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Variation in access to community rehabilitation services and length of stay in hospital following a hip fracture: a cross-sectional study.

ABSTRACT: To assess variation in access to and use of community rehabilitation services for patients with a hip fracture, and whether this affects length of stay in hospital.Cross-sectional study using administrative patient-level data from Hospital Episode Statistics (HES) and organisational survey data.A regional health economy in South West England served by four acute National Health Service (NHS) hospital trusts and six former Primary Care Trusts (PCTs).1230 hip fracture patients treated in an acute hospital between 1 April 2011 and 29 February 2012.Information about access to community rehabilitation services for each acute hospital and PCT, reported by organisational survey. Rates of patients transferred from acute hospital to community rehabilitation hospitals (CRH) across eight groups with varying access; determined by acute hospital and PCT. Median lengths of stay in the acute hospital, and in the acute hospital plus CRH combined. Associations between the rate of transfer to a CRH and median lengths of stay assessed using Spearman's rank correlation coefficient (rs).Access to community rehabilitation services varied, including the number of CRH inpatient beds, formal access criteria and waiting times. In one PCT, no home-based rehabilitation service was available. The percentage of patients transferred to a CRH ranged from 2.1% to 54.7%. A higher transfer rate was associated with a shorter median length of stay in the acute hospital (rs=-0.8; p=0.01), but a longer median combined length of stay in the acute hospital and CRH (rs=+0.7; p=0.04).Within one geographical area, there was wide variation in availability and use of community rehabilitation services for patients discharged from an acute hospital following a hip fracture. Reliance on transfers to community rehabilitation hospitals was associated with a longer length of stay in the NHS.

SUBMITTER: Neuburger J

PROVIDER: S-EPMC4160836 | biostudies-other | 2014 Sep

REPOSITORIES: biostudies-other

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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:Study questionCan the length of hospital stay for hip fracture affect a patient's risk of death 30 days after discharge?MethodsIn a retrospective cohort study, population based registry data from the New York Statewide Planning and Research Cooperative System (SPARCS) were used to investigate 188,208 patients admitted to hospital for hip fracture in New York state from 2000 to 2011. Patients were aged 50 years and older, and received surgical or non-surgical treatment. The main outcome measure was the mortality rate at 30 days after hospital discharge.Study answer and limitationsHospital stays of 11-14 days for hip fracture were associated with a 32% increased odds of death 30 days after discharge, compared with stays lasting one to five days (odds ratio 1.32 (95% confidence interval 1.19 to 1.47)). These odds increased to 103% for stays longer than 14 days (2.03 (1.84 to 2.24)). Other risk factors associated with early mortality included discharge to a hospice facility, older age, metastatic disease, and non-surgical management. The 30 day mortality rate after discharge was 4.5% for surgically treated patients and 10.7% for non-surgically treated patients. These findings might not be generalizable to populations in other US states or in other countries. The administrative claims data used could have been incomplete or include inaccurate coding of diagnoses and comorbid conditions. The database also did not include patient socioeconomic status, which could affect access to care to a greater extent in New York state than in European countries. Specific cause of death was not available because few autopsies are performed in this population.What this study addsBy contrast with recent findings in Sweden, decreased length of hospital stay for hip fracture was associated with reduced rates of early mortality in a US cohort in New York state. This could reflect critical system differences in the treatment of hip fractures between Europe and the USA.Funding, competing interests, data sharing University of Rochester grant from the Clinical Translational Science Institute for statistical analyses used in this work (National Institutes of Health (UL1 TR000042)) and the National Institutes of Health (K-08 AR060164-01A). No competing interests declared. Data may be obtained through SPARCS at https://www.health.ny.gov/statistics/sparcs/access/.

Project description:BackgroundHospital length of stays (LOS) for incident of hip fracture are decreasing, but it is unknown if these changes have negative impacts on vulnerable older patient populations, like those with Alzheimer's disease (AD). We aimed to assess if persons with and without AD have different hospital LOS for hip fracture, and is the LOS associated with hospital readmissions.MethodsUtilizing register-based data for a matched cohort study nested in the Medication use and Alzheimer's disease study (MEDALZ), we collected all community-dwelling persons in Finland diagnosed with AD during 2005-2012, had incident of first hip fracture between 2005 and 2015 after AD diagnosis, and were discharged alive from an acute care hospital. Hospital LOS and hospital readmissions within 30-days and 90-days were compared between those with and without AD and risk of readmission was assessed using binary logistic regression analysis.ResultsIn this matched cohort study of 12,532 persons (mean age 84.6 years (95% CI: 84.5-84.7), 76.8% women), the median LOS in an acute care hospital was 1 day shorter for those with AD (median 4 days, IQR 3-7) than those without AD (median 5 days, IQR 3-7) (P < 0.001). However, the AD cohort had respectively 6 days and 5 days longer median LOS in a community hospital, and total hospital stay compared to the non-AD cohort (P < 0.001 for all comparisons). Those with AD had fewer readmissions within 30-days (10.7%) and 90-days (16.9%) compared to those without AD (13.3% 30-days and 20.7% 90-days) (P < 0.001 for all comparisons). Both cohorts had a reduced readmission risk within 30-days when the LOS in an acute care hospital was 4-14 days, compared to a LOS less than 4 days.ConclusionsPersons with AD had shorter acute care hospital LOS, but had longer LOS in a community hospital setting compared to those without AD, which is similar to other findings when comparing total hospital LOS. These findings imply that short LOS in acute care hospitals may be associated with poor health outcomes for vulnerable older populations after hip fracture.

Project description:BackgroundAbout 50% of all hospitalized fragility fracture cases in older Americans are hip fractures. Approximately 3/4 of fracture-related costs in the USA are attributable to hip fractures, and these are mostly covered by Medicare. Hip fracture patients with dementia, including Alzheimer's disease, have worse health outcomes including longer hospital length of stay (LOS) and charges. LOS and hospital charges for dementia patients are usually higher than for those without dementia. Research describing LOS and acute care charges for hip fractures has mostly focused on these outcomes in trauma patients without a known pre-admission diagnosis of osteoporosis (OP). Lack of documented diagnosis put patients at risk of not having an appropriate treatment plan for OP. Whether having a diagnosis of OP would have an effect on hospital outcomes in dementia patients has not been explored. We aim to investigate whether having a diagnosis of OP, dementia, or both has an effect on LOS and hospital charges. In addition, we also report prevalence of common comorbidities in the study population and their effects on hospital outcomes.MethodsWe conducted a cross-sectional analysis of claims data (2012-2013) for 2175 Medicare beneficiaries (≥65 years) in the USA.ResultsCompared to those without OP or dementia, patients with demenia only had a shorter LOS (by 5%; P = .04). Median LOS was 6 days (interquartile range [IQR]: 5-7), and the median hospital charges were $45,100 (IQR: 31,500 - 65,600). In general, White patients had a shorter LOS (by 7%), and those with CHF and ischemic heart disease (IHD) had longer LOS (by 7 and 4%, respectively). Hospital charges were 6% lower for women, and 16% lower for White patients.ConclusionThis is the first study evaluating LOS in dementia in the context of hip fracture which also disagrees with previous reporting about longer LOS in dementia patients. Patients with CHF and IHD remains at high risk for longer LOS regardless of their diagnosis of dementia or OP.

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Variation in access to community rehabilitation services and length of stay in hospital following a hip fracture: a cross-sectional study.

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