An Outreach Rehabilitation Program for Nursing Home Residents After Hip Fracture May Be Cost-Saving.

BACKGROUND: We compared the cost-effectiveness of 10 weeks of outreach rehabilitation (intervention) versus usual care (control) for ambulatory nursing home residents after hip fracture. METHODS: Enrollment occurred February 2011 through June 2015 in a Canadian metropolitan region. Seventy-seven participants were allocated in a 2:1 ratio to receive a 10-week rehabilitation program (intervention) or usual care (control) (46 intervention; 31 control). Using a payer perspective, we performed main and sensitivity analyses. Health outcome was measured by quality-adjusted life years (QALYs), using the EQ5D, completed at study entry, 3-, 6-, and 12-months. We obtained patient-specific data for outpatient visits, physician claims, and inpatient readmissions; the trial provided rehabilitation utilization/cost data. We estimated incremental cost and incremental effectiveness. RESULTS: Groups were similar at study entry; the mean age was 87.9 ± 6.6 years, 54 (71%) were female and 58 (75%) had severe cognitive impairment. EQ5D QALYs scores were nonsignificantly higher for intervention participants. Inpatient readmissions were two times higher among controls, with a cost difference of -$3,350/patient for intervention participants, offsetting the cost/intervention participant of $2,300 for the outreach rehabilitation. The adjusted incremental QALYs/patient difference was 0.024 favoring the intervention, with an incremental cost/patient of -$621 for intervention participants; these values were not statistically significant. A sensitivity analysis reinforced these findings, suggesting that the intervention was likely dominant. CONCLUSION: A 10-week outreach rehabilitation intervention for nursing home residents who sustain a hip fracture may be cost-saving, through reduced postfracture hospital readmissions. These results support further work to evaluate postfracture rehabilitation for nursing home residents.

Rehabilitation After Hip Fracture for Nursing Home Residents: A Controlled Feasibility Trial.

BACKGROUND: This study compared functional outcomes at 3 months after hip fracture surgery between nursing home residents participating in a 10-week outreach rehabilitation program and those receiving usual care. Function, health-related quality of life, and mortality were also compared over 12 months, and outreach program feasibility was assessed. METHODS: A feasibility trial was undertaken in Canadian nursing homes; of 77 participants, 46 were allocated to Outreach and 31 to Control prior to assessing function or cognition. Outreach participants received 10 weeks of rehabilitation (30 sessions), and Control participants received usual posthospital fracture care in their nursing homes. The primary outcome was the Functional Independence Measure Physical Domain (FIMphysical) score 3 months post-fracture; we also explored FIM Locomotion and Mobility. Secondary outcomes were FIM scores, EQ-5D-3L scores, and mortality over 12 months. Program feasibility was also evaluated. RESULTS: The mean age was 88.7 ± 7.0 years, 55 (71%) were female, and 58 (75%) had severe cognitive impairment with no significant group differences (p > .14). Outreach participants had significantly higher FIM Locomotion than usual care (p = .02), but no significant group differences were seen in FIMphysical or FIM Mobility score 3 months post-fracture. In adjusted analyses, Outreach participants reported significant improvements in all FIM and EQ-5D-3L scores compared with Control participants over 12 months (p < .05). Mortality did not differ by group (p = .80). Thirty (65%) Outreach participants completed the program. CONCLUSIONS: Our feasibility trial demonstrated that Outreach participants achieved better locomotion by 3 months post-fracture compared with participants receiving usual postfracture care; benefits were sustained to 12 months post-fracture. In adjusted analyses, Outreach participants also showed sustained benefits in physical function and health-related quality of life.

Recovery of function following a hip fracture in geriatric ambulatory persons living in nursing homes: prospective cohort study.

OBJECTIVES: To measure 1-year post-hip fracture functional recovery, health-related quality of life (HRQL), and mortality in nursing home residents. DESIGN: Prospective longitudinal cohort study. SETTING AND PARTICIPANTS: Ambulatory nursing home residents with or without impaired cognition consecutively admitted with hip fracture to three Canadian tertiary-care hospitals from March 2008 through November 2009. MEASUREMENTS: Participants or proxy respondents completed the Functional Independence Measure Motor score (FIM(motor) ) and EuroQol5D index score (EQ-5D(index) ) in the hospital (prefracture status) and 3, 6, and 12 months after fracture. Complications over the first postfracture year were also ascertained; the primary outcome was functional recovery (change in FIM(motor) score). RESULTS: Of 92 eligible participants, 60 (64%) were enrolled. The mean age was 86.9 ± 8.1, 42 (70%) were female, and 45 (75%) had three or more comorbidities. Forty-three (72%) walked independently with or without aids before fracture. By 12 months, 27 (45%) participants had died, and 10 (17%) had withdrawn. Of the remaining 23 participants, functional status according to FIM(motor) score dropped substantially and significantly after the fracture (3 months, 34.0 ± 19.7; 6 months, 33.2 ± 19.7; 12 months, 32.0 ± 20.0; P < .001 from a baseline FIM(motor) score of 50.1 ± 16.1). By 12 months after the fracture, only eight (35%) were walking independently, and 11 (48%) were no longer ambulatory. HRQL according to the EQ-5D(index) also decreased significantly (P = .003), from 0.62 ± 0.20 before fracture to 0.42 ± 0.30 by 12 months after fracture. CONCLUSION: Hip fracture for nursing home residents was associated with substantial loss of functional independence, ambulation, and HRQL. Little recovery was evident after the first 3 months; there was almost 50% mortality within 12 months.

Best practices for elderly hip fracture patients. A systematic overview of the evidence.

OBJECTIVES: To determine evidence-based best practices for elderly hip fracture patients from the time of hospital admission to 6 months postfracture. DATA SOURCES: MEDLINE, Cochrane Library, CINAHL, Embase, PEDro, Ageline, NARIC, and CIRRIE databases were searched for potentially eligible articles published between 1985 and 2004. REVIEW METHODS: Two independent reviewers determined studies appropriate for inclusion using standardized selection criteria, extracted data, evaluated internal validity, and then rated studies according to levels of evidence. Only Level 1 or 2 evidence was included in our summary of clinical recommendations. RESULTS: Spinal anesthesia, pressure-relieving mattresses, perioperative antibiotics, and deep vein thromboses prophylaxes had consistent evidence of benefit. Routine preoperative traction was not associated with any benefits and should be abandoned. Types of surgical management, postoperative wound drainage, and even "multidisciplinary" care, lacked sufficient evidence to determine either benefit or harm. There was little evidence to either determine best subacute rehabilitation practices or to direct ongoing medical issues (e.g., nutrition). Studies conducted during the subacute recovery period were heterogeneous in terms of treatment settings, interventions, and outcomes studied and had no clear evidence for best treatment practices. CONCLUSIONS: The evidence for perioperative practices is relatively robust and evidence-based perioperative treatment guidelines can be easily established. Conversely, more evidence is required to better guide the care of elderly patients with hip fracture during the subacute recovery period and convalescence.

Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures.

UNLABELLED: Our objectives were to better define the rates and determinants of in-hospital and 1-year mortality after hip fracture. We studied a population-based cohort of 3981 hip fracture patients. Using multivariable regression methods, we identified risk factors for mortality (older age, male sex, long-term care residence, 10 prefracture co-morbidities) and calculated a hip fracture-specific score that could accurately predict or risk-adjust in-hospital and 1-year mortality. Our methods, after further validation, may be useful for comparing outcomes across hospitals or regions. INTRODUCTION: Hip fractures in the elderly are common and associated with significant mortality and variations in outcome. The rates and determinants of mortality after hip fracture are not well defined. Our objectives were (1) to define the rate of in-hospital and 1-year mortality in hip fracture patients, (2) to describe co-morbidities at the time of fracture, and (3) to develop and validate a multivariable risk-adjustment model for mortality. MATERIALS AND METHODS: We studied a population-based cohort of 3981 hip fracture patients > or =60 years of age admitted to hospitals in a large Canadian health region from 1994 to 2000. We collected sociodemographic and prefracture co-morbidity data. Main outcomes were in-hospital and 1-year mortality. We used multivariable regression methods to first derive a risk-adjustment model for mortality in 2187 patients treated at one hospital and then validated it in 1794 patients treated at another hospital. These models were used to calculate a score that could predict or risk-adjust in-hospital and 1-year mortality after hip fracture. RESULTS AND CONCLUSIONS: The median age of the cohort was 82 years, 71% were female, and 26% had more than four prefracture co-morbidities. In-hospital mortality was 6.3%; 10.2% for men and 4.7% for women (adjusted odds ratio, 1.8; 95% CI, 1.3-2.4). Mortality at 1 year was 30.8%; 37.5% for men and 28.2% for women (adjusted p < 0.001). Older age, male sex, long-term care residence, and 10 different co-morbidities were independently associated with mortality. Risk-adjustment models based on these variables had excellent accuracy for predicting mortality in-hospital (c-statistic = 0.82) and at 1 year (c-statistic = 0.74). We conclude that 1 in 15 elderly patients with hip fracture will die during hospitalization, and almost one-third of those who survive to discharge will die within the year. The determinants of mortality were primarily older age, male sex, and prefracture co-morbidities. Our hip fracture-specific risk-adjustment tool is pragmatic and reliable, and after further validation, may be useful for comparing outcomes across different hospitals or regions.

Effect of adjunctive range-of-motion therapy after primary total knee arthroplasty on the use of health services after hospital discharge.

INTRODUCTION: There is controversy as to whether continuous passive motion (CPM) after total knee arthroplasty (TKA), which is the standard treatment, confers significant benefit with respect to outcome. The primary purpose of this study was to determine if CPM or slider-board (SB) therapy, used as adjuncts to standardized exercises (SEs) during the acute-care hospital stay, resulted in a reduced total length of hospitalization and post-discharge rehabilitation in patients who underwent primary TKA. METHODS: We carried out a randomized, clinical trial on 120 patients who received a TKA at the University of Alberta Hospital, Edmonton, a tertiary care institution. The study horizon began at the point of discharge from the hospital and continued up to 6 months after operation. Postoperatively, patients (40 in each group) received CPM and SEs, SB therapy and SEs or SEs alone while in the tertiary Health service use was compared using transfer institution length of stay(LOS), post-discharge rehabilitation, readmission and complication rates and their associated costs. RESULTS: There were no differences in health service use or costs among the 3 groups over the 6-month study. The rates of postoperative complications and readmissions also were similar among the groups. Increased health service use associated with knee flexion that was less than 60 degrees at discharge, but similar proportions of patients with poor knee range of movement (ROM) at discharge were found in each group. CONCLUSIONS: This finding suggests that adjunctive ROM therapy, as used in this study, does not reduce health service use. Further research is required to determine if adjunctive ROM therapy after discharge from the surgical hospital decreases health service utilization in those patients who have poor knee ROM at the time of discharge.