Comparison of Discharge Functional Status After Rehabilitation in Skilled Nursing, Home Health, and Medical Rehabilitation Settings for Patients After Hip Fracture Repair

Psychiatric comorbidity and trauma: impact on inpatient outcomes and implications for future management

PURPOSE

This study aimed to quantify the impact of pre-existing psychiatric illness on inpatient outcomes after major trauma and to assess acuity of psychiatric presentation as a predictor of outcomes.

METHODS

A retrospective single-center cohort study identified adult trauma patients with an Injury Severity Score (ISS) ≥ 16 between January 2018 and December 2019. Bivariate analysis assessed patient characteristics, injury characteristics, and injury outcomes between patients with and without psychiatric comorbidity. A sub-group analysis explored further effects of psychiatric history and need for inpatient psychiatric consultation on outcomes.

RESULTS

Of 640 patients meeting inclusion criteria, 99 patients (15.4%) had at least one psychiatric comorbidity. Patients with psychiatric comorbidity sustained distinct mechanisms of injury and higher in-hospital morbidity (44% vs. 26%, OR 1.97, 95% CI 1.17-3.3, p = 0.01), including pulmonary morbidity (31% vs. 21%, p < 0.01), neurologic morbidity (18% vs 7%, p < 0.01), and deep wound infection (8% vs. 2%, p < 0.01) than the control cohort. Psychiatric patients also had significantly greater median intensive care unit (ICU), length of stay (LOS) (1 day vs. 0 days, p = 0.04), median inpatient ward LOS (10 days vs. 7 days, p = 0.02), and median overall hospital LOS (16 days vs. 11 days, p < 0.01). In sub-group analysis, patients with a history of psychiatric illness alone had comparable outcomes to the control group.

CONCLUSIONS

Psychiatric comorbidity negatively impacts inpatient morbidity and inpatient LOS. This effect is most pronounced among acute psychiatric episodes with or without a history of mental illness.

Considering Mobility Status and Home Environment in Readmission Risk After Total Knee Arthroplasty

BACKGROUND

Discharge disposition following total knee arthroplasty (TKA) offers varying levels of post-acute care monitoring depending on the medical status of the patient and his or her ability to function independently. Discharge disposition following TKA is associated with 30-day and 90-day hospital readmission, but prior studies have not consistently considered confounding due to mobility status after TKA, available caregiver support, and measures of home area deprivation. The purpose of this study was to examine 30-day and 90-day readmission risk for patients discharged to a skilled nursing facility (SNF) following TKA after controlling specifically for these factors, among other covariates.

METHODS

This was a retrospective cohort study of patients undergoing TKA at any of 11 hospitals in a single, large, academic health-care system between January 2, 2017, and August 31, 2022, who were discharged to an SNF or home health care (HHC). The adjusted relative risk of readmission within 30 and 90 days of discharge to an SNF compared with HHC was estimated using modified Poisson regression models.

RESULTS

There were 15,212 patients discharged to HHC and 1,721 patients discharged to SNFs. Readmission within 30 days was 7.1% among patients discharged to SNFs and 2.4% among patients discharged to HHC; readmission within 90 days was 12.1% for the SNF group and 4.8% for the HHC group. The adjusted relative risk after discharge to an SNF was 1.07 (95% confidence interval [CI], 0.79 to 1.46; p = 0.65) for 30-day readmission and 1.45 (95% CI, 1.16 to 1.82; p < 0.01) for 90-day readmission.

CONCLUSIONS

Discharge to an SNF compared with HHC was independently associated with 90-day readmission, but not with 30-day readmission, after controlling for mobility status after TKA, available caregiver support, and home Area Deprivation Index, among other covariates.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Effects of a Rehabilitation-at-Home Program Compared to Post-acute Skilled Nursing Facility Care on Safety, Readmission, and Community Dwelling Status: A Matched Cohort Analysis

OBJECTIVES

To evaluate the effectiveness and safety of Rehabilitation-at-Home (RaH), which provides high-frequency, multidisciplinary post-acute rehabilitative services in patients' homes.

DESIGN

Comparative effectiveness analysis.

SETTING AND PARTICIPANTS

Medicare Fee-For-Service patients who received RaH in a Center for Medicare and Medicaid Innovation Center Demonstration during 2016-2017 (N=173) or who received Medicare Skilled Nursing Facility (SNF) care in 2016-2017 within the same geographic service area with similar inclusion and exclusion criteria (N=5535).

METHODS

We propensity-matched RaH participants to a cohort of SNF patients using clinical and demographic characteristics with exact match on surgical and non-surgical hospitalizations. Outcomes included hospitalization within 30 days of post-acute admission, death within 30 days of post-acute discharge, length of stay, falls, use of antipsychotic medication, and discharge to community.

RESULTS

The majority of RaH participants were older than or equal to 85 years (57.8%) and non-Hispanic white (72.2%) with mean hospital length of stay of 8.1 (SD 7.6) days. In propensity-matched analyses, 10.1% (95% CI: 0.5%, 19.8) and 4.2% (95% CI: 0.1%, 8.5%) fewer RaH participants experienced hospital readmission and death, respectively. RaH participants had, on average, 2.8 fewer days (95% CI 1.4, 4.3) of post-acute care; 11.4% (95% CI: 5.2%, 17.7%) fewer RaH participants experienced fall; and 25.8% (95% CI: 17.8%, 33.9%) more were discharged to the community. Use of antipsychotic medications was no different.

CONCLUSIONS AND IMPLICATIONS

RaH is a promising alternative to delivering SNF-level post-acute RaH. The program seems to be safe, readmissions are lower, and transition back to the community is improved.

Evaluation of post-acute care and one-year outcomes among Medicare beneficiaries with hip fractures: a retrospective cohort study

BACKGROUND

Post-acute care (PAC) services after hospitalization for hip fracture are typically provided in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or at home via home health care (HHC). Little is known about the clinical course following PAC for hip fracture. We examined the nationwide burden of adverse outcomes by PAC setting in the year following discharge from PAC for hip fracture.

METHODS

This retrospective cohort included Medicare Fee-for-Service beneficiaries > 65 years who received PAC services in U.S. SNFs, IRFs, or HHC following hip fracture hospitalization between 2012 and 2018. Individuals who had a fall-related injury (FRI) during PAC or received PAC services in multiple settings were excluded. Primary outcomes included FRIs, all-cause hospital readmissions, and death in the year following discharge from PAC. Cumulative incidences and incidence rates for adverse outcomes were reported by PAC setting. Exploratory analyses examined risk ratios and hazard ratios between settings before and after inverse-probability-of-treatment-weighting, which accounted for 43 covariates.

RESULTS

Among 624,631 participants (SNF, 67.78%; IRF, 16.08%; HHC, 16.15%), the mean (standard deviation) age was 82.70 (8.26) years, 74.96% were female, and 91.30% were non-Hispanic White. Crude incidence rates (95%CLs) per 1000 person-years were highest among individuals receiving SNF care for FRIs (SNF, 123 [121, 123]; IRF, 105 [102, 107]; HHC, 89 [87, 91]), hospital readmission (SNF, 623 [619, 626]; IRF, 538 [532, 544]; HHC, 418 [414, 423]), and death (SNF, 167 [165, 169]; IRF, 47 [46, 49]; HHC, 55 [53, 56]). Overall, rates of adverse outcomes generally remained higher among SNF care recipients after covariate adjustment. However, inferences about the group with greater adverse outcomes differed for FRIs and hospital readmissions based on risk ratio or hazard ratio estimates.

CONCLUSIONS

In this retrospective cohort study of individuals hospitalized for hip fracture, rates of adverse outcomes in the year following PAC were common, especially among SNF care recipients. Understanding risks and rates of adverse events can inform future efforts to improve outcomes for older adults receiving PAC for hip fracture. Future work should consider calculating risk and rate measures to assess the influence of differential time under observation across PAC groups.

Post-Acute Care Setting After Hip Fracture Hospitalization and Subsequent Opioid Use in Older Adults

OBJECTIVE

Pain management in post-acute care (PAC) requires careful balance, with both opioid use and inadequate pain treatment linked to poor outcomes. We describe opioid use among older adults following discharge from PAC for hip fracture in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs).

DESIGN

Retrospective cohort.

SETTING AND PARTICIPANTS

Medicare beneficiaries with Medicare Provider Analysis (MedPAR) claims, aged 66 years and older with a hip fracture hospitalization between 2012 and 2018 followed by PAC in SNFs or IRFs and then discharge to the community.

METHODS

Individuals were followed from PAC discharge for up to 1 year to assess opioid use. Covariate-standardized risk ratios (RR) and risk differences (RD) for opioid use within 7 days of PAC discharge were estimated via parametric g-formula with modified Poisson regression, and hazard ratios (HRs) for any post-PAC opioid use and long-term opioid use via Fine-Gray sub-distribution hazards regression.

RESULTS

Of 101,021 individuals, 80% (n = 80,495) were discharged from SNFs and 20% (n = 20,526) from IRFs. Opioids were dispensed to 50,433 patients (50%) overall and the 1-year cumulative incidence was notably higher in IRF (68%) than SNF (46%) patients. The adjusted risk of discharge from PAC with an opioid was 41% lower after SNFs versus IRFs [RR: 0.59; 95% confidence limits (CLs): 0.57-0.61; and RD: -0.16; 95% CLs: -0.17 to -0.15]. The adjusted rate of any opioid use in the year after PAC discharge was 44% lower (HR: 0.56; 95% CLs: 0.54-0.57) and of long-term opioid use was 17% lower (HR: 0.83; 95% CLs: 0.80-0.87) after SNFs versus IRFs.

CONCLUSIONS AND IMPLICATIONS

Opioid use is highly prevalent upon discharge from PAC after hip fracture, with lower use after SNF versus IRF care. Future research should assess the benefits and harms of post-PAC opioid prescribing and whether care practices during PAC can be improved to optimize long-term opioid use.

Sources of Postacute Care Episode Payment Variation After Traumatic Hip Fracture Repair Among Medicare Beneficiaries: Cross-Sectional Retrospective Study

The objective of this study was to evaluate how much variation in postacute care (PAC) spending after traumatic hip fracture exists between hospitals, and to what degree this variation is explained by patient factors, hospital factors, PAC setting, and PAC intensity.

Background

Traumatic hip fracture is a common and costly event. This is particularly relevant given our aging population and that a substantial proportion of these patients are discharged to PAC settings.

Methods

It is a cross-sectional retrospective study. In a retrospective review using Medicare claims data between 2014 and 2019, we identified PAC payments within 90 days of hospitalization discharges and grouped hospitals into quintiles of PAC spending. The degree of variation present in PAC spending across hospital quintiles was evaluated after accounting for patient case-mix factors and hospital characteristics using multivariable regression models, adjusting for PAC setting choice by fixing the proportion of PAC discharge disposition across hospital quintiles, and adjusting for PAC intensity by fixing the amount of PAC spending across hospital quintiles. The study pool included 125,745 Medicare beneficiaries who underwent operative management for traumatic hip fracture in 2078 hospitals. The primary outcome was PAC spending within 90 days of discharge following hospitalization for traumatic hip fracture.

Results

Mean PAC spending varied widely between top versus bottom spending hospital quintiles ($31,831 vs $17,681). After price standardization, the difference between top versus bottom spending hospital quintiles was $8,964. Variation between hospitals decreased substantially after adjustment for PAC setting ($25,392 vs $21,274) or for PAC intensity ($25,082 vs $21,292) with little variation explained by patient or hospital factors.

Conclusions

There was significant variation in PAC payments after a traumatic hip fracture between the highest- and lowest-spending hospital quintiles. Most of this variation was explained by choice of PAC discharge setting and intensity of PAC spending, not patient or hospital characteristics. These findings suggest potential systems-level inefficiencies that can be targeted for intervention to improve the appropriateness and value of healthcare spending.

Association of Cognitive Impairment With Rate of Functional Gain Among Older Adults With Stroke

OBJECTIVES

This study explored the association between cognitive impairment at admission with self-care and mobility gain rate (amount of change per week) during a post-acute care stay (admission to discharge) for older adults with stroke.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Four inpatient rehabilitation and 6 skilled nursing facilities. A total of 100 adults with primary diagnosis of stroke; mean age 79 years (SD 7.7); 67% women.

METHODS

Retrospective cohort study. We evaluated the extent to which cognitive impairment at admission explained variation in weekly gain rate separately for self-care and mobility. Additional covariates were occupational and physical therapy minutes per day, self-care and mobility function at admission, age, and number of comorbidities.

RESULTS

Participants were classified as having severe (n = 16), moderate (n = 39), or mild (n = 45) cognitive impairment at admission. Occupational therapy minutes per day (β = 0.04; P < .01) and Functional Independence Measure (FIM) self-care function at admission (β = 0.48; P < .01) were both significantly associated with self-care gain rate (Adjusted R² = 0.18); cognitive impairment group, age, and number of comorbidities were not significant. Only FIM mobility function at admission (β = 0.29; P < .001) was significantly associated with mobility gain rate (Adjusted R² = 0.18); cognitive impairment group, physical therapy minutes, age, and number of comorbidities were not significant.

CONCLUSIONS AND IMPLICATIONS

These results provide preliminary evidence that patients with stroke who have severe cognitive impairment may benefit from intensive therapy services as well as less severely impaired patients, particularly occupational therapy for improvement in self-care function.

Predicting Need for Skilled Nursing or Rehabilitation Facility after Outpatient Total Hip Arthroplasty

Purpose

Outpatient classified total hip arthroplasty (THA) is a safe option for a select group of patients. An analysis of a national database was conducted to understand the risk factors for unplanned discharge to a skilled nursing facility (SNF) or acute rehabilitation (rehab) after outpatient classified THA.

Materials and Methods

A query of the National Surgical Quality Improvement Program (NSQIP) database for THA (Current Procedural Terminology [CPT] 27130) performed from 2015 to 2018 was conducted. Patient demographics, American Society of Anesthesiologists (ASA) classification, functional status, NSQIP morbidity probability, operative time, length of stay (LOS), 30-day reoperation rate, readmission rate, and associated complications were collected.

Results

A total of 2,896 patients underwent outpatient classified THA. The mean age of patients was 61.2 years. The mean body mass index (BMI) was 29.6 kg/m² with median ASA 2. The results of univariate comparison of SNF/rehab versus home discharge showed that a significantly higher percentage of females (58.7% vs. 46.8%), age >70 years (49.3% vs. 20.9%), ASA ≥3 (58.0% vs. 25.8%), BMI >35 kg/m² (23.3% vs. 16.2%), and hypoalbuminemia (8.0% vs. 1.5%) (P<0.0001) were discharged to SNF/rehab. The results of multivariable logistic regression showed that female sex (odds ratio [OR] 1.47; P=0.03), age >70 years (OR 3.08; P=0.001), ASA ≥3 (OR 2.56; P=0.001), and preoperative hypoalbuminemia (<3.5 g/dL) (OR 3.76; P=0.001) were independent risk factors for SNF/rehab discharge.

Conclusion

Risk factors associated with discharge to a SNF/rehab after outpatient classified THA were identified. Surgeons will be able to perform better risk stratification for patients who may require additional postoperative intervention.

Using comprehensive geriatric assessment for older adults undertaking a facility-based transition care program to evaluate functional outcomes: a feasibility study

BACKGROUND

The study aimed to evaluate the feasibility of using a comprehensive geriatric assessment (CGA) in a residential transition care setting to measure older adults' functional outcomes.

METHODS

A convenience sample of older adults (n = 10) and staff (n = 4) was recruited. The feasibility of using assessment tools that comprise a CGA to comprehensively measure function in physical, cognitive, social and emotional domains was evaluated pre- and post-rehabilitation.

RESULTS

10 older adults (mean ± SD age = 78.9 ± 9.1, n = 6 male) completed a CGA performed using assessments across physical, cognitive, social and emotional domains. The CGA took 55.9 ± 7.3 min to complete. Staff found CGA using the selected assessment tools to be acceptable and suitable for the transition care population. Older adults found the procedure to be timely and 60% found the assessments easy to comprehend. Participating in CGA also assisted older adults in understanding their present state of health. The older adults demonstrated improvements across all assessed domains including functional mobility (de Morton Mobility Index; baseline 41.5 ± 23.0, discharge 55.0 ± 24.0, p = 0.01) and quality of life (EQ-5D-5L; baseline 59.0 ± 21.7, discharge 78.0 ± 16.0, p < 0.01).

CONCLUSIONS

Incorporating CGA to evaluate functional outcomes in transition care using a suite of assessment tools was feasible and enabled a holistic assessment.

Factors Influencing Length of Stay and Discharge Destination of Patients with Hip Fracture Rehabilitating in a Private Care Setting

Background: Rehabilitation after a hip fracture has long-term importance, prompting some patients to utilise private services. Insufficient data regarding private rehabilitation in the UK can cause ambiguity and potential problems for all involved. Aim: The present study, involving patients with hip fractures rehabilitating in a private UK care setting, examined relationships between length of stay (LoS), discharge destination (DD) and 12 predictor variables. Methods: The variables included the retrospective measurement of the Functional Independence Measure. The variables were informed by a literature review and patient and public involvement. Retrospective data from the records of patients with hip fractures were utilised. Data were analysed using Spearman's rho, Mann-Whitney U, Kruskal-Wallis H and chi-squared tests as appropriate. Odds ratios, distribution quartiles and survivor analysis were also utilised. Results: The median length of stay (LoS) was 20.5 days: 82% returned home, 6.5% died and 11.5% remained as long-term residents. Significant relationships existed between LoS and age (p = 0.004), comorbidities (p = 0.001) and FIMadmission (p = 0.001). DD was associated with age (p = 0.007), delirium (p = 0.018), comorbidities (p = 0.001) and both FIMpre-fracture and FIMadmission (p = 0.000). Conclusions: Factors associated with length of stay were identified, but further research incorporating multiple sites is required for greater predictor precision. Discharge destination was evident by 90 days, facilitating long-term planning.

Team VA Video Connect (VVC) to optimize mobility and physical activity in post-hospital discharge older veterans: baseline assessment

Background

Telehealth is increasingly used for rehabilitation and exercise but few studies include older adult participants with comorbidities and impairment, particularly cognitive. Using Veterans Administration Video Connect (VVC), the aim of the present study is to present the screening, recruitment, baseline assessment, and initial telehealth utilization of post-hospital discharge Veterans in a VVC home-telehealth based program to enhance mobility and physical activity.

Methods

Older adult Veterans (n = 45, mean age 73), recently discharged from the hospital with physical therapy goals, were VVC-assessed in self-report and performance-based measures, using test adaptations as necessary, by a clinical pharmacy specialist and social worker team.

Results

Basic and instrumental ADL disabilities were common as were low mobility (Short Portable Performance Battery) and physical activity levels (measured by actigraphy). Half had Montreal Cognitive Assessment (MoCA) scores in the mild cognitive impairment range (< 24). Over 2/3 of the participants used VA-supplied tablets. While half of the Veterans were fully successful in VVC, 1/3 of these and an additional group with at least one failed connection requested in-person visits for assistance. One-quarter had no VVC success and sought help for tablet troubleshooting, and half of these eventually “gave up” trying to connect; difficulty with using the computer and physical impairment (particularly dexterity) were described prominently in this group. On the other hand, Veterans with at least mild cognitive impairment (based on MoCA scores) were present in all connectivity groups and most of these used caregiver support to facilitate VVC.

Conclusions

Disabled older post-hospital discharged Veterans with physical therapy goals can be VVC-assessed and enrolled into a mobility/physical activity intervention. A substantial proportion required technical support, including in-person support for many. Yet, VVC seems feasible in those with mild cognitive impairment, assuming the presence of an able caregiver. Modifications of assessment tools were needed for the VVC interface, and while appearing feasible, will require further study.

Trial registration

ClinicalTrials.gov NCT 04045054 05/08/2019.

Why and How to Demonstrate the Value of Rehabilitation Services

The health care delivery landscape in the United States is changing as payment models consider both costs and health outcomes, which are key components of value in health care. Without evidence about the effectiveness and costs of rehabilitation interventions, it is difficult to judge the value of rehabilitation interventions. Understanding the short- and long-term costs associated with implementing a rehabilitation intervention and the intervention's cost-effectiveness compared with other alternatives is critical to supporting decision-making by policymakers, health care administrators, and other decision makers. This article describes the policy context for considering the costs and outcomes of postacute care and rehabilitation interventions, introduces methods for assessing the value of rehabilitation interventions, and summarizes the challenges and opportunities associated with applying value measurement to rehabilitation services. Assessing the value of rehabilitation interventions is critical as we continue to identify, implement, and sustain evidence-based interventions that promote the health and function of people with disabilities.

Effectiveness of facility-based transition care on health-related outcomes for older adults: A systematic review and meta-analysis

BACKGROUND

Although Transition Care Programmes (TCP) are designed to assist older adults to regain functional ability after hospitalisation, it is unclear whether TCP improve older adults' health-related outcomes.

OBJECTIVES

The objective of the review was to synthesise the best available evidence for the effectiveness of TCP on health-related outcomes for older adults admitted to a transition care facility after hospitalisation.

METHODS

Searches were conducted using the databases PubMed, AMED (Ovid), Embase (Ovid), PscyINFO (Ovid) and CINAHL (Full text) and grey literature from January 2000 to May 2020 in English only. Studies that reported health-related outcomes of older adults (aged 65 and above) who received TCP in a facility setting were deemed eligible for inclusion following critical appraisal by two reviewers. Data were pooled in meta-analysis where possible, or reported narratively.

RESULTS

A total of 21 studies from seven countries [(n = 5 RCT, n = 16 observational cohort studies) participants' mean age 80.2 (±8.3)] were included. Pooled analysis (2069 participants, 7 studies) demonstrated that 80% of older adults undertaking TCP were discharged home [95% CI (0.78-0.82, p < 0.001), I² = 21.99%, very low GRADE evidence]. Proportions of older adults discharged home varied widely between countries (33.3%-86.4%). There was a significant improvement in ability to perform activities of daily living (2001 participants, 7 studies) as measured by the Modified Barthel Index [17.65 points (95% CI 5.68-29.62, p = 0.004), I²  = 0.00%, very low GRADE evidence].

CONCLUSIONS

The proportion of older adults discharged home from TCP compared to other discharge destinations differs between countries. This could be due to the intensity of the rehabilitation delivered and the maximum length of stay allowed prior to discharge.

IMPLICATIONS FOR PRACTICE

Future studies that comprehensively evaluate the efficacy of TCP on health-related outcomes including quality of life are required. Further investigation is required to identify which aspects of TCP affect successful discharge home.

Discharge Prediction for Patients Undergoing Inpatient Surgery: Development and validation of the DEPENDENSE score

BACKGROUND

A substantial proportion of patients undergoing inpatient surgery each year is at risk for postoperative institutionalization and loss of independence. Reliable individualized preoperative prediction of adverse discharge can facilitate advanced care planning and shared decision making.

METHODS

Using hospital registry data from previously home-dwelling adults undergoing inpatient surgery, we retrospectively developed and externally validated a score predicting adverse discharge. Multivariable logistic regression analysis and bootstrapping were used to develop the score. Adverse discharge was defined as in-hospital mortality or discharge to a skilled nursing facility. The model was subsequently externally validated in a cohort of patients from an independent hospital.

RESULTS

In total, 106 164 patients in the development cohort and 92 962 patients in the validation cohort were included, of which 16 624 (15.7%) and 7717 (8.3%) patients experienced adverse discharge, respectively. The model was predictive of adverse discharge with an area under the receiver operating characteristic curve (AUC) of 0.87 (95% CI 0.87-0.88) in the development cohort and an AUC of 0.86 (95% CI 0.86-0.87) in the validation cohort.

CONCLUSION

Using preoperatively available data, we developed and validated a prediction instrument for adverse discharge following inpatient surgery. Reliable prediction of this patient centered outcome can facilitate individualized operative planning to maximize value of care.

Causal variation modelling identifies large inter- and intra-regional disparities in physical therapy offered to hip fracture patients in Estonia

PURPOSE

An essential measure of hip fracture (HF) rehabilitation, the amount of physical therapy (PT) used per patient, has been severely understudied. This study (1) evaluates post-acute PT use after HF in Estonia, (2) presents causal variation modelling for examining inter- and intra-regional disparities, and (3) analyses its temporal trends.

MATERIALS AND METHODS

This retrospective cohort study used validated population-wide health data, including patients aged ≥50 years, with an index HF diagnosed between January 2009 and September 2017. Patients' 6-month PT use was analysed and reported separately for acute and post-acute phases.

RESULTS

While most of the included 11,461 patients received acute rehabilitation, only 40% of them received post-acute PT by a median of 6 h. Analyses based on measures of central tendency revealed 2.5 to 2.6-fold inter-regional differences in HF post-acute rehabilitation. Variation modelling additionally detected intra-regional disparities, showing imbalances in the fairness of allocating local rehabilitation resources between a county's patients.

CONCLUSIONS

This study demonstrates the advantages of causal variation modelling for identifying inter- and intra-regional disparities in rehabilitation. The analyses revealed persisting large multi-level disparities and accompanying overall inaccessibility of PT in HF rehabilitation in Estonia, showing an urgent need for system-wide improvements.Implications for rehabilitationThis study demonstrates the advantages of causal variation modelling for identifying inter- and intra-regional disparities in rehabilitation, using an essential outcome measure - used physical therapy hours.The study revealed large multi-level disparities and overall inaccessibility of physical therapy in hip fracture rehabilitation in Estonia, showing an urgent need for system-wide improvements.This study expands our knowledge on unstudied topics - hip fracture post-acute care and long-term physical therapy use.This regional analysis provides the first evidence-based regional-level basis for improving the rehabilitation system in Estonia.

A Simple Physical Therapy Algorithm Is Successful in Decreasing Skilled Nursing Facility Length of Stay and Increasing Cost Savings After Hip Fracture With No Increase in Adverse Events

Introduction:

Shorter length of stays (LOS) at a Skilled Nursing Facility (SNF) after hip fracture surgery would be expected to lead to costs savings for the healthcare system. Evidence also suggests that shorter SNF stays also leads to improved 30-day outcomes, thus compounding this value proposition. Our Integrated Fragility Hip Fracture Program created a simple algorithm at discharge to provide each post-operative hip fracture patient with an expected SNF LOS. We studied whether this intervention produced a shorter SNF LOS and other observable short-term outcomes.

Methods:

We retrospectively reviewed all original Medicare hip fracture patients treated with operative fixation who were admitted to our hospital in 2015, 2017 and 2018. We selected patients who were discharged to a single SNF following hospitalization, and excluded patients with incomplete records. The algorithm for the expected LOS recommendation was based on the degree of assistance the patient needed for ambulation: 7 days (“0-person assist”), 14 days (“1-person assist”), or 21 days (“2-person assist”). We compare the SNF LOS of our hip fracture patient population between those discharged to a program participant, those SNF that agreed to this algorithm, and those discharged to a non-program participant SNF.

Results:

We identified 246 patients meeting our selection criteria. 69 were discharged to a program participant SNF. Patients discharged to a participant SNF had similar baseline demographics and ASA distributions to those discharged to a non-participant provider. There was a statistically significant difference in length of stay between the groups, with program participant patients spending an average of 23 days at the SNF while the control group spent an average of 31 days. (p < 0.001). Program participant discharges were also associated with additional cost savings. There was no significant difference in ED visits within 90 days of discharge.

Discussion:

SNF LOS for geriatric hip fractures can be decreased with implementation of a simple physical therapy driven algorithm based on the patient’s ambulatory independence at hospital discharge. Conclusion: This is a simple, yet completely unique program that seems to have increased the value of healthcare provided.

Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review

OBJECTIVE

Exponential increases in rehabilitation intensity in skilled nursing facilities (SNFs) motivated recent changes in Medicare reimbursement policies, which remove financial incentives for providing more minutes of physical therapy, occupational therapy, and speech therapy. Yet, there is concern that SNFs will reduce therapy provision and patients will experience worse outcomes. The purpose of this systematic review was to synthesize current evidence on the relationship between therapy intensity and patient outcomes in SNFs.

METHODS

PubMed, Medline, Scopus, Embase, CINAHL, PEDro, and COCHRANE databases were searched. English-language studies published in the United States between 1998 and February 14, 2020, examining the relationship between therapy intensity and community discharge, hospital readmission, length of stay (LOS), and functional improvement for short-stay SNF patients were considered. Data extraction and risk of bias were performed using the American Academy of Neurology Classification of Evidence scale for causation questions. American Academy of Neurology criteria were used to assess confidence in the evidence for each outcome.

RESULTS

Eight observational studies met inclusion criteria. There was moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter LOS. One study provided very low-level evidence of associations between higher intensity therapy and lower hospital readmissions after total hip and knee replacement. There was low-level evidence indicating higher intensity therapy is associated with improvements in function.

CONCLUSIONS

This systematic review concludes with moderate confidence that higher intensity therapy in SNFs leads to higher community discharge rates and shorter LOS. Future research should improve quality of evidence on functional improvement and hospital readmissions.

IMPACT

This systematic review demonstrates that patients in SNFs may benefit from higher intensity therapy. Because new policies no longer incentivize intensive therapy, patient outcomes should be closely monitored to ensure patients in SNFs receive high-quality care.

Factors Associated with Duration of Rehabilitation Among Older Adults with Prolonged Hospitalization

BACKGROUND/OBJECTIVES

Older adults are prone to functional decline during prolonged hospitalization. Although rehabilitation therapy is critical to preserving function, little is known about rehabilitation duration (RD) in this population. We sought to determine the extent of rehabilitation therapy provided to older adults during prolonged hospitalization, and whether this differs by sociodemographic and clinical characteristics.

DESIGN

Retrospective cohort.

SETTING

Single-site safety-net hospital.

PARTICIPANTS

Older adults (≥65 years) hospitalized for ≥14 days between 2016 and 2017.

MEASUREMENTS

The primary outcome was RD, defined as the average number of minutes of physical and occupational therapy per week. We used a multivariable generalized linear model to assess for differences in RD by sociodemographic and clinical characteristics. For a sub-cohort of hospitalizations with a baseline mobility assessment, we repeated analyses including mobility limitation as a covariate.

RESULTS

Among 1,031 hospitalizations by 925 unique patients (median age 72, 49% female, 79% non-white, 40% non-English speaking), the median RD was 61.3 minutes/week (interquartile range = 16.5-127.3). Covariates associated with lesser RD included black (57.2 fewer minutes/week; 95% confidence interval (CI) = 22.9-91.4) and Hispanic (75.6 fewer minutes/week; 95% CI = 33.8-117.4) race/ethnicity, speaking a language other than English or Spanish (51.7 fewer minutes/week; 95% CI = 21.3-82.0), prolonged mechanical ventilation (30.0 fewer minutes/week; 95% CI = 6.6-53.3), and do-not-resuscitate code status (36.0 fewer minutes/week; 95% CI = 17.1-54.8). The inclusion of mobility limitation among the sub-cohort (n = 350) did not meaningfully change the associations.

CONCLUSION

We found large disparities in RD for racial/ethnic and language minorities and clinically vulnerable older adults (mechanical ventilation and do-not-resuscitate code status), independent of clinical severity and functional and cognitive impairment. Greater RD for these groups may improve functional outcomes and narrow the disparity gap.

Impact of Self-Care and Mobility on One or More Post-Acute Care Transitions

Objective: To investigate the association between functional status and post-acute care (PAC) transition(s). Methods: Secondary analysis of 2013-2014 Medicare data for individuals aged ≥66 years with stroke, lower extremity joint replacements, and hip/femur fracture discharged to one of three PAC settings (inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies). Functional scores were co-calibrated into a 0-100 scale across settings. Multilevel logistic regression was used to test the partition of variance (%) and the probability of PAC transition attributed to the functional score in the initial PAC setting. Results: Patients discharged to inpatient rehabilitation facilities with higher function were less likely to use additional PAC. Function level in an inpatient rehabilitation facility explained more of the variance in PAC transitions than function level while in a skilled nursing facility. Discussion: The function level affected PAC transitions more for those discharged to an inpatient rehabilitation facility than to a skilled nursing facility.

Association of Therapy Time Per Day With Functional Outcomes and Rate of Recovery in Older Adults After Elective Joint Replacement Surgery

OBJECTIVES

To explore the association between therapy minutes per length of stay (LOS) day (TMLD), functional outcomes, and rate of functional recovery among older adults after elective hip or knee replacement surgery across postacute (PAC) settings.

DESIGN

Secondary analysis of data collected for an observational cohort study from 2005 to 2010.

SETTING

Four inpatient rehabilitation facilities (IRF) and 7 skilled nursing facilities (SNF).

PARTICIPANTS

Adults aged 65 years or older (N=162) with Medicare fee-for-service insurance and a primary diagnosis of elective hip or knee replacement.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

FIM mobility and self-care measures at discharge.

RESULTS

The TMLD was divided into high, medium, and low categories. Participants were grouped into low, medium, and high gain rate groups based on their average change in mobility and self-care FIM measures per LOS day. Gain rate and TMLD groups were crossmapped to create 9 gain-TMLD groups separately for mobility and self-care. There were no significant differences in admission mobility or self-care measures by gain rate and TMLD trajectory or by facility type (IRF or SNF). TMLD was not significantly associated with discharge mobility measures. Participants in high gain trajectories attained independence with mobility and self-care tasks at discharge regardless of TMLD. Those in low gain trajectories needed supervision or assistance on all mobility tasks. Older age and greater pain at discharge were significantly associated with lower odds of being in the medium or high gain rate groups.

CONCLUSIONS

For clinicians and facility managers who must care for patients with constrained resources, the shift to value-based reimbursement for rehabilitation services in PAC settings has reinvigorated the question of whether the duration of therapy provided influences patient outcomes. Three hours of daily therapy after joint replacement surgery may exceed what is necessary for recovery. Postsurgical pain management remains a significant challenge in older adults.

Functional Recovery Rate: A Feasible Method for Evaluating and Comparing Rehabilitation Outcomes Between Skilled Nursing Facilities

OBJECTIVES

The recovery of patients' physical function and the rate at which this occurs are important parameters for evaluating value in post-acute care (PAC). However, no metrics are presently used to compare skilled nursing facilities (SNFs) based on the functional recovery rates (FRRs) for patients in their care. The objectives of this study were to examine whether the average FRR differed significantly among SNFs and to compare the FRR to other measures currently used to assess care quality in SNFs.

DESIGN

Retrospective observational study.

SETTING AND PARTICIPANTS

3913 patients discharged from hospitals in one health system to one of 10 partner SNFs between January 2017 and September 2019.

METHODS

The FRR-the difference in Activity Measure for Post-Acute Care 6-Clicks basic mobility score from SNF admission to discharge relative to the SNF length of stay (in days)-was the primary outcome. Secondary outcomes included metrics from the SNF Quality Reporting Program (functional recovery alone, discharge to the community, and 30-day hospital readmission). Differences in patients' outcomes between SNFs were tested using multiple regression in order to adjust for patient characteristics.

RESULTS

Across the 10 SNFs, the highest adjusted mean FRR was 0.70 [95% confidence interval (CI): 0.55, 0.90] and the lowest was 0.39 (95% CI: 0.33, 0.46) points per day. Two SNFs had an adjusted mean FRR statistically higher, and 2 had an FRR statistically lower, than the sample mean (0.50, 95% CI: 0.48-0.52). SNF rankings varied by metric.

CONCLUSIONS AND IMPLICATIONS

Individual SNFs vary in their mean FRR for patients making it a potentially useful measure of value for comparing SNFs. Standardized measurement and reporting of FRR could be beneficial to patients and their families as they consider specific SNFs for necessary post-acute rehabilitation and to hospital systems seeking to identify high-value PAC providers with whom to partner in collaborative care models.

Systematic review of clinical practice guidelines for adults with fractures: identification of best evidence for rehabilitation to develop the WHO's Package of Interventions for Rehabilitation

BACKGROUND

The identification of existing rehabilitation interventions and related evidence represents a crucial step along the development of the World Health Organization's (WHO) Package of Interventions for Rehabilitation (PIR). The methods for such identification have been developed by the WHO Rehabilitation Programme and Cochrane Rehabilitation under the guidance of the WHO's Guideline Review Committee secretariat. The aim of this paper is to report on the results of the systematic search for clinical practice guidelines (CPGs) relevant to the rehabilitation of adults with fractures and to present the current state of evidence available from the identified CPGs.

METHODS

This paper is part of the Best Evidence for Rehabilitation (be4rehab) series, developed according to the methodology presented in the World Health Organization's (WHO) Package of Interventions for Rehabilitation (PIR) introductory paper. It is a systematic review of existing CPGs on fractures in adult population published from 2009 to 2019.

RESULTS

We identified 23 relevant CPGs after title and abstract screening. According to inclusion/exclusion criteria, we selected 13 CPGs. After checking for quality, publication time, multiprofessionality, and comprehensiveness, we finally included five CPGs dealing with rehabilitative management of fractures in adult population, two CPGs addressing treatment of distal radius fracture and three the treatment of femoral/hip fracture.

CONCLUSION

The selected CPGs on management of distal radius and femoral/hip fracture include few recommendations regarding rehabilitation, with overall low to very low quality of evidence and weak/conditional strength of recommendation. Moreover, several gaps in specific rehabilitative topics occur. Further high-quality trials are required to upgrade the quality of the available evidence.

LEVEL OF EVIDENCE

Level 1.

Combining Items From 3 Federally Mandated Assessments Using Rasch Measurement to Reliably Measure Cognition Across Postacute Care Settings

OBJECTIVE

To combine items from the Functional Independence Measure, Minimum Data Set (MDS) 2.0, and the Outcome and Assessment Information Set (OASIS)-B to reliably measure cognition across postacute care settings and facilitate future studies of patient cognitive recovery.

DESIGN

Rasch analysis of data from a prospective, observational cohort study.

SETTING

Postacute care inclusive of inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies.

PARTICIPANTS

Patients (N=147) receiving rehabilitation services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional Independence Measure, MDS 2.0, and the OASIS-B.

RESULTS

Six cognition items demonstrated good construct validity with no misfitting items, unidimensionality, good precision (person separation reliability, 0.95), and an item hierarchy that reflected a clinically meaningful continuum of cognitive challenge.

CONCLUSIONS

This is the first attempt to combine the cognition items from the 3 historically, federally mandated assessments to create a common metric for cognition. These 6 items could be adopted as standardized patient assessment data elements to improve cognitive assessment across postacute care settings.

Postacute Care Disposition for Total Hip and Total Knee Replacement Surgery for Asian Americans

This study explored differences in postacute disposition for total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a focus on whether Asian Americans (AS) experience joint replacement disparities observed in other racial/ethnic minorities compared with majority white patients. We used data from the Nationwide Inpatient Sample for 2009 through 2012. We looked at disposition to home health care (HHC) and transfer to another facility for postacute care (e.g., skilled nursing facility, rehabilitation facility) for each of the 4 years under study. Findings for AS were mixed. There were differences in discharge to postacute facilities other than HHC for AS compared with whites for THA for 2011 and 2012. For TKA, there were differences in disposition to HHC for Asians compared with whites for 2009 and 2012; for disposition to postacute facilities other than HHC for TKA, there were differences for 2011 and 2012 only. Differences for AS in postacute disposition to facilities other than HHC appear to increase over the 4 years of the study. Further research with additional data is warranted.

Association of Length of Stay, Recovery Rate, and Therapy Time per Day With Functional Outcomes After Hip Fracture Surgery

IMPORTANCE

Medicare is shifting from payment for postacute care services based on the volume provided to payment based on value as determined by patient characteristics and functional outcomes. Matching therapy time and length of stay (LOS) to patient needs will be critical to optimize functional outcomes and manage costs.

OBJECTIVE

To investigate the association among therapy time, LOS, and functional outcomes for patients following hip fracture surgery.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study analyzed data on patients from 4 inpatient rehabilitation facilities and 7 skilled nursing facilities in the eastern and midwestern United States. Participants were patients aged 65 years or older who received inpatient rehabilitation services for hip fracture and had Medicare fee-for-service as their primary payer. Data were collected from 2005 to 2010. Analysis was conducted from November 2018 to June 2019.

EXPOSURE

Therapy minutes per LOS day.

MAIN OUTCOMES AND MEASURES

Functional Independence Measure mobility and self-care measures at discharge. Patients were categorized into 9 recovery groups based on low, medium, or high therapy minutes per LOS day and low, medium, or high rate of functional gain per day.

RESULTS

A total of 150 patients (101 [67.3%] female; 148 [98.6%] white; mean [SD] age, 82.0 [7.3] years) met inclusion criteria. Participants in all gain and therapy minutes per LOS day trajectories were similar in function at rehabilitation admission (mean [SD] mobility, 16.2 [3.2]; F8,141 = 1.26; P = .27) but differed significantly at discharge (mean [SD] mobility, 23.9 [5.2]; F8,141 = 14.34; P < .001). High-gain patients achieved mobility independence by discharge; low-gain patients needed assistance on nearly all mobility tasks. Medium-gain patients with a mean LOS of 27 days were independent in mobility at discharge; those with a mean LOS less than 21 days needed supervision with toilet transfers and were dependent with stairs. Length of stay and functional gain rate explained much of the variance in mobility and self-care scores at discharge. Although medium- and high-therapy minutes per LOS day groups were statistically significant in the regression model (β = 6.99; P = .001; and β = 11.46; P = .007, respectively), they explained only 1% of the variance in discharge outcome. Marginal means suggest that medium-gain patients with shorter LOS would have achieved mobility independence if LOS had been extended.

CONCLUSIONS AND RELEVANCE

In this study, rate of recovery and LOS in skilled nursing and inpatient rehabilitation facilities were associated with mobility and self-care outcomes at discharge following hip fracture surgery, particularly for medium-gain patients. Therapy time per day explained only 1% of the variance in discharge outcome. Discharging medium-gain patients before 21 days LOS may transfer burden of care to family and caregivers, home health, and outpatient services.

Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities

IMPORTANCE

Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes.

OBJECTIVE

To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019.

EXPOSURES

Inpatient rehabilitation received in IRFs vs SNFs.

MAIN OUTCOMES AND MEASURES

Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders.

RESULTS

Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses.

CONCLUSIONS AND RELEVANCE

In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

Continuity of care for patients with hip fracture after discharge from rehabilitation facility

Background and aims of the work: Hip fracture is a dramatic event especially in the elderly and the return to the pre-fracture functional and social state is often difficult to achieve. In the post-acute, the intensive rehabilitation period aims to recover as much autonomy as possible to these patients, but not always its duration is sufficient to ensure an effective and lasting result in returning home, hence the need for additional rehabilitation services. Our aim was to evaluate the use of additional rehabilitation services by patients who underwent hip fracture after an intensive rehabilitation treatment period performed at our hospital. Methods: This is a retrospective cohort study. We involved patients aged 45 years and older, admitted at our intensive rehabilitation, who joined a rehabilitation program for a hip fracture. Results: Our results showed how the use of further physiotherapy is associated with the type of surgical intervention and with higher Cumulative Illness Rating Scale CIRS scores. Similarly, the loss of autonomy is associated with the type of intervention, the increase in CIRS and the duration of the physiotherapy, and negatively associated with the duration of each session. The re-hospitalizations for each cause is positively associated with CIRS and negatively associated with the further use of physiotherapy. Conclusions: Our conclusion is that rehabilitation needs a personalized schedule, because the real discriminating factor in the management of frail patients should therefore be the quality, and not the quantity (i.e. longer session), of the rehabilitative intervention prescribed. (www.actabiomedica.it)

Community rehabilitation interventions after hip fracture: Pragmatic evidence-based practice recommendations

Practice development enables practitioners to develop their knowledge and allows the application of evidence-based care for their patients. It happens within the practitioner's own clinical practice area and enhances personal and professional growth whilst focusing on patients' specific needs. This is important when working with patients in the rehabilitation phase following fragility hip fracture whose care should be provided by practitioners knowledgeable about the best way to approach their needs. This article, which followed the methods for a scoping review, aims to provide the practitioner with an overview of rehabilitation interventions for patients following hip fracture discussed in the literature. There is an introduction to the nature of rehabilitation and the issues raised for the patient with a hip fracture, a discussion of the existing literature, and recommendations for practice based on both that evidence and a pragmatic approach to care. Scoping reviews provide overviews of broad topic areas (Peterson et al., 2017). This gives the reader the opportunity to consider how other factors, besides research evidence, can contribute to best practice and to reflect on how their own practice needs to develop. At the end of the discussion, an overview of pragmatic recommendations for practice is provided based on the findings of the literature considered. Some points for individual reflection are also provided to help the practitioner to consider how the contents of the paper might impact on their own practice.

The congressional mandate: standardised post-acute care quality measures

Background/Aims

This study describes the relationships between rehabilitation services intensity, post-acute care measures of Functional Performance Change, and length of stay for episodes of care provided in 93 skilled nursing facilities in the US.

Methods

The study used a secondary analysis of existing data on Medicare beneficiaries admitted to skilled nursing facilities from acute hospitals (n=518) who subsequently returned to the community. Data were selected from Minimum Data Set Section GG items reported by therapists.

Results

Statistically significant correlations were identified between rehabilitation services intensity and functional outcomes (P<0.001); and between rehabilitation intensity, medical condition, and length of stay (P<0.001) for rehabilitation patients in skilled nursing facilities.

Conclusions

The intensity of occupational and physical rehabilitation therapy services correlate with patients achieving higher functional outcomes, specifically improvement in self-care and mobility.

Changes in Discharge to Rehabilitation: Potential Unintended Consequences of Medicare Total Hip Arthroplasty/Total Knee Arthroplasty Bundled Payments, Should They Be Implemented on a Nationwide Scale?

BACKGROUND

As a part of the 2010 Affordable Care Act, Medicare was committed to changing 50% of its reimbursement to alternative payment models by 2018. One strategy included introduction of "bundled payments" or a fixed price for an episode of care. Early studies of the first operative bundles for elective total hip and knee arthroplasty (THA/TKA) suggest changes in discharge to rehabilitation. It remains unclear the extent to which such changes affect patient well-being. In order to address these concerns, the objective of this study is to estimate projected changes in discharge to various type of rehabilitation, 90-day outcomes, extent of therapy received, and patient health-related quality-of-life before and after introduction of bundled payments should they be implemented on a nationwide scale.

METHODS

A nationwide policy simulation was conducted using decision-tree methodology in order to estimate changes in overt and patient-centered outcomes. Model parameters were informed by published research on bundled payment effects and anticipated outcomes of patients discharged to various types of rehabilitation.

RESULTS

Following bundled payment introduction, discharge to inpatient rehabilitation facilities decreased by 16.9 percentage-points (95% confidence interval [CI] 16.5-17.3) among primary TKA patients (THA 16.8 percentage-points), a relative decline from baseline of 58.9%. Skilled nursing facility use fell by 24.0 percentage-points (95% CI 23.6-24.4). It was accompanied by a 36.7 percentage-point (95% CI 36.3-37.2) increase in home health agency use. Although simulation models predicted minimal changes in overt outcome measures such as unplanned readmission (TKA +0.8 percentage-points), changes in discharge disposition were accompanied by significant increases in the need for further assistive care (TKA +8.0 percentage-points) and decreases in patients' functional recovery and extent of therapy received. They collectively accounted for a 30% reduction in recovered motor gains.

CONCLUSION

The results demonstrate substantial changes in discharge to rehabilitation with accompanying declines in average functional outcomes, extent of therapy received, and health-related quality-of-life. Such findings challenge notions of reduced cost at no harm previously attributed to the bundled payment program and lend credence to concerns about reductions in access to facility-based rehabilitation.

Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility

IMPORTANCE

Use of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care.

OBJECTIVE

To investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary's home zip code and the closest home health agency and the closest skilled nursing facility as an instrument.

EXPOSURES

Receipt of postacute care at home vs in a skilled nursing facility.

MAIN OUTCOMES AND MEASURES

Readmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode.

RESULTS

A total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean [SD] age, 80.5 [7.9] years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P = .02). There were no significant differences in 30-day mortality rates (-2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (-1.9 percentage points; 95% CI, -12.0 to 8.2; P = .71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility (-$5384; 95% CI, -$6932 to -$3837; P < .001), as was total Medicare payment within the first 60 days after admission (-$4514; 95% CI, -$6932 to -$3837; P < .001).

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries eligible for postacute care at home or in a skilled nursing facility, discharge to home with home health care was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments.

Predictors of In-Hospital Ambulatory Status Following Low-Energy Hip Fracture Surgery

Introduction:

Twenty-five percent to seventy-five percent of independent patients do not walk independently after hip fracture (HF), and many patients experience functional loss. Early rehabilitation of functional status is associated with better long-term outcomes; however, predictors of early ambulation after HF have not been well described.

Purposes:

To assess the impact of perioperative and patient-specific variables on in-hospital ambulatory status following low-energy HF surgery.

Methods:

This is a retrospective analysis of 463 geriatric patients who required HF surgery at a metropolitan level-1 trauma center. The outcomes were time to transfer (out of bed to chair) and time to walk.

Results:

Three hundred ninety-two (84.7%) patients were able to transfer after surgery with a median time of 43.8 hours (quartile range: 24.7-53.69 hours), while 244 (52.7%) patients were able to walk with a median time of 50.86 hours (quartile range: 40.72-74.56 hours). Preinjury ambulators with aids (hazard ratio [HR]: 0.70, confidence interval [CI]: 0.50-0.99), age >80 years (HR: 0.66, CI: 0.52-0.84), peptic ulcer disease (HR: 0.57, CI: 0.57-0.82), depression (HR: 0.66, CI: 0.49- 0.89), time to surgery >24 hours (HR: 0.77, CI: 0.61-0.98), and surgery on Friday (HR: 0.73, CI: 0.56-0.95) were associated with delayed time to transfer. Delayed time to walk was observed in patients over 80 years old (HR: 0.74, CI: 0.56-0.98), females (HR: 0.67, CI: 0.48-0.94), peptic ulcer disease (HR: 0.23, CI: 0.84-0.66), and depression (HR: 0.51, CI: 0.33-0.77).

Conclusions:

Operative predictors of delayed time to transfer were surgery on Friday and time to surgery >24 hours after admission. Depression is associated with delayed time to transfer and time to walk. These data suggest that is important to perform surgeries within 24 hours of admission identify deficiencies in care during the weekends, and create rehabilitation programs specific for patient with depression. Improving functional rehabilitation after surgery may facilitate faster patient discharge, decrease inpatient care costs, and better long-term functional outcomes.

Age Alone Does Not Predict Complications, Length of Stay, and Cost for Patients Older Than 90 Years With Hip Fractures

The purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years. Patients 60 years and older with hip fractures treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patient demographics, comorbidities, length of stay, procedure performed, and inpatient complications were analyzed. Total cost of admission was obtained from the hospital finance department. Outcomes were compared between patients older than 90 years and patients younger than 90 years. A total of 500 patients with hip fractures were included in this study. There were 109 (21.8%) patients 90 years and older and 391 (78.2%) patients 60 to 89 years. There was no difference in fracture pattern, operation performed, Charlson Comorbidity Index, or length of stay between the 2 groups. The mean length of stay for patients 90 years and older with hip fractures was 7.8±4.3 days vs 7.6±4.2 days for the younger cohort (P=.552). There was no observed difference in perioperative complications. Finally, there was no difference in the total mean cost of admission. Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. [Orthopedics. 2019; 42(1):e51-e55.].

Post-acute Transitional Journey: Caring for Orthopedic Surgery Patients in the United States

As the geriatric population in the United States continues to age, there will be an increased demand for total hip and total knee arthroplasties (THAs and TKAs). Older patients tend to have more comorbidities and poorer health, and will require post-acute care (PAC) following discharge. The most utilized PAC facilities following THA and TKA are skilled nursing facilities (SNFs), in-patient rehabilitation facilities (IRFs), and home with home health care (HHC). Coordination of care between hospitals and PACs, including the complete transfer of patient information, continues to be a challenge which impacts the quality of care provided by the PACs. The increased demand of hospital resources and PACs by the geriatric population necessitates an improvement in this transition of care process. This review aims to examine the transition of care process currently utilized in the United States for orthopedic surgery patients, and discuss methods for improvement. Employing these approaches will play a key role in improving patient outcomes, decreasing preventable hospital readmissions, and reducing mortality following THA and TKA. The extensive nature of this topic and the ramification of different types of healthcare systems in different countries were the determinant factors limiting our work.

Residual Disability, Mortality, and Nursing Home Placement After Hip Fracture Over 2 Decades

OBJECTIVE

To examine trends in 12-month postfracture residual disability, nursing home placement, and mortality among patients with a hip fracture between 1990 and 2011.

DESIGN

Secondary analysis of 12-month outcomes from 3 cohort studies and control arms of 2 randomized controlled trials.

SETTING

Original studies were conducted as part of the Baltimore Hip Studies (BHS).

PARTICIPANTS

Community-dwelling patients ≥65 years of age hospitalized for surgical repair of a nonpathologic hip fracture (N=988).

MAIN OUTCOME MEASURES

Twelve-month residual disability, mortality, and nursing home residency were examined in case-mix adjusted models by sex and study. Residual disability was calculated by subtracting prefracture scores of Lower Extremity Physical Activities of Daily Living from scores at 12 months postfracture. We also examined the proportion of individuals with a 12-month score higher than their prefracture score (residual disability>0).

RESULTS

Only small improvements were seen in residual disability between 1990 and 2011. No significant differences were seen for men between BHS2 (enrollment 1990-1991; mean residual disability=3.1 activities; 95% confidence interval [CI], 2.16-4.10) and BHS7 (enrollment 2006-2011; mean=3.1 activities; 95% CI, 2.41-3.82). In women, residual disability significantly improved from BHS2 (mean=3.5 activities; 95% CI, 2.95-3.99) to BHS3 (enrollment 1992-1995; mean=2.7 activities; 95% CI, 2.01-3.30) with no significant improvements in later studies. After adjustment, a substantial proportion (91% of men and 79% of women) had a negative outcome (residual disability, died, or nursing home residence at 12 months) in the most recently completed study (BHS7).

CONCLUSIONS

Over 2 decades, patients undergoing usual care post-hip fracture still had substantial residual disability. Additional clinical and research efforts are needed to determine how to improve hip fracture treatment, rehabilitation, and subsequent outcomes.

Readmission Patterns Over 90-Day Episodes of Care Among Medicare Fee-for-Service Beneficiaries Discharged to Post-acute Care

OBJECTIVE

Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings.

DESIGN

Retrospective cohort study.

SETTING

Acute care hospitals.

PARTICIPANTS

Medicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge.

MEASUREMENTS

90-day unplanned readmissions.

RESULTS

The cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings.

CONCLUSIONS

We observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care.

Effectiveness of a Model Bundle Payment Initiative for Femur Fracture Patients

OBJECTIVES

To analyze the effectiveness of a Bundled Payment for Care Improvement (BPCI) initiative for patients who would be included in a future potential Surgical Hip and Femur Fracture Treatment bundle.

DESIGN

Retrospective cohort.

SETTING

Single Academic Institution.

PATIENTS/PARTICIPANTS

Patients discharged with operative fixation of a hip or femur fracture (Diagnosis-Related Group codes 480-482) between January 2015 and October 2016 were included. A BPCI initiative based on an established program for BPCI total joint arthroplasty was initiated for patients with hip and femur fractures in January 2016. Patients were divided into nonbundle (care before initiative) and bundle (care with initiative) cohorts.

INTERVENTION

Application of BPCI principles.

MAIN OUTCOME MEASURES

Length of stay, location of discharge, and readmissions.

RESULTS

One hundred sixteen patients participated in the "institutional bundle," and 126 received care before the initiative. There was a trend toward decreased mean length of stay (7.3 ± 6.3 days vs. 6.8 ± 4.0 days, P = 0.457) and decreased readmission within 90 days (22.2% vs. 18.1%, P = 0.426). The number of patients discharged home doubled (30.2% vs. 14.3%, P = 0.008). There was no difference in readmission rates in bundle versus nonbundle patients based on discharged home status; however, bundle patients discharged to a skilled nursing facility trended toward less readmissions than nonbundle patients discharged to a skilled nursing facility (37.3% vs. 50.6%, P = 0.402). Mean episode cost reduction due to initiative was estimated to be $6450 using Medicare reimbursement data.

CONCLUSION

This study demonstrates the potential success of a BPCI initiative at 1 institution in decreasing postacute care facility utilization and cost of care when used for a hip and femur fracture population.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical Technical Evidence Review of Hip Fracture Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Background:

Enhanced recovery pathways (ERPs) have been shown to improve patient outcomes in a variety of contexts. This review summarizes the evidence and defines a protocol for perioperative care of patients with hip fracture and was conducted for the Agency for Healthcare Research and Quality safety program for improving surgical care and recovery.

Study Design:

Perioperative care was divided into components or “bins.” For each bin, a semisystematic review of the literature was conducted using MEDLINE with priority given to systematic reviews, meta-analyses, and randomized controlled trials. Observational studies were included when higher levels of evidence were not available. Existing guidelines for perioperative care were also incorporated. For convenience, the components of care that are under the auspices of anesthesia providers will be reported separately. Recommendations for an evidence-based protocol were synthesized based on review of this evidence.

Results:

Eleven bins were identified. Preoperative risk factor bins included nutrition, diabetes mellitus, tobacco use, and anemia. Perioperative management bins included thromboprophylaxis, timing of surgery, fluid management, drain placement, early mobilization, early alimentation, and discharge criteria/planning.

Conclusions:

This review provides the evidence basis for an ERP for perioperative care of patients with hip fracture.

Planning post-discharge destination for gastrointestinal surgery patients: Room for improvement?

BACKGROUND

We compared short-term recovery for patients discharged to inpatient rehabilitation versus skilled nursing facilities after gastrointestinal surgery.

MATERIALS & METHODS

We conducted a propensity-matched cohort study of 12,939 adults discharged to inpatient rehabilitation or skilled nursing facilities after colectomy, pancreatectomy or hepatectomy at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2014. Primary outcomes were readmission and mortality rates 30 days after surgery.

RESULTS

9259 (72%) patients were discharged to skilled nursing facilities and 3680 (28%) to inpatient rehabilitation. Median age in both groups was 76 years and 82% of patients were white. There was no difference in 30-day readmission rates (16% for skilled nursing vs 16.8% for inpatient rehabilitation) but post-discharge mortality was higher for patients discharged to skilled nursing facilities (4.4%) compared to inpatient rehabilitation (1.6%, p < 0.001).

CONCLUSIONS

Increased utilization of inpatient rehabilitation services after gastrointestinal surgery may improve postoperative outcomes.

Health Services Research in Rehabilitation and Disability-The Time is Now

Policy drives practice, and health services research (HSR) is at the intersection of policy, practice, and patient outcomes. HSR specific to rehabilitation and disability is particularly needed. As rehabilitation researchers and providers, we are uniquely positioned to provide the evidence that guides reforms targeting rehabilitative care. We have the expertise to define the value of rehabilitation in a policy-relevant context. HSR is a powerful tool for providing this evidence. We need to continue building capacity for conducting rigorous, timely rehabilitation-related HSR. Fostering stakeholder engagement in these research efforts will ensure we maintain a patient-centered focus as we address the "Triple Aim" of better care, better health, and better value. In this Special Communication we discuss the role of rehabilitation researchers in HSR. We also provide information on current resources available in our field for conducting HSR and identify gaps for capacity building and future research. Health care reforms are a reality, and through HSR we can give rehabilitation a strong voice during these transformative times.

Justifying Rehabilitation Intensity Through Functional Performance Measures in Postacute Care

The Centers for Medicare and Medicaid Services (CMS) has scrutinized the provision of rehabilitation services in skilled nursing facilities (SNFs) for some time. Little research guidance exists on appropriate dosage or rehabilitation intensity (RI) among SNF patients or patients in other postacute care (PAC) settings. CMS developed a PAC assessment, the Continuity Assessment Record and Evaluation (CARE) Tool, in response to questions about what issues drive placement in various PAC settings under Medicare. The ability to adequately assess functional outcomes and correlate them to the RI provided by using the CARE Tool is promising. However, further research, policy advocacy, and practice analysis must be undertaken to promote and protect adequate access to occupational therapy and physical therapy in SNFs and other PAC settings. Individual practitioners must participate in data gathering to ensure that the data for analysis are fully informed by the occupational therapy perspective.

Functional outcomes after inpatient rehabilitation for trauma-improved but unable to return home

BACKGROUND

Twenty-five percent of trauma patients are discharged to postacute care, indicating a loss of physical function and need for rehabilitation. The purpose of this study was to quantify the functional improvements in trauma patients discharged from inpatient rehabilitation facility (IRF) and identify predictors of improvement.

MATERIALS AND METHODS

A retrospective cohort study of trauma patients aged ≥ 18 years were admitted to an IRF after discharge from a level-1 trauma center. Data included demographics, injury characteristics, hospital, and IRF course. The functional independence measure (FIM) was used to measure change in physical and cognitive function.

RESULTS

There were 245 patients with a mean age of 55.8 years and mean injury severity score (ISS) of 14.7. Fall was the leading mechanism of injury (45.7%). On IRF admission, 50.7% of patients required moderate or greater assistance. On discharge, the mean intraindividual change in FIM score was 29.9; 85.4% of the patients improved by ≥1 level of functioning. Before injury, 99.6% of patients were living at home, but only 56.0% were discharged home from the IRF, despite 81.8% requiring minimal assistance at most (23.5% to skilled nursing; 19.7% readmitted). Increasing age and lower ISS were associated with less FIM improvement, and increasing ISS was associated with increased FIM improvement.

CONCLUSIONS

More than 80% of the trauma patients experienced meaningful functional improvements during IRF admission. However, only half were discharged home, and a quarter required further institutional care. Further research is needed to identify the additional impediments to return to preinjury functioning.