Regional gaps in the provision of inpatient rehabilitation services for the elderly in Israel: Results of a national survey

Home Versus Hospital Rehabilitation of Older Adults Following Hip Fracture Yields Similar Patient-Reported Outcome Measures

The increase in hip fractures (HF) due to aging of the population and the rise in attractiveness of services provided at home following the COVID-19 pandemic, emphasize the need to compare outcomes of home versus hospital HF rehabilitation. To date, studies comparing the 2 services have focused primarily on clinical outcomes rather than patient-reported outcomes (PROs). This longitudinal observational study evaluated PROs of older adults with HF in the 2 settings. The SF36 questionnaire was used to measure PROs 3 times after surgery. The first PRO was retrospective and reflected pre-fracture health status. Descriptive statistics and mixed-effect logistic regression were used. Of 86 patients participating in the study, 41 had home rehabilitation and 45 had hospital rehabilitation. In both groups, the mental and physical scores plummeted 2 weeks after the HF, compared to pre-fracture status. The difference in improvement from pre-fracture status to recovery in both groups, were not significantly (P < .05) different, except for the pain domain. PROs of home versus hospital rehabilitation were similar, suggesting that rehabilitation at home can be as effective as hospital rehabilitation for suitable patients. This knowledge can improve quality of care in an aging global population.

Mortality, Survival, and Readmissions During a 12-Month Follow-Up After Hip Fracture: Inpatient Rehabilitation Versus Home Rehabilitation

PURPOSE

This study compared readmissions, survival, and mortality during a 12-month follow-up period of inpatient rehabilitation and home rehabilitation for older persons who had experienced a hip fracture.

METHODS

This work was retrospective cohort research. Between January 1 and December 30, 2019, the medical records of 280 elderly patients who were admitted to a hospital with a hip fracture were analyzed. Of these patients, 74.3% received inpatient rehabilitation, whereas 25.7% received home rehabilitation.

RESULTS

In terms of readmissions and death, there were no appreciable differences between the inpatient rehabilitation and home rehabilitation groups. The patients in the inpatient rehabilitation group were older; more likely to need assistance with activities of daily living; and were taking, on average, more prescription drugs on a daily basis than those in the home rehabilitation group.

CONCLUSIONS AND CLINICAL RELEVANCE

In conclusion, as better outcomes were expected for the home rehabilitation group, which on average included less complicated patients, our findings suggest that the home rehabilitation pathway may not be a good alternative to the inpatient rehabilitation pathway.

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.

Motorcycle-related head and neck injuries: increased risk among ethnic minorities

Background

Ethnic disparities have been associated with injury and mortality. The impact of ethnicity on head and neck injury (HNI), traumatic brain injury (TBI), in-hospital mortality and resource utilization following a motorcycle crash (MCC) is undetermined. This study explored the influence of ethnicity in these aspects and the effect of helmet use on HNI and TBI following a MCC.

Methods

The National Trauma Registry provided hospitalization data on motorcycle riders and passengers between 2008 and 2017. Ethnicity was classified as Jews or Arabs, the two major ethnic groups in Israel. Univariate followed by multivariable logistic models were applied to examine ethnic disparities. Mediation effect was tested by structural equation modeling.

Results

Among 6073 MCC casualties, Arabs had increased odds of HNI (OR = 1.37,95% CI = 1.12–1.65) and TBI (OR = 1.51,95%CI = 1.12–1.99), and a six-fold decreased odds of helmet use (OR = 0.16,95%CI = 0.12–0.22). The HNI and TBI associations with ethnicity were mediated by helmet use. Arabs had significantly higher odds for admission to intensive care unit (OR = 1.36,95%CI = 1.00–1.83), and lower odds for ambulance evacuation (OR = 0.73,95%CI = 0.61–0.89) and discharge to rehabilitation (OR = 0.55,95%CI = 0.39–0.7). In-hospital mortality was not associated with ethnicity.

Conclusions

Helmet non-use is an important etiologic factor associated with motorcycle-related HNI and TBI among Arabs. While in Israel, ethnic equality exists in in-hospital health care, disparities in ambulance and rehabilitation utilization was found. Intervention programs should target the Arab population and focus on helmet compliance.

High variability in hip fracture post-acute care and dementia patients having worse chances of receiving rehabilitation: an analysis of population-based data from Estonia

PURPOSE

Rehabilitation is a fundamental part of hip fracture (HF) care; however, the best strategies are unclear. This study maps index HF patients' post-acute care (PAC) in Estonia and compares the PAC of patients with and without a diagnosis of dementia.

METHODS

A retrospective cohort study was conducted using validated population-based data from the Estonian Health Insurance Fund using inclusion criteria: age ≥ 50 years, International Classification of Diseases code (S72.0-2) indicating HF between 1 January 2009 and 30 September 2017, and the survival of PAC. The presence of dementia diagnosis was based on the 10th revision of the International Classification of Diseases codes.

RESULTS

A total of 8729 patients were included in the study, 11% of whom had a dementia diagnosis. The PAC of HF patients varied from extensive to no care: 8.7% received combined inpatient and outpatient care; 59% received hospital care (13% had a length of stay (LOS) > 6 weeks; 33% had LOS between 2-4 weeks, 14% had LOS < 2 weeks); 4% received only community-based care; 28% received no PAC. Physical therapy (PT) was received by 56% of patients and by 35% of those with dementia diagnosis. Dementia patients had 1.5-fold higher odds of not receiving PT.

CONCLUSION

In Estonia, the PAC after index HF varies from extensive to no care, and the provision of PT is limited and unequal, affecting dementia patients in particular. Thus, there is an urgent need to standardise index HF PAC by reviewing the resources of PT and developing effective rehabilitation practices.

Effectiveness of a tele-rehabilitation intervention to improve performance and reduce morbidity for people post hip fracture - study protocol for a randomized controlled trial

BACKGROUND

Most surviving hip-fracture patients experience reduced mobility and lose some of their functional ability, which increases the risk of complications and rehospitalization. Post-discharge transitional programs to reduce readmissions and disabilities have shown some success. Telerehabilitation refers to the use of technologies to provide rehabilitation services to people in their homes. Considering the need for long-term follow-up care for people with hip fracture, in-home telerehabilitation could increase independence, decrease hospital stays and reduce the burden for caregivers. The objective of this study is to investigate the effectiveness of an intervention program based on telerehabilitation on activities of daily living (ADL), quality of life (QOL), depression and burden on caregivers compared to face-to-face home visits and usual care of community-dwelling older adults after hip fracture.

METHODS/DESIGN

This will be a three-armed randomized control trial (RCT) including pre/post intervention and follow-up. The trial will include 90 older people with hip fractures who will be randomly assigned to a telerehabilitation group (N = 30), face-to-face visits (N = 30) and a control group. The aim of the intervention is to improve the transition from rehabilitation units to community dwelling. It will include 10 videoconferencing/ face-to-face sessions from an occupational therapist in the presence of the primary caregiver. Each session will be utilized to guide the participants to achieve their self-identified goals, focusing on problem-solving for daily life situations and on the ability to implement the discussed strategies for a variety of activities. Outcome measures include Functional Independence Measure (FIM) for evaluation of ADL, SF-12 for evaluation of Health-related QOL, The Geriatric Depression Scale (GDS) and The Zarit Caregiver Burden Scale. Data will be analyzed using Repeated measures MANOVA.

DISCUSSION

The current study will enable the cost-effectiveness examination of a suggested rehabilitation service based on available technology. The proposed intervention will increase accessibility of in-home rehabilitation services, improve function and health, and reduce economic burden.

TRIAL REGISTRATION

NCT03376750 (12/15/2017).

Achieving ethnic equality in the Israel trauma healthcare system: the case of the elderly population

Objective

To determine if ethnic disparities exist with regard to the risk of injury and injury outcomes among elderly hospitalized casualties in Israel.

Methods

A retrospective study based on data from the Israeli National Trauma Registry between 2008 and 2017. Data included demographic, injury and hospitalization characteristics. Descriptive statistics and adjusted logistic regression were used to examine the differences between Jewish and Arab casualties, aged 65 and older.

Result

The study included 96,795 casualties. The proportion of elderly hospitalized casualties was 2.8 times greater than their proportion in the population (3.1 times greater among Jews and 2.1 times among Arabs). In comparison to Arabs, Jews suffered from a greater percentage of head injuries (10.5 and 8.9%, respectively for Jews and Arabs p < .001), but fewer extremity injuries (46.7% vs. 48.0% respectively for Jews and Arabs p < .05). Among severe/critical casualties and among casualties with severe head injuries, Arabs were more likely to be transported to the hospital in a private car (27% vs. 21% respectively for Arabs and Jews p < .001; 30.5% vs. 23.3% respectively for Arabs and Jews p < .001). Logistic regression analysis, adjusted for age, gender, injury severity, type of injury, type of trauma center and year of admission, shows that Jews, relative to Arabs, were more likely to be hospitalized for more than seven days, admitted to the intensive care unit (ICU) and to be discharged to a rehabilitation center (OR: 1.3, 1.3 and 2.4 respectively). No differences regarding surgery (OR: 0.95) or in-hospital mortality (OR: 0.99) were found.

Conclusions

Ethnic disparities between Jewish and Arab hospitalized casualties were observed with regard to hospital stay, ICU admission and rehabilitation transfer. However, no differences were found with regard to mortality and surgery. While the reported disparities may be due in part by cultural differences and accessibility, health policy decision makers should aim to reduce the gaps by optimizing the accessibility of ambulance and rehabilitation services as well as increasing awareness regarding the availability of these medical services among the Arab population.

The epidemiology and economic burden of hip fractures in Israel

Background

Hip fractures increase the risks of mortality and major morbidity in the elderly. Hip fractures are associated with chronic pain, reduced mobility, disability and increasing dependence. We evaluated the direct costs incurred to the Israeli healthcare system in 2013 as a result of hip fracture injuries in elderly patients.

Methods

Hip fractures costs evaluation consisted of first-year and long-term direct costs. Data on the incidence of hip fractures resulting in hospitalizations were retrieved from the Israeli Ministry of Health’s (MOH) Central Database of Hospital Admissions. Hospitalization, rehabilitation and nursing utilization rates and costs were estimated based on the professional literature and according to the MOH’s price list.

Results

During 2013, 6285 elderly patients were hospitalized in Israel due to hip fractures. Direct costs of hip fracture, comprising hospitalization, rehabilitation and nursing costs incurred during the first year after the injury, were estimated at 454 million New Israeli Shekels (NIS; 83,841 NIS per person). Long-term nursing care costs in 2013 were 265 million NIS, with an average cost of approximately 49,000 NIS for 1600 elderly persons receiving long-term nursing care as a result of a hip fracture. Overall, the total direct costs of hip fracture in the elderly population in Israel in 2013 were 719 million NIS.

Conclusions

The direct costs of hip fractures in Israel among the elderly are approximately 719 million NIS per year. The majority of costs are associated with the first year following the injury. To reduce healthcare costs in Israel, changes in the country’s healthcare policy on hip fractures are required. For example, there is a need for a program for detecting high- risk populations, and for early intervention following the injury.

Electronic supplementary material

The online version of this article (10.1186/s13584-018-0235-y) contains supplementary material, which is available to authorized users.

Inequities in access to inpatient rehabilitation after stroke: an international scoping review

Background Inequities in accessing inpatient rehabilitation after stroke have been reported in many countries and impact on patient outcomes. Objective To explore variation in international recommendations regarding which patients should receive inpatient rehabilitation after stroke and to describe reported access to rehabilitation. Methods A scoping review was conducted to identify clinical guidelines with recommendations regarding which patients should access inpatient rehabilitation after stroke, and data regarding the proportion of patients accessing stroke rehabilitation. Four bibliographic databases and grey literature were searched. Results Twenty-eight documents were included. Selection criteria for post-acute inpatient rehabilitation were identified for 14 countries or regions and summary data on the proportion of patients receiving inpatient rehabilitation were identified for 14 countries. In Australia, New Zealand, and the United Kingdom, it is recommended that all patients with stroke symptoms should access rehabilitation, whereas guidelines from the United States, Canada, and Europe did not consistently recommend rehabilitation for people with severe stroke. Access to inpatient rehabilitation ranged from 13% in Sweden to 57% in Israel. Differences in availability of early supported discharge/home rehabilitation programs and variations in reporting methods may influence the ability to reliably compare access to rehabilitation between regions. Conclusion Recommendations regarding which patients with moderate and severe strokes should access ongoing rehabilitation are inconsistent. Clinical practice guidelines from different countries regarding post-stroke rehabilitation do not always reflect the evidence regarding the likely benefits to people with stroke. Inequity in access to rehabilitation after stroke is an international issue.

Coming of age: health-care challenges of an ageing population in Israel

Although Israel is still young in years, with relatively high birth rates and older people (individuals aged 65 years or older) constituting only about 11% of its population, the absolute number of older people is growing rapidly. Life expectancy is high, and increasing numbers of people are living to advanced old age (older than 85 years). A wide spectrum of geriatric care is provided within a universal system providing health services to all citizens. Community and institutional care is available, and many innovative programmes are being developed. The unique demographic characteristics of the ageing society in Israel reflect cultural and multiethnic diversity, in addition to a high rate of immigration of older people. To meet the growing challenges, address disparities, and search for innovation will require planning and development of adequate services at the highest level.

Research and data systems to promote equal access to postacute rehabilitation

The first national study in Israel of post-acute rehabilitation service use for elderly patients with stroke and hip fracture reported regional variation in care receipt. Although lower likelihood of admission to inpatient rehabilitation was observed in districts with known shortages of rehabilitation beds, supply alone did not explain the findings. This commentary explores other potential contributing factors. It argues that greater uniformity in the process and documentation of discharge planning in combination with decision support would help to standardize provider behavior. Implementation of a system of functional status data collection that is linked to administrative data is recommended to enable examination of the impact of care receipt and variation. Additional research is needed to provide a clearer understanding of factors contributing to regional variation and to identify solutions to ensure equal access to post-acute rehabilitation services in Israel.