Pain Management Interventions for Hip Fracture: Comparative Effectiveness Review Number 30

Hip fractures are a source of significant morbidity and mortality. Incidence increases substantially with age, rising for men and women, respectively, from 22.5 and 23.9 per 100,000 populations at age 50, to 630.2 and 1,289.3 per 100,000 populations by age 80. Short-term mortality rates are high and range from 25 percent for women to 37 percent for men in the first year following a hip fracture. Furthermore, a large proportion of those patients who survive never recover to their prefracture level of function, and approximately 25 to 50 percent of elderly patients with hip fractures have not returned home by 1 year postfracture. Up to 25 percent of hip fractures occur in continuing care facilities (i.e., long-term residential care for dependent people). Pain following hip fracture has been associated with delirium, depression, sleep disturbance, and decreased response to interventions for other disease states. Therefore, it is important to treat and manage complaints of pain adequately during acute treatment for hip fracture. Furthermore, poorly managed postoperative pain is associated with delayed ambulation, pulmonary complications, and delayed transition to lower levels of care. The patient's self-report of pain is the gold standard for evaluating its character and intensity. However, those with dementia or acute delirium may have difficulty reporting pain levels. The potential for underreporting of pain has direct ramifications for the hip fracture population, as many patients are frail older people with postoperative confusion and an impaired ability to communicate. Key Questions include: Key Question (KQ) 1. In older adults (greater than or equal to 50 years) admitted to the hospital following acute hip fracture, what is the effectiveness of pharmacologic and/or nonpharmacologic pain management interventions for controlling acute (up to 30 days postfracture) and chronic pain (up to 1 year postfracture) compared with usual care or other interventions in all settings? KQ 2. In older adults (greater than or equal to 50 years) admitted to the hospital following acute hip fracture, what is the effectiveness of pharmacologic and/or nonpharmacologic pain management interventions on other outcomes up to 1 year postfracture compared with usual care or other interventions in all settings? Other outcomes include: a. Mortality (30-day and up to 1 year postfracture) b. Functional status c. Pain medication use; change in type and quantity d. Mental status e. Health-related quality of life f. Quality of sleep in the hospital g. Ability to participate in rehabilitation h. Return to prefracture living arrangements i. Health services utilization KQ 3. In older adults (greater than or equal to 50 years) admitted to the hospital following acute hip fracture, what is the nature and frequency of adverse effects that are directly or indirectly associated with pharmacologic and nonpharmacologic pain management interventions up to 1 year postfracture compared with usual care or other interventions in all settings? KQ 4. In older adults (greater than or equal to 50 years) admitted to the hospital following acute hip fracture, how do the effectiveness and safety of pharmacologic and nonpharmacologic pain management interventions vary in differing subpopulations following acute hip fracture up to 1 year after fracture compared with usual care or other interventions in all settings?