Hip fracture in the elderly is associated with excess mortality of 5 to 20%, and mobility problems that usually results in costly hospital stays and lengthy rehabilitation procedures. With this increase in the aging population, hip fracture represents a major and a fast growing health care problem in Taiwan. Currently, the incidence rate of hip fractures is 10 times of the incidence rate for the general population. Despite the use of advanced treatment, the one-year mortality rate (15.4%) remains significant, and many of the patients never recover completely in terms of activities of daily living functions. Many studies in the United States have proved that elderly patients with hip fracture can benefit from post-operative rehabilitation, early discharge planning programs, or transitional care programs. However, little is known about what intervention should be attempted for these patients and their families in Taiwan.

     The purpose of this study is to compare the costs and effectiveness of three care models- acute/sub-acute, comprehensive, and routine care models for hip fractured elders in Taiwan. In a pilot study supported by the NHRI, we have developed and pilot tested an acute/sub-acute care for hip fractured elders and their families. Preliminary findings revealed promising effectiveness of this interventional program on improving physical functions of the patients. Subjects who received the acute/subacute care model appeared to have better muscle power (p = 0.02), range of motion (ROM, p = 0.027), at affected limb, better recovery in walking ability (p < 0.05) and had better self-care ability and physical related quality of life during 1 year following discharge. On the other hand, we found that depressive symptoms and malnutrition appeared in around 2/3 of our subjects. Therefore, we further developed a comprehensive care model to extend the original acute and subacute care model to include health maintenance interventions, including depression detection/management, fall prevention and nutrition consultation. Therefore, in this proposed study, we would like to compare the cost and effectiveness of the three different care models: routine care, acute/subacute care and comprehensive care model in a randomized clinical trial.

     For the first year, we will pre-test the comprehensive care model in the actual clinical situations. From second to fourth year, we will conduct the formal clinical trial. One hundred subjects in each group including potential case losses were estimated according to previous pilot study. According to our previous experience, an average of 10 to 12 subjects can be collected per month. Therefore, we plan to finish the subject recruitment in 2 1/2 years and finished the one-year follow-up data collection in the beginning of the fifth year. At the end of the fifth year, we will complete the data analysis. Generalized estimating equations (GEE) will be used to determine the differences in changes of outcome variables between control groups and experimental groups. By the end of the fifth year, the cost effectiveness of three care models--routine care model, acute/sub-acute care model and comprehensive care model will be compared to determine which care model is the most cost-effective for hip fractured elders in Taiwan. Suggestions for decision-making and clinical implications will be made at this point.