Nutritional supplementation for hip fracture aftercare in older people

Alison Avenell; Helen HG Handoll

doi:10.1002/14651858.CD001880.pub4

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Analysis 1.1

Comparison 1 Multinutrient supplement (oral or nasogastric routes, or both) versus control, Outcome 1 Mortality by end of study.

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Analysis 1.2

Comparison 1 Multinutrient supplement (oral or nasogastric routes, or both) versus control, Outcome 2 Patients with complications at end of study.

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Analysis 1.3

Comparison 1 Multinutrient supplement (oral or nasogastric routes, or both) versus control, Outcome 3 Unfavourable outcome (death or complications) at end of study.

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Analysis 2.1

Comparison 2 Multinutrient supplement (oral or nasogastric routes, or both) versus control (split by nutritional status), Outcome 1 Mortality by end of study.

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Analysis 2.2

Comparison 2 Multinutrient supplement (oral or nasogastric routes, or both) versus control (split by nutritional status), Outcome 2 Patients with complications at end of study.

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Analysis 2.3

Comparison 2 Multinutrient supplement (oral or nasogastric routes, or both) versus control (split by nutritional status), Outcome 3 Unfavourable outcome (death or complications) at end of study.

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Analysis 3.1

Comparison 3 Multinutrient supplement (oral or nasogastric routes, or both) versus control (by allocation concealment), Outcome 1 Mortality by end of study (concealed? = yes; unknown; no).

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Analysis 4.1

Comparison 4 High protein containing supplement versus low protein or non‐protein containing supplement, Outcome 1 Mortality by end of study.

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Analysis 4.2

Comparison 4 High protein containing supplement versus low protein or non‐protein containing supplement, Outcome 2 Unfavourable outcome (death or complications) at end of study.

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Analysis 5.1

Comparison 5 Thiamin (vitamin B1) and water soluble vitamins versus control, Outcome 1 Mortality by end of study.

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Analysis 5.2

Comparison 5 Thiamin (vitamin B1) and water soluble vitamins versus control, Outcome 2 Patients with complications at end of study.

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Analysis 6.1

Comparison 6 Vitamin D versus control, Outcome 1 Patients with complications at end of study.

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Analysis 7.1

Comparison 7 Dietetic assistants versus usual care, Outcome 1 Mortality by end of study.

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Analysis 7.2

Comparison 7 Dietetic assistants versus usual care, Outcome 2 Patients with complications at end of study.

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Table 1. Quality assessment items

Items and scores

a. Was the assigned treatment adequately concealed prior to allocation?
2 = method did not allow disclosure of assignment (A)
1 = small but possible chance of disclosure of assignment or states random but no description(B)
0 = quasi‐randomised (C)

b. Were the outcomes of patients who withdrew described and included in the analysis (intention to treat)?
2 = intention‐to‐treat analysis based on all cases randomised possible or carried out
1 = states number and reasons for withdrawal but intention‐to‐treat analysis not possible
0 = not mentioned or not possible

c. Were the outcome assessors blinded to treatment status?
2 = action taken to blind assessors, or outcomes such that bias is unlikely
1 = small or moderate chance of unblinding of assessors
0 = not mentioned

d. Were the treatment and control group comparable at entry?
2 = good comparability of groups, or confounding adjusted for in analysis
1 = confounding small; mentioned but not adjusted for
0 = large potential for confounding, or not discussed

e. Were care programmes, other than the trial options, identical?
2 = care programmes clearly identical
1 = clear but unimportant differences
0 = not mentioned or clear and important differences in care programmes

f. Were the inclusion and exclusion criteria clearly defined?
2 = clearly defined
1 = inadequately defined
0 = not defined

g. Were the interventions clearly defined (including estimates of nutritional value)?
2 = clearly defined interventions are applied with a standardised protocol
1 = clearly defined interventions are applied but the application protocol is not standardised
0 = intervention and/or application protocol are poorly or not defined

h. Were the participants blind to assignment status following allocation?
2 = effective action taken to blind subjects
1 = small or moderate chance of unblinding subjects
0 = not possible, or not mentioned (unless double‐blind), or possible but not done

i. Were the treatment providers blind to assignment status?
2 = effective action taken to blind treatment providers
1 = small or moderate chance of unblinding of treatment providers
0 = not possible, or not mentioned (unless double‐blind), or possible but not done

j. Was follow‐up active and appropriate?
2 = optimal
1 = adequate
0 = not defined or not adequate

k. Was the overall duration of surveillance clinically appropriate?
2 = optimal (six months or more)
1 = adequate (one up to six months)
0 = not defined, or not adequate

Table 1. Quality assessment items

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Comparison 1. Multinutrient supplement (oral or nasogastric routes, or both) versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality by end of study Show forest plot	11	674	Risk Ratio (M‐H, Fixed, 99% CI)	0.91 [0.59, 1.40]

1.1 Oral supplement	7	337	Risk Ratio (M‐H, Fixed, 99% CI)	0.89 [0.47, 1.68]
1.2 Nasogastric tube feeding	3	280	Risk Ratio (M‐H, Fixed, 99% CI)	0.99 [0.50, 1.97]
1.3 Nasogastric tube feeding and oral supplement	1	57	Risk Ratio (M‐H, Fixed, 99% CI)	0.74 [0.23, 2.35]
2 Patients with complications at end of study Show forest plot	7	284	Risk Ratio (M‐H, Fixed, 99% CI)	0.85 [0.64, 1.13]

2.1 Oral supplement	5	209	Risk Ratio (M‐H, Fixed, 99% CI)	0.61 [0.36, 1.03]
2.2 Nasogastric tube feeding	1	18	Risk Ratio (M‐H, Fixed, 99% CI)	1.09 [0.73, 1.64]
2.3 Nasogastric tube feeding and oral supplement	1	57	Risk Ratio (M‐H, Fixed, 99% CI)	1.11 [0.75, 1.65]
3 Unfavourable outcome (death or complications) at end of study Show forest plot	3	139	Risk Ratio (M‐H, Fixed, 99% CI)	0.52 [0.32, 0.84]

3.1 Oral supplement	3	139	Risk Ratio (M‐H, Fixed, 99% CI)	0.52 [0.32, 0.84]
3.2 Nasogastric tube feeding	0	0	Risk Ratio (M‐H, Fixed, 99% CI)	0.0 [0.0, 0.0]
3.3 Nasogastric tube feeding and oral supplement	0	0	Risk Ratio (M‐H, Fixed, 99% CI)	0.0 [0.0, 0.0]

Comparison 1. Multinutrient supplement (oral or nasogastric routes, or both) versus control

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Comparison 2. Multinutrient supplement (oral or nasogastric routes, or both) versus control (split by nutritional status)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality by end of study Show forest plot	11	674	Risk Ratio (M‐H, Fixed, 99% CI)	0.91 [0.59, 1.40]

1.1 Malnourished targeted	3	163	Risk Ratio (M‐H, Fixed, 99% CI)	0.61 [0.28, 1.34]
1.2 Malnourished not targeted	8	511	Risk Ratio (M‐H, Fixed, 99% CI)	1.08 [0.64, 1.83]
2 Patients with complications at end of study Show forest plot	7	284	Risk Ratio (M‐H, Fixed, 99% CI)	0.85 [0.64, 1.13]

2.1 Malnourished targeted	1	29	Risk Ratio (M‐H, Fixed, 99% CI)	0.59 [0.23, 1.49]
2.2 Malnourished not targeted	6	255	Risk Ratio (M‐H, Fixed, 99% CI)	0.89 [0.66, 1.20]
3 Unfavourable outcome (death or complications) at end of study Show forest plot	3	139	Risk Ratio (M‐H, Fixed, 99% CI)	0.52 [0.32, 0.84]

3.1 Malnourished targeted	1	29	Risk Ratio (M‐H, Fixed, 99% CI)	0.47 [0.17, 1.31]
3.2 Malnourished not targeted	2	110	Risk Ratio (M‐H, Fixed, 99% CI)	0.54 [0.32, 0.92]

Comparison 2. Multinutrient supplement (oral or nasogastric routes, or both) versus control (split by nutritional status)

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Comparison 3. Multinutrient supplement (oral or nasogastric routes, or both) versus control (by allocation concealment)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality by end of study (concealed? = yes; unknown; no) Show forest plot	11	674	Risk Ratio (M‐H, Fixed, 99% CI)	0.91 [0.59, 1.40]

1.1 Allocation concealed	3	106	Risk Ratio (M‐H, Fixed, 99% CI)	0.44 [0.19, 1.02]
1.2 Uncertain if allocation concealed	5	327	Risk Ratio (M‐H, Fixed, 99% CI)	1.66 [0.83, 3.31]
1.3 Allocation not concealed (quasi‐randomised)	3	241	Risk Ratio (M‐H, Fixed, 99% CI)	0.78 [0.34, 1.79]

Comparison 3. Multinutrient supplement (oral or nasogastric routes, or both) versus control (by allocation concealment)

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Comparison 4. High protein containing supplement versus low protein or non‐protein containing supplement

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality by end of study Show forest plot	4	361	Risk Ratio (M‐H, Fixed, 99% CI)	1.42 [0.85, 2.37]

1.1 Protein containing supplement v non‐protein containing supplement	3	315	Risk Ratio (M‐H, Fixed, 99% CI)	1.38 [0.82, 2.34]
1.2 High protein containing supplement v low protein containing supplement	1	46	Risk Ratio (M‐H, Fixed, 99% CI)	2.18 [0.21, 22.42]
2 Unfavourable outcome (death or complications) at end of study Show forest plot	2	223	Risk Ratio (M‐H, Fixed, 99% CI)	0.78 [0.65, 0.95]

2.1 Protein containing supplement v non‐protein containing supplement	2	223	Risk Ratio (M‐H, Fixed, 99% CI)	0.78 [0.65, 0.95]
2.2 High protein containing supplement v low protein containing supplement	0	0	Risk Ratio (M‐H, Fixed, 99% CI)	0.0 [0.0, 0.0]

Comparison 4. High protein containing supplement versus low protein or non‐protein containing supplement

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Comparison 5. Thiamin (vitamin B1) and water soluble vitamins versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality by end of study Show forest plot	1		Risk Ratio (M‐H, Fixed, 99% CI)	Totals not selected

2 Patients with complications at end of study Show forest plot	1		Risk Ratio (M‐H, Fixed, 99% CI)	Totals not selected

Comparison 5. Thiamin (vitamin B1) and water soluble vitamins versus control

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Comparison 6. Vitamin D versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patients with complications at end of study Show forest plot	1		Risk Ratio (M‐H, Fixed, 99% CI)	Totals not selected

Comparison 6. Vitamin D versus control

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Comparison 7. Dietetic assistants versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality by end of study Show forest plot	1		Risk Ratio (M‐H, Fixed, 99% CI)	Totals not selected

2 Patients with complications at end of study Show forest plot	1		Risk Ratio (M‐H, Fixed, 99% CI)	Totals not selected

Comparison 7. Dietetic assistants versus usual care

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