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Bailey MD, Gambert S, Gruber-Baldini A, Guralnik J, Kozar R, Qato DM, Shardell M, Albrecht JS. Traumatic Brain Injury and Risk of Long-Term Nursing Home Entry among Older Adults: An Analysis of Medicare Administrative Claims Data. J Neurotrauma 2023; 40:86-93. [PMID: 35793112 PMCID: PMC10162579 DOI: 10.1089/neu.2022.0003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of injury-related disability among older adults, and there is increasing interest in post-discharge management as this population grows. We evaluated the association between TBI and long-term nursing home (NH) entry among a nationally representative sample of older adults. We identified 207,355 adults aged ≥65 years who received a diagnosis of either a TBI, non-TBI trauma, or were uninjured between January 2008 and June 2015 from a 5% sample of Medicare beneficiaries. The NH entry was operationalized as the first NH admission that resulted in a stay ≥100 days. Time to NH entry was calculated as the difference between the NH entry date and the index date (the date of TBI, non-TBI trauma, or inpatient/outpatient visit in the uninjured group). We used cause-specific Cox proportional hazards models with stabilized inverse probability of exposure weights to model time to NH entry as a function of injury in the presence of death as a competing risk and generated hazard ratios (HR) and 95% confidence intervals (CI). After excluding beneficiaries living in a NH at index, there were 60,600 TBI, 63,762 non-TBI trauma, and 69,893 uninjured beneficiaries in the sample. In weighted models, beneficiaries with TBI entered NHs at higher rates relative to the non-TBI trauma (HR 1.15; 95% CI 1.10, 1.20) and uninjured (HR 1.67; 95% CI 1.60, 1.74) groups. Future research should focus on interventions to retain older adult TBI survivors within the community.
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Affiliation(s)
- M. Doyinsola Bailey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Steven Gambert
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ann Gruber-Baldini
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jack Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rosemary Kozar
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Danya M. Qato
- Department of Pharmaceutical Health Services Research, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michelle Shardell
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Muchiri S, Pakdil F, Beazoglou H. The length of stay and readmissions of THA and TKA patients: A longitudinal analysis using a nationwide readmissions data. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2022. [DOI: 10.1080/20479700.2022.2099337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Steve Muchiri
- Department of Economics and Finance, Eastern Connecticut State University, Willimantic, CT, USA
| | - Fatma Pakdil
- Department of Marketing and Management, Eastern Connecticut State University, Willimantic, CT, USA
| | - Hannah Beazoglou
- Department of Marketing and Management, Eastern Connecticut State University, Willimantic, CT, USA
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Loggers SAI, Nijdam TMP, Folbert EC, Hegeman JHH, Van der Velde D, Verhofstad MHJ, Van Lieshout EMM, Joosse P. Prognosis and institutionalization of frail community-dwelling older patients following a proximal femoral fracture: a multicenter retrospective cohort study. Osteoporos Int 2022; 33:1465-1475. [PMID: 35396653 PMCID: PMC9187528 DOI: 10.1007/s00198-022-06394-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/30/2022] [Indexed: 11/24/2022]
Abstract
UNLABELLED Hip fractures are a serious public health issue with major consequences, especially for frail community dwellers. This study found a poor prognosis at 6 months post-trauma with regard to life expectancy and rehabilitation to pre-fracture independency levels. It should be realized that recovery to pre-trauma functioning is not a certainty for frail community-dwelling patients. INTRODUCTION Proximal femoral fractures are a serious public health issue in the older patient. Although a significant rise in frail community-dwelling elderly is expected because of progressive aging, a clear overview of the outcomes in these patients sustaining a proximal femoral fracture is lacking. This study assessed the prognosis of frail community-dwelling patients who sustained a proximal femoral fracture. METHODS A multicenter retrospective cohort study was performed on frail community-dwelling patients with a proximal femoral fracture who aged over 70 years. Patients were considered frail if they were classified as American Society of Anesthesiologists score ≥ 4 and/or a BMI < 18.5 kg/m2 and/or Functional Ambulation Category ≤ 2 pre-trauma. The primary outcome was 6-month mortality. Secondary outcomes were adverse events, health care consumption, rate of institutionalization, and functional recovery. RESULTS A total of 140 out of 2045 patients matched the inclusion criteria with a median age of 85 (P25-P75 80-89) years. The 6-month mortality was 58 out of 140 patients (41%). A total of 102 (73%) patients experienced adverse events. At 6 months post-trauma, 29 out of 120 (24%) were readmitted to the hospital. Out of the 82 surviving patients after 6 months, 41 (50%) were unable the return to their home, and only 32 (39%) were able to achieve outdoor ambulation. CONCLUSION Frail community-dwelling older patients with a proximal femoral fracture have a high risk of death, adverse events, and institutionalization and often do not reobtain their pre-trauma level of independence. Foremost, the results can be used for realistic expectation management.
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Affiliation(s)
- S A I Loggers
- Department of Surgery, Northwest Clinics Alkmaar, P.O. Box 501, 1800 AM, Alkmaar, The Netherlands
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - T M P Nijdam
- Department of Surgery, St. Antonius Ziekenhuis, P.O. Box 2500, 3430 EM, Nieuwegein, The Netherlands
| | - E C Folbert
- Department of Trauma Surgery, Ziekenhuisgroep Twente, P.O. Box 7600, 7600 SZ, Almelo, The Netherlands
| | - J H H Hegeman
- Department of Trauma Surgery, Ziekenhuisgroep Twente, P.O. Box 7600, 7600 SZ, Almelo, The Netherlands
| | - D Van der Velde
- Department of Surgery, St. Antonius Ziekenhuis, P.O. Box 2500, 3430 EM, Nieuwegein, The Netherlands
| | - M H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - E M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - P Joosse
- Department of Surgery, Northwest Clinics Alkmaar, P.O. Box 501, 1800 AM, Alkmaar, The Netherlands
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Cary MP, Zhuang F, Draelos RL, Pan W, Amarasekara S, Douthit BJ, Kang Y, Colón-Emeric CS. Machine Learning Algorithms to Predict Mortality and Allocate Palliative Care for Older Patients With Hip Fracture. J Am Med Dir Assoc 2021; 22:291-296. [PMID: 33132014 PMCID: PMC7867606 DOI: 10.1016/j.jamda.2020.09.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate a machine learning model designed to predict mortality for Medicare beneficiaries aged >65 years treated for hip fracture in Inpatient Rehabilitation Facilities (IRFs). DESIGN Retrospective design/cohort analysis of Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility-Patient Assessment Instrument data. SETTING AND PARTICIPANTS A total of 17,140 persons admitted to Medicare-certified IRFs in 2015 following hospitalization for hip fracture. MEASURES Patient characteristics include sociodemographic (age, gender, race, and social support) and clinical factors (functional status at admission, chronic conditions) and IRF length of stay. Outcomes were 30-day and 1-year all-cause mortality. We trained and evaluated 2 classification models, logistic regression and a multilayer perceptron (MLP), to predict the probability of 30-day and 1-year mortality and evaluated the calibration, discrimination, and precision of the models. RESULTS For 30-day mortality, MLP performed well [acc = 0.74, area under the receiver operating characteristic curve (AUROC) = 0.76, avg prec = 0.10, slope = 1.14] as did logistic regression (acc = 0.78, AUROC = 0.76, avg prec = 0.09, slope = 1.20). For 1-year mortality, the performances were similar for both MLP (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.96) and logistic regression (acc = 0.68, AUROC = 0.75, avg prec = 0.32, slope = 0.95). CONCLUSION AND IMPLICATIONS A scoring system based on logistic regression may be more feasible to run in current electronic medical records. But MLP models may reduce cognitive burden and increase ability to calibrate to local data, yielding clinical specificity in mortality prediction so that palliative care resources may be allocated more effectively.
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Affiliation(s)
- Michael P Cary
- School of Nursing, Duke University, Durham, NC, USA; Center for the Study of Aging and Human Development, Duke University, Durham, NC, USA.
| | - Farica Zhuang
- Department of Computer Science, Duke University, Durham, NC, USA
| | - Rachel Lea Draelos
- Department of Computer Science, Duke University, Durham, NC, USA; School of Medicine, Duke University, Durham, NC, USA
| | - Wei Pan
- School of Nursing, Duke University, Durham, NC, USA
| | | | | | - Yunah Kang
- School of Nursing, Duke University, Durham, NC, USA
| | - Cathleen S Colón-Emeric
- Center for the Study of Aging and Human Development, Duke University, Durham, NC, USA; School of Medicine, Duke University, Durham, NC, USA; Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, NC, USA
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Navarro SM, Frankel WC, Haeberle HS, Billow DG, Ramkumar PN. Evaluation of the volume-value relationship in hip fracture care using evidence-based thresholds. Hip Int 2020; 30:347-353. [PMID: 30912450 DOI: 10.1177/1120700019837130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Studies have shown high-volume surgeons and hospitals deliver higher value care. The aims of this study were to establish meaningful thresholds defining high-volume surgeons and hospitals performing hip fracture surgery and to examine the relative market share of hip fracture cases using these surgeon and hospital strata. METHODS We performed a retrospective cohort study in a database of 103,935 patients undergoing hip fracture repair. We generated stratum-specific likelihood ratio (SSLR) models of a receiver operating characteristic (ROC) curve using length of stay (LOS) and cost value metrics. Volume thresholds predictive of decreased LOS and costs for surgeons and hospitals were identified. RESULTS Analysis of annual surgeon hip fracture volume produced two volume categories for LOS and cost: 0-30 (low) and 31+ (high). Analysis of LOS by annual hospital hip fracture volume produced strata at: 0-59 (low), 60-146 (medium), and 147 or more (high). Analysis of cost by annual hospital volume produced strata at: 0-125 (low) and 126+ (high). LOS and cost both decreased significantly (p < 0.05) in progressively higher volume categories. Low-volume surgeons performed the majority of hip fracture cases, although they were performed at medium- or high-volume centres. CONCLUSIONS This study demonstrates a direct relationship between volume and value, translating to improvement in hip fracture care delivery for both surgeons and hospitals. Higher volume hospitals while lower volume surgeons perform the majority of hip fracture cases, suggesting optimisation opportunities. However, systems-based practices at the hospital level likely drive value to a greater extent than individual surgeons.
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Affiliation(s)
- Sergio M Navarro
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - William C Frankel
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Heather S Haeberle
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Damien G Billow
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Prem N Ramkumar
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Wallace MA, Hammes A, Rothman MS, Trizno AA, Jones CD, Cumbler E, McDevitt K, Carlson NE, Stoneback JW. Fixing a Fragmented System: Impact of a Comprehensive Geriatric Hip Fracture Program on Long-Term Mortality. Perm J 2019; 23:18.286. [PMID: 31702983 DOI: 10.7812/tpp/18.286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
CONTEXT Geriatric hip fractures are increasingly common and confer substantial morbidity and mortality. Fragmentation in geriatric hip fracture care remains a barrier to improved outcomes. OBJECTIVE To evaluate the impact of a comprehensive geriatric hip fracture program on long-term mortality. DESIGN We conducted a retrospective cohort study of patients aged 65 years and older admitted to our academic medical center between January 1, 2012, and March 31, 2016 with an acute fragility hip fracture. Mortality data were obtained for in-state residents from the state public health department. MAIN OUTCOME MEASURES Mortality within 1 year of index admission and overall survival based on available follow-up data. RESULTS We identified 243 index admissions during the study period, including 135 before and 108 after program implementation in October 2014. The postintervention cohort trended toward a lower unadjusted 1-year mortality rate compared with the preintervention cohort (15.7% vs 24.4%, p = 0.111), as well as lower adjusted mortality at 1 year (relative risk = 0.73, 95% confidence interval = 0.46-1.16, p = 0.18), although the differences were not statistically significant. The postintervention cohort had significantly higher overall survival than did the preintervention cohort (hazard ratio for death = 0.43, 95% confidence interval = 0.25-0.74, p = 0.002). CONCLUSION Fixing fragmentation in geriatric hip fracture care such as through an orthogeriatric model is essential to improving overall survival for this patient population.
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Affiliation(s)
- Mary Anderson Wallace
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Andrew Hammes
- Department of Biostatistics and Informatics, University of Colorado, Aurora
| | - Micol S Rothman
- Division of Endocrinology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Anastasiya A Trizno
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora
| | - Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Ethan Cumbler
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Kelly McDevitt
- University of Colorado Health, Longs Peak Hospital, Longmont
| | - Nichole E Carlson
- Department of Biostatistics and Informatics, University of Colorado, Aurora
| | - Jason W Stoneback
- Department of Orthopedic Surgery, University of Colorado School of Medicine, Aurora
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7
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Ouellet JA, Ouellet GM, Romegialli AM, Hirsch M, Berardi L, Ramsey CM, Cooney LM, Walke LM. Functional Outcomes After Hip Fracture in Independent Community-Dwelling Patients. J Am Geriatr Soc 2019; 67:1386-1392. [PMID: 30964203 DOI: 10.1111/jgs.15870] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/10/2019] [Accepted: 02/13/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To determine predictors of new activities of daily living (ADLs) disability and worsened mobility disability and secondarily increased daily care hours received, in previously independent hip fracture patients. DESIGN Retrospective cohort study. SETTING Academic hospital with ambulatory follow-up. PARTICIPANTS Community-dwelling adults 65 years or older independent in ADLs undergoing hip fracture surgery in 2015 (n = 184). MEASUREMENTS Baseline, 3- and 6-month ADLs, mobility, and daily care hours received were ascertained by telephone survey and chart review. Comorbidities, medications, and characteristics of hospitalization were extracted from patient charts. Models for each outcome used logistic regression with a backward elimination strategy, adjusting a priori for age, sex, and race. RESULTS Predictors of new ADL disability at 3 months were dementia (odds ratio [OR] = 11.81; P = .001) and in-hospital delirium (OR = 4.20; P = .002), and at 6 months were age (OR = 1.04; P = .014), dementia (OR = 9.91; P = .001), in-hospital delirium (OR = 3.00; P = .031) and preadmission opiates (OR = 7.72; P = .003). Predictors of worsened mobility at 3 months were in-hospital delirium (OR = 4.48; P = .001) and number of medications (OR = 1.13; P = .003), and at 6 months were age (OR = 1.06; P = .001), preadmission opiates (OR = 7.23; P = .005), in-hospital delirium (OR = 3.10; P = .019), and number of medications (OR = 1.13; P = .013). Predictors of increased daily care hours received at 3 and 6 months were age (3 months: OR = 1.07; P = .014; 6 months: OR = 1.06; P = .017) and number of medications (3 months: OR = 1.13; P = .004; 6 months: OR = 1.22; P = .013). The proportion of patients with ADL disability and care hours received did not change from 3 to 6 months, yet there were significant improvements in mobility. CONCLUSION Age, dementia, in-hospital delirium, number of medications, and preadmission opiate use were predictors of poor outcomes in independent older adults following hip fracture. Further investigation is needed to identify factors associated with improved mobility measures from 3 to 6 months to ultimately optimize recovery.
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Affiliation(s)
| | - Gregory M Ouellet
- Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut
| | | | | | - Lisa Berardi
- Yale New Haven Health System, New Haven, Connecticut
| | - Christine M Ramsey
- Yale School of Medicine, Yale Center for Medical Informatics, New Haven, Connecticut.,Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Leo M Cooney
- Section of Geriatrics, Yale School of Medicine, New Haven, Connecticut
| | - Lisa M Walke
- Division of Geriatrics, University of Pennsylvania, Philadelphia, Pennsylvania
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Abraham DS, Barr E, Ostir GV, Hebel JR, Golden J, Gruber-Baldini AL, Guralnik JM, Hochberg MC, Orwig DL, Resnick B, Magaziner JS. Residual Disability, Mortality, and Nursing Home Placement After Hip Fracture Over 2 Decades. Arch Phys Med Rehabil 2018; 100:874-882. [PMID: 30391413 DOI: 10.1016/j.apmr.2018.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/26/2018] [Accepted: 10/10/2018] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- Danielle S Abraham
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Erik Barr
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Glenn V Ostir
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; Institute of Gerontology, University of Georgia College of Public Health, Athens, GA
| | - J Richard Hebel
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Justine Golden
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Ann L Gruber-Baldini
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Marc C Hochberg
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Denise L Orwig
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | | | - Jay S Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD.
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Golinelli D, Bucci A, Toscano F, Filicori F, Fantini MP. Real and predicted mortality under health spending constraints in Italy: a time trend analysis through artificial neural networks. BMC Health Serv Res 2018; 18:671. [PMID: 30157828 PMCID: PMC6116437 DOI: 10.1186/s12913-018-3473-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 08/16/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND After 2008 global economic crisis, Italian governments progressively reduced public healthcare financing. Describing the time trend of health outcomes and health expenditure may be helpful for policy makers during the resources' allocation decision making process. The aim of this paper is to analyze the trend of mortality and health spending in Italy and to investigate their correlation in consideration of the funding constraints experienced by the Italian national health system (SSN). METHODS We conducted a 20-year time-series study. Secondary data has been extracted from a national, institution based and publicly accessible retrospective database periodically released by the Italian Institute of Statistics. Age standardized all-cause mortality rate (MR) and health spending (Directly Provided Services - DPS, Agreed-Upon Services - TAUS, and private expenditure) were reviewed. Time trend analysis (1995-2014) through OLS and Multilayer Feed-forward Neural Networks (MFNN) models to forecast mortality and spending trend was performed. The association between healthcare expenditure and MR was analyzed through a fixed effect regression model. We then repeated MFNN time trend forecasting analyses on mortality by adding the spending item resulted significantly related with MR in the fixed effect analyses. RESULTS DPS and TAUS decreased since 2011. There was a mismatch in mortality rates between real and predicted values. DPS resulted significantly associated to mortality (p < 0.05). In repeated mortality forecasting analysis, predicted MR was found to be lower when considering the pre-constraints health spending trend. CONCLUSIONS Between 2011 and 2014, Italian public health spending items showed a reduction when compared to prior years. Spending on services directly provided free of charge appears to be the financial driving force of the Italian public health system. The overall mortality was found to be higher than the predicted trend and this scenario may be partially attributable to the healthcare funding constraints experienced by the SSN.
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Affiliation(s)
- Davide Golinelli
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Andrea Bucci
- Department of Economics and Social Sciences, Marche Polytechnic University, Ancona, Italy
| | - Fabrizio Toscano
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, USA
| | - Filippo Filicori
- The Oregon Clinic, Division of Minimally Invasive Gastrointestinal Surgery, Portland, OR USA
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Vottis CT, Mitsiokapa E, Igoumenou VG, Megaloikonomos PD, Galanopoulos IP, Georgoudis G, Koulouvaris P, Papagelopoulos PJ, Mavrogenis AF. Fall Risk Assessment Metrics for Elderly Patients With Hip Fractures. Orthopedics 2018; 41:142-156. [PMID: 29738597 DOI: 10.3928/01477447-20180501-07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/09/2018] [Indexed: 02/03/2023]
Abstract
The most common surgery performed by orthopedic surgeons likely involves that for hip fractures. The incidence of hip fractures is anticipated to rise in the coming decades. Hip fractures most commonly occur in elderly women with osteoporosis after a fall from standing position. In an effort to reduce the incidence, improve the postoperative care, and accelerate the rehabilitation of hip fractures, it is important to evaluate the fall risk of these patients, as it is an objective indication of their level of physical activity. Metrics currently available for the evaluation of fall risk in the elderly vary widely, with each having been designed to assess a specific patient population. However, their applicability has often proved to be much broader than expected. This review summarizes the metrics available for fall risk assessment of elderly patients with hip fractures, describes their individual features and efficacy, and highlights those that seem to be more reliable for the assessment of rehabilitation of these patients after hip fracture surgery. [Orthopedics. 2018; 41(3):142-156.].
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11
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Epidemiology of hip fracture in nursing home residents with multiple sclerosis. Disabil Health J 2018; 11:591-597. [PMID: 29598927 DOI: 10.1016/j.dhjo.2018.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/26/2018] [Accepted: 03/08/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hip fracture risk is high in young people with multiple sclerosis (MS), but has not been examined in an institutionalized aging population with MS. OBJECTIVE We aimed to compare the hip fracture risk in nursing home (NH) residents with and without MS; and (2) examine risk factors for hip fracture in those with MS. METHODS We conducted a retrospective cohort study using national NH clinical assessment and Medicare claims data. Participants included age-, sex- and race-matched NH residents with/without MS (2007-2008). Multivariable competing risk regression was used to compare 2-year hip fracture risk, and to examine risk factors. RESULTS A total of 5692 NH residents with MS were matched to 28,460 without MS. Approximately 80% of residents with MS vs. 50% of those without MS required extensive assistance in walking at NH admission. The adjusted incidence rate of hip fracture was 7.1 and 18.6 per 1000 person-years in those with or without MS, respectively. Wandering and anxiolytic exposure were the main hip fracture risk factors in transfer independent residents with MS; while pneumonia and antidepressant use were the main factors in dependent residents with MS. CONCLUSIONS In contrast to prior comparisons from non-NH populations, the incidence of hip fracture was lower in NH residents with MS as compared with matched controls. Residents with MS were much more functionally dependent, which likely explains these findings. Fracture prevention strategies should focus on fall prevention in independent residents; and possibly improvement of health status and facility quality of care in dependent residents.
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12
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Anderson ME, Mcdevitt K, Cumbler E, Bennett H, Robison Z, Gomez B, Stoneback JW. Geriatric Hip Fracture Care: Fixing a Fragmented System. Perm J 2017; 21:16-104. [PMID: 28488991 PMCID: PMC5424597 DOI: 10.7812/tpp/16-104] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CONTEXT Fragmentation in geriatric hip fracture care is a growing concern because of the aging population. Patients with hip fractures at our institution historically were admitted to multiple different services and units, leading to unnecessary variation in inpatient care. Such inconsistency contributed to delays in surgery, discharge, and functional recovery; hospital-acquired complications; failure to adhere to best practices in osteoporosis management; and poor coordination with outpatient practitioners. OBJECTIVE To describe a stepwise approach to systems redesign for this patient population. DESIGN We designed and implemented a comprehensive geriatric hip fracture program for patients aged 65 years and older at our academic Medical Center in October 2014. Key interventions included admission of all ward-status patients to the Orthopedics Service with hospitalist comanagement; geographic placement on the Orthopedics Unit; and standardized, evidence-based electronic order sets bundling geriatric best practices and a streamlined workflow for discharge planning. MAIN OUTCOME MEASURES Hospital length of stay. RESULTS We identified 271 admissions among 267 patients between January 1, 2012, and March 31, 2016; of those, 154 were before and 117 were after program implementation. Mean hospital length of stay significantly improved from 6.4 to 5.5 days (p = 0.004). The 30-day all-cause readmission rate and discharge disposition remained stable. The percentage of patients receiving osteoporosis evaluation and treatment increased significantly. The rate of completed 30-day outpatient follow-up also improved. CONCLUSION Our comprehensive geriatric hip fracture program achieved and sustained gains in the quality and efficiency of care by improving fragmentation in the health care system.
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Affiliation(s)
- Mary E Anderson
- Assistant Professor in the Hospital Medicine Section of the Division of General Internal Medicine at the University of Colorado Denver School of Medicine.
| | - Kelly Mcdevitt
- Clinical Nurse Manager in the Department of Orthopedic Surgery at the University of Colorado Hospital in Aurora.
| | - Ethan Cumbler
- Professor in the Hospital Medicine Section of the Division of General Internal Medicine at the University of Colorado Denver School of Medicine.
| | - Heather Bennett
- Data Analyst for the Institute of Healthcare Quality, Safety, and Efficiency at the University of Colorado Hospital in Aurora.
| | - Zachary Robison
- Process Improvement Consultant for the Institute of Healthcare Quality, Safety, and Efficiency at the University of Colorado Hospital in Aurora.
| | - Bryan Gomez
- Process Improvement Consultant for the Institute of Healthcare Quality, Safety, and Efficiency at the University of Colorado Hospital in Aurora.
| | - Jason W Stoneback
- Assistant Professor in the Department of Orthopedic Surgery at the University of Colorado Denver School of Medicine.
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The Role of Radiographs and Office Visits in the Follow-Up of Healed Intertrochanteric Hip Fractures: An Economic Analysis. J Orthop Trauma 2016; 30:687-690. [PMID: 27763962 DOI: 10.1097/bot.0000000000000682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the role and the necessity of radiographs and office visits obtained during follow-up of intertrochanteric hip injuries. DESIGN Retrospective study. SETTING Two level I trauma centers. PATIENTS Four hundred sixty-five elderly patients who were surgically treated for an intertrochanteric fracture of the femur at 2 level I trauma centers between January 2009 and August 2014 were retrospectively identified from orthopaedic trauma databases. INTERVENTION Analysis of all healed intertrochanteric hip fractures, including demographic characteristics, quality of reduction, time of healing, number of office visits, number of radiographs obtained, and each radiograph for fracture alignment, implant position or any pathological changes. RESULTS The surgical fixation of 465 fractures included 155 short nails (33%), 232 long nails (50%), 69 sliding hip screw devices (15%), 7 trochanteric stabilizing plates (1.5%), and 2 proximal femur locking plates (0.5%). The average fracture healing time was 12.8 weeks and the average follow-up was 81.2 weeks. Radiographs of any patient obtained after the fracture had healed did not reveal any changes, including fracture alignment or implant position and hardware failure. In 9 patients, pathological changes, including arthritis (3), avascular necrosis (3), and ectopic ossification (3) were noted. The average number of elective office visits and radiographs obtained after the fracture had healed were 2.8 (range: 1-8) and 2.6 (range: 1-8), respectively. According to Medicare payments to the institution, these radiographs and office visits account for a direct cost of $360.81 and $192, respectively, per patient. CONCLUSION The current study strongly suggests that there is a negligible role for radiographs and office visits during the follow-up of a well-healed hip fracture when there is documented evidence of radiographic and clinical healing with acceptable fracture alignment and implant position. Implementation of this simple measure will help in reducing the cost of care and inconvenience to elderly patients. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Pitzul KB, Wodchis WP, Carter MW, Kreder HJ, Voth J, Jaglal SB. Post-acute pathways among hip fracture patients: a system-level analysis. BMC Health Serv Res 2016; 16:275. [PMID: 27430219 PMCID: PMC4950780 DOI: 10.1186/s12913-016-1524-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 07/07/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hip fractures among older adults are one of the leading causes of hospitalization and result in significant morbidity, mortality, and health care use. Guidelines suggest that rehabilitation after surgery is imperative to return patients to pre-morbid function. However, post-acute care (which encompasses rehabilitation) is currently delivered in a multitude of settings, and there is a lack of evidence with regards to which hip fracture patients should use which post-acute settings. The purpose of this study is to describe hip fracture patient characteristics and the most common post-acute pathways within a 1-year episode of care, and to examine how these vary regionally within a health system. METHODS This study took place in the province of Ontario, Canada, which has 14 health regions and universal health coverage for all residents. Administrative health databases were used for analyses. Community-dwelling patients aged 66 and over admitted to an acute care hospital for hip fracture between April 2008 and March 2013 were identified. Patients' post-acute destinations within each region were retrieved by linking patients' records within various institutional databases using a unique encoded identifier. Post-acute pathways were then characterized by determining when each patient went to each post-acute destination within one year post-discharge from acute care. Differences in patient characteristics between regions were detected using standardized differences and p-values. RESULTS Thirty-six thousand twenty nine hip fracture patients were included. The study cohort was 71.9 % female with a mean age of 82.9 (±7.5SD). There was significant variation between regions with respect to the immediate post-acute discharge destination: four regions discharged a substantially higher proportion of their patients to inpatient rehabilitation compared to all others. However, the majority of patient characteristics between those four regions and all other regions did not significantly differ. There were 49 unique post-acute pathways taken by patients, with the largest proportion of patients admitted to either community-based or short-term institutionalized rehabilitation, regardless of region. CONCLUSIONS The observation that similar hip fracture patients are discharged to different post-acute settings calls into question both the appropriateness of care delivered in the post-acute period and health system expenditures. As policy makers continue to develop performance-based funding models to increase accountability of institutions in the provision of quality care to hip fracture patients, ensuring patients receive appropriate rehabilitative care is a priority for health system planning.
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Affiliation(s)
- Kristen B. Pitzul
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
| | - Walter P. Wodchis
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario M561V7 Canada
| | - Michael W. Carter
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Department of Mechanical and Industrial Engineering, University of Toronto, 5 King’s College Road, Toronto, Ontario M5S3G8 Canada
| | - Hans J. Kreder
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Department of Surgery, University of Toronto, 2075 Bayview Avenue., MG-365, Toronto, Ontario M4N3M5 Canada
| | - Jennifer Voth
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario M561V7 Canada
| | - Susan B. Jaglal
- />Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
- />Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario M5T3M6 Canada
- />Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario M561V7 Canada
- />Department of Physical Therapy, University of Toronto, 160-500 University Avenue, Toronto, Ontario M5G1V7 Canada
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15
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Abstract
BACKGROUND Despite declines in both the incidence of and mortality following hip fracture, there are racial and socioeconomic disparities in treatment access and outcomes. We evaluated the presence and implications of disparities in delivery of care, hypothesizing that race and community socioeconomic characteristics would influence quality of care for patients with a hip fracture. METHODS We collected data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS), which prospectively captures information on all discharges from nonfederal acute-care hospitals in New York State. Records for 197,290 New York State residents who underwent surgery for a hip fracture between 1998 and 2010 in New York State were identified from SPARCS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multivariable regression models were used to evaluate the association of patient characteristics, social deprivation, and hospital/surgeon volume with time from admission to surgery, in-hospital complications, readmission, and 1-year mortality. RESULTS After adjusting for patient and surgery characteristics, hospital/surgeon volume, social deprivation, and other variables, black patients were at greater risk for delayed surgery (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.42, 1.57), a reoperation (hazard ratio [HR] = 1.21; CI = 1.11, 1.32), readmission (OR = 1.17; CI = 1.11, 1.22), and 1-year mortality (HR = 1.13; CI = 1.07, 1.21) than white patients. Subgroup analyses showed a greater risk for delayed surgery for black and Asian patients compared with white patients, regardless of social deprivation. Additionally, there was a greater risk for readmission for black patients compared with white patients, regardless of social deprivation. Compared with Medicare patients, Medicaid patients were at increased risk for delayed surgery (OR = 1.17; CI = 1.10, 1.24) whereas privately insured patients were at decreased risk for delayed surgery (OR = 0.77; CI = 0.74, 0.81), readmission (OR = 0.77; CI = 0.74, 0.81), complications (OR = 0.80; CI = 0.77, 0.84), and 1-year mortality (HR = 0.80; CI = 0.75, 0.85). CONCLUSIONS There are race and insurance-based disparities in delivery of care for patients with hip fracture, some of which persist after adjusting for social deprivation. In addition to investigation into reasons contributing to disparities, targeted interventions should be developed to mitigate effects of disparities on patients at greatest risk. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher J Dy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Joseph M Lane
- Department of Orthopaedic Surgery (J.M.L. and M.L.P.) and Healthcare Research Institute (J.M.L., T.J.P., M.L.P., and S.L.), Hospital for Special Surgery, New York, NY Weill Cornell Medical College, New York, NY
| | - Ting Jung Pan
- Department of Orthopaedic Surgery (J.M.L. and M.L.P.) and Healthcare Research Institute (J.M.L., T.J.P., M.L.P., and S.L.), Hospital for Special Surgery, New York, NY
| | - Michael L Parks
- Department of Orthopaedic Surgery (J.M.L. and M.L.P.) and Healthcare Research Institute (J.M.L., T.J.P., M.L.P., and S.L.), Hospital for Special Surgery, New York, NY
| | - Stephen Lyman
- Department of Orthopaedic Surgery (J.M.L. and M.L.P.) and Healthcare Research Institute (J.M.L., T.J.P., M.L.P., and S.L.), Hospital for Special Surgery, New York, NY Weill Cornell Medical College, New York, NY
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