Outcomes and Costs After Hip Fracture and Stroke: A Comparison of Rehabilitation Settings

Objective.—To assess whether outcomes and costs differ for elderly patients admitted to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes.Design.—Inception cohort stratified by provider type and followed prospectively for 6 months.Setting.—A total of 92 hospital-based u...

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Published in:	JAMA : the journal of the American Medical Association Vol. 277; no. 5; pp. 396 - 404
Main Authors:	Kramer, Andrew M, Steiner, John F, Schlenker, Robert E, Eilertsen, Theresa B, Hrincevich, Carol A, Tropea, Daryl A, Ahmad, Laura A, Eckhoff, Donald G
Format:	Journal Article
Language:	English
Published:	Chicago, IL American Medical Association 05-02-1997
Subjects:	Activities of Daily Living Aged Aged, 80 and over Biological and medical sciences Cerebrovascular Disorders - economics Cerebrovascular Disorders - rehabilitation Cohort Studies Cost-Benefit Analysis Data Collection Diagnosis-Related Groups Female Fractures Health care Hip Fractures - economics Hip Fractures - rehabilitation Hip joint Humans Male Medical sciences Medicare - economics Multivariate Analysis Neurology Nursing homes Older people Outcome and Process Assessment (Health Care) Prospective Studies Rehabilitation Rehabilitation Centers - economics Rehabilitation Centers - statistics & numerical data Skilled Nursing Facilities - economics Skilled Nursing Facilities - statistics & numerical data Stroke United States Vascular diseases and vascular malformations of the nervous system United States Human Evaluation Nervous system diseases Stroke Statistical analysis Diseases of the osteoarticular system Hip bone Cardiovascular disease Fracture Cerebral disorder Cost benefit ratio Vascular disease Prevention Nursing Mass campaign Health economy Cohort study Central nervous system disease Rehabilitation Elderly Cerebrovascular disease Comparative study
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Summary:	Objective.—To assess whether outcomes and costs differ for elderly patients admitted to rehabilitation hospitals, subacute nursing homes, and traditional nursing homes.Design.—Inception cohort stratified by provider type and followed prospectively for 6 months.Setting.—A total of 92 hospital-based units and freestanding facilities from 17 states.Patients.—A total of 518 randomly selected patients with hip fracture and 485 stroke patients admitted from November 1991 to February 1994.Main Outcome Measures.—At 6 months comparing community residence, recovery to premorbid levels in 5 activities of daily living (ADLs), Medicare costs, and the number of therapy and physician visits. Outcomes were adjusted for premorbid residence and function, caregiver availability, comorbid illness, admission function, cognition, depression, sensory deficits, and mobility impairments.Results.—On admission, rehabilitation hospital patients were more likely (P<.001) to have caregivers and better cognitive and physical function. Hip fracture patients admitted to rehabilitation hospitals did not differ from patients admitted to nursing homes in returning to the community (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.6-2.6) or in the number of ADLs recovered to premorbid level (difference, 0.09 ADL; 95% CI, —0.27-0.44), but stroke patients admitted to rehabilitation hospitals were more likely to return to the community (adjusted OR, 3.3; 95% CI, 1.5-7.2) and recover ADLs (difference, 0.63 ADL; 95% CI, 0.20-1.07). Subacute nursing home patients with stroke were more likely than traditional nursing home patients to return to the community (adjusted OR, 6.8; 95% CI, 2.2-21.4), there was no difference in return to the community for patients with hip fracture (adjusted OR, 1.6; 95% CI, 0.7-3.6), and there were no differences in recovery of ADLs for either condition. Medicare costs were greater (P<.001) for rehabilitation hospital patients than for subacute nursing home patients, and the costs for subacute nursing home patients were greater (P=.03 for stroke and.009 for hip fracture) than for traditional nursing home patients.Conclusions.—Study findings are consistent with enhanced outcomes for elderly patients with stroke treated in rehabilitation hospitals but not for patients with hip fracture. Subacute nursing homes were more effective than traditional nursing homes in returning patients with stroke to the community, despite comparable functional outcomes.
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ISSN:	0098-7484 1538-3598
DOI:	10.1001/jama.1997.03540290048031