Predicting place of discharge from hospital for patients with a stroke or hip fracture on admission

Discharge to a Skilled Nursing Facility After Hip Fracture Results in Higher Rates of Periprosthetic Joint Infection

BACKGROUND

Femoral neck fractures (FNFs) in elderly patients are associated with major morbidity and mortality. The influence of postoperative discharge location on recovery and outcomes after arthroplasty for hip fractures is not well understood.

METHODS

A multisite retrospective cohort from 9 academic centers identified patients who had FNF treated with hemiarthroplasty or total hip arthroplasty between 2010 and 2019. Patients who had diagnoses of dementia, stroke, age > 80 years, or high energy fracture were excluded. Discharge location was identified, including home-based health services (HHS), inpatient rehabilitation (IPR), or a skilled nursing facility (SNF). Rates of reoperation, periprosthetic joint infection (PJI), and mortality were compared between cohorts. Multivariate logistic regressions were performed, adjusting for age, American Society of Anesthesiologists (ASA) score, body mass index, sex, and tobacco use. Statistical significance was defined as P < .05.

RESULTS

A total of 672 patients (315 HHS, 144 IPR, and 213 SNF) were included in this study. The average follow-up was 30 months. The SNF cohort was significantly older (P < .0001) with higher ASA scores (P < .0001) than the HHS cohort. In a logistic regression model adjusting for age, ASA score, and body mass index, the SNF cohort had higher mortality rates than the HHS cohort (P = .0296) and were more likely to have PJI within 90 days (odds ratio = 4.55, 95% confidence interval = 1.40, 4.74) and within 1 year (odds ratio = 3.08, 95% confidence interval = 1.08, 8.78). Time to PJI was significantly shorter in the SNF cohort (SNF 38 versus HHS 231 days, P = .0155). No differences were seen in dislocation or reoperation rates between the SNF and HHS cohorts. No differences were seen in complication rates between the IPR and HHS cohorts.

CONCLUSIONS

Discharge to a SNF after arthroplasty for FNF is associated with increased mortality and higher rates of PJI. Hip fracture care pathways that uniformly discharge patients to SNFs may need to be re-evaluated, and surgeons should consider discharge to home with HHS when possible.

Early Predictors for Discharge to Geriatric Rehabilitation after Hip Fracture Treatment of Older Patients

OBJECTIVE

To investigate early predictors for discharge to a geriatric rehabilitation department at a skilled nursing home in older patients after hospitalization for hip fracture surgery.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Data from 21,176 patients with hip fracture aged ≥70 years, who were registered in the Dutch Hip Fracture Audit database between January 1, 2017, and December 31, 2019, were included.

METHODS

Patients were categorized into 3 discharge groups: home (n=7326), rehabilitation (n=11,738), and nursing home (n=2112). Age, gender, Pre-Fracture Mobility Score (PFMS), premorbid Katz index of independence in Activities of Daily Living (Katz-ADL), history of dementia, American Society of Anesthesiologists physical status classification (ASA score), type of anesthesia, fracture type, surgical treatment, and cotreatment by a geriatrician were gathered. Multinomial regression analysis was used to assess for early predictors.

RESULTS

Higher age, poor premorbid mobility, lower premorbid Katz-ADL, no history of dementia, ASA score 3-5, general anesthesia, intramedullary implant, and cotreatment by a geriatrician were independent predictors for discharge to geriatric rehabilitation vs discharge home. Identical predictors were found for discharge to a nursing home vs discharge home. History of dementia and premorbid Katz-ADL were distinguishing factors; a higher premorbid Katz-ADL and a history of dementia were associated with a higher risk of discharge to a nursing home vs discharge home. The multinomial regression model correctly predicted 86%, 38.6%, and 2.4% of the patients in the rehabilitation group, home group, and nursing home group, respectively.

CONCLUSIONS AND IMPLICATIONS

This study showed that age, PFMS, premorbid Katz-ADL, surgical treatment, ASA score, type of anesthesia, history of dementia, and cotreatment by a geriatrician were independent early predictors for discharge to geriatric rehabilitation vs discharge home in older patients after hip fracture surgery. Identical predictors were found as predictors for discharge to a nursing home vs discharge home, except for history of dementia and premorbid Katz-ADL.

Positive Beliefs and the Likelihood of Successful Community Discharge From Skilled Nursing Facilities

OBJECTIVES

To examine the association of patient and direct-care staff beliefs about patients' capability to increase independence with activities of daily living (ADL) and the probability of successful discharge to the community after a skilled nursing facility (SNF) stay.

DESIGN

Retrospective cohort study of SNF patients using 100% Medicare inpatient claims and Minimum Data Set resident assessment data. Linear probability models were used to estimate the probability of successful discharge based on patient and staff beliefs about the patient's ability to improve in function, as well as patient and staff beliefs together. Estimates were adjusted for demographics, health status, functional characteristics, and SNF fixed effects.

PARTICIPANTS

Fee-for-service Medicare beneficiaries (N=526,432) aged 66 years or older who were discharged to an SNF after hospitalization for stroke, hip fracture, or traumatic brain injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Successful community discharge (discharged alive within 90d of SNF admission and remaining in the community for ≥30d without dying or health care facility readmission).

RESULTS

Patients with positive beliefs about their capability to increase independence with ADLs had a higher adjusted probability of successful discharge than patients with negative beliefs (positive, 63.8%; negative, 57.8%; difference, 6.0%, 95% confidence interval [CI], 5.4-6.6). This remained true regardless of staff beliefs, but the difference in successful discharge probability between patients with positive and negative beliefs was larger when staff had positive beliefs. Conversely, the association between staff beliefs and successful discharge varied based on patient beliefs. If patients had positive beliefs, the difference in the probability of successful discharge between positive and negative staff beliefs was 2.5% (95% CI, 1.0-4.0). If patients had negative beliefs, the difference between positive and negative staff beliefs was -4.6% (95% CI, -6.0 to -3.2).

CONCLUSIONS

Patients' beliefs have a significant association with the probability of successful discharge. Understanding patients' beliefs is critical to appropriate goal-setting, discharge planning, and quality SNF care.

Post-acute care referral in United States of America: a multiregional study of factors associated with referral destination in a cohort of patients with coronary artery bypass graft or valve replacement

Background

The use of post-acute care (PAC) for cardiovascular conditions is highly variable across geographical regions. Although PAC benefits include lower readmission rates, better clinical outcomes, and lower mortality, referral patterns vary widely, raising concerns about substandard care and inflated costs. The objective of this study is to identify factors associated with PAC referral decisions at acute care discharge.

Methods

This study is a retrospective Electronic Health Records (EHR) based review of a cohort of patients with coronary artery bypass graft (CABG) and valve replacement (VR). EHR records were extracted from the Cerner Health-Facts Data warehouse and covered 49 hospitals in the United States of America (U.S.) from January 2010 to December 2015. Multinomial logistic regression was used to identify associations of 29 variables comprising patient characteristics, hospital profiles, and patient conditions at discharge.

Results

The cohort had 14,224 patients with mean age 63.5 years, with 10,234 (71.9%) male and 11,946 (84%) Caucasian, with 5827 (40.96%) being discharged to home without additional care (Home), 5226 (36.74%) to home health care (HHC), 1721 (12.10%) to skilled nursing facilities (SNF), 1168 (8.22%) to inpatient rehabilitation facilities (IRF), 164 (1.15%) to long term care hospitals (LTCH), and 118 (0.83%) to other locations. Census division, hospital size, teaching hospital status, gender, age, marital status, length of stay, and Charlson comorbidity index were identified as highly significant variables (p- values < 0.001) that influence the PAC referral decision. Overall model accuracy was 62.6%, and multiclass Area Under the Curve (AUC) values were for Home: 0.72; HHC: 0.72; SNF: 0.58; IRF: 0.53; LTCH: 0.52, and others: 0.46.

Conclusions

Census location of the acute care hospital was highly associated with PAC referral practices, as was hospital capacity, with larger hospitals referring patients to PAC at a greater rate than smaller hospitals. Race and gender were also statistically significant, with Asians, Hispanics, and Native Americans being less likely to be referred to PAC compared to Caucasians, and female patients being more likely to be referred than males. Additional analysis indicated that PAC referral practices are also influenced by the mix of PAC services offered in each region.

Effect of Enhanced Medical Rehabilitation on Functional Recovery in Older Adults Receiving Skilled Nursing Care After Acute Rehabilitation: A Randomized Clinical Trial

IMPORTANCE

Enhanced medical rehabilitation (EMR) is a systematic and standardized approach for physical and occupational therapists to engage patients. Higher patient engagement in therapy might lead to improved functional recovery in rehabilitation settings, such as skilled nursing facilities (SNFs).

OBJECTIVE

To determine whether EMR improves older adults' functional recovery.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, parallel-group, randomized clinical trial was conducted from July 29, 2014, to July 13, 2018, in 229 adults aged 65 years or older admitted to 2 US SNFs. Participants were randomized to receive EMR (n = 114) vs standard-of-care rehabilitation (n = 115). Intention-to-treat analysis was used.

INTERVENTIONS

The intervention group received their physical and occupational therapy from therapists trained in EMR. Based on models of motivation and behavior change, EMR is a toolkit of techniques to increase patient engagement and therapy intensity. The control group received standard-of-care rehabilitation from physical and occupational therapists not trained in EMR.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in function in activities of daily living and mobility, as assessed with the Barthel Index, which measures 10 basic activities of daily living or mobility items (scale range, 0-100), from SNF admission to discharge; secondary outcomes were gait speed for 10 m, 6-minute walk test, discharge disposition, rehospitalizations, and self-reported functional status at days 30, 60, and 90. To examine the rehabilitation process, therapists' engagement with patients and patient active time during therapy were measured for a sample of the sessions.

RESULTS

Of the 229 participants, 149 (65.1%) were women; 177 (77.3%) were white, and 51 (22.3%) were black; mean (SD) age was 79.3 (8.0) years. Participants assigned to EMR showed greater recovery of function than those assigned to standard of care (mean increase in Barthel Index score, 35 points; 95% CI, 31.6-38.3 vs 28 points; 95% CI, 25.2-31.7 points; P = .007). There was no evidence of a difference in the length of stay (mean [SD], 23.5 [13.1] days). However, there were no group by time differences in secondary outcome measures, including self-reported function after SNF discharge out to 90 days as measured on the Barthel Index (mean [SE] score: EMR, 83.65 [2.20]; standard of care, 84.67 [2.16]; P = .96). The EMR therapists used a median (interquartile range) of 24.4 (21.0-37.3) motivational messages per therapy session vs 2.3 (1.1-2.9) for nontrained therapists (P < .001), and EMR patients were active during a mean (SD) of 52.5 (6.6%) of the therapy session time vs 41.2 (6.8%) for nontrained therapists (P = .001).

CONCLUSIONS AND RELEVANCE

Enhanced medical rehabilitation modestly improved short-term functional recovery for selected older adults rehabilitating in SNFs. However, there was no evidence that the benefits persisted over the longer term. This study demonstrates the value of engaging and motivating older adults in rehabilitation therapy, but more work is needed to extend these benefits to longer-term outcomes after discharge home.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02114879.

Long-term care provision, hospital bed blocking, and discharge destination for hip fracture and stroke patients

We examine the relationship between long-term care supply (care home beds and prices) and (i) the probability of being discharged to a care home and (ii) length of stay in hospital for patients admitted to hospital for hip fracture or stroke. Using patient level data from all English hospitals and allowing for a rich set of demographic and clinical factors, we find no association between discharge destination and long-term care beds supply or prices. We do, however, find evidence of bed blocking: hospital length of stay for hip fracture patients discharged to a care home is shorter in areas with more long-term care beds and lower prices. Length of stay is over 30% shorter in areas in the highest quintile of care home beds supply compared to those in the lowest quintile.

Geriatric preinjury activities of daily living function is associated with glasgow coma score and discharge disposition: a retrospective, consecutive cohort study

The primary objective was to evaluate the associations of the Injury Severity Score (ISS), age, Glasgow Coma Score (GCS), preexisting medical conditions (PEMC), and preinjury activities of daily living (ADL) Katz score with discharge disposition in surviving geriatric trauma patients.Data were obtained from the trauma registry. The preinjury Katz ADL score was prospectively ascertained.Of 184 consecutive surviving geriatric trauma patients with an ISS of 4 to 30, age was 80 ± 8 years and 75% fell. A PEMC was present in 93%. Preinjury ADL limitation occurred in 33%. The Katz score had inverse associations with the number of PEMCs (P< .01) and dementia (P < .01). Preinjury residence was home in 93% and nursing home in 7%. Katz scores by discharge disposition were as follows: home (36%) 5.5 ± 1; nursing home (15%) 3.6 ± 2; rehabilitation (44%) 5.6 ± 1; long-term acute care (5%) 4.0 ± 3 (P < .01). Nursing home/long-term acute care discharge was independently associated (P< .01) withlower Katz score, higher age, and lower discharge GCS; dementia and the number of PEMCs had P > .05. The discharge GCS was associated with the Katz score (P < .01), head injury score (P < .01), dementia (P < .01), and admission GCS (P < .01). The discharge GCS was independently associated (P < .01) with the Katz score and admission GCS. The admission GCS was associated with the Katz score (P = .02), ISS (P < .01), head injury score (P < .01), and dementia (P < .01). The admission GCS was independently associated (P < .05) with the Katz score and ISS.The majority of geriatric trauma survivors with an ISS of 4 to 30 are not discharged home. Lower preinjury ADL function is associated with the lower admission and discharge GCS and greater care needs at discharge. Dementia and the number of PEMCs are not independent predictors of discharge disposition.

Factors associated with the course of health-related quality of life after a hip fracture

INTRODUCTION

The number of hip fracture patients is expected to grow the forthcoming decades. Knowledge of the impact of the fracture on the lives of elderly could help us target our care. The aim of the study is to describe HRQoL (Health-Related Quality of Life) after a hip fracture and to identify factors associated with the course of HRQoL in the first postoperative year.

MATERIALS AND METHODS

335 surgically treated hip fracture patients (mean age 79.4 years, SD 10.7, 68 % female) were included in a prospective observational cohort. HRQoL was measured with the SF-12 Health Survey, composed of the Physical and a Mental Component Summary Score (PCS, MCS), at admission (baseline) and at 3 and 12 months postoperatively. Eleven predefined factors known to be associated with the course of HRQoL were recorded: age, gender, physical status, having a partner at admission, living in an institution, prefracture level of mobility, anemia, type of fracture and treatment, delirium during hospital stay and length of stay.

RESULTS

HRQoL declined between baseline and 3 months, and recovered between three and 12 months. PCS HRQoL did not recover to baseline values, MCS HRQoL did. Age younger than 80 years, ASA classification I and II, higher prefracture level of mobility, intracapsular fracture and treatment with osteosynthesis (compared to arthroplasty) were associated with greater initial decline in PCS HRQoL, none of the recorded factors were significant for decline in MCS HRQoL.

CONCLUSIONS

Both PCS and MCS HRQoL declined after a hip fracture and PCS did not recover to baseline values. Healthier patients may need extra care to prevent them from having a steep decline in postoperative PCS HRQoL and arthroplasty should be considered with low threshold.

Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial

OBJECTIVES

For millions of disabled older adults each year, postacute care in skilled nursing facilities is a brief window of opportunity to regain enough function to return home and live independently. Too often this goal is not achieved, possibly because of therapy that is inadequately intense or engaging. This study tested Enhanced Medical Rehabilitation, an intervention designed to increase patient engagement in, and intensity of, daily physical and occupational therapy sessions in postacute-care rehabilitation.

DESIGN

Randomized controlled trial of Enhanced Medical Rehabilitation versus standard-of-care rehabilitation.

SETTING

Postacute care unit of a skilled nursing facility in St Louis, MO.

PARTICIPANTS

Twenty-six older adults admitted from a hospital for postacute rehabilitation.

INTERVENTION

Based on models of motivation and behavior change, Enhanced Medical Rehabilitation is a set of behavioral skills for physical and occupational therapists that increase patient engagement and intensity, with the goal of improving functional outcome, through (1) a patient-directed, interactive approach, (2) increased rehabilitation intensity, and (3) frequent feedback to patients on their effort and progress.

MEASUREMENTS

Therapy intensity: assessment of patient active time in therapy sessions. Therapy engagement: Rehabilitation Participation Scale. Functional and performance outcomes: Barthel Index, gait speed, and 6-minute walk.

RESULTS

Participants randomized to Enhanced Medical Rehabilitation had higher intensity therapy and were more engaged in their rehabilitation sessions; they had more improvement in gait speed (improving from 0.08 to 0.38 m/s versus 0.08 to 0.22 in standard of care, P = .003) and 6-minute walk (from 73 to 266 feet versus 40 to 94 feet in standard of care, P = .026), with a trend for better improvement of Barthel Index (+43 points versus 26 points in standard of care, P = .087), compared with participants randomized to standard-of-care rehabilitation.

CONCLUSION

Higher intensity and patient engagement in the postacute rehabilitation setting is achievable, with resultant better functional outcomes for older adults. Findings should be confirmed in a larger randomized controlled trial.

Predicting discharge location of hip fracture patients; the new discharge of hip fracture patients score

Purpose

This paper reports on the development and validity of a new instrument, called the discharge of hip fracture patients score (DHP), that predicts at admission the discharge location in patients living in their own home prior to hip fracture surgery.

Methods

A total of 310 patients aged 50 years and above were included. Risk factors for discharge to an alternative location (DAL) were analysed with a multivariable regression analysis taking the admission variables into account with different weights based on the estimates. The score ranged from 0–100 points. The cut-off point for DAL was calculated using a ROC analysis. Reliability of the DHP was evaluated.

Results

Risk factors for DAL were higher age, female gender, dementia, absence of a partner and a limited level of mobility. The cut-off point was set at 30 points, with a sensitivity of 83.8%, a specificity of 64.7% and positive predictive value of 79.2%.

Conclusion

The DHP is a valid, simple and short instrument to be used at admission to predict discharge location of hip fracture patients.

Risk factors for failure to return to the pre-fracture place of residence after hip fracture: a prospective longitudinal study of 444 patients

INTRODUCTION

Long-term place of residence after hip fracture is not often described in literature. The goal of this study was to identify risk factors, known at admission, for failure to return to the pre-fracture place of residence of hip fracture patients in the first year after a hip fracture.

METHODS

This is a prospective longitudinal study of 444 consecutive admissions of hip fracture patients aged ≥ 65 years. Place of residence prior to admission, at discharge, after 3 and 12 months was registered. Patients admitted from a nursing home (n = 49) were excluded from statistical analysis. Multivariable logistic regression analysis was performed, using age, gender, presence of a partner, ASA-score, dementia, anaemia at admission, type of fracture, pre-fracture level of mobility and level of activities of daily living (ADL) as possible risk factors.

RESULTS

Two hundred eighty-nine patients lived in their own home, 31.8% returned at discharge, 72.9% at 3 months and 72.8% at 12 months. Age, absence of a partner, dementia, and a lower pre-fracture level of ADL or mobility were independent contributors to failure to return to their own home at discharge, 3 or 12 months. 106 patients lived in a residential home; 33.3% returned at discharge, 68.4% at 3 months and 64.4% at 12 months. Age was an independent contributor to failure to return to a residential home.

CONCLUSIONS

Age, dementia and a lower pre-fracture level of ADL were the main significant risk factors for failure to return to the pre-fracture residence. As the 3- and 12-month return-rates were similar, 3-month follow-up might be used as an endpoint in future research.

Post-acute care services received by older adults following a cardiac event: a population-based analysis

BACKGROUND

Post-acute care (PAC) is available for older adults who need additional services after hospitalization for acute cardiac events. With the aging population and an increase in the prevalence of cardiac disease, it is important to determine current PAC use for cardiac patients to assist health care workers to meet the needs of older cardiac patients. The purpose of this study was to determine the current PAC use and factors associated with PAC use for older adults following hospitalization for a cardiac event that includes coronary artery bypass graft and valve surgeries, myocardial infarction (MI), percutaneous coronary intervention (PCI), and heart failure (HF).

METHODS AND RESULTS

A cross-sectional design and the 2003 Medicare part A database were used for this study. The sample (n = 1493521) consisted of patients 65 years and older discharged after their first cardiac event. Multinomial logistic regression was used to examine factors associated with PAC use. Overall, PAC use was 55% for cardiac valve surgery, 50% for MI, 45% for HF, 44% for coronary artery bypass graft, and 5% for PCI. Medical patients use more skilled nursing facility care, and surgical patients use more home health care. Only 0.1% to 3.4% of the cardiac patients use intermediate rehabilitation facilities. Compared with those who do not use PAC, those who use home health care and skilled nursing facility care are older and female, have a longer hospital length of stay, and have more comorbidity. Asians, Hispanics, and Native Americans were less likely to use PAC after hospitalization for an MI or HF.

CONCLUSIONS

The current rate of PAC use indicates that almost half of nondisabled Medicare patients discharged from the hospital following a cardiac event use one of these services. Health care professionals can increase PAC use for Asians, Hispanics, and Native Americans by including culturally targeted communication. Optimizing recovery for cardiac patients who use PAC may require focused cardiac rehabilitation strategies.

Effect of dysphasia and dysphagia on inpatient mortality and hospital length of stay: a database study

OBJECTIVES

To examine the effect of dysphasia and dysphagia on stroke outcome.

DESIGN

Retrospective database study.

SETTING

Norfolk, United Kingdom.

PARTICIPANTS

Two thousand nine hundred eighty-three men and women with stroke admitted to the hospital between 1997 and 2001.

MEASUREMENTS

Inpatient mortality and likelihood of longer length of hospital stay, defined as longer than median length of stay (LOS). Dysphagia was defined as difficulty swallowing any liquid (including saliva) or solid material. Dysphasia was defined as speech disorders in which there was impairment of the power of expression by speech, writing, or signs or impairment of the power of comprehension of spoken or written language. An experienced team assessed dysphagia and dysphasia using explicit criteria.

RESULTS

Two thousand nine hundred eighty-three patients (1,330 (44.6%) male), median age 78 (range 17-105), were included, of whom 77.7% had ischemic, 10.5% had hemorrhagic, and 11.8% had undetermined stroke types. Dysphasia was present in 41.2% (1,230) and dysphagia in 50.5% (1,506), and 27.7% (827) had both conditions. Having either or both conditions was associated with greater mortality and longer LOS (P<.001 for all). Using multiple logistic regression models controlling for age, sex, premorbid Rankin score, previous disabling stroke, and stroke type, corresponding odds ratios for death and longer LOS were 2.2 (95% confidence interval (CI)=1.8-2.7) and 1.4 (95% CI=1.2-1.6) for dysphasia; 12.5 (95% CI=8.9-17.3) and 3.9 (95% CI=3.3-4.6) for dysphagia, 5.5 (95% CI=3.7-8.2), 1.9 (95% CI=1.6-2.3) for either, and 13.8 (95% CI=9.4-20.4) and 3.7 (95% CI=3.1-4.6) if they had both, versus having no dysphasia, no dysphagia, or none of these conditions, respectively.

CONCLUSION

Patients with dysphagia have worse outcome in terms of inpatient mortality and length of hospital stay than those with dysphasia. When both conditions are present, the presence of dysphagia appears to determine the likelihood of poor outcome. Whether this effect is related just to stroke severity or results from problems related directly to dysphagia is unclear.

Socio-demographic factors predict the likelihood of not returning home after hospital admission following a fall

BACKGROUND

Falls in older people result in a substantial use of resources in the NHS and care homes. One way to reduce the burden would be to identify the factors associated with the likelihood of being discharged to a care home rather than being discharged home after fall-related hospitalization. We investigate the associations between discharge destination after fall-related hospital admission with ecological factors (area deprivation, ethnicity and rurality) and individual level factors (age, gender and co-morbidities).

METHODS

We extracted data for patients aged over 50 admitted from their 'usual residence' with a fall-related diagnosis from the Hospital Episode Statistics (HES) database.

RESULTS

Increasing age, people with severe co-morbidities and people who live in less deprived, predominantly white or rural areas, were more likely to be discharged to a different residence (all P-values < 0.001). We estimated that 88.3% of people from an area classified as most deprived, urban and >5% Asian would return home, compared with 78.0% from least deprived, village/isolated and all white area.

CONCLUSION

Further research is required to examine whether these patterns reflect appropriate care or alternatively that some sub-groups of society have less access to care homes than others. These factors may have public health implications for the equitable allocation of budgets for the provision of care for elderly patients discharged from hospital after a fall.

Older adults' use of postacute and cardiac rehabilitation services after hospitalization for a cardiac event

The purpose of this study was to describe older patients' use of postacute care (PAC) and outpatient cardiac rehabilitation (CR) services after a cardiac event and to describe the differences between older adults who use these services and those who do not. Under a longitudinal descriptive design, data were collected during hospitalization for a cardiac event, 3 and 6 weeks later, and 4 and 6 months later Of the 60 older adults in the sample, 73% used PAC after discharge. Older adults discharged home without PAC services had fewer complications and were less depressed than those who used PAC. Older adults discharged to a skilled nursing facility had poorer physical function both before the cardiac event and during hospitalization. Twenty-five percent participated in outpatient CR. Older adults who went to CR were male, had better physical function, and did not live alone. Understanding the use of PAC and CR services will help with discharge planning and customizing PAC and CR services for older adults to optimize cardiac recovery. The integration of CR principles into PAC may be an opportunity to enhance recovery for older adults, especially because only a small percentage of older adults attend CR.

Factors influencing discharge location following hip fracture

INTRODUCTION

Outcome measures following hip fracture usually consider morbidity and mortality following injury.(5) Few studies have looked at post injury discharge location as an outcome measure following hip fracture. Discharging patients to a different location frequently delays discharge whilst the necessary social arrangements are made. Early identification of these patients could reduce these delays. The aim of this study was to determine factors influencing discharge location following hip fracture.

METHODS

Three thousand two hundred and forty consecutive patients were admitted to our centre with a fractured neck of femur. Data was prospectively collected by independent audit clerks on a standardised proforma. Our outcome measure was whether the patient was discharged from hospital either to their place of normal residence or to an alternative location. Factors influencing discharge location were identified using multivariate logistic regression analysis.

RESULTS

Increasing age was associated with increasing risk of requiring discharge to an alternative location (DAL) (p<0.001). This risk rose from 13% in the sixth decade by approximately 10% every additional decade. Males were 2.5 times more likely than females to require DAL. Patients who were more independent prior to injury were less likely to require DAL. Patients who sustained their injury whilst in hospital were 2.3 times more likely to require DAL compared to those who fell in their own homes.

CONCLUSION

The following risk factors are associated with increased risk of requiring discharge to an alternative location: (1) pre-injury dependence, (2) increasing age, (3) male sex, (4) injury sustained whilst in hospital. Early identification of patients requiring DAL could reduce inpatient delays.

The Barthel Index and modified Rankin Scale as prognostic tools for long-term outcomes after stroke: a qualitative review of the literature

OBJECTIVE

Providing a quantitative prognosis after a stroke is important to clinicians and patients as well as to researchers interested in projecting the results of clinical trials and other studies. Thus, we critically reviewed the evidence supporting the prognostic value of two frequently-used measures, the Barthel Index (BI) and modified Rankin Scale (mRS) for long-term outcomes.

METHODS

A narrative review of the peer-reviewed medical literature obtained by searching Medline 1966 to January 2004--using the phrase '[stroke] AND [Barthel OR Rankin]'--was conducted to assess the strength of the evidence for these measures and answer three main questions: How good are the BI and mRS at predicting (1) the level of care required, (2) the time-course of recovery, and (3) mortality. Abstracts were screened for the presence of actual data on the prognostic impact of BI and mRS on these endpoints, and selected articles were fully reviewed and abstracted. Additional articles were identified from bibliographies of the retrieved papers.

RESULTS

Of 753 abstracts screened, 89 articles were selected for detailed assessment. Early disability and global outcome (< or = 7 days) were shown in 21 studies to be strong predictors of care needs. This relation appears to be mainly biological, not country-specific. Recovery was shown in 18 studies to be strongly related to early BI. In contrast, the 11 studies examining mortality provided insufficient information to directly support the prognostic value of either measure. Key limitations of this review include heterogeneity of available studies (e.g., time-points, outcome, parameterization) and relative lack of information on the mRS.

CONCLUSIONS

Despite the lack of uniformity in existing studies, the evidence overall is quite strong, supporting the use of BI and mRS as prognostic tools. External non-treatment modifiable factors which also determine long-term outcome (e.g., social support) have to be taken into account.

Variations in nursing home discharge rates for urban and rural nursing facility residents with hip fracture

CONTEXT

The more limited availability and use of community-based long-term care services in rural areas may be a factor in higher rates of nursing home use among rural residents.

PURPOSE

This study examined differences in the rates of nursing home discharge for older adults receiving posthospital care in a nursing facility.

METHODS

The study sample was comprised of a cohort of rural and urban residents newly admitted to nursing home care in Maine following surgery for hip fracture.

FINDINGS

The results indicated that rural residents who were hospitalized for hip fracture and subsequently admitted to a nursing facility for rehabilitation were significantly less likely than urban residents to be discharged within the first 30 days of their admission. Rural residents who stayed in the nursing facility beyond 30 days were also less likely to be discharged in the first 6 months. These geographic differences were not explained by service use and resident characteristics such as age, health, or functional status.

CONCLUSIONS

The finding of lower discharge rates among rural nursing facility residents appears to be consistent with previous studies demonstrating higher rates of nursing home use among rural residents. There continues to be a need for a better understanding of the role that service supply and accessibility and other factors play in the patterns and outcomes of rural long-term care.

Preventing avoidable hospital admission of older people

The National Service Framework for Older People (Department of Health, 2001) stresses the importance of preventing unnecessary hospital admissions for older people. Such admissions arise when there is inadequate health and social support available in the community to meet the needs of this age group. This article reports on a study designed to evaluate the effectiveness of a programme of enhanced primary care support intended to reduce the risk of hospital admission for people aged 75 years and above. Nineteen patients out of a possible 322 in one GP practice were judged by GPs and district nurses to be "at risk" of avoidable hospital admission. All at-risk patients were visited by a GP or district nurse to review their needs for enhanced support, six patients subsequently accepting a referral for additional support. No statistically significant difference in the number of hospital admissions in the intervention group was observed compared with a group of patients with similar demographic characteristics but deemed not to be at such high risk, suggesting that the intervention might have been effective in reducing the number of avoidable hospital admissions.