Comparison of Discharge Functional Status Rehabilitation: Hip Fracture Repair. Trudy Mallinson, PhD, OTR/L

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1 Comparison of Discharge Functional Status Rehabilitation: Hip Fracture Repair Trudy Mallinson, PhD, OTR/L

2 Acknowledgements Co-authors Anne Deutsch, PhD, CRRN Jillian Bateman, OTD, OTR/L Hsiang-Yi Tseng, MA, OTR/L Larry Manheim, PhD Orit Almagor, MA Allen W. Heinemann, PhD, ABPP Funding Support National Institute on Disability and Rehabilitation Research Rehabilitation Research and Training Center on Measuring Rehabilitation Outcomes and Effectiveness (Grant number: H133B040032) Comparative Effectiveness: Rehab for Hip Fracture Slide 2

3 Background Hip fracture rates and subsequent mortality are declining in the US, but levels of disability remain high Hip fracture patients are high utilizers of post-acute care (PAC) services ~95% of hip fracture patients receive PAC services 3.5 care transitions among PAC providers after acute discharge All PAC settings provide rehabilitation services but with varying therapy intensity and degrees of medical support Limited evidence regarding the comparative effectiveness of PAC settings for patients with hip fracture repair Comparative Effectiveness: Rehab for Hip Fracture Slide 3

4 Review of Rehabilitation CER Studies 3 studies completed prior to the implementation of prospective payment systems (PPS) (Kramer, 1997; Kane, 1998; Deutsch, 2005) No difference between hip fracture patients admitted to IRFs vs. SNFs For function at discharge Number of daily activities recovered at 6 months Inpatient rehabilitation (IRF) and home health (HHA) patients had better function at 6 weeks follow-up compared to skilled nursing (SNF) patients Studies are also equivocal after the implementation of PAC PPS (Munin, 2005 & 2006; Buntin, 2010; Tian, 2010) Advantage in function for patients admitted to IRFs vs. SNFs in a single provider system Advantage in mortality and return to the community for SNF vs. IRF in large study but did not examine functional status Comparative Effectiveness: Rehab for Hip Fracture Slide 4

5 Purpose Examine changes in self-care and mobility following rehabilitation across 3 PAC settings 1) How do hip fracture patients differ on key demographic and clinical factors at admission across PAC settings? 2) How are self-care and mobility function at discharge related to the type of PAC provider, after controlling for patient demographic, function, and clinical characteristics at baseline, and time from surgery? Comparative Effectiveness: Rehab for Hip Fracture Slide 5

6 Methods: Data Collection 4 IRFs, 6 SNFs, and 8 HHAs for this prospective cohort study Patients recruited from December 2005 through March 2010 Study approved by each site s IRB Data were collected within 48 hours of admission and discharge Functional status data were collected by trained nurses using the Functional Independence Measure (FIM ) using direct observation and/or abstracted from medical chart review Eligible patients were 65 years or older, receiving PAC rehabilitation services following hip fracture repair, Medicare primary payor. To facilitate enrollment, criteria were revised so HHA patients could receive prior IRF or SNF care Comparative Effectiveness: Rehab for Hip Fracture Slide 6

7 Methods: Data Collection Sites M N ME CO NE IA M O IL IN OH PA NY NJ 8 Home Health Agencies Bettendorf, IA South Bend, IN Quincy, IL Rockland, ME Kansas City, MO Millburn, NJ Akron, OH Radnor, PA 6 Skilled Nursing Facilities Broomfield, CO Downer's Grove, IL Lake Forest, IL Golden Valley, MN Lincoln, NE Getzville, NY 4 Inpatient Rehab Facilities Chicago, IL Wheaton, IL Lincoln, NE West Orange, NJ Comparative Effectiveness: Rehab for Hip Fracture Slide 7

8 Methods: Instrumentation Data were collected as part of a larger study All patients were scored on the IRF-PAI, MDS 2.0, and OASIS at both admission and discharge IRF PAI - record the most dependent functional performance in 48 hour admission/discharge time period Demographics items from all 3 instruments to get broad range of clincial data e.g., obesity from OASIS, cognition from MDS Comparative Effectiveness: Rehab for Hip Fracture Slide 8

9 Results: Demographic Factors SNF (n=69) IRF (n=78) HHA (n=34) Age Gender % Female Ethnicity % White Living Loc % Home Lives With % Alone Comparative Effectiveness: Rehab for Hip Fracture Slide 9

10 Results: Clinical Factors at Admission Type of surgery % Internal fixation SNF (n=69) IRF (n=78) HHA (n=34) Comorbidities * 4.0 Anemia * 5.9 Diabetes Cognition % Short-term mem. *P < * Comparative Effectiveness: Rehab for Hip Fracture Slide 10

11 Results: Unadjusted Functional Status Measures Functional Independence Measure Self Care Mobility SNF IRF HHA SNF IRF HHA IRF and SNF patients look similar at admission and discharge; HHA patients have greater function at admission and discharge, before controlling for selection differences. Comparative Effectiveness: Rehab for Hip Fracture Slide 11

12 Results: Length of Stay & Therapy Intensity Days Average Length of Stay (days) Average Therapy Intensity (Minutes Per Day) 28 days days 32 days 17 SNF IRF HHA Minutes per Day Total therapy minutes were similar for SNF (mean=2126 mins) and IRF (mean=2091 mins) but shorter length of stay means IRF patients have much more intensive rehabilitation than SNF patients. HHA patients receive only 567 total minutes of therapy. Comparative Effectiveness: Rehab for Hip Fracture Slide 12

13 Results: Regression of Function at Discharge Model Covariates Setting Self-Care Function at Discharge Model Model+LO S Mobility Function at Discharge Model Model+LO S β β 95% CI β β 95% CI IRF -1.7* to to 1.9 HHA -4.1** -4.8** -7.5 to to 2.4 Function Self-care/mobility at admission 0.8*** 0.9*** 0.7 to *** 1.1*** 0.8 to 1.3 Condition Severity Short-term memory -2.6** -3.0** -4.9 to * -2.9** -4.9 to -1.0 Diabetes mellitus -5.8* -6.0* to to 3.3 LOS 0.1** 0.0 to *** 0.1 to 0.2 R Adjusted R Full model included: Age, gender, type of surgery, No. of comorbid conditions, urinary incontinence, fecal incontinence, vision, daily decision-making, mood disorder, anemia, pressure ulcer, time from onset to PAC admission, and prior PAC usage. *P <.05; **P <.01; ***P <.001 Comparative Effectiveness: Rehab for Hip Fracture Slide 13

14 Summary IRF and HHA have less impact on self-care relative to SNF but no difference among settings for mobility Controlling for LOS affected results for self-care at discharge but not for mobility It remains unclear the extent to which rehabilitation intensity, content of therapy, or natural recovery influence functional status Comparative Effectiveness: Rehab for Hip Fracture Slide 14

15 Significance/Relevance to Policy & Practice This study informs the future direction for rehabilitation comparative effectiveness research (RCER) RCER is currently limited by: Psychometrically robust and comparable measures of functional status and medical severity across PAC settings Minimally clinically important differences have not been established Limited evidence-based consensus for the factors influencing recovery that should be routinely included in prediction models No consensus on when to measure Within how many hours of admission? What follow-up periods? (e.g. weekly and at discharge) If progress is to be made in RCER studies, these measurement limitations must be resolved Comparative Effectiveness: Rehab for Hip Fracture Slide 15

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