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, revealed a new study from Penn Medicine. The findings are published in Medical Care, a journal of the American Public Health Association.
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.
‘Post-acute care has a major impact on basic outcomes such as survival and walking ability among older adults hospitalized with hip fracture.’
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, 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
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%
were women, 92% 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
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