Predictors of change in ‘discharge destination’ following treatment for fracture neck of femur

doi:10.1016/j.injury.2014.02.005

Injury

Volume 45, Issue 7, July 2014, Pages 1080-1084

https://doi.org/10.1016/j.injury.2014.02.005 Get rights and content

Abstract

Objectives

The purpose of our study was to analyse the incidence and factors predicting the ‘change in discharge destination’ in patients with fractured neck of femur who were treated surgically.

Materials and methods

Fifteen hundred and seventy-three consecutive patients admitted with a fractured neck of femur, residing in their own home prior to admission were studied. Patients who did not have an operation (n = 70) for their hip fracture were excluded from the study.

Residential location in the UK is broadly categorised as:

(1)
living in their own home;
(2)
residential home;
(3)
nursing home;
(4)
hospitalised.

Results

A downward drift in “discharge destination” of 20% was noted after analysis. Univariate analysis revealed that age, gender, AMT score, place of fall, type of fracture, walking ability outdoor and indoor, ASA grade, medical co-morbidity requiring physician review and delay beyond 36 h to surgery had a significant effect.

Multiple logistic regression analysis revealed that increasing age, male gender (OR = 1.67), accompaniment for outdoor mobilisation (OR = 1.96), increasing ASA grade, AMT score <6 (OR = 4.86), pre-operative medical condition requiring physician review (OR = 2.27), delay greater than 36 h for medical reasons (OR = 4.38) were predictors of the change in discharge destination.

Conclusion

The most important predictors of the change in the discharge destination were the medical condition, cognitive and physical function of the patient at admission. Male gender and increasing age were contributory. The only clinician dependent factor that seemed to affect this change of residential status was delay to surgery secondary to medical problems. Awareness of key predictors that affect the “discharge destination” can be useful for the multidisciplinary team and patients’ families to evaluate and plan for an early, satisfactory and appropriate referral to either community services or institutional care, which in turn could have a significant socioeconomic impact.

Introduction

Fracture of the neck of femur is a significant injury in the elderly population. A common reason for admission to an orthopaedic trauma ward, it is a life changing event for the patient and has a major impact on health economics [1]. Demographic projections predict an estimated increase in the incidence and annual expenditure that could reach £2.2 billion by 2020 in the United Kingdom [1]. It is hence not surprising that care provided to the patients with fracture neck of femur is a topic of national debate and scrutiny.

Following a fracture neck of femur, many patients are unable to regain their pre-fracture status of mobility and daily activities [2]. As a result some are not able to return to their pre injury residential status in-spite of surgery and adequate rehabilitation. Hence, they may require institutional care for the rest of their life. Less than 60% of these patients return to their own place of residence [3] and even fewer reach their pre-injury ambulatory status [4]. Inability to return to their own home following rehabilitation inevitably has an emotional and psychological impact on these vulnerable patients and their relatives [5], which should not be underestimated. It has been shown that the high prevalence of anxiety or depression in patients following fracture neck of femur can be improved with social contact [6].

Planned treatment should be tailored not only to rehabilitate these patients to their pre-injury mobility status but also ideally targeted to return them to their own home environment. About 10–20% of the patients admitted from their home ultimately move to institutional care [1]. This downward ‘drift’ in ‘discharge destination’ has a substantial social and economic impact [7].

Vast amount of literature already exists regarding the morbidity, mortality, complications & multidisciplinary care for neck of femur fractures [8], [9], [10], [11], [12], [13], [14], [15] but very few studies have described alteration of residential status secondary to a fracture neck of femur using discharge destination as a measure of outcome [3], [16], [17].

The objective of our study was to analyse the incidence and the factors predicting this ‘change in discharge destination’. The factors studied and analysed were: age, gender, type of fracture and operation, pre-injury mobility status (walking ability indoor and outdoor), type of anaesthesia, ASA grade, AMT score, place of fall, type of operation, delay in surgery, other associated injuries if any, presence of pressure ulcers and the need for pre-operative acute medical review.

Section snippets

Materials and methods

Between January 2008 and March 2012, 1573 consecutive patients admitted to our institution with a fractured neck of femur, who lived in their own home prior to admission, were identified for inclusion in this study. Of this cohort, patients who did not undergo surgery (n = 70) were excluded from the study. One hundred and thirty three patients died before their final discharge, either in the hospital or during their rehabilitation in the community hospital and were excluded from the final

Results

One thousand and sixty eight patients were females and 435 were male. One hundred and thirty-three patients who died either in the hospital or during their rehabilitation in the community hospital before the final discharge were excluded from the final analysis.

Univariate logistic analysis of the variables (Table 1) revealed that age, gender, AMT score, walking ability outdoor and indoor, whether patient needed accompanying for indoor and/or outdoor mobility, ASA grade, need for acute pre-op

Discussion

The majority of the patients from our cohort (80%) returned to their own home following surgery for fractured neck of femur. A downward drift in “discharge destination” of 20% (n = 274) was noted. When all the positive predictors were present in patients aged over 80 years, they were approximately one thousand times more likely to experience this downward drift. The most important predictor was the medical condition of the patient. This has been indicated by the three factors that were found to

Conclusion

The downward drift in “discharge destination” was 20%. Our study showed that male patients, age more than 80 years, with poor outdoor pre-operative mobility, poor cognitive function, significant pre-operative medical co-morbidities, higher ASA grade and those who experienced surgical delay for medical reasons were key predictors of change in discharge destination. Notably, not a single surgical variable was a significant predictor. Awareness of key predictors that affect the “discharge

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Cited by (27)

Early Predictors for Discharge to Geriatric Rehabilitation after Hip Fracture Treatment of Older Patients
2021, Journal of the American Medical Directors Association
To investigate early predictors for discharge to a geriatric rehabilitation department at a skilled nursing home in older patients after hospitalization for hip fracture surgery.
Retrospective cohort study.
Data from 21,176 patients with hip fracture aged ≥70 years, who were registered in the Dutch Hip Fracture Audit database between January 1, 2017, and December 31, 2019, were included.
Patients were categorized into 3 discharge groups: home (n=7326), rehabilitation (n=11,738), and nursing home (n=2112). Age, gender, Pre-Fracture Mobility Score (PFMS), premorbid Katz index of independence in Activities of Daily Living (Katz-ADL), history of dementia, American Society of Anesthesiologists physical status classification (ASA score), type of anesthesia, fracture type, surgical treatment, and cotreatment by a geriatrician were gathered. Multinomial regression analysis was used to assess for early predictors.
Higher age, poor premorbid mobility, lower premorbid Katz-ADL, no history of dementia, ASA score 3-5, general anesthesia, intramedullary implant, and cotreatment by a geriatrician were independent predictors for discharge to geriatric rehabilitation vs discharge home. Identical predictors were found for discharge to a nursing home vs discharge home. History of dementia and premorbid Katz-ADL were distinguishing factors; a higher premorbid Katz-ADL and a history of dementia were associated with a higher risk of discharge to a nursing home vs discharge home. The multinomial regression model correctly predicted 86%, 38.6%, and 2.4% of the patients in the rehabilitation group, home group, and nursing home group, respectively.
This study showed that age, PFMS, premorbid Katz-ADL, surgical treatment, ASA score, type of anesthesia, history of dementia, and cotreatment by a geriatrician were independent early predictors for discharge to geriatric rehabilitation vs discharge home in older patients after hip fracture surgery. Identical predictors were found as predictors for discharge to a nursing home vs discharge home, except for history of dementia and premorbid Katz-ADL.
Prognostic factors of mortality one year after a hip fragility fracture. Anoia hip study
2021, Revista Espanola de Geriatria y Gerontologia
En su mayoría, los pacientes con fractura de cadera por fragilidad ósea se caracterizan por tener una edad avanzada, fragilidad, multimorbilidad y una elevada mortalidad al primer año. Nuestro objetivo es describir los factores pronósticos de mortalidad al año de una fractura de cadera por fragilidad ósea.
Estudio observacional prospectivo. Durante el periodo de estudio, se han incluido todos los pacientes mayores de 69 años con fractura de cadera por fragilidad ósea ingresados en la Unidad Geriátrica de Agudos.
Hemos seguido a 364 pacientes, de los cuales 100 fallecieron (27,5%). Los factores predictores independientes de mortalidad al año de una fractura de cadera han sido: tener una menor puntuación en la Escala de Lawton y Brody basal 0,603 (0,505-0,721) p < 0,001); tener una mayor puntuación en el Índice de Comorbilidad de Charlson 2,332 (1,308-4,157) p = 0,04); tener un tiempo de espera quirúrgico ≥ tres días 3,013 (1,330-6,829) p = 0,008); presencia de alteraciones hidroelectrolíticas y/o deterioro del filtrado glomerular 1,212 (1,017-1,444) (p = 0,031) durante el ingreso hospitalario; capacidad discriminatoria del área bajo la curva (AUC) (± 95%): 0,847 (0,803-0,891).
Son factores pronósticos predictores de mortalidad al año de una fractura de cadera por fragilidad ósea, aquellas variables que reflejan un peor estado de salud, la presencia de complicaciones durante el ingreso hospitalario y un mayor tiempo de espera quirúrgica.
Most of the patients who had a hip fragility fracture are characterized by advanced age, frailty, multimorbidity and high mortality rate into the first year. Our aim is to describe the prognostic factors of mortality one year after a hip fragility fracture.
Observational prospective study. During the study period we included patients older than 69 years with hip fragility fracture who were admitted to the Acute Geriatric Unit.
We have followed 364 patients, 100 of them died (27.5%). The independent prognostic factors of mortality one year after a hip fragility fracture had been: have a less basis score in Lawton and Brody Scale 0.603 (0.505-0.721) (p< 0.001); have a higher score in Charlson Comorbidity Index 2.332 (1.308-4.157) p = 0.04); have a surgical waiting time ≥ 3 days 3.013 (1.330-6.829) p = 0.008); finding hydroelectrolytic disorders and/or deterioration of glomerular filtration 1.212 (1.017-1.444) p = 0.031) during hospital stay; discriminatory capacity of the area under the curve (AUC) (± 95%): 0.888 (0.880-0.891).
Prognostic predictors of mortality at one year after a hip fragility fracture are those variables that reflect a worse state of health, complications during hospital stay and a longer surgical waiting time.
Identifying a clinical decision tool to predict discharge disposition following operative treatment of hip fractures in the United States
2020, Injury
Citation Excerpt :
Our results are consistent with prior studies investigating risk factors for discharge to a PAC following operative treatment of hip fractures. Previous studies have identified older age and higher ASA class as influential factors predictive of discharge location, with age being the strongest predictor [20,21]. Sathiyakumar et al. found the use of intramedullary nails to treat intertrochanteric fractures to be a significant risk factor for PAC utilization [20].
Post-discharge management following operative treatment of hip fractures continues to be performed on a case-by-case basis, with no uniform guidelines dictating management. Predicting discharge to post-acute care (PAC) facilities (i.e. skilled nursing facilities and inpatient rehabilitation facilities) can assist preoperative planning and potentially decrease length of stay secondary to disposition issues. The goal of this study was to develop a nomogram using easily identified variables to preoperatively predict discharge disposition following operative treatment of hip fractures.
Using the National Surgical Quality Improvement Program database, patients who underwent surgical intervention for hip fractures between 2012 and 2015 were identified. A multivariable logistic regression model was used to identify risk factors for discharge to a PAC facility, and a predictive nomogram was created based on these results.
From 2012 to 2015, 33,371 hip fractures were identified: 13,336 (40%) femoral neck fractures, and 20,035 (60%) intertrochanteric femur fractures. Of the patients identified, 26,082 (78.2%) were discharged to a PAC while the remainder were discharged home with or without home health. 70% of patients were female and 92.4% were Caucasian. When accounting for comorbidities, using the American Society of Anesthesiologists (ASA) classification system, 6,122 patients (18.4%) had ‘Mild Systemic Disease’ (ASA 2), 20,872 (62.6%) patients had ‘Severe Systemic Disease’ (ASA 3), and 6,006 (18.1%) had ‘Life Threatening Disease’ (ASA 4/5). The majority of patients were brought in from a ‘Home’ setting, while 10.4% of patients were admitted from a ‘Long-Term Care’ setting. After controlling for confounding variables, older age and increasing ASA class were predictive of an increased risk of discharge to a PAC. Diabetes, dyspnea, congestive heart failure, and chronic obstructive pulmonary disease were not associated with an increased risk of discharge to a PAC.
Discharge disposition following operative treatment of hip fractures can be reliably predicted using a nomogram with commonly identified preoperative variables.
Level III, Retrospective Cohort Design, Observational Study
Independent Association Between Preoperative Cognitive Status and Discharge Location After Surgery: A Strategy to Reduce Resource Use After Surgery for Deformity
2018, World Neurosurgery
Citation Excerpt :
Accordingly, identifying prognostic variables for discharge to post–acute care facilities health system–wide process improvements are needed to optimize the transition-of-care process, improve patient outcomes, and reduce unnecessary healthcare resource utilization. Preoperative identification of at-risk patients for non-home discharge expedites transitions of care by creating more opportunity for coordination between medical teams, families, and continuing-care facilities.2,18,19 Patients with impaired cognitive status often have complex medical problems requiring discharge coordination between different teams of physicians, nurses, occupational and physical therapists, pharmacists, and social workers.2
The aim of this study is to determine whether preoperative scores on a screening measure for cognitive status (the Saint Louis University mental status examination), were associated with discharge to a location other than home in older patients undergoing surgery for deformity.
Older patients (≥65 years) undergoing a planned elective spinal surgery for correction of adult degenerative scoliosis were enrolled in this study. Preoperative baseline cognition was assessed using the validated Saint Louis University mental status (SLUMS) test. SLUMS is 11 questions with a maximum of 30 points. Mild cognitive impairment was defined as a SLUMS score of 21–26 points, and severe cognitive impairment as a SLUMS score of 20 points or greater. Normal cognition was defined as a SLUMS score of 27 points or more. Postoperative length of stay and discharge location were recorded on all patients.
Eighty-two subjects were included, with mean ± standard deviation age of 73.26 ± 6.08 years; 51% of patients were discharged to a facility (skilled nursing or acute rehabilitation). After adjustment for demographic variables, comorbidities, and baseline cognitive impairment, patients with preoperative cognitive impairment were 4-fold more likely to be discharged to a facility (skilled nursing or acute rehabilitation) compared with patients with normal cognitive status (odds ratio [OR], 3.93). In addition, patients who were not ambulatory before surgery were also more likely to be discharged to a facility (OR, 7.14).
In geriatric patients undergoing surgery for deformity correction, cognitive screening before surgery can identify patients with impaired cognitive status who are less likely than those with normal cognitive status to return home after surgery.
Discriminative ability of commonly used indices to predict adverse outcomes after poster lumbar fusion: a comparison of demographics, ASA, the modified Charlson Comorbidity Index, and the modified Frailty Index
2018, Spine Journal
Citation Excerpt :
Its primary purpose is to describe the amount of physiological reserve that a patient has, and it is also used as a method of modifying health-care billing [17]. Similarly to the CCI, the ASA has been often used in orthopedic research and has been shown to be associated with poor patient prognosis through various regressions in many orthopedic interventions, including posterior lumbar fusions (PLFs) [2,18–20]. A third comorbidity index that has seen increasing use in orthopedics is the Canadian Study of Health and Aging Frailty Index (FI).
As research tools, the American Society of Anesthesiologists (ASA) physical status classification system, the modified Charlson Comorbidity Index (mCCI), and the modified Frailty Index (mFI) have been associated with complications following spine procedures. However, with respect to clinical use for various adverse outcomes, no known study has compared the predictive performance of these indices specifically following posterior lumbar fusion (PLF).
This study aimed to compare the discriminative ability of ASA, mCCI, and mFI, as well as demographic factors including age, body mass index, and gender for perioperative adverse outcomes following PLF.
A retrospective review of prospectively collected data was performed.
Patients undergoing elective PLF with or without interbody fusion were extracted from the 2011–2014 American College of Surgeons National Surgical Quality Improvement Program (NSQIP).
Perioperative adverse outcome variables assessed included the occurrence of minor adverse events, severe adverse events, infectious adverse events, any adverse event, extended length of hospital stay, and discharge to higher-level care.
Patient comorbidity indices and characteristics were delineated and assessed for discriminative ability in predicting perioperative adverse outcomes using an area under the curve analysis from the receiver operating characteristics curves.
In total, 16,495 patients were identified who met the inclusion criteria. The most predictive comorbidity index was ASA and demographic factor was age. Of these two factors, age had the larger discriminative ability for three out of the six adverse outcomes and ASA was the most predictive for one out of six adverse outcomes. A combination of the most predictive demographic factor and comorbidity index resulted in improvements in discriminative ability over the individual components for five of the six outcome variables.
For PLF, easily obtained patient ASA and age have overall similar or better discriminative abilities for perioperative adverse outcomes than numerically tabulated indices that have multiple inputs and are harder to implement in clinical practice.
Factors that affect fractured neck of femur outcome: Clinical commissioning groups influence length of stay and discharge destination
2016, Injury
Citation Excerpt :
When analysing discharges it is essential to consider change in discharge destination; that is patients who are admitted from home but are discharged to nursing or residential care. Factors that predict a change in discharge destination include increasing age, male sex, poor outdoor pre-operative mobility, poor cognitive function, dementia, pre-operative co-morbidities, higher ASA grade, delay to surgery over 36 h, AMTS score less than 6 and absence of partner [19–21]. We have demonstrated that the CCG from which the patient originates should now also be considered as this can significantly affect home discharge rates.
The average length of stay (LOS) following a hip fracture in hospitals around the UK has been approximately 20 days in recent years. This can vary between hospitals and there are numerous factors that can affect LOS. We had the impression that LOS varied by Clinical Commissioning Group (CCG) from which the patient originates. The aim of our study was to discover whether the concern was valid, and if so, what the reasons may be.
We analysed hip fracture data collected at our Trust between September 2008 and December 2014. LOS was compared for each of three CCGs in our Trust's catchment areas, and those patients admitted from outlying CCGs. Sub-analysis was performed by patient age, ASA grade, abbreviated mental test score, procedure type and discharge destination to determine which factors influence LOS.
1847 patients were identified. After excluding deaths, missing data and extreme outliers, 1603 patients were included in the analysis. The median LOS varied from 14.9 to 23.4 days across CCGs. The major reason for this variation was discharge destination. CCGs associated with longer LOS had a significantly higher rate of discharge to the patient's own home, rather than institutional care. This was independent of patient age, mental status, ASA grade and promptness of surgery.
We have shown that CCGs vary in their performance to aid discharge. This directly influences a Trust's performance on the National Hip Fracture Database. Compared with other hospitals, our results show a poor outcome in terms of length of stay, but much better performance regarding home discharge. We recommend that more emphasis in future be placed on discharge destination than LOS.

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Predictors of change in ‘discharge destination’ following treatment for fracture neck of femur

Abstract

Objectives

Materials and methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Injury

Injury

J Arthroplasty

The Management of hip fractures in adults

Effects of nursing interventions within an integrated care pathway for patients with hip fracture

J Adv Nurs

Ambulatory ability after hip fracture: a prospective study in geriatric patients

Clin Orthop Relat Res

Living alone, loneliness, and psychological well-being of older persons in Singapore

Curr Gerontol Geriatr Res

Outcomes following acute hospital care for stroke or hip fracture: how useful is an assessment of anxiety or depression for older people?

Int J Geriatr Psychiatry

Dictionary Soc

Mortality associated with delay in operation after hip fracture: observational study

BMJ

Coordinated multidisciplinary rehabilitation after hip fracture

Disabil Rehabil