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An Examination of the First 30 Days After Patients are Discharged to the Community From Hip Fracture Postacute Care

Leland, Natalie E. PhD*,†; Gozalo, Pedro PhD; Christian, Thomas J. PhD; Bynum, Julie MD, MPH§; Mor, Vince PhD; Wetle, Terrie F. PhD; Teno, Joan M. MD, MS

doi: 10.1097/MLR.0000000000000419
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Background: Postacute care (PAC) rehabilitation aims to maximize independence and facilitate a safe community transition. Yet little is known about PAC patients’ success in staying home after discharge or differences on this outcome across PAC providers.

Objectives: Examine the percentage of PAC patients who remain in the community at least 30 days after discharge (ie, successful community discharge) after hip fracture rehabilitation and describe differences among PAC facilities based on this outcome.

Research Design: Retrospective observational study.

Subjects: Community-dwelling, Medicare fee-for-service beneficiaries 75 years of age and above who experienced their first hip fracture between 1999 and 2007 (n=880,779). PAC facilities admitting hip fracture patients in 2006.

Measures: Successful community discharge, sites of readmission after PAC discharge.

Results: Between 1999 and 2007, 57% of patients achieved successful community discharge. Black were less likely (adjusted odds ratios=0.84; 95% confidence interval, 0.82–0.86) than similar whites to achieve successful community discharge. Among all who reentered the community (n=581,095), 14% remained in the community <30 days. Acute hospitals (67.5%) and institutional PAC (16.8%) were the most common sites of reentry. The median proportion of successful community discharge among facilities was 49% (interquartile range, 33%–66%). Lowest-quartile facilities admitted older (85.9 vs. 84.1 y of age), sicker patients (eg, higher rates of hospital complications 6.0% vs. 4.6%), but admitted fewer annually (7.1 vs. 19.3), compared with the highest quartile.

Conclusions: Reentry into the health care system after PAC community discharge is common. Because of the distinct care needs of the PAC population there is a need for a quality measure that complements the current 30-day hospital readmission outcome and captures the objectives of PAC rehabilitation.

*T.H. Chan Division of Occupational Science and Occupational Therapy, Herman Ostrow School of Dentistry & Davis School of Gerontology, the University of Southern California, Los Angeles, CA

Department of Health Services, Policy and Practice and the Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, RI

Abt Associates, Boston, MA

§The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth, Hanover, NH

Supported by the Shaping Long Term Care in America Project funded by the National Institute on Aging (1P01AG027296), the Agency for Healthcare Research and Quality (AHRQ) National Research Services Awards (NRSA) (5T32HS000011-24), and the Rehabilitation Research Career Development (RRDC) Program, National Center for Medical Rehabilitation Research (NICHD), National Institutes of Health (K12 HD055929).

No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

P.G., T.F.W., and J.T. are affiliated with the Warren Alpert School of Medicine at Brown University none of these relationships pose a conflict of interest or potential conflict of interest. J.B. is affiliated with Dartmouth Medical School & Dartmouth Institute for Health Policy and Clinical Practice neither of these relationships pose a conflict of interest or potential conflict of interest. N.L. was affiliated with the Warren Alpert School of Medicine at Brown University at the time of the study and is now affiliated with the T.H. Chan Division of Occupational Science and Occupational Therapy in the Herman Ostrow School of Dentistry & Davis School of Gerontology at University of Southern California, none of these relationships pose a conflict of interest or potential conflict of interest. T.J.C. was affiliated with the Warren Alpert School of Medicine at Brown University at the time of the study and is now affiliated with Abt Associates. V.M. is on the board of PointRight Inc. and is a consultant to NaviHealth Inc. and to hcr-Manorcare; he also owns stock in PointRight Inc. and NaviHealth Inc. V.M. reports receiving grants from the National Institutes of Health (NIH) and the Robert Wood Johnson Foundation and grants pending from NIH and the Commonwealth Fund. He has received an honorarium from the Alliance for Health Care Quality and attended Academy Health.

Reprints: Natalie E. Leland, PhD, University of Southern California, 1540 Alcazar St, CHP 133, Los Angeles, CA 90089. E-mail: nleland@usc.edu.

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