Home exercise rehabilitation for frailty after hospital discharge: the HERO trial

The HERO trial (Health Technology Assessment 30(4):1-40; PMID 41557460) is the largest NIHR-funded randomised controlled trial of community rehabilitation for frailty to date. Across 15 NHS sites, 740 older adults with moderate to severe frailty (Clinical Frailty Scale 5–7) following hospital discharge were randomised to a 24-week therapist-delivered home exercise programme or usual care. The primary outcome was physical health-related quality of life measured by the SF-36 Physical Component Summary at 12 months. The trial found no statistically significant improvement: adjusted mean difference −0.22 (95% CI −1.47 to 1.03; p=0.73). The economic analysis returned an incremental cost-effectiveness ratio of £58,375 per quality-adjusted life year, well above the conventional NICE threshold of £20,000–£30,000.

A secondary hospitalisation signal warrants attention: the intervention group showed a borderline higher rate of re-hospitalisation (incidence rate ratio 1.12; p=0.05). The trial’s process evaluation found high fidelity to the intervention protocol — the exercise programme was delivered as designed. The investigators conclude that the null result reflects a limitation of the model’s design rather than its delivery: a standardised post-discharge exercise programme, applied uniformly to a heterogeneous frailty population, does not produce measurable population-level gains in physical quality of life.

This finding sits alongside a concurrent Japanese multicentre retrospective cohort study (Umegaki et al., PMID 42105048) validating a four-item bedside risk score for hospital-associated disability in older adults. The score — based on routine admission data — achieved an AUC of 0.796 across the validation cohort. Taken together, these two studies illustrate a complementary direction: where uniform post-discharge exercise programmes do not demonstrate benefit at the population level, validated admission-based stratification tools may enable more precise targeting of rehabilitation resource to those most likely to benefit.

The clinical practice implication is specific. The HERO trial does not argue against rehabilitation for frail older adults; it argues against undifferentiated delivery. Objective functional measurement at admission — to identify patients at highest risk of hospital-associated disability and to define rehabilitation goals — becomes the necessary prerequisite before community rehabilitation models can be expected to move the needle on health-related quality of life. Services that cannot yet stratify by functional trajectory should treat the HERO result as an active prompt to build that capability, not as evidence against rehabilitation itself.