Measuring rehabilitation outcome in post-acute hip fractured patients

The effectiveness of a physiatrist-led acute hospital based postoperative hip fracture inpatient rehabilitation program: A single-center retrospective study

Background

Postoperative hip fracture rehabilitation in Singapore has historically been carried out in both acute and community hospitals (CH). An increasing majority of patients with hip fractures now receive inpatient rehabilitation in CH, and it is often believed that Acute hospital (AH) - based rehabilitation may be less cost-effective than their CH counterparts. Objective: This retrospective study aims to review the effectiveness of an AH-based hip fracture postoperative rehabilitation program.

Methods

This study retrospectively reviewed the database of postoperative hip fracture patients who underwent a physiatrist-led AH-based inpatient rehabilitation from Jan 2010 to Dec 2016. The primary outcomes were the functional improvement assessed by functional independence measure (FIM) and FIM efficiency. The secondary outcome included the length of stay (LOS), successful discharge to home rate, mortality rate, and complication rate.

Results

A total of 293 cases were included in the study. After participation in the inpatient rehabilitation program, the mean total FIM increased from 83.9 ± 12.7 (mean ± SD) to 93.9 ± 16.2 ( p < .001). The motor FIM increased from 47.1 ± 10.9 to 56.1 ± 10.1 ( p < .001). 269 (91.8%) patients were successfully discharged home. Inpatient mortality was 0.3% (1/293). The complications rate during inpatient rehabilitation was 16.0% with urinary tract infection being the most frequent complication (10.2%). The median LOS for inpatient rehabilitation was 19 days (15, 28).

Conclusions

After completing a physiatrist-led postoperative hip fracture inpatient rehabilitation program in an acute hospital, patients demonstrated significant functional improvement ( p < .0001). The inpatient rehabilitation program has a high discharge home rate and low in-hospital mortality.

Does the type of hip fracture affect functional recovery in elderly patients undergoing inpatient rehabilitation?

BACKGROUND

Hip fractures should not be considered as a single, homogeneous condition. Various determinants of functional recovery of patients with hip fracture have been proposed, such as age or type of fracture. The aim of this study was to determine if patients with an intertrochanteric fracture (ITF) had lower functional recovery characteristics with respect to those with a femoral neck fracture (FNF).

METHODS

A retrospective study was carried out on 531 elderly patients with hip fracture, surgically treated, admitted to a rehabilitation institute between December 1, 2014, and December 31, 2017. Patients underwent an individualized rehabilitation program for improving their physical function. The outcome measures of this study were the length of stay (LOS) in the rehabilitation institute, the Functional Independence Measure (FIM) gain, i.e. the difference in FIM score between discharge and admission, and the FIM efficiency, which represents the daily gain. Patients were also stratified by age categories and by different levels of functional independence, as evaluated with the FIM total score at baseline.

RESULTS

Age (p<0.05), LOS (p<0.005) and rehabilitation outcomes (FIM score and efficiency; p<0.05) differed significantly between patients with FNF and ITF. In particular, patients with ITF were older and more dependent at baseline. Moreover, they showed a lower FIM efficiency with respect to patients with FNF (p<0.05), which obtained a similar improvement in FIM total score of about 26 points but were discharged on average 3 days before. With aging, FIM efficiency decreased, while LOS increased. Patients highly dependent at baseline (FIM total score <40) had the lowest FIM gain and efficiency and the longest LOS respect to the more independent patients. Moreover, in older (85+ years) and in higher dependent patients the differences in the outcome measures between ITF and FNF were reduced.

CONCLUSIONS

The type of hip fracture could affect the LOS and FIM efficiency of younger and more independent patients with hip fracture during inpatient rehabilitation. In particular, patients with ITF require a longer rehabilitation period to achieve a similar functional gain as those with FNF.

Patients from residential aged care with hip fractures-Does discharge destination from acute care affect outcomes?

OBJECTIVE

The aim of this study was to describe the demographics of patients from residential aged care facilities (RACFs) who underwent fixation of hip fracture and to compare 12-month functional and mortality outcomes for those returning to their RACF with those admitted to a subacute facility (SAF) following their acute hospital stay.

METHODS

A retrospective review was undertaken of all patients from a RACF with high-level care needs admitted to Alfred Hospital, Melbourne, for fixation of hip fracture in 2014-2015. Data including demographic and hospital event details, length of stay (LOS), discharge destination and 12-month functional outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E), were collected. Factors related to discharge destination and outcomes were analysed.

RESULTS

Ninety patients from a RACF were included in this study, with 68 patients (76%) returning to their RACF and 22 (24%) admitted to a SAF after acute hospital stay. Those discharged to a SAF had an average LOS at this facility of 20.79 days (SD 8.02). The SAF group also had a longer acute LOS (7 days IQR 5-10, compared to 6 days IQR 4-7.5) but there was no difference between groups at 12 months in terms of mortality or function, with 50% of all patients deceased at this time point (n = 40) and the remaining 40 patients (50%) reporting a poor functional outcome.

CONCLUSIONS

Mobility status during acute and subacute stay, and 12-month functional and mortality outcomes were similar in both groups irrespective of discharge destination, with the influence of cognition and concomitant medical issues currently unknown. Further research is required to evaluate the efficacy of current hip fracture models of care, the factors that influence clinician discharge planning decision-making and to interrogate new models of care that support rehabilitation and complex medical management in RACFs.

Developing quality indicators for in-patient post-acute care

BACKGROUND

This paper describes an integrated series of functional, clinical, and discharge post-acute care (PAC) quality indicators (QIs) and an examination of the distribution of the QIs in skilled nursing facilities (SNF) across the US. The indicators use items available in interRAI based assessments including the MDS 3.0 and are designed for use in in-patient post-acute environments that use the assessments.

METHODS

Data Source: MDS 3.0 computerized assessments mandated for all patients admitted to US skilled nursing facilities (SNF) in 2012. In total, 2,380,213 patients were admitted to SNFs for post-acute care. Definition of the QI numerator, denominator and covariate structures were based on MDS assessment items. A regression strategy modeling the "discharge to the community" PAC QI as the dependent variable was used to identify how to bring together a subset of seven candidate PAC QIs for inclusion in a summary scale. Finally, the distributional property of the summary scale (the PAC QI Summary Scale) across all facilities was explored.

RESULTS

The risk-adjusted PAC QIs include indicators of improved status, including measures of early, middle, and late-loss functional performance, as well as measures of walking and changed clinical status and an overall summary functional scale. Many but not all patients demonstrated improvement from baseline to follow-up. However, there was substantial inter-state variation in the summary QI scores across the SNFs.

CONCLUSIONS

The set of PAC QIs consist of five functional, two discharge and eight clinical measures, and one summary scale. All QIs can be derived from multiple interRAI assessment tools, including the MDS 2.0, interRAI-LTCF, MDS 3.0, and the interRAI-PAC-Rehab. These measures are appropriate for wide distribution in and out of the United States, allowing comparison and discussion of practices associated with better outcomes.

The Barthel Index and the Cumulated Ambulation Score are superior to the de Morton Mobility Index for the early assessment of outcome in patients with a hip fracture admitted to an acute geriatric ward

PURPOSE

To examine clinimetric properties of the de Morton Mobility Index (DEMMI) in patients with hip fracture in comparison with the modified Barthel Index (BI), Cumulated Ambulation Score (CAS), and 30-s Chair Stand Test (30-s CST).

MATERIALS AND METHODS

Two hundred and twenty two patients with a hip fracture admitted to a geriatric ward following surgery were assessed on day 1 and at discharge (mean of 9 [SD 5.1] post-surgery days).

RESULTS

Ninety eight percent and 89% of patients were not able to perform the 30-s CST at baseline and at discharge (large floor effect), respectively. Corresponding floor effects were 39% and 31% for DEMMI, 12% and 5% for BI, and 22% and 6%, respectively, for CAS. Convergent validity was strong between DEMMI and CAS (r = 0.76, 95% CI: 0.69-0.81), and moderate between DEMMI and BI (r = 0.58, 95% CI: 0.48-0.66) and CAS and BI (r = 0.49, 95% CI: 0.39-0.59). Responsiveness, as indicated by the effect size was 0.76 for DEMMI, 1.78 for BI and 1.04 for CAS. Baseline scores of DEMMI, BI, and CAS showed similar properties in predicting discharge destination of patients from own home.

CONCLUSIONS

The value of using DEMMI and 30-s CST in patients with hip fracture during the acute hospitalization seems limited in comparison with BI and CAS. DEMMI and CAS seem to assess similar constructs. Implications for Rehabilitation Outcome measures used for the evaluation of patients with hip fracture should be validated in the specific time-line and rehabilitation setting following surgery, before being implemented in daily clinical practice. We suggest the Cumulated Ambulation Score for monitoring basic mobility during the acute hospitalization for the entire group of patients recovering from a hip fracture, while DEMMI seems more feasible for the subgroup of patients with higher functional levels. The modified Barthel Index seems useful for the assessment of activities of daily living in the acute care setting of patients with hip fracture. We cannot recommend the original 30-s Chair Stand Test to be used for the evaluation of patients with hip fracture in the acute hospital setting.

Performance-based outcomes of inpatient rehabilitation facilities treating hip fracture patients in the United States

OBJECTIVE

To examine the influence of facility and aggregate patient characteristics of inpatient rehabilitation facilities (IRFs) on performance-based rehabilitation outcomes in a national sample of IRFs treating Medicare beneficiaries with hip fracture.

DESIGN

Secondary data analysis.

SETTING

U.S. Medicare-certified IRFs (N=983).

PARTICIPANTS

Data included patient records of Medicare beneficiaries (N=34,364) admitted in 2009 for rehabilitation after hip fracture.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Performance-based outcomes included mean motor function on discharge, mean motor change (mean motor score on discharge minus mean motor score on admission), and percentage discharged to the community.

RESULTS

Higher mean motor function on discharge was explained by aggregate characteristics of patients with hip fracture (lower age [P=.009], lower percentage of blacks [P<.001] and Hispanics [P<.001], higher percentage of women [P=.030], higher motor function on admission [P<.001], longer length of stay [P<.001]) and facility characteristics (freestanding [P<.001], rural [P<.001], for profit [P=.048], smaller IRFs [P=.014]). The findings were similar for motor change, but motor change was also associated with lower mean cognitive function on admission (P=.008). Higher percentage discharged to the community was associated with aggregate patient characteristics (lower age [P<.001], lower percentage of Hispanics [P=.009], higher percentage of patients living with others [P<.001], higher motor function on admission [P<.001]). No facility characteristics were associated with the percentage discharged to the community.

CONCLUSIONS

Performance-based measurement offers health policymakers, administrators, clinicians, and consumers a major opportunity for securing health system improvement by benchmarking or comparing their outcomes with those of other similar facilities. These results might serve as the basis for benchmarking and quality-based reimbursement to IRFs for 1 impairment group: hip fracture.