Extended home exercise after acute admission does not improve quality of life in older people with frailty, HERO trial finds

Prescott et al. (Health Technology Assessment; PMID 41557460) report the HERO trial: a pragmatic, multicentre, individually randomised controlled superiority trial of extended rehabilitation for older people with frailty, with economic and process evaluations. Across 15 sites, 740 participants aged 65 and over with mild-to-severe frailty (Clinical Frailty Scale 5–7), discharged home after an acute admission with illness or injury, were randomised 1.28:1 to a 24-week home-based, manualised, progressive exercise programme delivered by NHS therapists, or to usual care. The primary outcome — physical health-related quality of life (modified SF-36 physical component score) at 12 months — showed no evidence of benefit: adjusted mean difference −0.22 (95% confidence interval −1.47 to 1.03; p=0.73). The economic analysis found an incremental cost of £1,401 per participant and a 0.024 quality-adjusted life-year gain, an incremental cost-effectiveness ratio of £58,375. The authors do not recommend routine commissioning of extended rehabilitation on this model. [Primary Study]

The null result is not explained away by poor delivery. The embedded process evaluation found the intervention was largely delivered as intended and acceptable to most participants, and over half of participants completed more than 75% of prescribed exercises — although fewer than half (45.9%) completed the full 24 weeks, and 64.7% of the trial completed 12-month follow-up. Recruitment spanned the COVID-19 pandemic; the authors report that analyses accounting for this detected no difference in primary or secondary outcomes. One secondary finding ran the other way — some evidence of a higher all-cause hospitalisation rate in the control arm (incidence rate ratio 1.12, 95% confidence interval 1.00 to 1.25; p=0.05) — but no other outcome differed. A well-designed programme, delivered broadly as intended, did not move the outcome it was built to move.

Read against this register’s pattern VF-P1 — earlier specialist input produces better outcomes — HERO marks the pattern’s boundary rather than a contradiction of it. The trial tested input extended later: more therapist-delivered exercise, added downstream of the acute episode, after discharge. The pattern’s converse — that more input later in the pathway also pays — is exactly what this trial fails to support in this population. It also sits in deliberate tension with the recent systematic review evidence that activity- and exercise-based home rehabilitation improves daily function in community-dwelling older adults with low physical performance: different population (HERO’s participants were recruited at the frailest, post-acute end), different question (extended rehabilitation as a discharge follow-on, not home rehabilitation per se). Both can be true, and the space between them is the finding. Through the value-added time lens, HERO is a caution against equating contact time with value: twenty-four weeks of skilled therapist time per participant, delivered largely as designed, produced no measurable gain in how patients experienced their physical health. Where rehabilitation time lands in the pathway — and what model it serves — appears to matter more than how much of it there is. The authors’ own direction for future work points the same way: organise core intermediate care and community rehabilitation so that older people feel ready for discharge and are enabled to maintain independence, rather than extending standalone exercise programmes beyond them.