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Association of Length of Stay, Recovery Rate, and Therapy Time per Day With Functional Outcomes After Hip Fracture Surgery.

ABSTRACT: Importance:Medicare is shifting from payment for postacute care services based on the volume provided to payment based on value as determined by patient characteristics and functional outcomes. Matching therapy time and length of stay (LOS) to patient needs will be critical to optimize functional outcomes and manage costs. Objective:To investigate the association among therapy time, LOS, and functional outcomes for patients following hip fracture surgery. Design, Setting, and Participants:This retrospective cohort study analyzed data on patients from 4 inpatient rehabilitation facilities and 7 skilled nursing facilities in the eastern and midwestern United States. Participants were patients aged 65 years or older who received inpatient rehabilitation services for hip fracture and had Medicare fee-for-service as their primary payer. Data were collected from 2005 to 2010. Analysis was conducted from November 2018 to June 2019. Exposure:Therapy minutes per LOS day. Main Outcomes and Measures:Functional Independence Measure mobility and self-care measures at discharge. Patients were categorized into 9 recovery groups based on low, medium, or high therapy minutes per LOS day and low, medium, or high rate of functional gain per day. Results:A total of 150 patients (101 [67.3%] female; 148 [98.6%] white; mean [SD] age, 82.0 [7.3] years) met inclusion criteria. Participants in all gain and therapy minutes per LOS day trajectories were similar in function at rehabilitation admission (mean [SD] mobility, 16.2 [3.2]; F8,141?=?1.26; P?=?.27) but differed significantly at discharge (mean [SD] mobility, 23.9 [5.2]; F8,141?=?14.34; P?

SUBMITTER: Cogan AM

PROVIDER: S-EPMC6991278 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Association of Length of Stay, Recovery Rate, and Therapy Time per Day With Functional Outcomes After Hip Fracture Surgery.

Cogan Alison M AM Weaver Jennifer A JA McHarg Matt M Leland Natalie E NE Davidson Leslie L Mallinson Trudy T

JAMA network open 20200103 1

<h4>Importance</h4>Medicare is shifting from payment for postacute care services based on the volume provided to payment based on value as determined by patient characteristics and functional outcomes. Matching therapy time and length of stay (LOS) to patient needs will be critical to optimize functional outcomes and manage costs.<h4>Objective</h4>To investigate the association among therapy time, LOS, and functional outcomes for patients following hip fracture surgery.<h4>Design, setting, and p ...[more]

PMID: 31977059

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Project description:IMPORTANCE:More than 300,000 hip fractures occur each year in the United States. Recent practice guidelines have advocated greater use of regional anesthesia for hip fracture surgery. OBJECTIVE:To test the association of regional (ie, spinal or epidural) anesthesia vs general anesthesia with 30-day mortality and hospital length of stay after hip fracture. DESIGN, SETTING, AND PATIENTS:We conducted a matched retrospective cohort study involving patients 50 years or older who were undergoing surgery for hip fracture at general acute care hospitals in New York State between July 1, 2004, and December 31, 2011. Our main analysis was a near-far instrumental variable match that paired patients who lived at different distances from hospitals that specialized in regional or general anesthesia. Supplementary analyses included a within-hospital match that paired patients within the same hospital and an across-hospital match that paired patients at different hospitals. EXPOSURES:Spinal or epidural anesthesia; general anesthesia. MAIN OUTCOMES AND MEASURES:Thirty-day mortality and hospital length of stay. Because the distribution of length of stay had long tails, we characterized this outcome using the Huber M estimate with Huber weights, a robust estimator similar to a trimmed mean. RESULTS:Of 56,729 patients, 15,904 (28%) received regional anesthesia and 40,825 (72%) received general anesthesia. Overall, 3032 patients (5.3%) died. The M estimate of the length of stay was 6.2 days (95% CI, 6.2 to 6.2). The near-far matched analysis showed no significant difference in 30-day mortality by anesthesia type among the 21,514 patients included in this match: 583 of 10,757 matched patients (5.4%) who lived near a regional anesthesia-specialized hospital died vs 629 of 10,757 matched patients (5.8%) who lived near a general anesthesia-specialized hospital (instrumental variable estimate of risk difference, -1.1%; 95% CI, -2.8 to 0.5; P?=?.20). Supplementary analyses of within and across hospital patient matches yielded mortality findings to be similar to the main analysis. In the near-far match, regional anesthesia was associated with a 0.6-day shorter length of stay than general anesthesia (95% CI, -0.8 to -0.4, P?<?.001). Supplementary analyses also showed regional anesthesia to be associated with shorter length of stay, although the observed association was smaller in magnitude than in the main analysis. CONCLUSIONS AND RELEVANCE:Among adults in acute care hospitals in New York State undergoing hip repair, the use of regional anesthesia compared with general anesthesia was not associated with lower 30-day mortality but was associated with a modestly shorter length of stay. These findings do not support a mortality benefit for regional anesthesia in this setting.

Project description:Importance:Although wait times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications. Objective:To use population-based wait-time data to identify the optimal time window in which to conduct hip fracture surgery before the risk of complications increases. Design, Setting, and Participants:Population-based, retrospective cohort study of adults undergoing hip fracture surgery between April 1, 2009, and March 31, 2014, at 72 hospitals in Ontario, Canada. Risk-adjusted restricted cubic splines modeled the probability of each complication according to wait time. The inflection point (in hours) when complications began to increase was used to define early and delayed surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched early and delayed surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs). Exposure:Time elapsed from hospital arrival to surgery (in hours). Main Outcomes and Measures:Mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia). Results:Among 42 230 patients with hip fracture (mean [SD] age, 80.1 years [10.7], 70.5% women) who met study entry criteria, overall mortality at 30 days was 7.0%. The risk of complications increased when wait times were greater than 24 hours, irrespective of the complication considered. Compared with 13 731 propensity-score matched patients who received surgery earlier, 13 731 patients who received surgery after 24 hours had a significantly higher risk of 30-day mortality (898 [6.5%] vs 790 [5.8%]; % absolute RD, 0.79; 95% CI, 0.23-1.35) and the composite outcome (1680 [12.2%]) vs 1383 [10.1%]; % absolute RD, 2.16; 95% CI, 1.43-2.89). Conclusions and Relevance:Among adults undergoing hip fracture surgery, increased wait time was associated with a greater risk of 30-day mortality and other complications. A wait time of 24 hours may represent a threshold defining higher risk.

Project description:PurposeThe 30-day mortality rate after hip fracture surgery has been considered as an indirect indicator of the quality of care. The aim of this work is to analyse preoperative and postoperative factors potentially related to early 30-day mortality in patients over 65 undergoing hip fracture surgery.MethodsProspective cohort study including all consecutive primary hip fracture patients over 65 admitted to Trauma and Orthopaedics department from January 1, 2018 to December 31, 2019. Bed-ridden, non- surgically treated patients, and high energy trauma or tumoral aetiology fractures were excluded. A total of 943 patients were eligible (attrition rate: 2.1%). Follow-up included 30-days after discharge. We noted the 30-day mortality after hip fracture surgery, analysing 130 potentially related variables including biodemographic, fracture-related, preoperative, and postoperative clinical factors. Qualitative variables were assessed by χ2, and quantitative variables by non-parametric tests. Odds ratio determined by binary logistic regression. We selected preventable candidate variables for multivariate risk assessment by logistic regression.ResultsA total of 923 patients were enrolled (mean age 86.22±6.8, 72.9% women). The 30-day mortality rate was 6.0%. We noted significant increased mortality on men (OR = 2.381[1.371-4.136], p = 0.002), ageing patients (ORyear = 1.073[1.025-1.122], p = 0.002), and longer time to surgery (ORday = 1.183[1.039-1146], p<0.001), on other 20 preoperative clinical variables, like lymphopenia (lymphocyte count <103/μl, OR = 1.842[1.063-3.191], p = 0.029), hypoalbuminemia (≤3.5g/dl, OR = 2.474[1.316-4.643], p = 0.005), and oral anticoagulant intake (OR = 2.499[1.415-4.415], p = 0.002), and on 25 postoperative clinical variables, like arrhythmia (OR = 13.937[6.263-31.017], p<0.001), respiratory insufficiency (OR = 7.002[3.947-12.419], p<0.001), hyperkalaemia (OR = 10.378[3.909-27.555], p<0.001), nutritional supply requirement (OR = 3.576[1.894-6.752], p = 0.021), or early arthroplasty dislocation (OR = 6.557[1.206-35.640], p = 0.029). We developed a predictive model for early mortality after hip fracture surgery based on postoperative factors with 96.0% sensitivity and 60.7% specificity (AUC = 0.863).ConclusionWe revealed that not only preoperative, but also postoperative factors have a great impact after hip fracture surgery. The influence of post-operative factors on 30-day mortality has a logical basis, albeit so far they have not been identified or quantified before. Our results provide an advantageous picture of the 30-day mortality after hip fracture surgery.

Dataset Information

Association of Length of Stay, Recovery Rate, and Therapy Time per Day With Functional Outcomes After Hip Fracture Surgery.

Publications

Association of Length of Stay, Recovery Rate, and Therapy Time per Day With Functional Outcomes After Hip Fracture Surgery.

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