Initial Recovery Trajectories Among Patients With Hip Fracture: A Conceptual Approach to Exploring Comparative Effectiveness in Postacute Care

Patient reported outcomes measures (PROMs) trajectories after elective hip arthroplasty: a latent class and growth mixture analysis

Background

Patient-reported outcome measures (PROMs) are an extensively used tool to assess and improve the quality of healthcare services. PROMs can be related to individual demographic and clinical characteristics in patients undergoing hip arthroplasty (HA). The aim of this study is to identify distinct subgroups of patients with unique trajectories of PROMS scores and to determine patients’ features associated with these subgroups.

Methods

We conducted a prospective, cohort study in which PROMs questionnaires (Euro Quality 5 Dimensions 3L, EQ-5D-3L, Euro-Quality-Visual-Analytic-Score, EQ-VAS, Hip disability and Osteoarthritis Outcome Score, HOOS-PS) were administered to patients undergoing elective HA pre-operatively, and at 6 and 12 months after surgery. For each measure, latent class growth analysis and growth mixture models were used to identify subgroups of patients with distinct trajectories of scores. Demografic and clinical predictors of the latent classes in growth mixture model were identified using a 3-step approach.

Results

We found three distinct trajectories for each PROM score. These trajectories indicated a response heterogeneity to the HA among the patients (n = 991). Patient’s gender, ASA score, and obesity were significantly associated with different PROMs trajectories.

Conclusions

We identified three distinct trajectories for each of the three PROMs indicators. Several demographic and clinical characteristics are associated with the different trajectories of PROMs at 6 and 12 months after HA and could be used to identify groups of patients with different outcomes following HA surgery. These findings underline the importance of patient-centered care, supporting the usefulness of integrating PROMs data alongside routinely collected healthcare records for guiding clinical care and maximizing patients’ positive outcomes.

Trial registration: Protocol version (1.0) and trial registration data are available on the platform www.clinicaltrial.gov with the identifier NCT03790267, posted on December 31, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00503-5.

Examining trajectories of hospital readmission in older adults hospitalised with hip fracture from residential aged care and the community

Hip fracture trajectories have not been examined for older adults in aged care or living in the community. Trajectories of health care use were defined by distinct predictive factors. These results can inform the development of targeted strategies to reduce health service use following hip fracture.

OBJECTIVE

To examine hospital service use trajectories of older adults who were hospitalised for hip fracture and living in a residential aged care facility (RACF) or the community, and to identify factors predictive of trajectory group membership. These findings may inform future programmes aimed at reducing unexpected hospitalisations and subsequently reduce health care costs.

METHODS

A group-based trajectory analysis of hospitalisations was conducted for adults aged ≥ 65 years hospitalised for hip fracture during 2008-2009 in New South Wales, Australia. Linked hospitalisation and RACF data were examined for a 5-year period. Group-based trajectory models were derived for RACF and community-dwelling older adults based on the number of subsequent hospital admissions following the index hip fracture. Multinomial logistic regression examined predictors of trajectory group membership for subsequent hospital admissions.

RESULTS

There were 5752 hip fracture hospitalisations, with two-thirds of hip fractures occurring in community-dwellers. Key predictors of trajectory group membership for both RACF residents and community-dwellers were age group, sex, hospital length of stay and cognitive impairment. Assistance with activities of daily living and complex health care needs were also predictive of group membership in RACF residents. Location of residence and time to move to a RACF were additional predictors of group membership for community-dwellers.

CONCLUSION

Health service use trajectories differed for RACF residents and community-dwellers; however, there were similar patient characteristics that defined trajectory group membership. Low users of hospital services living in RACFs or the community included older adults with generally unfavourable health conditions, potentially indicating that palliative care or advanced care directives and community-care initiatives, respectively, have played a part in the lowered frequency of rehospitalisation.

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.

Variation in Rehabilitation Treatment Patterns for Hip Fracture Treated With Arthroplasty

BACKGROUND

Recommendations for health care redesign often advocate for comparative effectiveness research that is patient-centered. For patients who require rehabilitation services, a first step in this research process is to understand current practices for specific patient groups.

OBJECTIVE

To document in detail the physical and occupational therapy treatment activities for inpatient hip fracture rehabilitation among 3 patient subgroups distinguished by their early rate of functional recovery between time of surgery to rehabilitation admission.

DESIGN

Multicenter prospective observational cohort, practice-based evidence, study.

SETTING

Seven skilled nursing facilities and 11 inpatient rehabilitation facilities across the United States.

PARTICIPANTS

A total of 226 patients with hip fractures treated with hip arthroplasty.

METHODS

Comparisons of physical and occupational therapy treatment activities among 3 groups with different initial recovery trajectory (IRT) rates (slower, moderate, faster).

MAIN OUTCOME MEASURE(S)

Percent of patients in each IRT group exposed to each physical and occupational therapy activity (exposure), and mean minutes per week for each activity (intensity).

RESULTS

The number of patients exposed to different physical or occupational therapy activities varied within the entire sample. More specifically, among the 3 IRT groups, significant differences in exposure occurred for 44% of physical therapy activities and 39% of occupational therapy activities. More patients in the slower recovery group, IRT 1, received basic activities of daily living treatments and more patients in the faster recovery group, IRT 3, received advanced activities. The moderate recovery group, IRT 2, had some treatments similar to IRT 1 group and others similar to IRT 3 group.

CONCLUSIONS

Analyses of practice-based evidence on inpatient rehabilitation of hip fracture patients treated with arthroplasty identified differences in therapy activities among three patient groups classified by IRT rates. These results may enhance physiatrists', other physicians', and rehabilitation teams' understanding of inpatient rehabilitation for these patients and help design future comparative effectiveness research.

Clinical update on nursing home medicine: 2013

This is the seventh article in the series of Clinical Updates on Nursing Home Care. The topics covered are antiresorptive drugs, hip fracture, hypertension, orthostatic hypotension, depression, undernutrition, anorexia, cachexia, sarcopenia, exercise, pain, and behavioral and psychological symptoms of dementia.

Walking recovery after a hip fracture: a prospective follow-up study among community-dwelling over 60-year old men and women

PURPOSE

Recovery of walking outdoors after hip fracture is important for equal participation in the community. The causes of poor recovery are not fully understood. This study investigates recovery of walking outdoors and associated determinants after hip fracture.

METHODS

A prospective follow-up study, among clinical sample of 81 community-dwelling hip fracture patients over 60 years. Perceived difficulty in walking outdoors and 500 meters was assessed before fracture, at discharge to home (3.2 ± 2.2 weeks after surgery), and on average 6.0 ± 3.3 weeks after discharge. Potential determinants for walking recovery were assessed. Linear latent trajectory model was used to analyse changes during follow-up. Association between walking trajectories and potential determinants was analysed with a logistic regression model.

RESULTS

Two trajectories, No-to-minor-difficulty and Catastrophic, were found. Thirty-eight percent of the participants ended up in the Catastrophic trajectory for walking outdoors and 67% for 500 meters. Multivariate logistic regression analysis revealed that use of walking aid and indoor falls before fracture and prolonged pain were independently associated with catastrophic decline in both primary outcomes: difficulty in walking outdoors and 500 meters.

CONCLUSIONS

A large proportion of community-dwelling older people recovering from hip fracture experienced catastrophic decline in outdoor walking. Acknowledging recovery prognoses at early stage enables individualized rehabilitation.