The care of elderly patients with hip fracture. Changes since implementation of the prospective payment system

Characterizing pre-discharge interventions to reduce length of stay for older adults: A scoping review

BACKGROUND

Hospital pre-discharge interventions are becoming one of the leading strategies to promote early discharge. For older adult patients, it remains unclear what these interventions are and how they affect discharge outcomes.

OBJECTIVE

This scoping review categorizes pre-discharge interventions promoting early acute care hospital discharging or total hospital length of stay reductions among older adults, synthesizes contextual factors (e.g., cost, staffing) driving implementation, and assesses the perceived intervention's impact.

DESIGN

The review followed the five states of the Arksey and O'Malley framework and the PRISMA-ScR extension. The PubMed, Embase, and Scopus databases were searched from 1983 to 2020 for pre-discharge interventions designed or adapted to discharge older adults earlier in their stay from acute care hospitals. Potentially relevant articles were screened against eligibility criteria. Findings were extracted and collated in data charting forms followed by brief thematic analyses.

RESULTS

The search yielded 5,455 articles of which 91 articles were included. Eight pre-discharge intervention categories were identified: clinical management, diagnostic/risk assessment tools, staffing enhancements, drug administration, length of stay protocols, nutrition planning, and communication improvements. Leading motivations for intervention implementation included the nationwide drive to reduce care costs and hospitals' need to increase hospital profitability, improve quality of care, or optimize resource utilization. Discharge outcomes reported included hospitalization costs, readmission rates, mortality rates, resource utilization rates and costs, and length of stay. Mixed results were found regarding the effectiveness of early discharge interventions on discharge outcomes based on expressed author sentiment.

CONCLUSIONS

The drive for pre-discharge interventions that reduce older adult hospital stays and associated costs continues to stem primarily from economic and governmental policies. Follow-up studies may be required to emphasize patient perspectives and care trajectories to avoid unintentional costly and health-deteriorating consequences.

Peripheral Nerve Block Delays Mobility and Increases Length of Stay in Patients With Geriatric Hip Fracture

INTRODUCTION

Peripheral nerve blocks (PNB) has been increasingly used in the care of patients with geriatric hip fracture to reduce perioperative opiate use and the need for general anesthesia. However, the associated motor palsy may impair patients' ability to mobilize effectively after surgery and subsequently may increase latency to key mobility milestones postoperatively, as well as increase inpatient length of stay (LOS). The aim of this study was to investigate time-to-mobility milestones and length of hospital stay between peripheral, epidural, and general anesthesia.

METHODS

A retrospective review identified 1,351 patients aged 65 years or older who underwent surgery for hip fracture between 2012 and 2018 at a single academic health system. Patients were excluded if baseline nonambulatory, restricted weight-bearing postoperatively, or sustained concomitant injuries precluding mobilization, with a final cohort of 1,013 patients. Time-to-event analyses for discharge and mobility milestones were assessed using univariate Kaplan-Meier and multivariate Cox proportional hazard regression analyses.

RESULTS

PNB was associated with delayed postoperative time to ambulation ( P < 0.001) and time to out-of-bed ( P = 0.029), along with increased LOS ( P < 0.001). Epidural anesthesia was associated with less delay to first out-of-bed ( P = 0.002), less delay to ambulation ( P = 0.001), and overall reduced length of stay ( P < 0.001).

DISCUSSION

PNB was associated with slower mobilization and longer hospitalization while epidural anesthesia was associated with quicker mobilization and shorter hospital stays. Epidural anesthesia may be a preferable anesthesia choice in patients with geriatric hip fracture when possible.

LEVEL OF EVIDENCE

Level III.

Does prospective payment influence quality of care? A systematic review of the literature

In the light of rising health expenditures, the cost-efficient provision of high-quality inpatient care is on the agenda of policy-makers worldwide. In the last decades, prospective payment systems (PPS) for inpatient care were used as an instrument to contain costs and increase transparency of provided services. It is well documented in the literature that prospective payment has an impact on structure and processes of inpatient care. However, less is known about its effect on key outcome indicators of quality of care. In this systematic review, we synthesize evidence from studies investigating how financial incentives induced by PPS affect indicators of outcome quality domains of care, i.e. health status and user evaluation outcomes. We conduct a review of evidence published in English, German, French, Portuguese and Spanish language produced since 1983 and synthesize results of the studies narratively by comparing direction of effects and statistical significance of different PPS interventions. We included 64 studies, where 10 are of high, 18 of moderate and 36 of low quality. The most commonly observed PPS intervention is the introduction of per-case payment with prospectively set reimbursement rates. Abstracting evidence on mortality, readmission, complications, discharge disposition and discharge destination, we find the evidence to be inconclusive. Thus, claims that PPS either cause great harm or significantly improve the quality of care are not supported by our findings. Further, the results suggest that reductions of length of stay and shifting treatment to post-acute care facilities may occur in the course of PPS implementations. Accordingly, decision-makers should avoid low capacity in this area.

Differences in health care spending and utilization among older frail adults in high-income countries: ICCONIC hip fracture persona

OBJECTIVE

This study explores differences in spending and utilization of health care services for an older person with frailty before and after a hip fracture.

DATA SOURCES

We used individual-level patient data from five care settings.

STUDY DESIGN

We compared utilization and spending of an older person aged older than 65 years for 365 days before and after a hip fracture across 11 countries and five domains of care as follows: acute hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, and outpatient drugs. Utilization and spending were age and sex standardized..

DATA COLLECTION/EXTRACTION METHODS

The data were compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries as follows: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.

PRINCIPAL FINDINGS

The sample ranged from 1859 patients in Spain to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia. The majority of patients across countries were female. Relative to other countries, the United States had the lowest inpatient length of stay (11.3), but the highest number of days were spent in post-acute care rehab (100.7) and, on average, had more visits to specialist providers (6.8 per year) than primary care providers (4.0 per year). Across almost all sectors, the United States spent more per person than other countries per unit ($13,622 per hospitalization, $233 per primary care visit, $386 per MD specialist visit). Patients also had high expenditures in the year prior to the hip fracture, mostly concentrated in the inpatient setting.

CONCLUSION

Across 11 high-income countries, there is substantial variation in health care spending and utilization for an older person with frailty, both before and after a hip fracture. The United States is the most expensive country due to high prices and above average utilization of post-acute rehab care.

Post-acute Use of Opioids and Psychotropics in Patients after Hip Fracture: Unintended Consequences of Implementing Diagnosis-Related Grouping Payment

OBJECTIVE

How implementing diagnostic-related grouping (DRG) payment affected the use of opioids and psychotropics by hip fracture patients following hospitalization remained unknown.

DESIGN

A retrospective, pre-post design, cohort study of data excerpted from Taiwan's National Health Insurance Research database (NHIRD).

SETTING AND PARTICIPANTS

Adults aged ≥ 65 years first admitted for hip fracture surgery from 2007 to 2012 were identified and divided into two 1:1 propensity-score matched groups: pre-DRG (2007-2009); DRG (2010-2012).

MEASUREMENTS

The outcome measures were use of opioid and/or psychotropic drugs within 30 days, 90 days, 180 days, and 365 days after discharge.

RESULTS

Data of 16,522 subjects were excerpted, and 8,261 propensity-score matched subjects each classified into the pre-DRG and DRG groups. After adjustment, the DRG group was significantly more likely than the pre-DRG group to have used antipsychotics after discharge from hip fracture surgery (≤30 days, ≤90 days, ≤180 days and ≤365 days). The DRG group also had significantly higher prescription rates of benzodiazepines and antipsychotics during the observation period. Moreover, the DRG group was less likely to use non-steroidal anti-inflammatory drugs (≤30 days, ≤90 days, ≤180 days and ≤365 days) and more likely to use acetaminophen (≤30 days, ≤180 days, and ≤365 days).

CONCLUSIONS

In conclusion, DRG implementation in Taiwan substantially increased post-acute prescription of antipsychotic and psychotropic agents for hip fracture patients, and changed use of analgesics, which may result in suboptimal quality and safety for these patients. Further research is needed to evaluate the long-term outcomes of DRG implementation, and the potential benefits of appropriate post-acute care bundled with DRG payment.

Impact of bundled payments on hip fracture outcomes: a nationwide population-based study

Objective

Establishing one price for all bundled services for a particular illness, which has become the key to healthcare reform efforts, is designed to encourage health professionals to coordinate their care for patients. Limited information is available, however, concerning whether bundled payments are associated with changes in patient outcomes. Nationwide longitudinal population-based data were used to examine the effect of bundled payments on hip fracture outcomes.

Design

An interrupted time series design with a comparison group.

Setting

General acute care hospitals throughout Taiwan.

Participants

A total of 178 586 hip fracture patients admitted over the period 2007-12 identified from the Taiwan's National Health Insurance Research Database.

Intervention

Bundled payments for hip fractures were implemented in Taiwan in January 2010.

Main Outcome Measures

The 30-day unplanned readmission and postdischarge mortality. Segmented generalized estimating equation regression models were used after adjustment for trends, patient, physician and hospital characteristics to assess the effect of bundled payments on 30-day outcomes for hip fracture compared with a reference condition.

Results

The 30-day unplanned readmission rate for hip fracture showed a relative decreasing trend after the implementation of bundled payments compared with the trend before the implementation relative to that of the reference condition.

Conclusions

This finding might imply that the implementation of bundled payments encourages health professionals to coordinate their care, leading to reduced readmission for hip fracture.

First-dollar cost-sharing for skilled nursing facility care in medicare advantage plans

BACKGROUND

The initial days of a Medicare-covered skilled nursing facility (SNF) stay may have no cost-sharing or daily copayments depending on beneficiaries' enrollment in traditional Medicare or Medicare Advantage. Some policymakers have advocated imposing first-dollar cost-sharing to reduce post-acute expenditures. We examined the relationship between first-dollar cost-sharing for a SNF stay and use of inpatient and SNF services.

METHODS

We identified seven Medicare Advantage plans that introduced daily SNF copayments of $25-$150 in 2009 or 2010. Copays began on the first day of a SNF admission. We matched these plans to seven matched control plans that did not introduce first-dollar cost-sharing. In a difference-in-differences analysis, we compared changes in SNF and inpatient utilization for the 172,958 members of intervention and control plans.

RESULTS

In intervention plans the mean annual number of SNF days per 100 continuously enrolled inpatients decreased from 768.3 to 750.6 days when cost-sharing changes took effect. Control plans experienced a concurrent increase: 721.7 to 808.1 SNF days per 100 inpatients (adjusted difference-in-differences: -87.0 days [95% CI (-112.1,-61.9)]). In intervention plans, we observed no significant changes in the probability of any SNF service use or the number of inpatient days per hospitalized member relative to concurrent trends among control plans.

CONCLUSIONS

Among several strategies Medicare Advantage plans can employ to moderate SNF use, first-dollar SNF cost-sharing may be one influential factor.

TRIAL REGISTRATION

Not applicable.

Early Home Rehabilitation for the Patient with a Hip Fracture

This article is a report on the Peterborough hip fracture project, which is uniquely facilitated by the availability of the hospital at home service. It discusses the results of the first 44 months of the project and describes the role of the occupational therapist in this team approach to the management of the elderly patient with a broken hip.

New developments in hip fracture treatment

With current surgical and anaesthetic methods almost all hip fractures should be treated surgically. Delays to surgery continue to be reduced, although the optimum timing for surgery remains controversial. More intensive or specialized perioperative care, particularly for fluid resuscitation and analgesia, may improve outcome. Many of the implants used have not changed much over the last 50 years, but there have been considerable improvements in surgical technique. For intracapsular fractures there is little evidence to suggest that total hip replacements or bipolars have any advantage over the traditional hemiarthroplasties. For trochanteric fractures the sliding hip screw remains the implant of choice, although the newer intramedullary nails are valuable for more specific fracture types and their use will become more common. After surgery the majority of patients should be allowed to mobilize without any restrictions on weight bearing or hip movements. Optimum surgical rehabilitation should enable the majority of patients to be able to go home with hospital stays of less than two weeks.

Utilizing an integrated infrastructure for outcomes research: a systematic review

OBJECTIVE

To explore the ability of an integrated health information infrastructure to support outcomes research.

METHODS

A systematic review of articles published from 1983 to 2012 by Regenstrief Institute investigators using data from an integrated electronic health record infrastructure involving multiple provider organisations was performed. Articles were independently assessed and classified by study design, disease and other metadata including bibliometrics.

RESULTS

A total of 190 articles were identified. Diseases included cognitive, (16) cardiovascular, (16) infectious, (15) chronic illness (14) and cancer (12). Publications grew steadily (26 in the first decade vs. 100 in the last) as did the number of investigators (from 15 in 1983 to 62 in 2012). The proportion of articles involving non-Regenstrief authors also expanded from 54% in the first decade to 72% in the last decade. During this period, the infrastructure grew from a single health system into a health information exchange network covering more than 6 million patients. Analysis of journal and article metrics reveals high impact for clinical trials and comparative effectiveness research studies that utilised data available in the integrated infrastructure.

DISCUSSION

Integrated information infrastructures support growth in high quality observational studies and diverse collaboration consistent with the goals for the learning health system. More recent publications demonstrate growing external collaborations facilitated by greater access to the infrastructure and improved opportunities to study broader disease and health outcomes.

CONCLUSIONS

Integrated information infrastructures can stimulate learning from electronic data captured during routine clinical care but require time and collaboration to reach full potential.

The Impact of Certificate-of-Need Laws on Nursing Home and Home Health Care Expenditures

Over the past two decades, nursing homes and home health care agencies have been influenced by several Medicare and Medicaid policy changes including the adoption of prospective payment for Medicare-paid postacute care and Medicaid-paid long-term home and community-based care reforms. This article examines how spending growth in these sectors was affected by state certificate-of-need (CON) laws, which were designed to limit the growth of providers and have remained unchanged for several decades. Compared with states without CON laws, Medicare and Medicaid spending in states with CON laws grew faster for nursing home care and more slowly for home health care. In particular, we observed the slowest growth in community-based care in states with CON for both the nursing home and home health industries. Thus, controlling for other factors, public postacute and long-term care expenditures in CON states have become dominated by nursing homes.

Patient expectation is the most important predictor of discharge destination after primary total joint arthroplasty

The purpose of this study was to identify preoperative predictors of discharge destination after total joint arthroplasty. A retrospective study of three hundred and seventy-two consecutive patients who underwent primary total hip and knee arthroplasty was performed. The mean length of stay was 2.9 days and 29.0% of patients were discharged to extended care facilities. Age, caregiver support at home, and patient expectation of discharge destination were the only significant multivariable predictors regardless of the type of surgery (total knee versus total hip arthroplasty). Among those variables, patient expectation was the most important predictor (P < 0.001; OR 169.53). The study was adequately powered to analyze the variables in the multivariable logistic regression model, which had a high concordance index of 0.969.

Perioperative management of elderly patients

The older population only represents 13.7% of the US population but has grown by 21% since 2002. The centenarian population is growing at a faster rate than the total US population. This unprecedented growth has significantly increased surgical demand. The establishment of quality and performance improvement data has allowed researchers to focus attention on the older patient population, resulting in an exponential increase in studies. Although there is still much work to be done in this field, overlying themes regarding the perioperative management of elderly patients are presented in this article based on a thorough literature review.

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis

Background

Activity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care.

Methods

We undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication.

Results

Of 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk  = 1.24, 95% CI 1.18–1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences.

Conclusions

Transitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes.

Changes in frailty-related characteristics of the hip fracture population and their implications for healthcare services: evidence from Quebec, Canada

SUMMARY

This study provides evidence that a number of frailty-related characteristics (older age, de novo admission to long-term care (LTC), comorbidities [Charlson Index, osteoporosis, osteoporosis risk factors, sarcopenia risk factors, and dementia]) have increased in the hip fracture population from 2001-2008. This will have significant impact on community resources, as the number of people discharged to the community is also increasing.

INTRODUCTION

The aim of this study is to estimate secular changes in the prevalence of selected frailty-related characteristics among the hip fracture population in the Canadian province of Quebec (2001-2008) and the potential impact of these changes on healthcare services.

METHODS

The Quebec hospitalization database was used to identify nontraumatic hip fractures for the purposes of calculating age- and sex-specific rates. Also estimated were time trends for selected frailty-related characteristics and discharge destinations.

RESULTS

A significant decline in fracture rates was evident for all age groups except for those <65; sex differences were also observed. Almost all frailty-related characteristics increased over time, ranging from 2 to 14 % per year, which translates to an estimated increase from 16 to 112 %, over the study period. For those whose prior living arrangement was LTC, rates of hip fractures declined significantly (women OR = 0.93, 0.91-0.95; men OR = 0.97, 0.94-0.99). In-hospital mortality and discharge to inpatient rehabilitation decreased, while discharges back to community and to LTC increased.

CONCLUSIONS

Although hip fracture rates decreased for older hip fracture patients, the absolute number and prevalence of specific frailty-related characteristics increased. Policy makers should review care models to ensure that adequate resources are provided to the community to offset the expected increase in demand arising from ongoing changes in patients' characteristics.

Regional variation in acute care length of stay after orthopaedic surgery total joint replacement surgery and hip fracture surgery

OBJECTIVE

To examine change in regional variations in acute care length of stay (LOS) after orthopedic surgery following expiration of the New York (NY) State exemption to the Prospective Payment System and implementation of the Medicare Short Stay Transfer Policy.

METHODS

Time series analyses were conducted to evaluate change in LOS across regions after policy implementations. Small area analyses were conducted to examine residual variation in LOS. The dataset included A 100% sample of fee-for-service Medicare patients undergoing surgical repair for hip fracture or elective joint replacement surgery between 1996 and 2001. Data files from Centers for Medicare and Medicaid Services 1996-2001 Medicare Provider Analysis and Review file, 1999 Provider of Service file, and data from the 2000 United States Census were used for analysis.

RESULTS

In 1996, LOS in NY after orthopedic procedures was much longer than the remainder of the country. After policy changes, LOS fell. However, significant residual variation in LOS persisted. This residual variation was likely partly explained by differences variation in regional managed care market penetration, patient management practices and unmeasured characteristics associated with the hospital location.

CONCLUSIONS

NY hospitals responded to changes in reimbursement policy, reducing variation in LOS. However, even after 5 years of financial pressure to constrain costs, other factors still have a strong impact on delivery of patient care.

Impact of generic alendronate cost on the cost-effectiveness of osteoporosis screening and treatment

Introduction

Since alendronate became available in generic form in the Unites States in 2008, its price has been decreasing. The objective of this study was to investigate the impact of alendronate cost on the cost-effectiveness of osteoporosis screening and treatment in postmenopausal women.

Methods

Microsimulation cost-effectiveness model of osteoporosis screening and treatment for U.S. women age 65 and older. We assumed screening initiation at age 65 with central dual-energy x-ray absorptiometry (DXA), and alendronate treatment for individuals with osteoporosis; with a comparator of “no screening” and treatment only after fracture occurrence. We evaluated annual alendronate costs of $20 through $800; outcome measures included fractures; nursing home admission; medication adverse events; death; costs; quality-adjusted life-years (QALYs); and incremental cost-effectiveness ratios (ICERs) in 2010 U.S. dollars per QALY gained. A lifetime time horizon was used, and direct costs were included. Base-case and sensitivity analyses were performed.

Results

Base-case analysis results showed that at annual alendronate costs of $200 or less, osteoporosis screening followed by treatment was cost-saving, resulting in lower total costs than no screening as well as more QALYs (10.6 additional quality-adjusted life-days). When assuming alendronate costs of $400 through $800, screening and treatment resulted in greater lifetime costs than no screening but was highly cost-effective, with ICERs ranging from $714 per QALY gained through $13,902 per QALY gained. Probabilistic sensitivity analyses revealed that the cost-effectiveness of osteoporosis screening followed by alendronate treatment was robust to joint input parameter estimate variation at a willingness-to-pay threshold of $50,000/QALY at all alendronate costs evaluated.

Conclusions

Osteoporosis screening followed by alendronate treatment is effective and highly cost-effective for postmenopausal women across a range of alendronate costs, and may be cost-saving at annual alendronate costs of $200 or less.

Effect of in-hospital comprehensive geriatric assessment (CGA) in older people with hip fracture. The protocol of the Trondheim Hip Fracture trial

Background

Hip fractures in older people are associated with high morbidity, mortality, disability and reduction in quality of life. Traditionally people with hip fracture are cared for in orthopaedic departments without additional geriatric assessment. However, studies of postoperative rehabilitation indicate improved efficiency of multidisciplinary geriatric rehabilitation as compared to traditional care. This randomized controlled trial (RCT) aims to investigate whether an additional comprehensive geriatric assessment of hip fracture patients in a special orthogeriatric unit during the acute in-hospital phase may improve outcomes as compared to treatment as usual in an orthopaedic unit.

Methods/design

The intervention of interest, a comprehensive geriatric assessment is compared with traditional care in an orthopaedic ward. The study includes 401 home-dwelling older persons >70 years of age, previously able to walk 10 meters and now treated for hip fracture at St. Olav Hospital, Trondheim, Norway. The participants are enrolled and randomised during the stay in the Emergency Department. Primary outcome measure is mobility measured by the Short Physical Performance Battery (SPPB) at 4 months after surgery. Secondary outcomes measured at 1, 4 and 12 months postoperatively are place of residence, activities of daily living, balance and gait, falls and fear of falling, quality of life and depressive symptoms, as well as use of health care resources and survival.

Discussion

We believe that the design of the study, the randomisation procedure and outcome measurements will be of sufficient strength and quality to evaluate the impact of comprehensive geriatric assessment on mobility and other relevant outcomes in hip fracture patients.

Trials registration

ClinicalTrials.gov, NCT00667914

A classification of diabetic foot infections using ICD-9-CM codes: application to a large computerized medical database

Background

Diabetic foot infections are common, serious, and varied. Diagnostic and treatment strategies are correspondingly diverse. It is unclear how patients are managed in actual practice and how outcomes might be improved. Clarification will require study of large numbers of patients, such as are available in medical databases. We have developed and evaluated a system for identifying and classifying diabetic foot infections that can be used for this purpose.

Methods

We used the (VA) Diabetes Epidemiology Cohorts (DEpiC) database to conduct a retrospective observational study of patients with diabetic foot infections. DEpiC contains computerized VA and Medicare patient-level data for patients with diabetes since 1998. We determined which ICD-9-CM codes served to identify patients with different types of diabetic foot infections and ranked them in declining order of severity: Gangrene, Osteomyelitis, Ulcer, Foot cellulitis/abscess, Toe cellulitis/abscess, Paronychia. We evaluated our classification by examining its relationship to patient characteristics, diagnostic procedures, treatments given, and medical outcomes.

Results

There were 61,007 patients with foot infections, of which 42,063 were classifiable into one of our predefined groups. The different types of infection were related to expected patient characteristics, diagnostic procedures, treatments, and outcomes. Our severity ranking showed a monotonic relationship to hospital length of stay, amputation rate, transition to long-term care, and mortality.

Conclusions

We have developed a classification system for patients with diabetic foot infections that is expressly designed for use with large, computerized, ICD-9-CM coded administrative medical databases. It provides a framework that can be used to conduct observational studies of large numbers of patients in order to examine treatment variation and patient outcomes, including the effect of new management strategies, implementation of practice guidelines, and quality improvement initiatives.

Alzheimer's disease: visual system review

BACKGROUND

Ten million baby boomers in the United States will get Alzheimer's disease. Optometrists can benefit from understanding the impact the Alzheimer's disease process has on the visual system. This can result in more effective management of the condition and in more effective communication with members of the Alzheimer's disease multidisciplinary team.

METHODS

This is a review of the literature but by no means a completely exhaustive review. Alzheimer's disease is a complex disease. A rapidly expanding body of knowledge covers multiple disciplines.

RESULTS

The visual system shows deficits early in the degenerative process of Alzheimer's disease. Biomarkers through the visual system such as nerve fiber deficits, lens opacities, and functional losses in the magnocellular pathway, such as contrast sensitivity and temporal processing, may prove to not only help detect Alzheimer's disease early but also detect it before there are the classic cognitive and memory losses.

CONCLUSIONS

The effects of Alzheimer's disease are devastating. Optometrists, as primary care clinicians, can make critical contributions in the diagnosis, treatment, and management of this neurodegenerative disease.

Disparities in utilization of outpatient rehabilitative care following hip fracture hospitalization with respect to race and ethnicity

OBJECTIVE

To compare the prevalence of discharge home to self-care after hip fracture hospitalization among the elderly in 3 racial groups: whites, Hispanics, and blacks.

DESIGN

Secondary data analysis.

SETTING

US hospitals.

PARTICIPANTS

Patients (N=34,203) aged 65 and older with Medicare insurance discharged after hip fracture hospitalization between 2001 and 2005.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Discharge home to self-care.

RESULTS

Bivariate analyses showed higher rates of discharge home to self-care among minorities, 16.4% for Hispanics, 8.7% for blacks, and 5.9% for whites. Hispanics had 3-fold higher odds of being discharged home to self-care, and blacks had about 50% higher odds of being discharged home to self-care after adjusting for age, sex, Klabunde's comorbidity index, income, year of admission, type of hip fracture, surgical stabilization procedure, and length of hospital stay.

CONCLUSIONS

The higher rate of discharge home to self-care among minorities underscores the risk of suboptimal outpatient rehabilitative care among minorities with hip fracture.

[Acute orthogeriatric care (I). Healthcare issues]

The present article reviews the historical development of several collaborative care models between orthopaedic and geriatrics departments for the care of patients with hip fracture. Subacute orthogeriatric units are described and special emphasis is placed on geriatric consulting teams and acute orthogeriatric units, as well as on their benefits for the patient and the healthcare service. We also review evidence-based studies that support this type of care for patients with acute hip fracture and guidelines from scientific associations involved in the care of these patients. The cost of care is also analyzed. Lastly, the term "orthogeriatrics" is proposed as a common term for this activity and the need for improved future care is discussed.

Predictors of hospital readmission in a cohort of 236 elderly discharged after surgical repair of hip fracture: one-year follow-up

BACKGROUND AND AIMS

Few studies have investigated predictors for hospital readmission after hip fracture repair.

METHODS

In a prospective cohort study we evaluated factors associated with early (within 3 months) and late (between 3-12 months), single and multiple hospital readmission in 236 hip-fractured older adults admitted to an orthopedic unit. Baseline patient characteristics and hospital course (functional and cognitive status, comorbidity, type of fracture, time to surgery, in-hospital stay, complications) were recorded. Hospital readmission over 12 months and ICD-9 principal diagnosis were ascertained from administrative sources. Functional status at the end of the rehabilitation program was assessed by telephone interviews.

RESULTS

Seventy-one patients (30.1%) were readmitted to hospital within twelve months of discharge and 22 (9.3%) had two or more readmission. The total number of readmissions was 105, 43 (41%) occurred in the first three months. The most common readmission causes were cardiac, infectious and cerebrovascular; surgical complication accounted for 5.7%. Patients with a single readmission, like those with multiple readmissions, were sicker (CIRS-CI subscore 4.0+/-1.8 vs 3.2+/-1.6, p=0.010) and more functionally impaired at the end of rehabilitation (2 months' Katz index 2.1+/-2 vs 2.9+/-2.3, p=0.007) than controls. In a multiple logistic regression model, comorbidity and functional status at the end of rehabilitation were the only factors associated with the risk of readmission.

CONCLUSIONS

Subjects at high risk of readmission can be reliably assessed, since few significant variables were associated with rehospitalization. Subgroups of patients with an elevated risk of rehospitalization after hip fracture may be the target for strategies to reduce the burden of excessive hospital use and improve overall outcomes.

[Epidemiology and perspectives in traumatology of the elderly]

Corresponding to the demographic development, fractures of the humerus, wrist, or hip will occur noticeably more often during the next four decades. The number of patients with hip fractures will increase to 170% of present-day numbers, and in the age group >80 years to 250%. Trauma surgical departments should train their staff as well as adapt their workflows and ambient conditions to this demanding clientele to be prepared for these changes. For the elderly, a fracture may lead to need for permanent home care, which is why postoperative transfer to ambulatory care is especially important. The expected cost progression in traumatology of the elderly may be moderated by the conjunction of inpatient and ambulatory care, the utilization of synergies among the different service types, and by implementation of prophylaxis for osteoporosis and falls.

Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture

BACKGROUND

Although more than 1200 hip fracture repairs are performed in United States Department of Veterans Affairs hospitals annually, little is known about the relationship between perioperative care and short-term outcomes for veterans with hip fracture. The purpose of the present study was to test whether perioperative care impacts thirty-day outcomes, with patient characteristics being taken into account.

METHODS

A national sample of 5683 community-dwelling male veterans with an age of sixty-five years or older who had been hospitalized for the operative treatment of a hip fracture at one of 108 Veterans Administration hospitals between 1998 and 2003 was identified from the National Surgical Quality Improvement Program data set. Operative care characteristics were assessed in relation to thirty-day outcomes (mortality, complications, and readmission to a Veterans Administration facility for inpatient care).

RESULTS

A surgical delay of four days or more after admission was associated with a higher adjusted mortality risk (odds ratio, 1.29; 95% confidence interval, 1.02 to 1.61) but a reduced risk of readmission (odds ratio, 0.70; 95% confidence interval, 0.54 to 0.91). Compared with spinal or epidural anesthesia, general anesthesia was related to a significantly higher risk of both mortality (odds ratio, 1.27; 95% confidence interval, 1.01 to 1.55) and complications (odds ratio, 1.33; 95% confidence interval, 1.15 to 1.53). The type of procedure was not significantly associated with outcome after controlling for other variables in the model. However, a higher American Society of Anesthesiologists Physical Status Classification (ASA class) was associated with worse thirty-day outcomes.

CONCLUSIONS

In addition to recognizing the importance of patient-related factors, we identified operative factors that were related to thirty-day surgical outcomes. It will be important to investigate whether modifying operative factors, such as reducing surgical delays to less than four days, can directly improve the outcomes of hip fracture repair.

Post-operative considerations in hip fracture management

Hip fractures are among the most important causes for disability, reduced quality of life, and death in older persons. Hip fracture patients are typically characterized by older age and a large complexity in their underlying conditions, comorbidities, and clinical histories. Therefore, large, well-designed studies are difficult to perform and the available evidence for most treatments is limited compared with other disease entities of this magnitude. This paper illuminates the current issues and recommendations for post-operative hip fracture care. Efforts to improve osteoporosis assessment and management, the multidisciplinary team approach, and clinical pathways are areas that have received attention recently.

[High quality and restricted resources--a contradiction in terms?]

The aim of quality management is to optimize the quality of care under given circumstances, which include the provided resources. If these resources no longer suffice, a deterioration of the achievable quality will follow. This could be avoided by 1) recognizing and eliminating unnecessary or deficient health services, 2) excluding health services from funding when adequate scientific proof of effectiveness is lacking, and 3) modifying the definition of the level of quality to be achieved. Outcome quality of health care is measured, on the one hand, by prevention of avoidable mortality and morbidity and, on the other hand, by improvement of quality of life and patient satisfaction. Methodologically, it is difficult to determine which part of the quality of life and of patient satisfaction is to be attributed to private life style. Since the evidence for effects on quality of life and patient satisfaction is often worse than for mortality and morbidity, there is the risk that they will become increasingly less relevant when defining the quality that is to be achieved for the community of the insured. In order to prevent this from happening unnoticed, measurements of the outcome quality of care with the indicator group mortality, morbidity, quality of life and patient satisfaction need to be intensified.

Proximale Femurfrakturen im Alter

BACKGROUND

The section of geriatric trauma ("AG-Alterstraumatologie") of the "Deutsche Gesellschaft für Unfallchirurgie" (DGU) and the "Lohmann & Birkner Health Care Consulting GmbH" in co-operation with the health insurance funds (VdAK and AEV) supplied the relevant data of approximately 23 million insured persons from the years 2002 to 2004.

METHODS

All data from patients over the age of 60 staying in hospital because of proximal femur fractures and without further injuries as the main diagnosis were extracted from the available amount of data and then analysed. There were 68,929 (9.5%) cases diagnosed with proximal femur fractures of 724,606 patients treated in hospital.

RESULTS

There was a significant age-dependent increase in incidents of proximal femur fractures with a maximum of 3,000 injuries around the age of 82 years. The surgical treatment of proximal femur fractures was carried out with a joint-preserving stabilising method (osteosynthesis-screws-"DHS"-nailing systems) in 49.5%, with endoprosthesis in 48.6 % as well as other methods in 1.9% of the cases. In comparison to hip replacement care, a shorter hospital stay could be proved with osteosynthetic methods.

The management of subcapital fractures in the elderly — with an emphasis on economic aspects

About 86 000 hip fractures occur each year in the United Kingdom (Donaldson et al., 1990) and approximately half are intracapsular (Singer et al., 1994). Mortality is 5—10% after 1 month and one third of patients will have died by 1 year (Johnell et al., 1992; French et al., 1995, 2006). The total estimated cost to society is almost £726 million per annum with over half of the cost attributed to social care of patients recovering from a broken hip as more than 10% of survivors will be unable to return to their previous residence (Keene et al.,1993). Hip fractures account for approximately 20% of orthopaedic bed occupancies in the UK, and based on current population trends, the number of hip fractures may rise to 120 000 per annum by 2015 (Johnell et al., 1992). In this article the management of elderly patients with subcapital or intracapsular type fractures is described with an emphasis on economic aspects.

Evaluation of clinical prognosis and activities of daily living using functional independence measure in patients with hip fractures

BACKGROUND

The functional independence measure (FIM) is an evaluation method of activities of daily living (ADL) that assesses motor functions and cognitive functions in the Uniform Data System. The FIM has recently been used to assess disability. The purpose of this study was to standardize criteria using the FIM for determining when and to where patients can be discharged following surgery for hip fracture.

METHODS

Patients with hip fracture (n=68) aged>or=65 years who underwent surgery at our hospital were classified by their residence at the time of injury (their own home, a hospital, or an elderly care facility) and by postoperative residence after discharge from hospital. We investigated the FIM of these patients before injury and at the time of discharge and retrospectively compared the results with the Japan Orthopaedic Association (JOA) hip score at the time of discharge.

RESULTS

Patients who entered a facility after discharge following surgery demonstrated a reduction in motor function score on the FIM. Cognitive function scores in each group were not reduced postoperatively in the short term. The average reduction in scores on the FIM for patients who were discharged from hospital to their own home was 15.9 points, and it was 25.9 points for those who were injured in their own home and transferred to a facility after discharge. There was a significant correlation between the FIM and the JOA hip score at the time of discharge.

CONCLUSIONS

The FIM cannot determine whether such patients should be discharged to their home or transferred to a care facility. However, the motor function scores on the FIM are valid for assessing hip fracture patients and may be suitable as a standardized procedure for determining their postdischarge residence.

Outcome after surgery for fracture of the hip in patients aged over 95 years

Despite the increase in numbers of the extreme elderly, little data is available regarding their outcome after surgery for fracture of the hip. We performed a prospective study of 50 patients aged 95 years and over who underwent this procedure. Outcome measures included morbidity, mortality, hospital stay, residential and walking status. Comparison was made with a control group of 200 consecutive patients aged less than 95 years who had a similar operation. The mortality at 28 and 120 days was higher (p = 0.005, p = 0.001) in the patients over 95 years. However, the one-year cumulative post-operative mortality was neither significantly different between the two groups (p = 0.229) nor from the standardised mortality rate for the age-matched population (p = 0.445). Predictors of mortality included the ASA grade, the number of comorbid medical conditions and active medical problems on admission. Patients over 95 were unlikely to recover their independence and at a mean follow-up of 29.3 months (12.1 to 48) 96% required permanent institutional care.

Recovery after hip fracture

OBJECTIVES

The aim was to monitor the inhospital progress of 170 patients sustaining proximal femoral fractures. The extent of delay in discharge was recorded and what effect this prolonged hospitalisation had on nosocomial infection rates.

SETTING

A regional trauma centre.

DESIGN

A prospective observational study.

PATIENTS AND PARTICIPANTS

All consecutive patients sustaining proximal femoral fracture over 60 years of age.

INTERVENTION

The same clinician monitored each patient throughout their inhospital stay. Factors recorded included nosocomial infection acquired and when, mobility scores, loss of independence, delay in discharge amongst others.

MAIN OUTCOME

Delay in discharge, incidence of nosocomial infection and mobility scores.

RESULTS

Nosocomial infection occurred in 58% of patients (99 patients) when discharge was delayed beyond 8 days (after surgery). Eighty-five per cent of patients (145 patients) achieved their maximum mobility score by the 8th, and 95% (162 patients) by the 10th postoperative day.

CONCLUSIONS

Patients with proximal femoral fracture derive no benefit from acute hospital admission of more than 8 days and the majority acquire nosocomial infection after this.

An analysis of the length of stay and effectiveness of treatment for hip fracture patients in Japan: evaluation of the 2002 Revision of the Medical Service Fee Schedule

The length of hospital stay and effectiveness of medical treatment are analyzed using data of patients hospitalized due to hip fractures of four hospitals in Japan. The influence of the Revision of the Medical Service Fee Schedule in April, 2002, is evaluated, and factors which may have affected the length of stay and effectiveness of treatment (walking ability upon departure from the hospital) are also analyzed by a newly developed simultaneous equation model.

Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare

OBJECTIVES

To assess the impact of a specifically designed model of orthopedic-geriatric cocare on hip fracture (HF) outcomes.

SETTING

Tertiary teaching hospital (level I trauma center).

DESIGN

Prospective observational study with a retrospective (historical) control. Data on 951 consecutive patients 60 years of age or older admitted to the authors' institution with a nonpathologic HF over a 7-year period (1995 to 2002) were analyzed. Between 1995 and 1997, medical problems were managed by a geriatric medicine (GM) consultation-only service (retrospective audit). In 1998, a GM registrar began overseeing daily medical care with weekly geriatrician consultant review (prospective study). Outcomes for 2 time periods were compared: a 3-year period before (no GM; 504 patients) and a 4-year period after (GM; 447 patients) the introduction of GM cocare.

MAIN OUTCOME MEASUREMENTS

Postoperative medical complications, mortality, length of stay, discharge destination, use of thromboprophylaxis, and antiosteoporotic treatment.

RESULTS

While comparing 2 periods (GM and no GM), significant reductions in postoperative medical complications and comorbid conditions (in total 49.5% vs. 71.0%, P<0.001) and mortality (4.7% vs. 7.7%, P<0.01) occurred and rehospitalization to medical wards within 6 months decreased (28% vs. 7.6%). However, no differences were observed in median length of hospital stay (10.8 vs. 11.0 days) or in discharge destination. Antiosteoporotic treatment (12% to 69%) and specific thromboprophylaxis (63% to 94%) increased in the GM period.

CONCLUSIONS

Orthopedic-geriatric cocare for the older patients with HF was associated with significant reductions in morbidity and mortality, and increases in optimal postoperative care. Options for further improvement of orthopedic-GM cocare need to be investigated.

Comparison of early postoperative functional levels following total hip replacement using minimally invasive versus standard incisions. A prospective randomized blinded trial

OBJECTIVE

To compare the results of single-incision minimally invasive total hip replacement (< or = 10 cm) to standard-incision (16 cm) total hip replacement in the early postoperative period with respect to functional and mobilizing ability (transfers, mobilizing, walking and stair assessment).

SETTING

Orthopaedic wards of a regional orthopaedic centre.

SUBJECTS

Two hundred and nineteen total hip replacement patients were tested between December 2003 and June 2004.

INTERVENTIONS

Patients were randomized to either total hip replacement through a minimally invasive (< or = 10 cm) or standard incision (16 cm). A single surgeon performed all procedures using the same type of component fixation. Postoperative physiotherapy assessment and treatment was standardized. Analgesia was also standardized. All patients, physiotherapy staff and assessors were blinded to the incision used.

MAIN OUTCOME MEASURES

Patients were tested two days post operatively and were assessed for the following activities: transfer from supine to sit, transfer from sitting to standing, mobilizing, ascending and descending stairs and weight-bearing.

RESULTS

The shorter incision offered no significant improvement in patient ability in relation to transfer from lying to sitting, transfer from sitting to standing, mobilizing or weight-bearing. Ascending/descending stairs gave a total time for the minimal incision of 38.7 s against 40.8 s for a standard incision. There was no difference in walking velocity between the standard incision and minimal incision groups two days post operatively (minimal incision = 0.26 m/s versus standard incision = 0.26 m/s) or six weeks post operatively (minimal incision = 0.90 m/s versus standard incision = 0.93 m/s). There was no difference between groups with respect to walking aids at six-week review. The mean length of stay for the minimally invasive approach was 3.65 days (SD 2.04) against 3.68 days (SD 2.45) for the standard approach. This was not significantly different.

CONCLUSION

Total hip replacement performed through a minimally invasive incision of < or = 10 cm compared with a standard incision of 16 cm offers no significant benefit in terms of the rate or ability of patients to mobilize and perform functional tasks necessary for safe discharge.

Operative treatment for hip fractures in patients 100 years of age and older: is it justified?

OBJECTIVES

To evaluate a unique group of elderly patients over 100 years of age who had hip fractures.

DESIGN

Retrospective database analysis.

SETTINGS

Academic teaching hospital.

PATIENTS

All patients who had hip fractures between January 1990 and December 2001 and were over 100 years old were included.

INTERVENTION

In this study, we evaluated the age, gender, type of fracture, type of treatment, background disease, rehabilitation, and time until death of all patients over 100 years, whether treated operatively or nonoperatively.

RESULTS

Twenty-three patients (17 females and 6 males) were identified with ages ranging from 100 to 107 (mean: 101.8). The group had 4 subcapital and 19 pertrochanteric fractures and between 1 and 4 major background diseases. Four patients were treated nonoperatively (1 due to major pneumonia and 3 refused the operative procedure). Three of those 4 patients died in the same month of admission, and 1 patient died during the second month. Among the 19 patients who underwent operation, 17 patients have died, living between 0 and 78 months (mean: 13.8) postoperatively. Two are still alive (21 and 45 months) after the operation. Eight patients died prior to 6 months, and 11 lived more than a year after the operation. A comparison between these 2 groups showed greater major background disease in the patients who died prior to 6 months (P < 0.05).

CONCLUSIONS

Most hip fractures in patients over 100 years of age are pertrochanteric. Patients with 2 or more major background diseases have an increased risk for dying in the first 6 months after the operation. Most patients having operations in this age group had a postoperative reduction in mobility status and in performing basic activities of daily living.

Impact of fractures on health care in a major university hospital in Rome

BACKGROUND AND AIMS

The aim of the study was to investigate the impact of fractures (i.e., hip, Colles, humeral and vertebral fractures), compared with that of other common diseases requiring hospitalization, on health care in the main hospital in Rome (Italy).

METHODS

Hospital discharge forms, filled in according to the 9th International Classification of Diseases, were examined from 1996 to 1999. Data on fractures were compared with those related to other diseases which occupy a considerable proportion of hospital operating time in Italy: coronary heart disease (CHD), cerebrovascular disorders (CVD), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD) and breast cancer (BC).

RESULTS

In all groups of patients, the mean age of females was significantly higher (p<0.0001) than that of males. Male patients with hip fractures had hospital stays significantly longer than females (p<0.0001), whereas women with Colles fractures had significantly (p<0.02) longer stays. When patients were divided according to age (i.e., over or under 60 years), mean hospital stays did not differ between younger and older patients in all groups except Colles fractures (p<0.001). Hip fractures in older patients showed striking in-hospital mortality. Throughout the study period, hip fractures accounted for the highest overall and per-patient costs. The number of female patients with fractures (and, obviously, breast cancer) was higher, while the opposite applied to the other disorders. Male patients with fractures, CHD and CVD were significantly younger than females (p<0.0001). When the percentage of deaths was added to that of patients discharged to other institutions, fractures showed the poorest outcome of any hospitalization event. Per-patient costs were remarkably higher for CHD, followed by fractures.

CONCLUSIONS

Fractures represent a growing but often underestimated burden for hospital care in Italy; further studies are needed on this issue.