Rehabilitation in a convalescent rehabilitation ward following an acute ward improves functional recovery and mortality for hip fracture patients: a sequence in a single hospital

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.

Insufficient Postoperative Rehabilitation in Patients with Both Proximal Femoral Fracture and Antecedent Mental Illness

Introduction:

Though a combination of proximal femoral fracture and mental illness is likely, the management of this combination is not well established. The aim of this study was to clarify the current disposition of acute care and rehabilitation for patients with this combination of conditions at our institution.

Methods:

We retrospectively analyzed the records of 192 patients hospitalized in the psychiatric ward who present with a proximal femoral fracture and an antecedent mental illness. We investigated walking ability prior to injury and after surgery, at discharge from our institution, using the Functional Independence Measure (FIM) score.

Results:

Although patients in the psychiatric ward demonstrated postoperative hospital stays approximately 10 days longer than those in the orthopedic ward, more than half of the patients in the psychiatric ward were discharged from our institution with a functional level of complete dependence for walking ability. In addition, nearly 90% of the patients studied were transferred to a psychiatric hospital where no physical therapy or rehabilitation was provided to the inpatients.

Conclusions:

At our institution, patients with proximal femoral fracture and antecedent mental illness tended to be discharged with complete dependence in walking ability, often to a psychiatric hospital without physical therapy or rehabilitation. We hope this paper will draw attention to the need for rehabilitation in these patients.

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.

Predictive factors associated with poor outcomes for older adult inpatients in the convalescent rehabilitation ward

This study aimed to determine predictive factors associated with poor outcomes among older adult inpatients in the convalescent rehabilitation ward. We also examined the validity of factors that were identified as predictive of poor outcomes. Study subjects were 104 older adult inpatients in the convalescent rehabilitation ward, divided into two groups based on outcome at discharge. Group I included the outcomes of death or transfer to an acute care hospital and Group II included all other outcomes. Data were retrospectively collected from older adults' medical records, including: activities of daily living, swallowing grade, nutritional index, and blood biochemistry data. Logistic regression analysis was used to extract predictive factors associated with poor outcomes. Next, we calculated the Stratum-specific likelihood ratio (SSLR) for each extracted factor. Two items were extracted as predictive factors with AUCs ≥ 0.7 : N-terminal pro-brain natriuretic peptide (NT-proBNP) and days from onset to hospitalization. The SSLRs showed the risk for a poor outcome increased when NT-proBNP was ≥ 2500 pg / ml, and when there were ≥ 35 days from onset to hospitalization. Our findings suggest these predictive factors provide a valid index to predict poor outcomes among older adults from the early stage of admission. J. Med. Invest. 67 : 304-310, August, 2020.

Occlusal support is associated with nutritional improvement and recovery of physical function in patients recovering from hip fracture

OBJECTIVE

This study aimed to elucidate the association between occlusal support and nutritional improvement and recovery of activities of daily living (ADLs) among elderly patients recovering from hip fracture.

BACKGROUND

Many patients with hip fracture are malnourished, and malnutrition is associated with poor functional outcomes. Poor oral status is one reason for malnutrition because loss of occlusal support leads to masticatory disorders and can cause nutrient deficiencies.

METHODS

We evaluated 202 elderly patients aged 65 years and older (mean age, 84.9 ± 7.9 years). We assessed nutritional status using the Mini Nutritional Assessment-Short Form and ADLs using functional independence measure (FIM) scores. Occlusal support was recorded in accordance with the Eichner Index. We categorised participants into two groups according to the presence or absence of occlusal support, and statistical analyses were performed to investigate the differences between the groups.

RESULTS

One group contained 152 participants (mean age, 85.5 ± 7.4 years) with occlusal support, and the other group contained 50 participants (mean age, 83.0 ± 8.9 years) without occlusal support. The group with occlusal support had greater gain of FIM and higher FIM efficiency than did the other group. Multivariate analyses showed that occlusal support was independently associated with nutritional improvement [odds ratio (OR) = 4.00, 95% confidence intervals (CI) = 1.90-8.43] and motor FIM efficiency (R²  = .338, P < .001).

CONCLUSIONS

Our findings suggest that occlusal support is associated with nutritional improvement and the recovery of ADLs in patients recovering from hip fracture.

Changing trends in the mortality rate at 1-year post hip fracture - a systematic review

BACKGROUND

Traditionally, the mortality rate at 1-year post hip fracture was quoted as approximately 30% of all hip fractures. There have been recent improvements in hip fracture care in the main driven by national hip fracture registries with reductions in 30-d mortality rates reported.

AIM

To address recent 1-year post hip fracture mortality rates in the literature.

METHODS

Systematic literature review, national hip fracture registries/databases, local studies on hip fracture mortality, 5 years limitation (2013-2017), cohorts > 100, studies in English. Outcome measure: Mortality rate at 1-year post hip fracture.

RESULTS

Recent 1-year mortality rates were reviewed using the literature from 8 National Registries and 36 different countries. Recently published 1-year mortality rates appear lower than traditional figures and may represent a downward trend.

CONCLUSION

There appears to be a consistent worldwide reduction in mortality at 1-year post hip fracture compared to previously published research. Globally, those which suffer hip fractures may currently be benefiting from the results of approximately 30 years of national registries, rigorous audit processes and international collaboration. The previously quoted mortality rates of 10% at 1-mo and 30% at 1-year may be outdated.