Session I - Hip Fractures

Outcome Following Hip Fracture: Utilization and Efficacy of Acute Inpatient Rehabilitation

Kenneth J. Koval, MD, Gina Aharonoff, MPH, Mary L. Skovron, Dr. PH, Joseph D. Zuckerman, MD

Hospital for Joint Diseases, New York, NY

Introduction: Controversy exists over the proper utilization and efficacy of hospital inpatient services (acute care and rehabilitation) after hip fracture. Implementation of the prospective payment system has led to a reduction in the amount of acute hospital care given to patients with hip fractures, resulting in an increased rate of discharge to skilled nursing facilities. More recently, there has been early transfer to inpatient rehabilitation units in an effort to decrease acute care length of stay and improve recovery of function. The current study was initiated in an attempt to determine whether patient outcome justifies utilization of intensive inhospital rehabilitation following hip fracture.

Methods: The study sample comprised all hip fracture patients admitted to the authors' hospital between July 1987 and June 1994 who had sustained a femoral neck or intertrochanteric fracture of nonpathologic origin and were age 65 years, previously ambulatory, home-dwelling, and cognitively intact. All patients in the sample were treated operatively and followed a similar postoperative protocol consisting of early mobilization with unrestricted ambulation. All patients were identified at the time of admission, prospectively followed, and contacted at 3, 6, and 12 months postsurgery or until death. Before 1990, the hospital did not have an inpatient rehabilitation program. After this date, the hospital had a DRG-exempt acute rehabilitation program; patient admission to this program was made after evaluation by a staff physiatrist. Analysis was performed to evaluate inpatient rehabilitation utilization and the relationship between patient discharge status, living status at one year, and functional recovery prior to and after the initiation of the hospital's DRG exempt program.

Results: 609 patients were enrolled in this study: 301 patients prior to January 1990 and 308 after initiation of the DRG-exempt rehabilitation program. No significant differences in patient demographics existed between the two groups of patients. Before 1990, 8.9% of patients were discharged to an outside rehabilitation facility. After 1/90, the percentage of patients who were discharged to the hospital's DRG exempt program increased yearly, from 15.2% in 1990 to 32.8% in 1993; this difference was statistically significant (p < .001). Prior to 1990, patients' hospital length of stay (LOS) averaged 21.9 days. After 1/90, LOS for those patients who did not go into the rehabilitation program averaged 20.0 days, while LOS for those who did go into the rehabilitation program averaged a total of 31.4 days (acute care 16.1 days, rehabilitation program 15.6 days); this difference was significant (p < .01). Significant differences were found in the rates of discharge to a skilled nursing facility (1.7% vs. 0.6%, p <.05) and in the percentages of patients residing in such a facility after 1 year (11% vs 8.8%, p < .001) prior to and after initiation of the DRG-exempt rehabilitation unit; there was, however, no significant change in percent functional recovery, based on patient mobility and ADL dependency, at 1 year follow-up after initiation of this program.

Discussion: Initiation of DRG-exempt inpatient rehabilitation programs has been an effective method for hospitals to reduce their acute care patient length of stay while continuing to provide inpatient services. In our hospital, the percentage of patients discharged to the rehabilitation unit significantly increased since its inception, from 8.9% to 32.8%, with a nearly twofold increase in the first year alone; acute care patient LOS decreased, but the total LOS significantly increased. In view of the high cost of acute inpatient rehabilitation (~$700/day at our hospital), one may ask whether its effect on patient outcome warrants its use. A significantly lower skilled nursing facility discharge rate and skilled nursing facility placement rate at 1 year follow-up was found after initiation of the DRG-exempt rehabilitation unit; it is important to note, however, that as a result of our hospital's interdisciplinary care program, our rate of discharge to skilled nursing facilities has historically been significantly lower than that reported in the literature. There was no significant difference in patients' percent functional recovery at 1 year follow-up prior to and following initiation of the DRG-exempt rehabilitation unit. This raises serious questions regarding the global cost-effectiveness of this program.