Exercise for acutely hospitalised older medical patients

Natalie de Morton; Jennifer L Keating; Kim Jeffs

doi:10.1002/14651858.CD005955.pub2

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Figure 1

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Analysis 1.1

Comparison 1 Function ‐ multidisciplinary intervention versus usual care, Outcome 1 Maintained or improved ADL scores between hospital admission and discharge ‐ MDI versus usual care.

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Analysis 1.2

Comparison 1 Function ‐ multidisciplinary intervention versus usual care, Outcome 2 Maintained or improved mobility scores between hospital admission and discharge ‐ MDI versus usual care.

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Analysis 1.3

Comparison 1 Function ‐ multidisciplinary intervention versus usual care, Outcome 3 Maintained or improved ADL scores between 2 weeks prior to hospital admission and discharge‐ MDI v usual care.

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Analysis 2.1

Comparison 2 Function ‐ additional exercise only versus usual care, Outcome 1 Change in Barthel Index between hospital admission and discharge ‐ additional exercise versus usual care.

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Analysis 2.2

Comparison 2 Function ‐ additional exercise only versus usual care, Outcome 2 Change in TUG scores between hospital admission and discharge ‐ additional exercise versus usual care.

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Analysis 3.1

Comparison 3 Adverse events ‐ multidisciplinary intervention versus usual care, Outcome 1 Patient mortality during hospitalisation ‐ MDI versus usual care.

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Analysis 3.2

Comparison 3 Adverse events ‐ multidisciplinary intervention versus usual care, Outcome 2 Patient mortality 3 months after hospital discharge ‐ MDI versus usual care.

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Analysis 3.3

Comparison 3 Adverse events ‐ multidisciplinary intervention versus usual care, Outcome 3 Patient complications during hospitalisation ‐ MDI versus usual care.

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Analysis 4.1

Comparison 4 Adverse events ‐ additional exercise versus usual care, Outcome 1 Patient mortality during hospitalisation ‐ additional exercise versus usual care.

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Analysis 4.2

Comparison 4 Adverse events ‐ additional exercise versus usual care, Outcome 2 Admission to the Intensive Care Unit (ICU) ‐ additional exercise versus usual care.

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Analysis 4.3

Comparison 4 Adverse events ‐ additional exercise versus usual care, Outcome 3 Falls during hospitalisation ‐ additional exercise versus usual care.

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Analysis 5.1

Comparison 5 Hospital outcomes ‐ multidisciplinary intervention versus usual care, Outcome 1 Discharge to preadmission residence/home from hospital ‐ MDI versus usual care.

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Analysis 5.2

Comparison 5 Hospital outcomes ‐ multidisciplinary intervention versus usual care, Outcome 2 Acute hospital length of stay ‐ MDI versus usual care.

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Analysis 5.3

Comparison 5 Hospital outcomes ‐ multidisciplinary intervention versus usual care, Outcome 3 Cost of acute hospital stay ‐ MDI versus usual care.

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Analysis 6.1

Comparison 6 Hospital outcomes ‐ additional exercise versus usual care, Outcome 1 Discharge to preadmission residence/home from hospital ‐ additional exercise versus usual care.

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Analysis 6.2

Comparison 6 Hospital outcomes ‐ additional exercise versus usual care, Outcome 2 Acute hospital length of stay ‐ additional exercise versus usual care.

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Analysis 6.3

Comparison 6 Hospital outcomes ‐ additional exercise versus usual care, Outcome 3 Total (acute plus subacute) hospital length of stay‐ additional exercise versus usual care.

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Table 1. Clinical relevance table for dichtomous outcomes

Outcome	Comparison	#patients (#trials)	Control event rate	ARD (95%CI), %	Wt Rel % change	NNT (95% CI)	Statistically sig	Quality of evidence
Maintain or improve ADL scores between admission and discharge	MDI v UC ‐ function	2271 (3)	901/1111 (82.0%)	0.05 (‐0.03, 0.12) , 5%	5% (I)	NA	Not statistically significant	Silver
Maintain or improve mobility scores between admission and discharge	MDI v UC ‐ function	2119 (3)	894/1032 (86.6%)	0.03 (0.00, 0.06), 3%	3% (I)	NA	Not statistically significant	Silver
Maintain or improve ADL scores between 2 weeks prior to hospital admission and discharge	MDI v UC ‐ function	2001 (2)	648/990 (65.5%)	0.04 (0.00, 0.04), 4%	7% (I)	NA	Not statistically significant	Silver
Mortality during hospitalisation	MDI v UC ‐ adverse events	3552 (6)	102/1910 (5.3%)	0.00 (‐0.03, 0.03), 0%	1% (I)	NA	Not statistically significant	Silver
Mortality 3 months after hospital discharge	MDI v UC ‐ adverse events	2595 (3)	214/1311 (16.3%)	0.00 (‐0.03, 0.03), 0%	1% (I)	NA	Not statistically significant	Silver
Complications during hospitalisation	MDI v UC ‐ adverse events	550 (2)	88/372 (23.7%)	‐0.01 (‐0.09, 0.06), ‐1%	6% (I)	NA	Not statistically significant	Silver
Mortality during hospitalisation	Exercise only versus UC ‐ adverse events	696 (3)	4/357 (1.1%)	0.01 (‐0.01, 0.03), 1%	98% (W)	NA	Not statistically significant	Silver
Admission to ICU during hospitalisation	Exercise only versus UC ‐ adverse events	396 (2)	4/206 (1.9%)	0.01 (‐0.07, 0.09), 1%	6% (W)	NA	Not statistically significant	Silver
Falls during hospitalisation	Exercise only versus UC ‐ adverse events	384 (2)	7/203 (3.5%)	0.00 (‐0.04, 0.04), 0%	12% (W)	NA	Not statistically significant	Silver
Discharge to preadmission residence/home	MDI v UC ‐ hospital outcomes	1675 (4)	739/980 (75.4%)	0.06 (0.02, 0.10), 6%, 6 more patients out of 100	8% (I)	16 (11, 43)	Statistically significant	Silver
Discharge to preadmisison residence/home	Exercise only versus UC ‐ hospital outcomes	380 (2)	131/201 (65.2%)	0.08 (‐0.10, 0.26), 8%	15% (I)	NA	Not statistically significant	Silver
Legend: ADL=activities of daily living; ICU=intensive care unit	MDI=multidisciplinary intervention; UC=usual care			ARD=absolute risk difference	Wt Rel=weighted relative change	NNT=number needed to treat	sig=significant

Table 1. Clinical relevance table for dichtomous outcomes

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Table 2. Clinical Relevance Table for continuous outcomes (using the same scale)

Outcome (scale)	#patients (#trials)	Control baseline m	Wt absolute change	Relative % change	NNT	Statistical sig	Quality of evidence
Change in TUG score (seconds)‐ additional exercise versus usual care	188 (2)	20.59 (de Morton et al.)	‐2.52 seconds	2.52/20.59 = 0.12 = 12%	NA	Not statistically significant	Silver
Acute hospital LOS ‐ MDI versus usual care	3478 (6)	6.3 days (Counsell et al.)	‐1.08 days	1.08/6.3 = 0.17 = 17%	16	Significant	Silver
Cost of acute hospital stay ‐ MDI versus usual care	3241 (5)	0	‐$278.65	NA	26	Significant	Silver
Acute hospital LOS ‐ additional exercise versus usual care	680 (3)	6.0 (de Morton et al.)	0.01	0.01/6.0 = 0.002 =0.2%	NA	Not statistically significant	Silver
Total LOS (acute plus subacute)‐ additional exercise versus usual care	380 (2)	6.0 (de Morton et al.)	‐0.70 days	0.70/6.0 = 0.12 = 12%	NA	Not statistically significant	Silver
Legend: TUG=timed up and go test; LOS=length of stay; MDI=multidisciplinary intervention		m=mean	Wt=weighted		NNT=number needed to treat	sig=signficant

Table 2. Clinical Relevance Table for continuous outcomes (using the same scale)

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Table 3. Clinical Relevance Table for continuous outcomes (using different scale)

Outcome (scale)	# patients (#trials)	Control baseline m	Wt absolute change	Relative % change	NNT	Statistical sig	Quality of evidence
Barthel Index (original and modified versions, scale range 0‐100) ‐ additional exercise versus usual care	293 (2)	68.09 (de Morton et al.)	0.17 x 26.08 = 4.43. This represents 4.45 more points on a 100 point Barthel Index scale.	4.43/68.09 = 0.06 = 6%	NA	Not statistically significant	Silver
Legend:		m=mean	wt=weighted		NNT=number needed to treat	sig=significant

Table 3. Clinical Relevance Table for continuous outcomes (using different scale)

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Comparison 1. Function ‐ multidisciplinary intervention versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maintained or improved ADL scores between hospital admission and discharge ‐ MDI versus usual care Show forest plot	3	2271	Risk Ratio (M‐H, Random, 95% CI)	1.05 [0.97, 1.15]

2 Maintained or improved mobility scores between hospital admission and discharge ‐ MDI versus usual care Show forest plot	3	2119	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.99, 1.06]

3 Maintained or improved ADL scores between 2 weeks prior to hospital admission and discharge‐ MDI v usual care Show forest plot	2	2001	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [1.00, 1.13]

Comparison 1. Function ‐ multidisciplinary intervention versus usual care

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Comparison 2. Function ‐ additional exercise only versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Change in Barthel Index between hospital admission and discharge ‐ additional exercise versus usual care Show forest plot	2	293	Std. Mean Difference (IV, Fixed, 95% CI)	0.17 [‐0.06, 0.40]

2 Change in TUG scores between hospital admission and discharge ‐ additional exercise versus usual care Show forest plot	2	188	Mean Difference (IV, Random, 95% CI)	‐2.52 [‐5.75, 0.71]

Comparison 2. Function ‐ additional exercise only versus usual care

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Comparison 3. Adverse events ‐ multidisciplinary intervention versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patient mortality during hospitalisation ‐ MDI versus usual care Show forest plot	6	3552	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.59, 1.64]

2 Patient mortality 3 months after hospital discharge ‐ MDI versus usual care Show forest plot	3	2595	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.83, 1.17]

3 Patient complications during hospitalisation ‐ MDI versus usual care Show forest plot	2	550	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.68, 1.29]

Comparison 3. Adverse events ‐ multidisciplinary intervention versus usual care

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Comparison 4. Adverse events ‐ additional exercise versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Patient mortality during hospitalisation ‐ additional exercise versus usual care Show forest plot	3	696	Risk Ratio (M‐H, Fixed, 95% CI)	1.98 [0.64, 6.18]

2 Admission to the Intensive Care Unit (ICU) ‐ additional exercise versus usual care Show forest plot	2	396	Risk Ratio (M‐H, Random, 95% CI)	1.06 [0.04, 30.44]

3 Falls during hospitalisation ‐ additional exercise versus usual care Show forest plot	2	384	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.40, 3.15]

Comparison 4. Adverse events ‐ additional exercise versus usual care

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Comparison 5. Hospital outcomes ‐ multidisciplinary intervention versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discharge to preadmission residence/home from hospital ‐ MDI versus usual care Show forest plot	4	1675	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [1.03, 1.14]

2 Acute hospital length of stay ‐ MDI versus usual care Show forest plot	6	3478	Mean Difference (IV, Random, 95% CI)	‐1.08 [‐1.93, ‐0.22]

3 Cost of acute hospital stay ‐ MDI versus usual care Show forest plot	5	3241	Mean Difference (IV, Fixed, 95% CI)	‐278.65 [‐491.85, ‐65.44]

Comparison 5. Hospital outcomes ‐ multidisciplinary intervention versus usual care

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Comparison 6. Hospital outcomes ‐ additional exercise versus usual care

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Discharge to preadmission residence/home from hospital ‐ additional exercise versus usual care Show forest plot	2	380	Risk Ratio (M‐H, Random, 95% CI)	1.15 [0.80, 1.66]

2 Acute hospital length of stay ‐ additional exercise versus usual care Show forest plot	3	680	Mean Difference (IV, Random, 95% CI)	0.01 [‐1.23, 1.26]

3 Total (acute plus subacute) hospital length of stay‐ additional exercise versus usual care Show forest plot	2	380	Mean Difference (IV, Random, 95% CI)	‐0.70 [‐2.58, 1.17]

Comparison 6. Hospital outcomes ‐ additional exercise versus usual care

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