***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: A r and omized controlled trial was performed to examine the cost-effectiveness of external hip protectors in the prevention of hip fractures . Since the hip protectors were not effective in preventing hip fractures in our study , the main objective became to examine whether the use of hip protectors results in lower average costs per participant in the  hip protector group as compared with the control group . In addition , the average costs of a hip fracture and subsequent rehabilitation in frail , institutionalized elderly were calculated . Residents from apartment houses for the elderly , homes for the elderly and nursing homes with a high risk for hip fractures were r and omized to the hip protector group ( n=276 ) or control group ( n=285 ) . Costs were calculated for the hip fracture and subsequent rehabilitation until 1 year after the fracture . Six months after each hip fracture , a nurse was interviewed and after 12 months , a question naire was sent to the general practitioner or nursing home physician to determine the utilization of health care re sources . Differences in costs between the groups were analyzed using non-parametric bootstrapping . Eighteen hip fractures occurred in the intervention group and 20 hip fractures ( in 19 persons ) in the control group ( log rank P-value=0.86 ) . The average costs per participant , including the costs of the intervention , were € 913 in the intervention group and € 502 in the control group ( cost difference of € −411 ; 95 % confidence interval : −723 ; 57 ) . The average costs of a hip fracture and subsequent rehabilitation were € 8100 ( 95 % CI : 6716–10,010 ) . The use of hip protectors was not associated with lower costs . In addition , the average costs of a hip fracture and subsequent rehabilitation in the first year after the fracture were estimated at € 8100 in institutionalized elderly Abstract Objective To assess the effectiveness of a targeted , multiple intervention falls prevention programme in reducing falls and injuries related to falls in a subacute hospital . Design R and omised controlled trial of a targeted multiple intervention programme implemented in addition to usual care compared with usual care alone . Setting Three subacute wards in a metropolitan hospital specialising in rehabilitation and care of elderly patients . Participants 626 men and women aged 38 to 99 years ( average 80 years ) were recruited from consecutive admissions to subacute hospital wards . Intervention Falls risk alert card with information brochure , exercise programme , education programme , and hip protectors . Main outcome measures Incidence rate of falls , injuries related to falls , and proportion of participants who experienced one or more falls during their stay in hospital . Results Participants in the intervention group ( n = 310 ) experienced 30 % fewer falls than participants in the control group ( n = 316 ) . This difference was significant ( Peto log rank test P = 0.045 ) and was most obvious after 45 days of observation . In the intervention group there was a trend for a reduction in the proportion of participants who experienced falls ( relative risk 0.78 , 95 % confidence interval 0.56 to 1.06 ) and 28 % fewer falls result ed in injury ( log rank test P = 0.20 ) . Conclusions A targeted multiple intervention falls prevention programme reduces the incidence of falls in the subacute hospital setting Background Nearly 340,000 hip fractures occur each year in the U.S. With current demographic trends , the number of hip fractures is expected to double at least in the next 40 years . Purpose The Hip Impact Protection Project ( HIP PRO ) was design ed to investigate the efficacy and safety of hip protectors in an elderly nursing home population . This paper describes the innovative clustered matched-pair research design used in HIP PRO to overcome the inherent limitations of clustered r and omization . Methods Three clinical centers recruited 37 nursing homes to participate in HIP PRO . They were r and omized so that the participating residents in that home received hip protectors for either the right or left hip . Informed consent was obtained from either the resident or the resident 's responsible party . The target sample size was 580 residents with replacement if they dropped out , had a hip fracture , or died . One of the advantages of the HIP PRO study design was that each resident was his/her own case and control , eliminating imbalances , and there was no confusion over which residents wore pads ( or on which hip ) . Limitations Generalizability of the findings may be limited . Adherence was higher in this study than in other studies because of : ( 1 ) the use of a run-in period , ( 2 ) staff incentives , and ( 3 ) the frequency of adherence assessment s. The use of a single pad is not analogous to pad use in the real world and may have caused unanticipated changes in behavior . Fall assessment was not feasible , limiting the ability to analyze fractures as a function of falls . Finally , hip protector design s continue to evolve so that the results generated using this pad may not be applicable to other pad design s. However , information about factors related to adherence will be useful for future studies . Conclusions The clustered matched-pair study design avoided the major problem with previous cluster-r and omized investigations of this question — unbalanced risk factors between the experimental group and the control group . Because each resident served as his/her own control , the effects of unbalanced risk factors on treatment effect were virtually eliminated . In addition , the use of frequent adherence assessment s allowed us to study the effect of various demographic and environmental factors on adherence , which was vital for the assessment of efficacy . Clinical Trials 2008 ; 5 : 347—355 . OBJECTIVES To investigate the effect of use of external hip protectors on occurrence of  hip fracture . DESIGN R and omized controlled trial , with r and omization at the individual level . SETTING residential aged-care facilities in urban areas of New South Wales , Australia . PARTICIPANTS 174 women , aged 75 years and older , who had had two or more falls or one fall requiring hospital admission in the previous 3 months , and who lived in hostels or nursing homes . Eighty-six subjects were in the intervention group and 88 in the control group . INTERVENTION Use of external hip protectors and encouragement by nurses to use the protectors . MEASUREMENTS Follow-up visits at approximately 2 weeks and 2 , 10 and 18 months to determine falls and fall injury ( including hip fracture ) ; we also measured adherence to hip protector use . RESULTS The mean age of participants was 85 ; they lived in 32 different aged-care facilities , two-thirds of which were nursing homes . Intervention and control groups had similar baseline characteristics , with a mean Barthel index of 58 at enrollment and a mean Short Portable Mental Status Question naire score of six errors , indicating severe disability and major cognitive impairment . During follow-up , a mean of 4.6 falls per person occurred . There was no difference in mortality , with 28 deaths in each group . Eight hip fractures occurred in the intervention group and seven in the control group ( hazard ratio 1.46 ; 95 % confidence interval 0.53 - 4.51 ) . No hip fractures occurred when hip protectors were being worn as directed . Adherence was about 57 % over the duration of the study and hip protectors were worn at the time of 54 % of falls in the intervention group . Adherence varied markedly between institutions , but the greatest was about 80 % . CONCLUSION Hip protectors were not effective in reducing the incidence of hip fractures in this study , but because of low statistical power , a reduction in risk of hip fracture of up to 50 % may not have been detected . There was limited adherence with their use , result ing in a large number of falls occurring without hip protectors in place . All hip fractures in the intervention group occurred when hip protectors were not being used Abstract : A method to protect the hips during falls could effectively reduce the incidence of  hip fractures . We report the results of the first hip protector  trial in Japan , performed between July 1996 , and September 1999 . One hundred and sixty-four elderly female residents of nursing homes , with Activities of Daily Living above the wheelchair level , agreed to participate in this study . Among them , 88 were r and omly selected to wear a hip protector and 76 controls did not .  All falls and result ing injuries were recorded daily . In anthropometric measurements and ultrasonic bone evaluation , no significant differences were found between the two groups , except in height . During an average of 377 days , the wearers and the non-wearers fell a total of 131 and 90 times , respectively . Among the wearers , there were two non-hip fractures and one hip fracture , so the annual hip fracture rate was calculated at 1.2 % , against 8 hip fractures among the non-wearers , or 9.7 % per year . The hip fracture rate was significantly lower among the wearers than non-wearers , while the annual number of falls per subject and the distribution of fallers remained the same . According to Cox ’s proportional hazard regression analysis , the effect of the hip protector on hip fracture prevention was independent of anthropometric data , ultrasonic bone assessment values or number of falls . Moreover , even after limiting the subjects to fallers only , the annual hip fracture rate in non-wearers was higher than in wearers ( 19.8 % vs 2.0 % ) and the annual hip fracture rate per fall in wearers was lower than that in non-wearers ( 0.8 % vs 8.2 % ) . It was thus concluded that the hip protector is a beneficial device for the prevention of hip fractures OBJECTIVES To evaluate the effectiveness of a multifaceted , nonpharmaceutical intervention on incidence of falls and fallers . DESIGN Prospect i ve , cluster-r and omized , controlled 12-month trial . SETTING Six community nursing homes in Germany . PARTICIPANTS Long-stay residents ( n = 981 ) aged 60 and older ; mean age 85 ; 79 % female . INTERVENTIONS Staff and resident education on fall prevention , advice on environmental adaptations , progressive balance and resistance training , and hip protectors . MEASUREMENTS Falls , fallers , and fractures . RESULTS The incidence density rate of falls per 1,000 resident years ( RY ) was 2,558 for the control group ( CG ) and 1,399 for the intervention group ( IG ) ( relative risk ( RR ) = 0.55 , 95 % confidence interval ( CI ) = 0.41 - 0.73 ) . Two hundred forty-seven ( 52.3 % ) fallers were detected in the CG and 188 ( 36.9 % ) in the IG ( RR = 0.75 , 95 % CI = 0.57 - 0.98 ) . The incidence density rate of frequent fallers ( > 2/year ) was 115 ( 24.4 % ) for the CG and 66 ( 13.0 % ) for the IG ( RR = 0.56 , 95 % CI = 0.35 - 0.89 ) . The incidence density rate of hip fractures per 1,000 RY was 39 for the CG and 43 for the IG ( RR = 1.11 , 95 % CI = 0.49 - 2.51 ) . Other fractures were diagnosed with an incidence density rate of 52 per 1,000 RY for CG and 41 per 1,000 RY for IG ( RR = 0.78 , 95 % CI = 0.57 - 1.07 ) . CONCLUSION The incidence density rate of falls and fallers differed considerably between the control and intervention groups . The study was underpowered to demonstrate a significant difference of hip or nonhip fractures . Because of a low fracture rate in both groups , the investigation of fracture rates would have required a larger sample size to detect an effect of the intervention Summary For people at high risk of hip fracture living in community setting s , providing hip protectors at no cost increased adherence , but the additional effect of an educational programme was limited . Overall , the level of adherence was modest . Introduction The objective of the study was to increase adherence with hip protector use by older people at high risk of hip fracture . The study included two r and omised controlled trials with 308 older people recruited from three hospital rehabilitation wards and 171 older people recruited from the community . Methods Participants were r and omised into three groups . The control group received a brochure about hip protectors . The no cost group were fitted with free hip protectors and asked to use them . The combined group received free hip protectors and education sessions about their use .  Adherence with the use of hip protectors at 3 and 6 months after recruitment was measured . Secondary outcomes were falls , fractures and hospitalisations . Results Very few participants in the two control groups bought a hip protector . Overall adherence in the four intervention groups was modest , but higher in the community recruitment setting ( 49 % ) than in the hospital recruitment setting ( 36 % ) at 6 months . In the community recruitment group , at 3 months of follow-up , a significantly higher number of participants in the combined group ( 62 % ) were wearing hip protectors compared to the no cost group ( 43 % , p = 0.04 ) . Five hip fractures occurred during the study , with four sustained whilst not wearing the hip protectors . Conclusion Providing hip protectors at no cost to community living older people at high risk of hip fractures modestly increases initial acceptance and adherence with hip protector use . Additional education may further increase hip protector use in people living in the community in the short term Summary A comparison between soft- and hard-shelled hip protectors in nursing homes shows no clinical relevant difference in acceptance and probability of continued use . However , significantly more users of the soft hip protector used the 
    Output:
    
Hip protectors probably reduce the risk of hip fractures if made available to older people in nursing care or residential care setting s , without increasing the frequency of falls .
However , hip protectors may slightly increase the small risk of pelvic fractures .