PERFECTED enhanced recovery pathway (PERFECT-ER) versus standard acute hospital care for people after hip fracture surgery who have cognitive impairment: a feasibility cluster randomised controlled trial

Jane L Cross, Simon P Hammond, Lee Shepstone, Fiona Poland, Catherine Henderson, Tamara Backhouse, Bridget Penhale, Simon Donell, Martin Knapp, Douglas Lewins, Alasdair Maclullich, Martyn Patel, Opinder Sahota, Toby O Smith, Justin Waring, Robert Howard, Clive Ballard, Chris Fox

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Objectives: Assess feasibility of a cluster randomised controlled trial (RCT) to measure clinical and cost-effectiveness of an enhanced recovery pathway for people with hip fracture and cognitive impairment (CI).

Design: Feasibility trial undertaken between 2016 and 2018.

Setting: Eleven acute hospitals from three UK regions.

Participants: 284 participants (208 female:69 male). Inclusion criteria: aged >60 years, confirmed proximal hip fracture requiring surgical fixation and CI; preoperative AMTS ≤8 in England or a 4AT score ≥1 in Scotland; minimum of 5 days on study ward; a ‘suitable informant’ able to provide proxy measures, recruited within 7 days of hip fracture surgery. Exclusion criteria: no hip surgery; not expected to survive beyond 4 weeks; already enrolled in a clinical trial.

Intervention: PERFECT-ER, an enhanced recovery pathway with 15 quality targets supported by a checklist and manual, a service improvement lead a process lead and implemented using a plan–do–study–act model.

Primary and secondary outcome measures: Feasibility outcomes: recruitment and attrition, intervention acceptability, completion of participant reported outcome measures, preliminary estimates of potential effectiveness using mortality, EQ-5D-5L, economic and clinical outcome scores.

Results: 282 participants were consented and recruited (132, intervention) from a target of 400. Mean recruitment rates were the same in intervention and control sites, (range: 1.2 and 2.7 participants/month). Retention was 230 (86%) at 1 month and 54%(144) at 6 months. At 3 months a relatively small effect (one quarter of an SD) was observed on health-related quality of life of the patient measured with EQ-5D-5L proxy in the intervention group.

Conclusion: This trial design was feasible with modifications to recruitment. Mechanisms for delivering consistency in the PERFECT-ER intervention and participant retention need to be addressed. However, an RCT may be a suboptimal research design to evaluate this intervention due to the complexity of caring for people with CI after hip fracture.
Original languageEnglish
Article numbere055267
JournalBMJ Open
Issue number2
Publication statusPublished - 28 Feb 2022


  • Hip
  • delirium & cognitive disorders
  • geriatric medicine
  • rehabilitation medicine

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