A cost-minimisation study of alternative discharge policies after hip fracture repair

Recommendations made by patients, caregivers, providers, and decision-makers to improve transitions in care for older adults with hip fracture: a qualitative study in Ontario, Canada

Background

Older adults frequently experience fall-related injuries, including hip fractures. Following a hip fracture, patients receive care across a number of settings and from multiple different providers. Transitions between providers and across settings have been noted as a vulnerable time, with potentially negative impacts. Currently, there is limited research on how to improve experiences with transitions in care following a hip fracture for older adults from the perspectives of those with lived experienced. The purpose of this study was to explore service recommendations made by patients, caregivers, healthcare providers, and decision-makers for improving transitions in care for older adults with hip fracture.

Methods

This descriptive qualitative study was part of a larger longitudinal qualitative multiple case study. Participants included older adults with hip fracture, caregivers supporting an individual with hip fracture, healthcare providers, and decision-makers. In-depth, semi-structured interviews were conducted with all participants, with patients and caregivers having the opportunity to participate in follow-up interviews as they transitioned out of hospital. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically.

Results

A total of 47 participants took part in 65 interviews. We identified three main categories of recommendations: (1) hospital-based recommendations; (2) community-based recommendations; and (3) cross-sectoral based recommendations. Hospital-based recommendations focused on treating patients and families with respect, improving the consistency, frequency, and comprehensiveness of communication between hospital providers and between providers and families, and increasing staffing levels. Community-based recommendations included the early identification of at-risk individuals and providing preventative and educational programs. Cross-sectoral based recommendations were grounded in enhanced system navigation through communication and care navigators, particularly within primary and community care settings.

Conclusions

Our findings highlighted the central role primary care can play in providing targeted, integrated services for older adults with hip fracture. The recommendations outlined have the potential to improve experiences with care transitions for older adults with hip fracture, and thus, addressing and acting on them should be a priority.

Discharge to inpatient care facilities following hip fracture surgery: incidence, risk factors, and 30-day post-discharge outcomes

BACKGROUND

Discharge to an inpatient care facility (skilled-care or rehabilitation) has been shown to be associated with adverse outcomes following elective total joint arthroplasties. Current evidence with regard to hip fracture surgeries remains limited.

METHODS

The 2015-2016 ACS-NSQIP database was used to query for patients undergoing total hip arthroplasty, hemiarthroplasty and open reduction internal fixation for hip fractures. A total of 15,655 patients undergoing hip fracture surgery were retrieved from the database. Inpatient facility discharge included discharges to skilled-care facilities and inpatient rehabilitation units. Multi-variate regression analysis was used to assess for differences in 30-day post-discharge outcomes between home-discharge versus inpatient care facility discharge, while adjusting for baseline differences between the 2 study populations.

RESULTS

A total of 12,568 (80.3%) patients were discharged to an inpatient care facility. Discharge to an inpatient care facility was associated with higher odds of any complication (OR 2.03 [95% CI, 1.61-2.55]; p < 0.001), wound complications (OR 1.79 [95% CI, 1.10-2.91]; p = 0.019), cardiac complications (OR 4.49 [95% CI, 1.40-14.40]; p = 0.012), respiratory complication (OR 2.29 [95% CI, 1.39-3.77]; p = 0.001), stroke (OR 7.67 [95% CI, 1.05-56.29]; p = 0.045, urinary tract infections (OR 2.30 [95% CI, 1.52-3.48]; p < 0.001), unplanned re-operations (OR 1.37 [95% CI, 1.03-1.82]; p = 0.029) and readmissions (OR 1.38 [95% CI, 1.16-1.63]; p < 0.001) following discharge.

CONCLUSION

Discharge to inpatient care facilities versus home following hip fracture surgery is associated with higher odds of post-discharge complications, re-operations and readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimise the risk of complications.

Developing a multidisciplinary rehabilitation package following hip fracture and testing in a randomised feasibility study: Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR)

BACKGROUND

Proximal femoral fracture is a major health problem in old age, with annual UK health and social care costs of £2.3B. Rehabilitation has the potential to maximise functional recovery and maintain independent living, but evidence of clinical effectiveness and cost-effectiveness is lacking.

OBJECTIVES

To develop an enhanced community-based rehabilitation package following surgical treatment for proximal femoral fracture and to assess acceptability and feasibility for a future definitive randomised controlled trial (RCT) and economic evaluation.

DESIGN

Phase I - realist review, survey and focus groups to develop the rehabilitation package. Phase II - parallel-group, randomised (using a dynamic adaptive algorithm) feasibility study with focus groups and an anonymised cohort study.

SETTING

Recruitment was from orthopaedic wards of three acute hospitals in the Betsi Cadwaladr University Health Board, North Wales. The intervention was delivered in the community following hospital discharge.

PARTICIPANTS

Older adults (aged ≥ 65 years) who had received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by the clinical team) and received rehabilitation in the North Wales area.

INTERVENTIONS

Participants received usual care (control) or usual care plus an enhanced rehabilitation package (intervention). Usual care was variable and consisted of multidisciplinary rehabilitation delivered by the acute hospital, community hospital and community services depending on need and availability. The intervention was designed to enhance rehabilitation by improving patients' self-efficacy and increasing the amount and quality of patients' practice of physical exercise and activities of daily living. It consisted of a patient-held information workbook, a goal-setting diary and six additional therapy sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the Barthel Activities of Daily Living (BADL) index. The secondary outcome measures included the Nottingham Extended Activities of Daily Living (NEADL) scale, EuroQol-5 Dimensions, ICEpop CAPability measure for Older people, General Self-Efficacy Scale, Falls Efficacy Scale - International (FES-I), Self-Efficacy for Exercise scale, Hospital Anxiety and Depression Scale (HADS) and service use measures. Outcome measures were assessed at baseline and at 3-month follow-up by blinded researchers.

RESULTS

Sixty-two participants were recruited (23% of those who were eligible), 61 were randomised (control, n = 32; intervention, n = 29) and 49 (79%) were followed up at 3 months. Compared with the cohort study, a younger, healthier subpopulation was recruited. There were minimal differences in most outcomes between the two groups, including the BADL index, with an adjusted mean difference of 0.5 (Cohen's d = 0.29). The intervention group showed a medium-sized improvement on the NEADL scale relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d = 0.63). There was a trend for greater improvement in FES-I and HADS in the intervention group, but with small effect sizes, with an adjusted mean difference of 4.2 (Cohen's d = 0.31) and 1.3 (Cohen's d = 0.20), respectively. The cost of delivering the intervention was £231 per patient. There was a possible small relative increase in quality-adjusted life-years in the intervention group. No serious adverse events relating to the intervention were reported.

CONCLUSIONS

Trial methods were feasible in terms of eligibility, recruitment and retention, although recruitment was challenging. The NEADL scale was more responsive than the BADL index, suggesting that the intervention could enable participants to regain better levels of independence compared with usual care. This should be tested in a definitive Phase III RCT. There were two main limitations of the study: the feasibility study lacked power to test for differences between the groups and a ceiling effect was observed in the primary measure.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN22464643.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 44. See the NIHR Journals Library for further project information.

Impact and experiences of delayed discharge: A mixed-studies systematic review

Background

The impact of delayed discharge on patients, health‐care staff and hospital costs has been incompletely characterized.

Aim

To systematically review experiences of delay from the perspectives of patients, health professionals and hospitals, and its impact on patients’ outcomes and costs.

Methods

Four of the main biomedical databases were searched for the period 2000‐2016 (February). Quantitative, qualitative and health economic studies conducted in OECD countries were included.

Results

Thirty‐seven papers reporting data on 35 studies were identified: 10 quantitative, 8 qualitative and 19 exploring costs. Seven of ten quantitative studies were at moderate/low methodological quality; 6 qualitative studies were deemed reliable; and the 19 studies on costs were of moderate quality. Delayed discharge was associated with mortality, infections, depression, reductions in patients’ mobility and their daily activities. The qualitative studies highlighted the pressure to reduce discharge delays on staff stress and interprofessional relationships, with implications for patient care and well‐being. Extra bed‐days could account for up to 30.7% of total costs and cause cancellations of elective operations, treatment delay and repercussions for subsequent services, especially for elderly patients.

Conclusions

The poor quality of the majority of the research means that implications for practice should be cautiously made. However, the results suggest that the adverse effects of delayed discharge are both direct (through increased opportunities for patients to acquire avoidable ill health) and indirect, secondary to the pressures placed on staff. These findings provide impetus to take a more holistic perspective to addressing delayed discharge.

GAPN Postacute Care Coordination Improves Hip Fracture Outcomes

We tested the effectiveness of a nursing intervention model to improve health, function, and return-home outcomes in elders with hip fracture via a 2-year randomized clinical trial. Thirty three elders (age > 65 years) were tracked from hospital discharge to 12 months postfracture. The treatment group had a gerontologic advanced practice nurse as postacute care coordinator for 6 months who intervened with each elder regardless of the postacute care setting, making biweekly visits and/or phone calls. The coordinator assessed health and function, and informed elders, families, long-term care staff, and physicians of the patient's progress. The control group had care based on postacute facility protocols. Nonnormal distribution of data led to nonparametric analysis using Freidman's test with post hoc comparisons (Mann—Whitney U tests, Bonferroni adjustment). The treatment group had better function at 12 months on several activities and instrumental activities of daily living, and no differences in health, depression, or living situation.

Costs after hip fracture in independently living patients: a randomised comparison of three rehabilitation modalities

OBJECTIVE

To evaluate costs and cost-effectiveness of physical and geriatric rehabilitation after hip fracture.

DESIGN

Prospective randomised study (mean age 78 years, 105 male, 433 female) in different rehabilitation settings: physically oriented (187 patients), geriatrically oriented (171 patients), and healthcare centre hospital (control, 180 patients).

MAIN MEASURES

At 12 months post-fracture, we collected data regarding days in rehabilitation, post-rehabilitation hospital treatment, other healthcare service use, number of re-operations, taxi use by patient or relative, and help from relatives.

RESULTS

Control rehabilitation (4945,2€) was significantly less expensive than physical (6609.0€, p=0.002) and geriatric rehabilitation (7034.7€ p<0.001). Total institutional care costs (primary treatment, rehabilitation, and post-rehabilitation hospital care) were lower for control (13,438.4€) than geriatric rehabilitation (17,201.7€, p<0.001), but did not differ between control and physical rehabilitation (15659.1€, p=0.055) or between physical and geriatric rehabilitation ( p=0.252). Costs of help from relatives (estimated as 30%, 50% and 100% of a home aid's salary) with physical rehabilitation were lower than control ( p=0.016) but higher than geriatric rehabilitation ( p=0.041). Total hip fracture treatment costs were lower with physical (36,356€, 51,018€) than control rehabilitation (38,018€, 57,031€) at 50% and 100% of salary ( p=0.032, p=0.014, respectively). At one year post-fracture, 15D-score was significantly higher in physical rehabilitation group (0.697) than geriatric rehabilitation group (0.586, p=0.008) and control group (0.594, p=0.009).

CONCLUSIONS

Considering total costs one year after hip fracture the treatment including physical rehabilitation is significantly more cost-effective than routine treatment. This effect could not be seen between routine treatment and treatment including geriatric rehabilitation.

Costs and consequences of hip fracture occurrence in old age: An economic perspective

PURPOSE

To summarize the reported short- and long-term costs associated with hip fracture occurrence in old age, based on a systematic literature review of published studies. A further aim is to provide a clinician-oriented discussion of the different types of economic evaluations, with an emphasis on studies that examined potential determinants of the costs of care after hip fracture.

METHOD

Literature review.

MAIN RESULTS

Even after the initial hospitalization, hip fractures continue to generate significant costs throughout the one-year period after discharge, but particularly during the first three months. Cost estimates based on data obtained prospectively from hip-fracture patients and matched controls showed that the costs associated with the treatment of hip-fracture patients are about three times greater than those resulting from the treatment of age and residence-matched controls without a fracture. Two-fifths of these excess costs are incurred during the first three months following hospital discharge. Increasing age at the time of injury and living in an institution before the fracture are among the most important determinants of an increased cost of care after hospital discharge. Programs that focus on continuity of care, adopt a multidisciplinary approach, and accelerate rehabilitation have shown to be able to reduce the cost of care after hip fracture.

CONCLUSIONS

This review emphasizes the importance of current and future interventions to decrease the incidence of hip fracture. While the current review cannot provide definite answers to the questions of cost containment, our review provides critically important evidence about the need to base health policy decisions on empirical observations. Comprehensive economic analyses of financial costs and health outcomes are needed to develop cost-effective strategies.

[Early interdisciplinary geriatric rehabilitation after hip fracture : Effective concept or just transfer of costs?]

BACKGROUND

Modern strategies for postoperative care of patients with hip fractures include early discharge from the acute care hospital to inpatient interdisciplinary rehabilitation facilities. Whether these programs are effective for the patients and improve their long-term outcomes or if they simply transfer costs, with a reduction of the inpatient days in the acute care hospital, is currently under discussion.

PATIENTS AND METHODS

This prospective study included 282 patients with hip fracture admitted to our trauma center were included into the prospective study. The mean patient age was 86+/-8 (65-110) years. All patients were treated operatively. After a mean of 12+/-9 days, the patients underwent inpatient interdisciplinary geriatric rehabilitation for a mean of 27+/-13 (4-103) days. The primary outcome measure was their activities of daily living (Barthel index) before, at the end of rehabilitation, and 1 year after trauma. In addition, patient-related variables were correlated with the Barthel index.

RESULTS

With discharge from the acute care hospital, the Barthel index was 42+/-20 points and it increased during rehabilitation to 65+/-26 points. One year later the Barthel index was 67+/-28 points. Ninety percent of patients improved their Barthel index during rehabilitation. Within 1 year, 40% of patients deteriorated in their activities of daily living. Fifty one percent of patients were reintegrated back to their homes. Patients who lived at home before trauma and were reintegrated back to their homes had a significant higher Barthel index (75+/-24) 1 year after trauma than patients who were living in a nursing care facility before the trauma (Barthel index 52+/-27). The variables of age, level of cognition, and type of fracture had no influence on the long-term outcome. An extension of rehabilitation above the mean time period did not improve the sustainable clinical outcome.

CONCLUSION

Postoperative inpatient rehabilitation programs enhance short-term activities of daily living. In particular, patients who lived at home before the trauma and were reintegrated back home benefited in perpetuity from geriatric rehabilitation. A policy for early discharge to geriatric rehabilitation is associated with extension of overall hospital stay. This association along with the related increased health care costs should be weighed against the sociofunctional effectiveness of these programs.

Care home versus hospital and own home environments for rehabilitation of older people

BACKGROUND

Rehabilitation for older people has acquired an increasingly important profile for both policy-makers and service providers within health and social care agencies. This has generated an increased interest in the use of alternative care environments including care home environments. Yet, there appears to be limited evidence on which to base decisions.This review is the first update of the Cochrane review which was published in 2003.

OBJECTIVES

To compare the effects of care home environments (e.g. nursing home, residential care home and nursing facilities) versus hospital environments and own home environments in the rehabilitation of older people.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Specialised Register and Pending Folder, MEDLINE (1950 to March Week 3 2007), EMBASE (1980 to 2007 Week 13), CINAHL (1982 to March, Week 4, 2007), other databases and reference lists of relevant review articles were additionally reviewed. Date of most recent search: March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) that compared rehabilitation outcomes for persons 60 years or older who received rehabilitation whilst residing in a care home with those who received rehabilitation in hospital or own home environments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

In this update, 8365 references were retrieved. Of these, 339 abstracts were independently assessed by 2 review authors, and 56 studies and 5 review articles were subsequently obtained. Full text papers were independently assessed by two or three review authors and none of these met inclusion criteria.

AUTHORS' CONCLUSIONS

There is insufficient evidence to compare the effects of care home environments versus hospital environments or own home environments on older persons rehabilitation outcomes. Although the authors acknowledge that absence of effect is not no effect. There are three main reasons; the first is that the description and specification of the environment is often not clear; secondly, the components of the rehabilitation system within the given environments are not adequately specified and; thirdly, when the components are clearly specified they demonstrate that the control and intervention sites are not comparable with respect to the methodological criteria specified by Cochrane EPOC group. The combined effect of these factors resulted in the comparability between intervention and control groups being very weak.

Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: the cumulated ambulation score

OBJECTIVE

To validate the cumulated ambulation score as an early postoperative predictor of short-term outcome in hip fracture patients.

DESIGN

Prospective, descriptive study.

SETTING

An orthopaedic hip fracture unit in a university hospital.

PATIENTS

Four hundred and twenty-six consecutive hip fracture patients with an independent walking function admitted from their own home. Rehabilitation followed a well-defined multimodal rehabilitation regimen and discharge criteria.

MAIN OUTCOME MEASURE

Admission tests with a new mobility score to assess prefracture functional mobility and a short mental score for cognitive dysfunction were performed. On the first three postoperative days patients were assessed with the cumulated ambulation score consisting of a cumulated assessment of simple ambulation characteristics with a score from 0 to 18 (fully mobile). The three assessments were correlated to short-term outcome parameters.

RESULTS

The cumulated ambulation score was a highly significant predictor for length of hospitalization, time to discharge status, 30-day mortality and postoperative medical complications (P < 0.001 for all). The cumulated ambulation score was superior in its association with all postoperative outcome parameters to both the New Mobility Score and the mental score. A cumulated ambulation score of > or = 10 correlated with a 99% survival at one month and 93% discharge to own home.

CONCLUSION

The cumulated ambulation score is a potentially valuable score for early prediction of short-term postoperative outcome after hip fracture surgery.

Economic evaluation of integrated care: an introduction

BACKGROUND

Integrated care has emerged in a variety of forms in industrialised countries during the past decade. It is generally assumed that these new arrangements result in increased effectiveness and quality of care, while being cost-effective or even cost-saving at the same time. However, systematic evaluation, including an evaluation of the relative costs and benefits of these arrangements, has largely been lacking.

OBJECTIVES

To stimulate fruitful dialogue and debate about the need for economic evaluation in integrated care, and to outline possibilities for undertaking economic appraisal studies in this relatively new field.

THEORY

Key concepts, including e.g. scarcity and opportunity costs, are introduced, followed by a brief overview of the most common methods used in economic evaluation of health care programmes. Then a number of issues that seem particularly relevant for economic evaluation of integrated care arrangements are addressed in more detail, illustrated with examples from the literature.

CONCLUSION AND DISCUSSION

There is a need for well-designed economic evaluation studies of integrated care arrangements, in particular in order to support decision making on the long-term financing of these programmes. Although relatively few studies have been done to date, the field is challenging from a methodological point of view, offering analysts a wealth of opportunities. Guidance to realise these opportunities is provided by the general principles for economic evaluation, which can be tailored to the requirements of this particular field.