Xiong Ribo, Xie Fengjiao, Wen Shuang
Department of Rehabilitation, The Seventh Affiliated Hospital of Southern Medical University, Foshan, China.
Department of General Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China.
Trials. 2025 Aug 27;26(1):316. doi: 10.1186/s13063-025-09070-8.
Patients with osteoporotic fracture (OF) after discharge to home represent a vulnerable population who are susceptible to adverse events as a result of a poorly designed healthcare system in China. Transitional care (TC) has been proved to be effective in addressing fragmented care and preventing adverse outcomes, but the definitive description of TC that was used successfully in the real world for this group has not been formed in China.
The aim of this study was to evaluate the effect of a 24-week TC program on health outcomes in patients with OF.
It was a randomized controlled trial. Patients in the intervention group received ongoing rehabilitation both at the community healthcare centers and at home through a multidisciplinary team, while individuals in the control group received routine follow-up visits by primary healthcare physicians. Outcomes were measured by the Short-Form Health Survey-36 (SF-36), Modified Barthel Index (MBI), and Caregiver Strain Index (CSI) at 12 and 24 weeks, respectively.
A total of 74 participants were randomly assigned (intervention n = 37, control n = 37). Mean values of the Physical Components Summary (PCS), an integral component of SF-36, and MBI were significantly better in the intervention group at 24 weeks (F = 19.30, P = 0.000 and P = 21.24, P = 0.000, respectively). Mean values of the changes from the baseline to 24 weeks were significantly better in the intervention group regarding PCS (F = 36.13, P = 0.000) and MBI (F = 21.05, P = 0.000).
The TC program has been proven to be feasible and to improve functional performance when applied to patients with OF.
China Clinical Trials on May 28, 2022, with registration number ChiCTR220006032.
骨质疏松性骨折（OF）患者出院回家后属于弱势群体，由于中国医疗保健系统设计不完善，他们易发生不良事件。过渡性护理（TC）已被证明在解决碎片化护理和预防不良结局方面有效，但在中国尚未形成在现实世界中成功用于该群体的TC的确切描述。
本研究旨在评估一项为期24周的TC计划对OF患者健康结局的影响。
这是一项随机对照试验。干预组患者通过多学科团队在社区医疗中心和家中接受持续康复治疗，而对照组患者由初级保健医生进行常规随访。分别在第12周和第24周通过简明健康调查36项量表（SF-36）、改良巴氏指数（MBI）和照顾者负担指数（CSI）对结局进行测量。
共有74名参与者被随机分配（干预组n = 37，对照组n = 37）。在第24周时，干预组的SF-36的一个组成部分即生理健康总分（PCS）以及MBI的平均值显著更好（F分别为19.30，P = 0.000；P = 21.24，P = 0.000）。干预组从基线到24周的PCS（F = 36.13，P = 0.000）和MBI（F = 21.05，P = 0.000）变化平均值显著更好。
TC计划已被证明应用于OF患者时是可行的，并能改善功能表现。
于2022年5月28日在中国临床试验注册，注册号为ChiCTR220006032。
