Hip fracture patients fare best during recovery in high-occupancy nursing homes with higher level physician staffing
PHILADELPHIA – Hip fractures are a common and disabling condition that occurs more than 300,000 times each year in the United States in those 65 and older–1.6 million times worldwide. A new study from Penn Medicine, which compared outcome variations in acute and post-acute care facilities, suggests that for older adults hospitalized with hip fracture, the quality of the post-acute care they receive has a greater impact on long-term recovery than the care they received at the hospital. This study was published today online ahead of print in Medical Care, a journal of the American Public Health Association.
In an analysis of over 42,000 Medicare patients, researchers found that the impact of post-acute care – care received in a nursing homes, rehabilitation facilities, at-home care, etc. – on outcomes, including mortality and mobility, was three to eight times greater than the impact of hospital factors. Overall, nursing home factors explained three times more variation in a patient's probability of dying at 30 days than hospital factors, seven times more variation in the probability of dying at 180 days, and eight times more variation in the probability of dying or being newly unable to walk at 180 days.
"These results highlight the major impact that post-acute care has on basic outcomes such as survival and walking ability among this patient population," said the study's lead author Mark D. Neuman, MD, MSc, an assistant professor of Anesthesiology and Critical Care in the Perelman School of Medicine at the University of Pennsylvania, and director of the Penn Center for Perioperative Outcomes Research and Transformation (PCORI).
Researchers performed a retrospective cohort study using Medicare data of older adult, hip fracture patients who were previously nursing home residents between 2005 and 2009. Of the 42,000 patients, 75 percent were women, 92 percent white and all patients were over 80 years old. While patient characteristics represented the principal determinants of outcomes after hip fractures, selected hospital and nursing home characteristics were associated with short-and long-term outcomes. Hospital characteristics – nurse-to-bed ratio, mean hospital nurse skill mix, and hospital for-profit status, for example – were not consistently associated with outcomes, while multiple nursing home characteristics – bed count, chain membership, and performance on selected quality measures – did predict outcomes.
For instance, patients treated at a nursing home with low occupancy, more than 150 beds versus a facility with less than 100 beds, and with historically high mortality rates, were more likely to die or have a new inability to walk after 30 days. Nursing home market concentration – a higher number of nursing homes in a specific region – and ownership by a multi-facility organization were also modestly associated with 30-day mortality. More, facilities that used more full-time physician extenders – physician assistants and nurse practitioners – and those with a full-time Director of Nursing were modestly associated with 180-day mortality. Nursing homes located within a hospital was also associated with 180-day mortality.
From a policy standpoint, this paper is important because it informs policymakers on which care setting contributes most to outcomes. Post-acute care represents a large and growing source of health care spending in the United States, the authors said.
Medicare costs exceeded $62 billion in 2012, with evidence that spending on post-acute care now outpaces spending on patients hospitalized for common conditions. The authors added, as payment models move more and more towards bundled payments for acute and post-acute care, studies such as this can help guide decisions about how best to allocate resources by health systems and payers.
"For patients, it sends the simple message that post-acute care, for instance, at a nursing home, may have a major impact on recovery in the long term," Neuman said.
The next phase of this research should explore the impact on these factors on outcomes for older adults hospitalized for conditions other than hip fractures, as well as the processes within facilities that may help explain the variations in the outcomes observed in this study, the authors wrote.
Additional authors on the study include senior author Rachel M. Werner, Jeffrey H. Silber, and Molly A. Passarella. This study was supported by the National Institutes on Aging (K08AG043548 and K24AG047908).
Penn Medicine is one of the world's leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania(founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $5.3 billion enterprise.
The Perelman School of Medicine has been ranked among the top five medical schools in the United States for the past 17 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $409 million awarded in the 2014 fiscal year.
The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center — which are recognized as one of the nation's top "Honor Roll" hospitals by U.S. News & World Report — Chester County Hospital; Lancaster General Health; Penn Wissahickon Hospice; and Pennsylvania Hospital — the nation's first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Chestnut Hill Hospital and Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine.
Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2014, Penn Medicine provided $771 million to benefit our community.