Survival and functional outcomes after hip fracture among nursing home residents.
ABSTRACT: Little is known regarding outcomes after hip fracture among long-term nursing home residents.To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture.Retrospective cohort study of 60,111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009.Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture.Of 60,111 patients, 21,766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ?75 years: hazard ratio [HR], 2.17; 95% CI, 2.09-2.26 [P?
Project description:To quantify the contribution of acute versus postacute care factors to survival and functional outcomes after hip fracture.Retrospective cohort study using Medicare data; subjects included previously ambulatory nursing home residents hospitalized for hip fracture between 2005 and 2009.We used logistic regression to measure the associations of hospital and nursing home factors with functional and survival outcomes at 30 and 180 days among patients discharged to a nursing facility; we quantified the contribution of hospital versus nursing home factors to outcomes by the ? statistic.Among 45,996 hospitalized patients, 1814 (3.9%) died during hospitalization. A total of 42,781 (93%) were discharged alive to a nursing home. Of these, 12,126 (28%) died within 180 days and 20,479 (48%) died or were newly unable to walk within 180 days. Hospital characteristics were not consistently associated with outcomes. Multiple nursing home characteristics predicted 30- and 180-day outcomes, including bed count, chain membership, and performance on selected quality measures. Nursing home factors explained 3 times more variation in the odds of 30-day mortality than did hospital factors [?, hospital vs. nursing home: 0.32; 95% confidence interval (CI), 0.11, 0.96], 7 times more variation in the odds of 180-day mortality (?: 0.15; 95% CI, 0.04, 0.61), and 8 times more variation in the odds of 180-day death or new dependence in locomotion (?: 0.12; 95% CI, 0.05, 0.31).Nursing home factors explain a larger proportion of the variation in clinical outcomes following hip fracture than do hospital factors.
Project description:While 30-day risk-adjusted mortality is a performance measure for hip fracture care, it has not been shown to predict long-term outcomes. We assessed whether hospital rankings based on historical 30-day mortality predicted subsequent hip fracture outcomes.Using national Medicare data, we calculated annual hospital performance rankings based on standardized 30-day hip fracture mortality ratios. We used logistic regression to measure the association of patients' survival at 180 days with their hospital's ranking for the year prior to admission. Subgroup analyses assessed whether associations between hospital performance and 180-day outcomes were similar for community-dwelling patients as well as those living in nursing homes prior to fracture.Out of 378,077 patients hospitalized with hip fractures between January 1, 2007 and June 30, 2009, 81,653 (21.6%) died by 180 days. Worse historical hospital performance was associated with a greater adjusted odds of 30 day mortality (odds ratio (OR), fourth vs. first quartile: 1.24, 95% confidence interval (CI): 1.18, 1.29, P<0.001) and 180 day mortality (OR, fourth vs. first quartile: 1.15, 95% CI 1.11, 1.18, P<0.001). Past hospital performance was associated with death or new nursing home placement among community dwellers (OR, fourth vs. first quartile: 1.09, 95% CI 1.05, 1.13, P<0.001), but was not associated with death or new dependence in locomotion among nursing home residents (OR 1.05, 95% CI 0.97, 1.15, P=0.229).Better historical hospital hip fracture mortality predicts modest decreases in mortality at 180 days for subsequent patients, but is inconsistently associated with changes in functional outcomes.Level 3 (Non-randomized controlled cohort study).
Project description:<h4>Background</h4>A hip fracture is a debilitating condition that consumes significant resources in the United States. Surgical treatment of hip fractures can achieve better survival and functional outcomes than nonoperative treatment, but less is known about its economic benefits.<h4>Questions/purposes</h4>We asked: (1) Are the societal benefits of hip fracture surgery enough to offset the direct medical costs? (2) Nationally, what are the total lifetime benefits of hip fracture surgery for a cohort of patients and to whom do these benefits accrue?<h4>Methods</h4>We estimated the effects of surgical treatment for displaced hip fractures through a Markov cohort analysis of patients 65 years and older. Assumptions were obtained from a systematic literature review, analysis of Medicare claims data, and clinical experts. We conducted a series sensitivity analyses to assess the effect of uncertainty in model parameters on our estimates. We compared costs for medical care, home modification, and long-term nursing home use for surgical and nonoperative treatment of hip fractures to estimate total societal savings.<h4>Results</h4>Estimated average lifetime societal benefits per patient exceeded the direct medical costs of hip fracture surgery by USD 65,000 to USD 68,000 for displaced hip fractures. With the exception of the assumption of nursing home use, the sensitivity analyses show that surgery produces positive net societal savings with significant deviations of 50% from the base model assumptions. For an 80-year-old patient, the breakeven point for the assumption on the percent of patients with hip fractures who would require long-term nursing home use with nonoperative treatment is 37% to 39%, compared with 24% for surgical patients. Nationally, we estimate that hip fracture surgery for the cohort of patients in 2009 yields lifetime societal savings of USD 16 billion in our base model, with benefits and direct costs of USD 21 billion and USD 5 billion, respectively. For an 80-year-old, societal benefits ranged from USD 2 billion to USD 32 billion, using our range of estimates for nursing home use among nonoperatively treated patients who are immobile after the fracture.<h4>Conclusions</h4>Surgical treatment of hip fractures produces societal savings. Although the magnitude of these savings depends on model assumptions, the finding of societal savings is robust to a range of parameter values.<h4>Level of evidence</h4>Level