Do severity measures explain differences in length of hospital stay? The case of hip fracture

OBJECTIVE: To examine whether judgments about hospital length of stay (LOS) vary depending on the measure used to adjust for severity differences. DATA SOURCES/STUDY SETTING: Data on admissions to 80 hospitals nationwide in the 1992 MedisGroups Comparative Database. STUDY DESIGN: For each of 14 severity measures, LOS was regressed on patient age/sex, DRG, and severity score. Regressions were performed on trimmed and untrimmed data. R-squared was used to evaluate model performance. For each severity measure for each hospital, we calculated the expected LOS and the z-score, a measure of the deviation of observed from expected LOS. We ranked hospitals by z-scores. DATA EXTRACTION: All patients admitted for initial surgical repair of a hip fracture, defined by DRG, diagnosis, and procedure codes. PRINCIPAL FINDINGS: The 5,664 patients had a mean (s.d.) LOS of 11.9 (8.9) days. Cross-validated R-squared values from the multivariable regressions (trimmed data) ranged from 0.041 (Comorbidity Index) to 0.165 (APR-DRGs). Using untrimmed data, observed average LOS for hospitals ranged from 7.6 to 23.9 days. The 14 severity measures showed excellent agreement in ranking hospitals based on z-scores. No severity measure explained the differences between hospitals with the shortest and longest LOS. CONCLUSIONS: Hospitals differed widely in their mean LOS for hip fracture patients, and severity adjustment did little to explain these differences.     

Medical consultation for the elderly patient with hip fracture

BACKGROUND: This article describes a family physician geriatrician's perspective on the comprehensive management of hip fracture in frail elderly patients. Primary care physicians might be called upon to provide medical consultation for these patients. METHODS: Guidelines were developed by a combination of personal experience in consulting for several hundred elderly patients with hip fracture at a large community hospital, literature review using the key words "hip fractures," "aged," and "aged, 80 and over," and educational presentations for family practice residents. RESULTS AND CONCLUSIONS: Elderly patients with hip fracture offer a prime opportunity for comprehensive geriatric assessment. Intertrochanteric fractures are almost always treated with internal fixation, whereas femoral neck fractures can be treated by either fixation or by hemiarthroplasty. Hip fracture should be regarded as a surgical urgency, and generally operation should not be delayed, even if patients have serious comorbidity. The family physician can be instrumental in preparing the patient for surgery, preventing and treating complications, and assisting in the placement and rehabilitation of patients after hospital discharge.     

Use of demographic and clinical characteristics in predicting length of psychiatric hospital stay: A final evaluation.

The literature on patient demographic and clinical characteristics as predictors of length of psychiatric hospital stay suggests that investigators have been unsuccessful in producing a prediction model using this information to account for any substantial criterion variance. The present study maximized predictions of length of hospital stay by using a more powerful statistical procedure and an expanded number of predictor variables. Data were obtained on 877 patients who were discharged from psychiatric hospitals in 1980. Results show that despite these improvements, the resulting proportion of variance was moderate at best. It is concluded that increases in similar information are unlikely to improve predictions. The use of untapped variables (e.g., management philosophies and politically based information) is discussed. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prognosis one year after hip fracture

This study evaluates the demography and health in a hip fracture population, and predictors of outcome one year after the fractures occurred. Physical, mental and social functioning in 109 patients who were referred from home with hip fractures were assessed retrospectively; during the hospital stay, at discharge, and after 4 and 12 months. Mobility, Katz' ADL-index and a short-version of MMSE were used in assessing their physical and mental conditions. No essential changes were found in either demography or health. The most significant predictors of outcome were age, prefracture mobility and post-fracture mental status. The proportion of patients suffering from acute confusion was considerable. The result was a higher risk of mortality, institutionalisation and poor physical outcome. It is important to pay more attention to the prevention and treatment of cases involving acute confusion.     

The quality circle of hip fracture care

Elderly patients with hip fractures have many medical, physical, and psychosocial challenges. Their care can become complex and require the integration of various disciplines. In this article, the author describes and explains the hip fracture preoperative assessment tool that contains various "red flag" indicators and tools used for data collection. The case manager can use this tool to assess patients before surgery and appropriately plan for discharge. Outcome results are discussed, including functional status, length of stay, and costs.     

Cardiovascular collapse after femoral prosthesis surgery for acute hip fracture

Traumatic rupture of Dupuytren's contracture is rare. It has been reported only twice in recent times and only on four previous occasions over the last millenium. These cases are reported and the forces involved in rupturing Dupuytren's contracture are discussed.     

Predictors of mortality after acute hip fracture

To identify determinants of mortality after hip fracture, we performed a multicenter, retrospective study of 390 Medicare beneficiaries. Independent predictors of 30-day mortality included a history of congestive heart failure (odds ratio [OR] 32; 95% confidence interval [CI] 5, 192), angina (OR 26; 95% CI 4, 184), or chronic pulmonary disease (OR 11; 95% CI 2, 62). Postoperative use of aspirin was associated with a reduced risk of mortality (OR 0.24; 95% CI 0.08, 0.70). Cardiovascular events were the presumed cause of 63% of in-hospital deaths. Aspirin may have significant potential to reduce mortality in this population and deserves further study.     

The role of chair exercises for older adults following hip fracture

OBJECTIVES: To examine the influence of regular participation in chair exercises on postoperative deconditioning in respect of selected physiological, psychological and anthropometric variables. DESIGN: Quasi-experimental, non-randomised control group pre-test/post-test design where test group (N = 20) and control group (N = 10) were not equivalent because random selection and assignment were not possible. SUBJECTS: Patients discharged from an orthopaedic ward 8-10 days after hip surgery who were cognitively competent (mean score on Mini-Mental State Examination 26 (SD 3.5)), sedentary (mean score on Habitual Physical Activity Questionnaire for the Elderly 7.4 (SD 3.3)) women aged 70 years and above (mean 80 (SD 6.6) years). SETTING: Hip fracture patients admitted to a multidisciplinary geriatric hospital for further medical observation. MEASUREMENTS: Abstraction of medical records provided information about co-morbidities and questionnaires assessed demographic, affective and cognitive function. Physiological, psychological and anthropometric status was measured pre- and post-intervention. RESULTS: Data revealed high variability, suggesting that the effect of the independent variable was obscured by the heterogeneity of the cohort. Both groups improved similarly in grip strength, and in levels of depression and confidence. Body composition data explained the weight maintenance as a consequence of significant gains in fat-free mass in the experimental group. The significant change in systolic blood pressure and heart rate over the exercise and recovery period suggested that the 6-week period of moderate-intensity exercise was adequate to stimulate cardiovascular adaptations. CONCLUSIONS: Whether or not the submaximal chair exercise regimen was of optimal benefit remains unclear. However, the intervention did appear to have contributed to the maintenance of the physical condition of older women temporarily disabled as a result of a fracture and subsequent hip surgery.     

Intracapsular hip pressure after femoral neck fracture

A consecutive series of 34 patients with femoral neck fractures was included in a prospective study aimed at evaluating preoperative variations in intracapsular pressure after changes in hip position, hip traction, and aspiration of hemarthrosis and their influence on the development of femoral head necrosis. Patients were observed for 7 years after surgery. Before aspiration, the mean intracapsular pressure in the antalgic physiologic position was 44.4 mm Hg. There were no differences between displaced and undisplaced fractures. The pressure was a maximum (mean value, 124.8 mm Hg) with the hip in extension and inward rotation, this pressure being greater than the blood systolic pressure in most cases. Hip traction of 3 kg in the antalgic physiologic position was found to be highly effective in preventing any bone flow tamponade effect in displaced and undisplaced femoral neck fractures: the mean intracapsular pressure decreased to 28.5 mm Hg. Aspiration of the hemarthrosis induced a significant decrease in intracapsular pressure only in cases with impaired vascularity of the femoral head as measured by scintigraphy using 99mTc labeled methyldiphosphonate. Aspiration of the hemarthrosis therefore is indicated only in the above cases, although it is less effective than hip traction in the antalgic position. There was no significant correlation between intracapsular pressure and the scintigraphy ratio. Avascular necrosis of the femoral head was detected in six cases. Among these, five patients had an intracapsular pressure below their diastolic blood pressure. This could indicate that vascular damage related to the fracture could be an important cause of bone necrosis despite that blood supply can be decreased by a tamponade effect.     

Functional outcome after hip fracture in Japan

One thousand one hundred sixty-nine elderly Japanese patients who sustained a hip fracture were observed prospectively. Ninety-two percent had operative fracture treatment. Hospital length of stay averaged 67 days; 81% of patients were discharged to their place of residence where they resided before sustaining the fracture. Mortality rates at 120 days, 1 year, and 2 years after injury were 6%, 11%, and 19%, respectively. At 1-year followup, ambulatory status was recovered to that of the level experienced before injury in 67% of patients.     

Cost analysis of early discharge after hip fracture

OBJECTIVE: To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN: Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING: District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS: 1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES: Cost per patient episode and number of bed days spent in hospital. RESULTS: Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS: About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.     

Variations in the performance of hip fracture procedures

OBJECTIVE: To determine the cause and frequency of unplanned readmissions to a coronary care unit (CCU) after initial transfer to a general cardiac unit, but before hospital discharge. DESIGN: Analysis of 1776 admissions to a CCU during a 16-month period. SETTING: The CCU of a major teaching hospital in South Australia. PARTICIPANTS: All patients admitted to the CCU during the 16-month period. OUTCOME MEASURES: CCU readmissions before hospital discharge were categorized as either "planned" or "unplanned." The latter were investigated for determination of casualty and variations in patient characteristics (including age, sex, initial diagnosis, pharmacotherapy, and duration of stay in the CCU). RESULTS: Of the 1776 CCU admissions examined, 44 (2.5% of total) were unplanned readmissions before hospital discharge. Most of these (39 of 44) were related to "reactivation" of acute myocardial ischemia. Patients whose initial diagnosis was acute myocardial infarction or unstable angina pectoris were more likely to require a further unplanned CCU admission (p < 0.05); those with unstable angina pectoris had a second stay in CCU significantly longer than their first (p < 0.05). Six patients were readmitted within 6 hours of cessation of a heparin infusion (4 of the 6 without aspirin administration), and 11 patients had not received antiplatelet therapy after their initial CCU stay. Overall, a disproportionate number of men were readmitted to CCU (p < 0.05). CONCLUSIONS: In the current study, unplanned readmissions to the CCU: (1) were relatively infrequent, (2) were more protracted than initial stays in CCU, (3) may have been prevented in 15 of the 44 cases with more appropriate pharmacotherapy, and (4) involved a disproportionate number of male patients.     

Clinical evaluation of the Alta hip bolt in peritrochanteric hip fractures

We reviewed the clinical and radiographic results of 58 patients with peritrochanteric fractures treated with the Alta hip bolt (a sliding compression device that inserts a dome plunger in the femoral head instead of a hip screw). This group was compared with a group of 53 patients treated with conventional hip screws. Three patients (5.2%) treated with the Alta hip bolt and three patients (5.7%) treated with conventional hip screw had failure of fixation. Failure of fixation consistently occurred in patients with unstable fracture patterns or significant osteopenia. There were no cases of bolt cut-out in stable intertrochanteric fractures. We conclude that the Alta hip bolt performs as well as sliding hip screws in peritrochanteric fractures, but the additional learning curve and increased cost do not justify its routine use at this point in time.     

Hospital- and patient-related characteristics determining length of hospital stay for hip and knee replacements

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most prestigious health care technologies. Their popularity has grown rapidly, and an increasing proportion of health care resources is allocated to them. We studied patient- and hospital-related factors that cause variation in a major determinant of hospital costs, the length of hospital stay (LOS) for THA and TKA. We gathered data on 10,288 hip and 5,173 knee patients with primary or secondary arthrosis from the Finnish Arthroplasty Register, which we linked with the Finnish Hospital Discharge Register. Patient- and hospital-related variations in LOS were explained using regression models. Of the patient-related factors, complications caused the greatest prolongation of hospital stay, but patient's age, gender, and charge category also influenced LOS. Hospital-related factors were major causes of LOS variation. In the hospitals the average case-mix-adjusted LOS ranged from less than a week to 3 weeks. The number of arthroplasties performed in hospital was inversely related to LOS. The within-hospital LOS figures for THA and TKA were strikingly similar and persistent.     

Functional outcomes of posthospital care for stroke and hip fracture patients under medicare

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge. METHODS: Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA). RESULTS: In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement. CONCLUSIONS: The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.     

Estimating the costs of hip fracture and potential savings

Shaker mutant rats are characterized by the adult-onset degeneration of cerebellar anterior lobe Purkinje cells and temporally correlated development of ataxia and tremor. Normal E-13 Purkinje cells were transplanted into the anterior cerebellum in adult shaker mutant rats to study donor/host interactions in an animal with adult-onset heredodegeneration. Donor Purkinje cells from extraparenchymal transplant sites migrated radially into the host molecular layer and differentiated. Donor Purkinje cell dendrites expanded to fill the host molecular layer, spinous processes were apparent, and axonal projections into the host gray and white matter were observed. Donor Purkinje cells remaining in the extraparenchymal transplant sites differentiated if they were located relatively close to the host cerebellum. Donor Purkinje cells located intraparenchymally in the host white matter or granule cell layer survived, but were stunted in their development. The orthogonal movement of donor Purkinje cells away from transplant sites in the host cerebellum was spatially restricted. The findings from this study indicate that host cerebellar cortex with adult-onset heredodegeneration of Purkinje cells supports the survival and differentiation of transplanted normal embryonic Purkinje cells.     

Effect of a video intervention on functional recovery following hip replacement and hip fracture repair

Although much research has documented the functional outcomes in hip repair surgery, few studies have identified effective interventions to improve functional outcomes. The purpose of this study was to test the use of generic and individualized videos on patients' return to preoperative levels of independent functioning, increased physical performance, improved coping ability, and enhanced perception of ability to care for self. Two rehabilitation units in separate acute care facilities were used to recruit subjects. Data were collected on 82 participants on admission to the study, on discharge from rehabilitation, 1 week after discharge, and 3 months post discharge. The results indicate that video intervention has some benefit to persons recovering from hip repair surgery. The benefits were realized in physical performance as evidenced by a significant difference in the distance walked and time walked of participants in the treatment group.     

Right axis deviation as a criterion for echocardiographic evaluation of aircrew candidates

BACKGROUND: Significant pressures exist in the resource-limited environment of military aviation to select only those candidates for flight training who are both physically able to withstand the demands of the flight environment and likely to complete a career in aviation. As medical technology has advanced, uncertainty has arisen regarding the appropriate use of additional studies in the screening of aircrew candidates. At the Naval Operational Medicine Institute (NOMI), where all U.S. Navy aviation duty candidates' medical qualifications are reviewed, current policy is to perform 2D-echocardiography on all candidates who exhibit a right axis deviation of +95 degrees or greater on their initial electrocardiogram. METHODS: The records of all aircrew candidates referred to the Department of Internal Medicine for evaluation of right axis deviation during the years 1993, 1994, and 1995 were reviewed. A cost benefit analysis was performed to assess the cost effectiveness of using echocardiography to screen candidates suspected of having disqualifying physical defects based on a finding of right axis deviation on electrocardiogram. RESULTS: Of the 69 cases reviewed, only 1 candidate was disqualified due to cardiovascular disease. He suffered from a large atrial septal defect initially discovered on physical examination. CONCLUSIONS: It is not cost effective to use 2D-echocardiography to screen aircrew candidates for disqualifying cardiac defects based on a finding of a right axis deviation of +95 degrees or greater on electrocardiogram.