Survival and functional outcomes after hip fracture among nursing home residents.
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ABSTRACT:
SUBMITTER: Neuman MD
PROVIDER: S-EPMC4122620 | biostudies-other | 2014 Aug
REPOSITORIES: biostudies-other
Publications
Survival and functional outcomes after hip fracture among nursing home residents.
Neuman Mark D MD Silber Jeffrey H JH Magaziner Jay S JS Passarella Molly A MA Mehta Samir S Werner Rachel M RM
JAMA internal medicine 20140801 8
<h4>Importance</h4>Little is known regarding outcomes after hip fracture among long-term nursing home residents.<h4>Objective</h4>To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture.<h4>Design, setting, and participants</h4>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.<h4> ...[more]
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Project description:BACKGROUND:Hip fracture risk is high in young people with multiple sclerosis (MS), but has not been examined in an institutionalized aging population with MS. OBJECTIVE:We aimed to compare the hip fracture risk in nursing home (NH) residents with and without MS; and (2) examine risk factors for hip fracture in those with MS. METHODS:We conducted a retrospective cohort study using national NH clinical assessment and Medicare claims data. Participants included age-, sex- and race-matched NH residents with/without MS (2007-2008). Multivariable competing risk regression was used to compare 2-year hip fracture risk, and to examine risk factors. RESULTS:A total of 5692 NH residents with MS were matched to 28,460 without MS. Approximately 80% of residents with MS vs. 50% of those without MS required extensive assistance in walking at NH admission. The adjusted incidence rate of hip fracture was 7.1 and 18.6 per 1000 person-years in those with or without MS, respectively. Wandering and anxiolytic exposure were the main hip fracture risk factors in transfer independent residents with MS; while pneumonia and antidepressant use were the main factors in dependent residents with MS. CONCLUSIONS:In contrast to prior comparisons from non-NH populations, the incidence of hip fracture was lower in NH residents with MS as compared with matched controls. Residents with MS were much more functionally dependent, which likely explains these findings. Fracture prevention strategies should focus on fall prevention in independent residents; and possibly improvement of health status and facility quality of care in dependent residents.
| S-EPMC6150858 | biostudies-literature
Project description:OBJECTIVES:To quantify the variation in hip fracture incidence across U.S. nursing home (NH) facilities and states and examine how hip fracture incidence varies according to facility- and state-level characteristics. DESIGN:Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. SETTING:U.S. NHs with 100 or more beds. PARTICIPANTS:Long-stay NH residents between May 1, 2007, and April 30, 2008, from 1,481 facilities and 46 U.S. states (N = 201,892). MEASUREMENTS:Incident hip fractures were ascertained using Medicare Part A diagnostic codes. Each resident was followed for up to 2 years. RESULTS:The mean adjusted incidence rate of hip fractures for all facilities was 3.13 (95% confidence interval (CI) = 3.01-3.26) per 100 person-years (range 1.20, 95% CI = 1.15-1.26 to 6.40, 95% CI = 6.07-6.77). Facilities with the highest rates of hip fracture had greater percentages of residents taking psychoactive medications (top tertile 27.2%, bottom tertile 24.8%), and fewer nursing (top tertile 3.43, bottom tertile 3.53) and direct care (top tertile 3.22, bottom tertile 3.29) hours per day per resident. The combination of state and facility characteristics explained 6.7% of the variation in hip fracture, and resident characteristics explained 7.6%. CONCLUSION:Much of the variation in hip fracture incidence remained unexplained, although these findings indicate that potentially modifiable state and facility characteristics such as psychoactive drug prescribing and minimum staffing requirements could be addressed to help reduce the rate of hip fracture in U.S. NHs.
| S-EPMC5849498 | biostudies-literature
Project description:Background:Influenza illness may impact the risk of falls and fractures during acute illness due to unsteady gait or dizziness. We evaluated the association between influenza and hip fracture hospitalizations in long-stay (LS) nursing home (NH) residents. Methods:We analyzed weekly rates of hospitalization in a retrospective cohort of LS NH residents between January 1, 2000 to December 31, 2009. Hip fracture and influenza like illness (ILI) hospitalizations were identified with Medicare fee-for-service part A claims. We evaluated unadjusted and adjusted models with the primary exposures, weekly rate of influenza-like illness hospitalizations, city-wide mortality, and NH influenza vaccination rate and primary outcome of weekly rate of hip fracture hospitalizations. Results:There were 9,237 incident hip fractures in the cohort. Facility wide ILI hospitalization rate was associated with the hip fracture hospitalization rate in the unadjusted (incidence rate ratio [IRR] 1.13, 95% confidence interval [CI]: 1.08, 1.17) and adjusted (IRR 1.13, 95% CI: 1.09, 1.18) analyses. City-wide influenza mortality was associated with hip fracture hospitalization rates for the unadjusted (IRR 1.03, 95% CI: 1.02, 1.04), and adjusted (IRR 1.02, 95% CI: 1.01, 1.03) analyses. NH influenza vaccination rates were not associated with changes in hip fracture hospitalization rates. Conclusions:ILI hospitalizations are associated with a 13% average increase in hip fracture hospitalization risk. In a given NH week, an increase in the number ILI hospitalizations from none to two was associated with an approximate one percentage point increase in hip fracture hospitalization risk. Strategies to reduce influenza risk should be investigated to reduce hip fracture risk.
| S-EPMC6230207 | biostudies-literature
Project description:OBJECTIVE:The Food and Drug Administration recommends a reduced dose of nonbenzodiazepine hypnotics in women, yet little is known about the age-, sex-, and dose-specific effects of these drugs on risk of hip fracture, especially among nursing home (NH) residents. We estimated the age-, sex-, and dose-specific effects of nonbenzodiazepine hypnotics on the rate of hip fracture among NH residents. DESIGN AND SETTING:Case-crossover study in US NHs. PARTICIPANTS:A total of 691 women and 179 men with hip fracture sampled from all US long-stay NH residents. MEASUREMENTS:Measures of patient characteristics were obtained from linked Medicare and the Minimum Data Set (2007-2008). The outcome was hospitalization for hip fracture with surgical repair. We estimated rate ratios (RRs) and 95% confidence intervals (CIs) from conditional logistic regression models for nonbenzodiazepine hypnotics (vs nonuse) comparing 0 to 29?days before hip fracture (hazard period) with 60 to 89 and 120 to 149?days before hip fracture (control periods). We stratified analyses by age, sex, and dose. RESULTS:The average RR of hip fracture was 1.7 (95% CI 1.5-1.9) for any use. The RR of hip fracture was higher for residents aged ?90?years vs <70?years (2.2 vs 1.3); however, the CIs overlapped. No differences in the effect of the hypnotic on risk of hip fracture were evident by sex. Point estimates for hip fracture were greater with high-dose versus low-dose hypnotics (RR 1.9 vs 1.6 for any use), but these differences were highly compatible with chance. CONCLUSIONS:The rate of hip fracture in NH residents due to use of nonbenzodiazepine hypnotics was greater among older patients than among younger patients and, possibly, with higher doses than with lower doses. When clinicians are prescribing a nonbenzodiazepine hypnotic to any NH resident, doses of these drugs should be kept as low as possible, especially among those with advanced age.
| S-EPMC5871542 | biostudies-literature
Project description:Importance:The decision whether to surgically repair a hip fracture in nursing home (NH) residents with advanced dementia can be challenging. Objective:To compare outcomes, including survival, among NH residents with advanced dementia and hip fracture according to whether they underwent surgical hip fracture repair. Design, Setting, and Participants:We conducted a retrospective cohort study of 3083 NH residents with advanced dementia and hip fracture, but not enrolled in hospice care, using nationwide Medicare claims data linked with Minimum Data Set (MDS) assessments from January 1, 2008, through December 31, 2013. Methods:Residents with advanced dementia were identified using the MDS. Medicare claims were used to identify hip fracture and to determine whether the fracture was managed surgically. Survival between surgical and nonsurgical residents was compared using multivariable Cox proportional hazards with inverse probability of treatment weighting (IPTW). All analyses took place between November 2015 and January 2018. Among 6-month survivors, documented pain, antipsychotic drug use, physical restraint use, pressure ulcers, and ambulatory status were compared between surgical and nonsurgical groups. Results:Among 3083 residents with advanced dementia and hip fracture (mean age, 84.2 years; 79.2% female [n?=?2441], 28.5% ambulatory [n?=?879]), 2615 (84.8%) underwent surgical repair. By 6-month follow-up, 31.5% (n?=?824) and 53.8% (n?=?252) of surgically and nonsurgically managed residents died, respectively. After IPTW modeling, surgically managed residents were less likely to die than residents without surgery (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.79-0.98). Among 2007 residents who survived 6 months, residents with surgical vs nonsurgical management had less docmented pain (29.0% [n?=?465] vs 30.9% [n?=?59]) and fewer pressure ulcers (11.2% [n?=?200] vs 19.0% [n?=?41]). In IPTW models, surgically managed residents reported less pain (aHR, 0.78; 95% CI, 0.61-0.99) and pressure ulcers (aHR, 0.64; 95% CI, 0.47-0.86). There was no difference between antipsychotic drug use and physical restraint use between the groups. Few survivors remained ambulatory (10.7% [n?=?55] of surgically managed vs 4.8% [n?=?1] without surgery). Conclusions and Relevance:Surgical repair of a hip fracture was associated with lower mortality among NH residents with advanced dementia and should be considered together with the residents' goals of care in management decisions. Pain and other adverse outcomes were common regardless of surgical management, suggesting the need for broad improvements in the quality of care provided to NH residents with advanced dementia and hip fracture.
| S-EPMC5997966 | biostudies-literature
Project description:BackgroundElderly nursing home residents are at increased risk of hip fracture; however, the efficacy of fracture prevention strategies in this population is unclear.ObjectiveWe performed a scoping review of randomized controlled trials of interventions tested in the long-term care (LTC) setting, examining hip fracture outcomes.MethodsWe searched for citations in 6 respective electronic searches, supplemented by hand searches. Two reviewers independently reviewed all citations and full-text papers; consensus was achieved on final inclusion. Data was abstracted in duplicate.FindingsWe reviewed 22,349 abstracts or citations and 949 full-text papers. Data from 20 trials were included: 7--vitamin D (n = 12,875 participants), 2--sunlight exposure (n = 522), 1--alendronate (n = 327), 1--fluoride (n = 460), 4--exercise or multimodal interventions (n = 8,165), and 5--hip protectors (n = 2,594). Vitamin D, particularly vitamin D(3) > or = 800 IU orally daily, reduced hip fracture risk. Hip protectors reduced hip fractures in included studies, although a recent large study not meeting inclusion criteria was negative. Fluoride and sunlight exposure did not significantly reduce hip fractures. Falls were reduced in three studies of exercise or multimodal interventions, with one study suggesting reduced hip fractures in a secondary analysis. A staff education and risk assessment strategy did not significantly reduce falls or hip fractures. In a study underpowered for fracture outcomes, alendronate did not significantly reduce hip fractures in LTC.ConclusionsThe intervention with the strongest evidence for reduction of hip fractures in LTC is Vitamin D supplementation; more research on other interventions is needed.
| S-EPMC2831075 | biostudies-literature
Project description:ImportanceBreast cancer surgery, the most common cancer operation performed in nursing home residents, is viewed as a low-risk surgical intervention. However, outcomes in patients with high functional dependence and limited life expectancy are poorly understood.ObjectiveTo assess the overall survival and functional status changes after breast cancer surgery in female nursing home residents stratified by surgery type.Design, setting, and participantsThis study used Medicare claims from 2003 to 2013 to identify 5969 US nursing home residents who underwent inpatient breast cancer surgery. Using the Minimum Data Set Activities of Daily Living (MDS-ADL) summary score, this study examined preoperative and postoperative function and identified patient characteristics associated with 30-day and 1-year mortality and 1-year functional decline after surgery. Cox proportional hazards regression was used to estimate unadjusted and adjusted hazard ratios (HRs) of mortality. Fine-Gray competing risks regression was used to estimate unadjusted and adjusted subhazard ratios (sHRs) of functional decline. Statistical analysis was performed from January 2016 to January 2018.Main outcomes and measuresFunctional status and death.ResultsFrom 2003 to 2013, a total of 5969 female nursing home residents (mean [SD] age, 82 [7] years; 4960 [83.1%] white) underwent breast cancer surgery: 666 (11.2%) underwent lumpectomy, 1642 (27.5%) underwent mastectomy, and 3661 (61.3%) underwent lumpectomy or mastectomy with axillary lymph node dissection (ALND). The 30-day mortality rates were 8% after lumpectomy, 4% after mastectomy, and 2% after ALND. The 1-year mortality rates were 41% after lumpectomy, 30% after mastectomy, and 29% after ALND. Among 1-year survivors, the functional decline rate was 56% to 60%. The mean MDS-ADL score increased (signifying greater dependency) by 3 points for lumpectomy, 4 points for mastectomy, and 5 points for ALND. In multivariate analysis, poor baseline MDS-ADL score (range, 20-28) was associated with a higher 1-year mortality risk (lumpectomy: HR, 1.92 [95% CI, 1.23-3.00], P = .004; mastectomy: HR, 1.80 [95% CI, 1.35-2.39], P < .001; and ALND: HR, 1.77 [95% CI, 1.46-2.15], P < .001). After multivariate adjustment, preoperative decline in MDS-ADL score (lumpectomy: sHR, 1.59 [95% CI, 1.25-2.03], P < .001; mastectomy: sHR, 1.79; [95% CI, 1.52-2.09], P < .001; and ALND: sHR, 1.72 [95% CI, 1.56-1.91], P < .001) and cognitive impairment (lumpectomy: sHR, 1.27 [95% CI, 1.03-1.56], P = .02; mastectomy: sHR, 1.26 [95% CI, 1.09-1.45], P = .002; and ALND: sHR, 1.14 [95% CI, 1.04-1.24], P = .003) were significantly associated with 1-year functional decline across all breast cancer surgery groups.Conclusions and relevanceFor female nursing home residents who underwent breast cancer surgery, 30-day mortality and survival as well as 1-year mortality and functional decline were high. The 1-year survivors had significant functional decline. This study's findings suggest that this information should be incorporated into collaborative surgical decision-making processes.
| S-EPMC6433538 | biostudies-literature
Project description:Interventions to improve the fracture prevention in nursing homes are needed.Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n=67) with > or =10 residents with a diagnosis of osteoporosis or recent hip fracture (n=606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering.No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P=.72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models.Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities.
| S-EPMC2288656 | biostudies-literature
Project description:Clinicians struggle with whether to prescribe osteoporosis medications for fracture prevention for older nursing home (NH) residents with dementia, given the lack of evidence in this population. To better understand real-world clinical practice, we conducted a retrospective cohort study examining patterns of fracture prevention medication use for older NH residents with dementia and high fracture risk. Data sources included 2015-16 Medicare claims, Part D prescriptions, and Minimum Data Set (MDS) assessments. Among NH residents aged 65+ with dementia and prior fracture or high fracture risk based on the MDS FRAiL (Fracture Risk Assessment in Long-term care), we assessed medications for fracture prevention using prescription data from 1 year prior through 90 days after the first MDS assessment. Multivariable logistic regression was used to evaluate factors associated with receiving treatment. Most of the sample (n = 72,639) was >80 years (78%), female (82%), and white (88%); 63% had moderate/severe dementia and 60% had an osteoporosis diagnosis. Only 11.6% received fracture prevention medications. In adjusted analyses, treated residents were more likely to be female, Hispanic or other non-black minority, <90 years old, and newly admitted to the NH. Other associated factors included osteoporosis diagnosis, walker or wheelchair use, bone disorders (eg, Paget disease), >5 medications, steroid or proton pump inhibitor use, and regions outside of the Northeast. Resident characteristics suggestive of comorbidity burden and worsening dementia were associated with reduced likelihood of treatment. Low use of fracture prevention medications for NH residents with dementia may reflect an attempt by prescribers reconcile medication use with changing goals of care, or inappropriate underuse in patients who still have high fracture risk. Additional research is needed to help clinicians better evaluate when to use these medications in this heterogeneous and vulnerable population.
| S-EPMC8358966 | biostudies-literature
Project description:OBJECTIVES:To compare the standardized incidence rates (IRs) of hip fracture for Native Americans versus other racial groups in U.S. nursing homes (NHs). METHODS:We studied Medicare fee-for-service NH residents aged ?65?years who became long-stay (index date) between 1/1/2008 and 12/31/2009 (n?=?1,136,544). Residents were followed from the index date until occurrence of hip fracture, death, Medicare disenrollment, or study end (12/31/2013). We calculated hip fracture IRs by race and used inverse probability weighting to standardize the rates for baseline demographic and clinical characteristics collected from the Minimum Data Set and Medicare claims data. We compared characteristics of NHs used by residents of different races using Online Survey, Certification and Reporting (OSCAR) data. RESULTS:Among long-stay U.S. NH residents, the standardized IR of hip fracture per 100 person-years was highest in Native Americans [2.16; 95% confidence interval (CI) 1.91-2.44] and white residents (2.05; 2.03-2.06), and lowest in black residents (0.82; 0.79-0.85). NHs caring for Native American residents were more likely to be rurally located as compared to other racial group. CONCLUSIONS:In U.S. NHs, Native Americans and whites have the highest standardized IR of hip fracture and should receive particular attention in fracture prevention efforts.
| S-EPMC6527125 | biostudies-literature