison
R S
RS
Mount Sinai School of Medicine, New York, New York 10029, USA. smorriso@smtplink.mssm.edu
Chassin
M R
MR
Siu
A L
AL
D000058:Accidental Falls / Q000517:prevention & control; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003693:Delirium / Q000517:prevention & control; D019317:Evidence-Based Medicine; D006620:Hip Fractures / Q000150:complications / Q000534:rehabilitation / Q000628:therapy*; D006801:Humans; D017053:Infection Control; D007388:Internal Medicine; D017063:Outcome Assessment, Health Care; D010819:Physician's Role; D011182:Postoperative Care; D013923:Thromboembolism / Q000517:prevention & control; D013997:Time Factors; D014570:Urologic Diseases / Q000517:prevention & control
D000900:Anti-Bacterial Agents