Discharge destination following hip fracture: comparative effectiveness and cost analyses

Association of Fragmented Readmissions and Electronic Information Sharing With Discharge Destination Among Older Adults

Importance

When an older adult is hospitalized, where they are discharged is of utmost importance. Fragmented readmissions, defined as readmissions to a different hospital than a patient was previously discharged from, may increase the risk of a nonhome discharge for older adults. However, this risk may be mitigated via electronic information exchange between the admission and readmission hospitals.

Objective

To determine the association of fragmented hospital readmissions and electronic information sharing with discharge destination among Medicare beneficiaries.

Design, Setting, and Participants

This cohort study retrospectively examined data from Medicare beneficiaries hospitalized for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues in 2018 and their 30-day readmission for any reason. The data analysis was completed between November 1, 2021, and October 31, 2022.

Exposures

Same hospital vs fragmented readmissions and presence of the same health information exchange (HIE) at the admission and readmission hospitals vs no information shared between the admission and readmission hospitals.

Main Outcomes and Measures

The main outcome was discharge destination following the readmission, including home, home with home health, skilled nursing facility (SNF), hospice, leaving against medical advice, or dying. Outcomes were examined for beneficiaries with and without Alzheimer disease using logistic regressions.

Results

The cohort included 275 189 admission-readmission pairs, representing 268 768 unique patients (mean [SD] age, 78.9 [9.0] years; 54.1% female and 45.9% male; 12.2% Black, 82.1% White, and 5.7% other race and ethnicity). Of the 31.6% fragmented readmissions in the cohort, 14.3% occurred at hospitals that shared an HIE with the admission hospital. Beneficiaries with same hospital/nonfragmented readmissions tended to be older (mean [SD] age, 78.9 [9.0] vs 77.9 [8.8] for fragmented with same HIE and 78.3 [8.7] years for fragmented without HIE; P < .001). Fragmented readmissions were associated with 10% higher odds of discharge to an SNF (adjusted odds ratio [AOR], 1.10; 95% CI, 1.07-1.12) and 22% lower odds of discharge home with home health (AOR, 0.78; 95% CI, 0.76-0.80) compared with same hospital/nonfragmented readmissions. When the admission and readmission hospital shared an HIE, beneficiaries had 9% to 15% higher odds of discharge home with home health (patients without Alzheimer disease: AOR, 1.09 [95% CI, 1.04-1.16]; patients with Alzheimer disease: AOR, 1.15 [95% CI, 1.01-1.32]) compared with fragmented readmissions where information sharing was not available.

Conclusions and Relevance

In this cohort study of Medicare beneficiaries with 30-day readmissions, whether a readmission is fragmented was associated with discharge destination. Among fragmented readmissions, shared HIE across admission and readmission hospitals was associated with higher odds of discharge home with home health. Efforts to study the utility of HIE for care coordination for older adults should be pursued.

Factors associated with non-home discharge of patients hospitalized for hip fracture: A nationwide retrospective study using the Japanese diagnostic procedure combination database

In Japan, the length of stay in acute care hospitals has been shortened, home medical care has been promoted following national policy. However, many issues remain in promoting home medical care. The aim of this study was to clarify the profiles of patients with hip fractures, aged ≥ 65 years, who were hospitalized in acute care institutions at the time of discharge and the influence on nonhome discharge. This study used data from patients who satisfied all the following conditions: Patients aged ≥ 65 years who were hospitalized and discharged between April 2018 and March 2019; Patients with hip fractures, and; Patients who were admitted from home. The patients were classified into the home discharge and nonhome discharge groups. Multivariate analysis was conducted by comparing socio-demographic status, patient background factors, patient status at discharge, and hospital function. This study included 31,752 patients (73.7%) and 11,312 patients (26.3%) in the nonhome discharge group and home discharge group, respectively. Overall, the proportions of males and females were 22.2% and 77.8%, respectively. The average (standard deviation) age of the patients was 84.1 years (7.4) and 81.3 years (8.5) in the nonhome discharge and home discharge groups, respectively (P < .01). The following factors affected nonhome discharge: 75 to 84 years (odds ratio [OR] = 1.81, 95% confidence interval [CI] = 1.68-1.96), ≥85 years (OR = 2.17, 95% CI = 2.01-2.36), electrocardiography or respiratory treatment "(Factor A3) (OR = 1.44, 95% CI = 1.23-1.68), level of assistance with activities of daily living "(Factor B1)" (OR = 4.56, 95% CI = 4.22-4.92), and hospital where the patient-to-nurse ratio is 7:1 (OR = 2.12, 95% CI = 1.91-2.35). The results suggested that support from activities of daily living caregivers and implementing medical treatments such as respiratory care are required to advance home medical care. This study's method enables analysis focusing on aspiration pneumonia and cerebral infarction, which are common among older adults. Furthermore, specific measures for promoting home medical care for patients who are highly dependent on medical and long-term care may be developed.

Postsurgery paths and outcomes for hip fracture patients (POST-OP HIP PATHS): a population-based retrospective cohort study protocol

INTRODUCTION

Hip fracture patients receive varying levels of support posthip fracture surgery and often experience significant disability and increased risk of mortality. Best practice guidelines recommend that all hip fracture patients receive active rehabilitation following their acute care stay, with rehabilitation beginning no later than 6 days following surgery. Nevertheless, patients frequently experience gaps in care including delays and variation in rehabilitation services they receive. We aim to understand the factors that drive these practice variations for older adults following hip fracture surgery, and their impact on patient outcomes.

METHODS AND ANALYSIS

We will conduct a retrospective population-based cohort study using routinely collected health administrative data housed at ICES. The study population will include all individuals with a unilateral hip fracture aged 50 and older who underwent surgical repair in Ontario, Canada between 1 January 2015 and 31 December 2018. We will use unadjusted and multilevel, multivariable adjusted regression models to identify predictors of rehabilitation setting, time to rehabilitation and length of rehabilitation, with predictors prespecified including patient sociodemographics, baseline health and characteristics of the acute (surgical) episode. We will examine outcomes after rehabilitation, including place of care/residence at 6 and 12 months postrehabilitation, as well as other short-term and long-term outcomes.

ETHICS AND DISSEMINATION

The use of the data in this project is authorised under section 45 of Ontario's Personal Health Information Protection Act and does not require review by a Research Ethics Board. Results will be disseminated through conference presentations and in peer-reviewed journals.

Assessing the Knowledge and Attitude towards Osteoporosis among Syrian Women: A Cross-Sectional Study

BACKGROUND

Osteoporosis is a progressive decline in the bone mass, which occurs with no alterations to the bone's composition. It is associated with increased bone fragility that may eventually lead to fractures. In this study, we aim to assess the level of awareness that Syrian women possess regarding osteoporosis and spread the knowledge about its prevention measures.

METHODS

This study was approved by the Institutional Review Board of the Syrian Private University. A validated questionnaire was asked to be filled in by women aged 18 and above, who were presented to clinics at Damascus, Al Helal, and Al Zahrawi hospitals between 28 November 2021 and 5 March 2022.

RESULTS

6082 women were included, of which 63.9% (n = 3884) were under 30 years old and 89.3% (n = 5429) were in their reproductive age. The average knowledge score of osteoporosis was 69.2 ± 7.7 (28-100); 88.1% correctly defined osteoporosis while the majority (93.4%) has heard of it. The majority of our participants were living in rural areas (77.2%; n = 4698) while only 22.8% (n = 1384) were living in urban areas. The respondents from urban areas reported the highest knowledge scores (OR = 1.472; 95% CI: 1.258-1.723; P < 0.0001). 75.60% agreed that aging is a risk factor for osteoporosis. 64.6% were aware that osteoporosis is directly responsible for hip fractures. Smoking, family history, lack of exercise, and menopause were the main risk factors for osteoporosis, at 53.6%, 53.1%, 84.6%, and 60.7%, respectively. Social media represented the ultimate source of information on osteoporosis (64.70%).

CONCLUSION

Our study is the largest in the region and the first of its kind in the country. Syrian women had an average knowledge score regarding osteoporosis; the vast majority has defined it correctly and has heard of it. We found no statistical significance between age or educational level and adequate knowledge about osteoporosis.

Association among cognition, frailty, and falls and self‐reported incident fractures: results from the Canadian Longitudinal Study on Aging ( CLSA )

Cognition, frailty, and falls have been examined independently as potential correlates of fracture risk, but not simultaneously. Our objective was to explore the association between cognition, frailty, and falls and self‐reported incident fractures to determine if these factors show significant independent associations or interactions. We included participants who completed the Canadian Longitudinal Study on Aging (CLSA) 2012–2015 baseline comprehensive assessment, did not experience any self‐reported fractures in the year prior to cohort recruitment, and completed the follow‐up questionnaire at year 3 (n = 26,982). We compared all baseline cognitive measures available in the CLSA, the Rockwood Frailty Index (FI), and presence of self‐reported falls in the past 12 months in those with versus without self‐reported incident fractures in year 3 of follow‐up. We used multivariable logistic regression adjusted for covariates and examined two‐way interactions between cognition, frailty, and prior falls. CLSA specified analytic weights were applied. The mean ± standard error (SE) age of participants was 59.5 ± 0.1 years and 52.2% were female. A total of 715 participants (2.7%) self‐reported incident fractures at 3‐year follow‐up. Participants who experienced incident fractures had similar baseline cognition scores (mean ± SE; Rey Auditory Verbal Learning Test [RAVLT]: Immediate recall 6.1 ± 0.1 versus 5.9 ± 0.0; standardized difference [d] 0.124); higher FI scores (mean ± SE; FI 0.134 ± 0.005 versus 0.116 ± 0.001; d 0.193), and a greater percentage had fallen in the past 12 months (weighted n [%] 518 [7.2] versus 919 [3.5]; d 0.165). FI (each increment of 0.08) was associated with a significantly increased risk of self‐reported incident fractures in participants of all ages and those aged 65 years or older (adjusted odd ratio [OR] 1.24, 95% confidence limit [CL] 1.10–1.40; adjusted OR 1.44, 95% CL 1.11–1.52, respectively). The adjusted odds for self‐reported incident fractures in participants of all ages was also significantly associated with falls in the past 12 months prior to baseline (adjusted OR 1.83; 95% CL 1.13–2.97), but not in those aged 65 years or older. No interactions between cognition, frailty, and prior falls were found. However, considering the relatively young age of our cohort, it may be appropriate to make strong inferences in individuals older than 65 years of age. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Artificial intelligence in orthopaedic surgery: transforming technological innovation in patient care and surgical training

Artificial intelligence (AI) is an exciting field combining computer science with robust data sets to facilitate problem-solving. It has the potential to transform education, practice and delivery of healthcare especially in orthopaedics. This review article outlines some of the already used AI pathways as well as recent technological advances in orthopaedics. Additionally, this article further explains how potentially these two entities could be combined in the future to improve surgical education, training and ultimately patient care and outcomes.

An update of the prevalence of osteoporosis, fracture risk factors, and medication use among community-dwelling older adults: results from the Canadian Longitudinal Study on Aging (CLSA)

The prevalence of self-reported and DXA-confirmed osteoporosis was 7.8% (males 2.2%; females 12.7%), and 3.6% (males 1.2%; females 5.9%), respectively. We found that most community-dwelling older adults at high fracture risk are not taking osteoporosis medication, particularly males. There is a major opportunity for improved primary fracture prevention in the community.

PURPOSE

To provide an up-to-date prevalence estimate of osteoporosis, fracture risk factors, fracture risk, and the proportion of older Canadians at high fracture risk who are not taking an osteoporosis medication.

METHODS

We included Canadian Longitudinal Study on Aging (CLSA) participants: a community-dwelling cohort aged 45 to 85 years who completed the baseline (2015) comprehensive interview and had dual-energy X-ray absorptiometry (DXA) scans (N = 30,097). We describe the age- and sex-stratified prevalence of (1) self-reported osteoporosis; (2) DXA-confirmed osteoporosis; (3) fracture risk factors and people who are at high risk (FRAX® major osteoporotic fracture probability ≥ 20%); and (4) people who are at high fracture risk not taking osteoporosis medications. Sampling weights, as defined by the CLSA, were applied.

RESULTS

The mean age of participants was 70.0 (SD 10.3). Overall, 7.8% had self-reported osteoporosis (males 2.2%; females 12.7%) while 3.6% had DXA-confirmed osteoporosis (males 1.2%; females 5.9%), and 2.8% were at high fracture risk (males 0.3%; females 5.1%). Of people who had osteoporosis and were at high risk, 77.3% were not taking an osteoporosis medication (males 92.3%; females 76.8%).

CONCLUSIONS

Our study provides an up-to-date prevalence estimate of osteoporosis for community-dwelling older Canadians. We found that most community-dwelling older adults at high fracture risk are not taking an osteoporosis medication, particularly males. There is a major opportunity for improved primary fracture prevention in the community.

Discharge to inpatient care facilities following hip fracture surgery: incidence, risk factors, and 30-day post-discharge outcomes

BACKGROUND

Discharge to an inpatient care facility (skilled-care or rehabilitation) has been shown to be associated with adverse outcomes following elective total joint arthroplasties. Current evidence with regard to hip fracture surgeries remains limited.

METHODS

The 2015-2016 ACS-NSQIP database was used to query for patients undergoing total hip arthroplasty, hemiarthroplasty and open reduction internal fixation for hip fractures. A total of 15,655 patients undergoing hip fracture surgery were retrieved from the database. Inpatient facility discharge included discharges to skilled-care facilities and inpatient rehabilitation units. Multi-variate regression analysis was used to assess for differences in 30-day post-discharge outcomes between home-discharge versus inpatient care facility discharge, while adjusting for baseline differences between the 2 study populations.

RESULTS

A total of 12,568 (80.3%) patients were discharged to an inpatient care facility. Discharge to an inpatient care facility was associated with higher odds of any complication (OR 2.03 [95% CI, 1.61-2.55]; p < 0.001), wound complications (OR 1.79 [95% CI, 1.10-2.91]; p = 0.019), cardiac complications (OR 4.49 [95% CI, 1.40-14.40]; p = 0.012), respiratory complication (OR 2.29 [95% CI, 1.39-3.77]; p = 0.001), stroke (OR 7.67 [95% CI, 1.05-56.29]; p = 0.045, urinary tract infections (OR 2.30 [95% CI, 1.52-3.48]; p < 0.001), unplanned re-operations (OR 1.37 [95% CI, 1.03-1.82]; p = 0.029) and readmissions (OR 1.38 [95% CI, 1.16-1.63]; p < 0.001) following discharge.

CONCLUSION

Discharge to inpatient care facilities versus home following hip fracture surgery is associated with higher odds of post-discharge complications, re-operations and readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimise the risk of complications.

The application of machine learning algorithms in predicting the length of stay following femoral neck fracture

PURPOSE

Femoral neck fracture is a frequent cause of hospitalization, and length of stay is an important marker of hospital cost and quality of care provided. As an extension of traditional statistical methods, machine learning provides the possibility of accurately predicting the length of hospital stay. The aim of this paper is to retrospectively identify predictive factors of the length of hospital stay (LOS) and predict the postoperative LOS by using machine learning algorithms.

METHOD

Based on the admission and perioperative data of the patients, linear regression was used to analyze the predictive factors of the LOS. Multiple machine learning models were developed, and the performance of different models was compared.

RESULT

Stepwise linear regression showed that preoperative calcium level (P = 0.017) and preoperative lymphocyte percentage (P = 0.007), in addition to intraoperative bleeding (p = 0.041), glucose and sodium chloride infusion after surgery (P = 0.019), Charlson Comorbidity Index (p = 0.007) and BMI (P = 0.031), were significant predictors of LOS. The best performing model was the principal component regression (PCR) with an optimal MAE (1.525) and a proportion of prediction error within 3 days of 90.91%.

CONCLUSION

Excessive intravenous glucose and sodium chloride infusion after surgery, preoperative hypocalcemia, preoperative high percentages of lymphocytes, excessive intraoperative bleeding, lower BMI and higher CCI scores were related to prolonged LOS by using linear regression. Machine learning could accurately predict the postoperative LOS. This information allows hospital administrators to plan reasonable resource allocation to fulfill demand, leading to direct care quality improvement and more reasonable use of scarce resources.

Discharge destination after hip fracture: findings from the Irish hip fracture database

PURPOSE

Although home continues to be the place from which the majority of patients are admitted, less than one third of patients are Discharged Directly Home (DDH) following hip fracture. Once ready for discharge, DDH as opposed to Discharge to an Alternative Location (DAL), i.e., community care, rehabilitation facility or long-term care, is a high priority for patients and clinicians alike. Not only is DDH integral to the quality of life of patients, it is also an essential driver of the socioeconomic cost of hip fracture care.

METHODS

We analysed 21,819 cases in the Irish Hip Fracture Database from 2013 to 2019. Descriptive and analytical statistics were conducted.

RESULTS

29% (n = 6476) of patients were DDH during the study period. On multivariate analysis, the odds of DDH decreased as age increased (OR 0.28, p < 0.01, 95% CI 0.24-0.34). Patients who were independently mobile prior to fracture were 47% more likely to be DDH (OR 1.47, p < 0.01, 95% CI 1.29-1.68). Those mobilised early post operatively were 24% more likely to be DDH (OR 1.24, p < 0.01, 95% CI 1.06-1.45). Patients who waited > 72 h prior to surgery were 30% less likely to be DDH (OR 0.70, p < 0.01, 95% CI 0.56-0.88).

CONCLUSION

The authors identified patient characteristics that increased the likelihood of DDH, i.e., younger patients independently mobile prior to fracture, who received timely surgery and early post-operative mobilisation. The Irish Hip Fracture Standards (IHFS) incorporate 2 out the 3 modifiable factors identified, which reinforces the importance of the IHFS in improving patient outcomes.

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.

Patient and hospital factors influencing discharge destination following hip fracture

OBJECTIVE

To compare demographics, treatment and health outcomes for individuals hospitalised with a hip fracture and examine predictors of postacute discharge destination.

METHODS

A retrospective analysis of data from the Australian and New Zealand Hip Fracture Registry of individuals aged ≥50 years hospitalised with a hip fracture from 2015 to 2018 (n = 29 881). Multinominal logistic regression was used to examine factors associated with discharge destination for individuals from private residences.

RESULTS

Advancing age, impaired cognition, reduced walking ability and poorer pre-operative health were predictors for discharge to residential aged care. The odds of discharge to a rehabilitation unit were higher for individuals with extracapsular fractures, treated at major trauma centres or at hospitals with home-based rehabilitation. Individuals in rural areas had higher odds of discharge to another hospital or ward.

CONCLUSION

In addition to well-known demographics, injury and treatment factors, non-clinical factors including geographic area of residence also affect discharge destination.

Intensive Inpatient vs. Home-Based Rehabilitation After Hip Fracture in the Elderly Population

Background: As the population ages, the rate of hip fractures and the need for rehabilitation increases. Home-based rehabilitation (HBR) is an alternative to classic inpatient rehabilitation (IR), which is an expensive framework with non-negligible risks.

Methods: A retrospective study of patients 65 years and above following surgery to repair a hip fracture who underwent HBR or IR between 2016 and 2019. The two rehabilitation frameworks were compared for rehabilitation outcome and factors predicting successful rehabilitation. The outcome was determined with the Montebello Rehabilitation Factor Score-Revised (MRFS-R).

Results: Data were collected for 235 patients over 3 years. The mean age was 81.3 ± 8.0 and 172 (73.3%) were women. Of these, 138 underwent IR and 97 HBR. The HBR group had better family support and fewer lived alone. There were also differences in the type of fracture and surgery. The medical condition of the IR group was more complex, as reflected in a higher Charlson's comorbidity scores, higher rates for delirium and more infectious complications, a lower Norton score, lower serum hemoglobin, and albumin levels, and higher serum creatinine and urea levels. It also had a more significant functional decline after surgery and required a longer rehabilitation period. However, no difference was found in the rehabilitation outcomes between the two groups (MRFS-R ≥ 50). The independent predictors for rehabilitation in the IR group were serum albumin level, comorbidity, and cognitive state. There were no independent predictors in the HBR group.

Conclusions: In this retrospective study, there was no significant difference in short-term rehabilitation outcomes between the HBR and IR groups event though the patients in the IR group were medically more complex. This result should be taken into account when planning rehabilitation services after hip fracture and tailoring rehabilitation frameworks to patients.

Artificial intelligence in orthopaedics: false hope or not? A narrative review along the line of Gartner's hype cycle

Artificial Intelligence (AI) in general, and Machine Learning (ML)-based applications in particular, have the potential to change the scope of healthcare, including orthopaedic surgery.

The greatest benefit of ML is in its ability to learn from real-world clinical use and experience, and thereby its capability to improve its own performance.

Many successful applications are known in orthopaedics, but have yet to be adopted and evaluated for accuracy and efficacy in patients’ care and doctors’ workflows.

The recent hype around AI triggered hope for development of better risk stratification tools to personalize orthopaedics in all subsequent steps of care, from diagnosis to treatment.

Computer vision applications for fracture recognition show promising results to support decision-making, overcome bias, process high-volume workloads without fatigue, and hold the promise of even outperforming doctors in certain tasks.

In the near future, AI-derived applications are very likely to assist orthopaedic surgeons rather than replace us. ‘If the computer takes over the simple stuff, doctors will have more time again to practice the art of medicine’.⁷⁶

Cite this article: EFORT Open Rev 2020;5:593-603. DOI: 10.1302/2058-5241.5.190092

Postacute Care Utilization in Postsurgical Orthogeriatric Hip Fracture Care

INTRODUCTION

Among surgical patients, utilization of institutional-based postacute care (PAC) presents a notable financial burden and is associated with increased risk of complications and mortality rates when compared with discharge home. The purpose of this study was to identify predictors of postdischarge disposition to PAC in geriatric patients after surgical fixation of native hip fractures.

METHODS

We have done a query of the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained surgical femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to compute risk factors for discharge to and prolonged stay (>30 days) in PAC.

RESULTS

Eight thousand one hundred thirty-three geriatric hip fracture patients with sufficient follow-up data were identified. Of these, 6,670 patients (82.0%) were initially discharged to PAC after their hip fracture episode of care, and 2,986 patients (36.7%) remained in PAC for >30 days. Age (odds ratio [OR] 1.06 [1.05 to 1.08], P < 0.001), partial (OR 2.41 [1.57 to 3.71], P < 0.001) or total dependence (OR 3.03 [1.92 to 4.46], P < 0.001) for activities of daily living, dementia (OR 1.62 [1.33 to 1.96], P < 0.001), diabetes (OR 1.46 [1.14 to 1.85], P = 0.002), hypertension (OR 1.32 [1.10 to 1.58], P = 0.002), and total hospital length of stay (OR 1.04 [1.01 to 1.08], P = 0.006) were independent risk factors for discharge to PAC. Age (OR 1.05 [1.04 to 1.06], P < 0.001), partial (OR 2.86 [1.93 to 3.79], P < 0.001) or total dependence (OR 3.12 [1.45 to 4.79], P < 0.001) for activities of daily living, American Society of Anesthesiologist's classification (OR 1.27 [1.13 to 1.43], P < 0.001), dementia (OR 1.49 [1.28 to 1.74], P < 0.001), and total hospital length of stay (OR 1.10 [1.08 to 1.13], P < 0.001) were independent risk factors for prolonged PAC stay >30 days.

DISCUSSION

Discharge to PAC is the norm among patients undergoing hip fracture surgery. Provider foreknowledge of risk factors may help improve hip fracture outcomes and decrease healthcare costs.

Cost-effectiveness of a multidisciplinary co-management program for the older hip fracture patients in Beijing

The multidisciplinary co-management program for geriatric patients with hip fracture is cost-effective in the Chinese population and it has the potential to be scaled up in China.

INTRODUCTION

The study aimed to investigate the cost-effectiveness of a multidisciplinary co-management program for patients with hip fracture in China.

METHODS

Hip fracture patients who were admitted to an orthopedic hospital in Beijing were included in the multidisciplinary co-management program. The cost-effectiveness of intervention was evaluated compared to the conventional management. A Markov microsimulation model was developed to simulate lifetime costs and effectiveness. Costs including intervention, hospitalization, medications, and long-term care costs were expressed using 2019 US dollars and the healthcare perspective was adopted. Effectiveness was evaluated using both 1-year mortality-averted and quality-adjusted life years (QALYs). Costs and effectiveness were discounted at 5% per annum. The willingness-to-pay (WTP) threshold was set at $26,481 per QALY gained which was three times gross domestic product (GDP) per capita in China. One-way and probabilistic sensitivity analyses were conducted.

RESULTS

The lifetime cost for the conventional management (n = 1839) and intervention group (n = 1192) was $11,975 and $13,309 respectively. The lifetime QALYs were 2.38 and 2.45 years and the first-year mortality was 17.8% and 16.1%. The incremental cost-effectiveness ratio was $19,437 per QALY gained or $78,412 per 1-year mortality-averted. Given the Chinese WTP threshold, the intervention had a 78% chance being cost-effective. The cost-effectiveness of the intervention was sensitive to cost of intervention and the proportion of patients who underwent surgery within 48 h.

CONCLUSIONS

The multidisciplinary co-management program for patients with hip fracture is cost-effective and it has the potential to be scaled up in the Chinese population.

Analysis of an overlapping surgery policy change on costs in a high-volume neurosurgical department

OBJECTIVE

Overlapping surgery remains a controversial topic in the medical community. Although numerous studies have examined the safety profile of overlapping operations, there are few data on its financial impact. The authors assessed direct hospital costs associated with neurosurgical operations during periods before and after a more stringent overlapping surgery policy was implemented.

METHODS

The authors retrospectively reviewed the records of nonemergency neurosurgical operations that took place during the periods from June 1, 2014, to October 31, 2014 (pre–policy change), and from June 1, 2016, to October 31, 2016 (post–policy change), by any of the 4 senior neurosurgeons authorized to perform overlapping cases during both periods. Cost data as well as demographic, surgical, and hospitalization-related variables were obtained from an institutional tool, the Value-Driven Outcomes database.

RESULTS

A total of 625 hospitalizations met inclusion criteria for cost analysis; of these, 362 occurred prior to the policy change and 263 occurred after the change. All costs were reported as a proportion of the average total hospitalization cost for the entire cohort. There was no significant difference in mean total hospital costs between the prechange and postchange period (0.994 ± 1.237 vs 1.009 ± 0.994, p = 0.873). On multivariate linear regression analysis, neither the policy change (p = 0.582) nor the use of overlapping surgery (p = 0.273) was significantly associated with higher total hospital costs.

CONCLUSIONS

A more restrictive overlapping surgery policy was not associated with a reduction in the direct costs of hospitalization for neurosurgical procedures.

Discharge destination following hip fracture in Canada among previously community-dwelling older adults, 2004-2012: database study

Little is known about post-acute care following hip fracture surgery. We investigated discharge destinations from surgical hospitals for nine Canadian provinces. We identified significant heterogeneity in discharge patterns across provinces suggesting different post-acute recovery pathways. Further work is required to determine the impact on patient outcomes and health system costs.

INTRODUCTION

To examine discharge destinations by provinces in Canada, adjusting for patient, injury, and care characteristics.

METHODS

We analyzed population-based hospital discharge abstracts from a national administrative database for community-dwelling patients who underwent hip fracture surgery between 2004 and 2012 in Canada. Discharge destination was categorized as rehabilitation, home, acute care, and continuing care. Multinomial logistic regression modeling compared proportions of discharge to rehabilitation, acute care, and continuing care versus home between each province and Ontario. Adjusted risk differences and risk ratios were estimated.

RESULTS

Of 111,952 previously community-dwelling patients aged 65 years or older, 22.5% were discharged to rehabilitation, 31.6% to home, 27.0% to acute care, and 18.2% to continuing care, with significant variation across provinces (p < 0.001). The proportion of discharge to rehabilitation ranged from 2.4% in British Columbia to 41.0% in Ontario while the proportion discharged home ranged from 20.3% in Prince Edward Island to 52.2% in British Columbia. The proportion of discharge to acute care ranged from 15.2% in Ontario to 58.8% in Saskatchewan while the proportion discharged to continuing care ranged from 9.3% in Manitoba and Prince Edward Island to 22.9% in New Brunswick. Adjusting for hospital type changed the direction of the provincial effect on discharge to continuing care in two provinces, but statistical significance remained consistent with the primary analysis.

CONCLUSIONS

Discharge destination from the surgical hospital after hip fracture is highly variable across nine Canadian provinces. Further work is required to determine the impact of this heterogeneity on patient outcomes and health system costs.

Conceptual Framework for an Episode of Rehabilitative Care After Surgical Repair of Hip Fracture

Researchers face a challenge when evaluating the effectiveness of rehabilitation after a surgical procedure for hip fracture. Reported outcomes of rehabilitation will vary depending on the end point of the episode of care. Evaluation at an inappropriate end point might suggest a lack of effectiveness leading to the underuse of rehabilitation that could improve outcomes. The purpose of this article is to describe a conceptual framework for a continuum-care episode of rehabilitation after a surgical procedure for hip fracture. Definitions are proposed for the index event, end point, and service scope of the episode. Challenges in defining the episode of care and operationalizing the episode, and next steps for researchers are discussed. The episode described is intended to apply to all patients eligible for entry to rehabilitation after hip fracture and includes most functional recovery end points. This framework will provide a guide for rehabilitation researchers when designing and interpreting evaluations of the effectiveness of rehabilitation after hip fracture. Evaluation of all potential care episodes facilitates transparency in reporting of outcomes, enabling researchers to determine the true effectiveness of rehabilitation after a surgical procedure for hip fracture.

Decreased Lean Psoas Cross-Sectional Area Is Associated With Increased 1-Year All-Cause Mortality in Male Elderly Orthopaedic Trauma Patients

OBJECTIVES

To investigate the association between lean psoas cross-sectional area (CSA) and 1-year all-cause mortality in elderly patients sustaining pelvic and long bone fractures.

DESIGN

Retrospective cohort.

SETTING

Level I trauma center.

PATIENTS

Elderly trauma patients admitted from 2007 to 2014.

METHODS

We reviewed demographic and clinical data, injury mechanism, fracture OTA/AO classification, and mortality. Axial computed tomography images were used to measure lean psoas CSA at the L3-L4 disk space. Cox proportional hazard regression analysis was used to estimate 1-year mortality association with psoas CSA in crude and adjusted for age, body mass index, Injury Severity Score, medical comorbidities, and discharge destination in total population and stratified by sex.

MAIN OUTCOME MEASUREMENT

One-year all-cause mortality defined as death within 12 months from date of hospitalization.

RESULTS

Five hundred fifty-eight patients (54% female, 46% male) were analyzed. The pelvis was most commonly fractured (37.81%). A statistically significant association was observed between decreased lean psoas CSA and 1-year mortality in total population {hazard ratio [HR] = 0.93 [95% confidence interval (CI) = 0.90-0.96], P < 0.0001}. Stratification by gender revealed a statistically significant mortality HR in male patients [HR = 0.89 (95% CI = 0.84-0.96), P = 0.002]. We did not find a statistically significant mortality HR in female patients [HR = 0.95 (95% CI = 0.89-1.01), P = 0.103].

CONCLUSIONS

In this cohort of elderly orthopaedic trauma patients, decreased lean psoas CSA was associated with increased 1-year all-cause mortality in total population and males. Further investigation of the association of sarcopenia with mortality in the elderly is warranted.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.