Study Examines Rehabilitation Settings for Veterans Following Hospital Discharge for Hip Fracture

BACKGROUND:
Changes in Medicare payment incentives to increase efficiency have reduced post-acute care use, and problems have been compounded by continued uncertainty about best venues for rehabilitative care for most clinical diagnoses. VA offers comprehensive rehabilitation care for Veterans eligible for VA surgical treatments, and Veterans with hip fracture are an important subset of patients who often require rehabilitation care following surgery. Approximately 1,200 hip fracture surgeries are performed in VA annually, while many more Veterans have hip fracture surgeries through Medicare. This retrospective study explored the factors that impact choice of VA rehabilitation setting after acute hip fracture repair procedures. Using VA data, including data from VA's National Surgical Quality Improvement Program (VASQIP), investigators identified 11,083 Veterans who had hip fracture surgeries in a VA hospital from FY98 through FY05. Investigators then examined the setting to which Veterans were discharged immediately after hospitalization: inpatient rehabilitation; nursing home; or discharge to community, which included home health, home with VA outpatient rehabilitation, or home without VA-paid rehabilitation. Demographics, comorbidities, service-related disability, and rural residence also were assessed.

FINDINGS:

• Following hospitalization for hip fracture, nearly half (48%) of the Veterans in this study were discharged directly home – without VA-paid rehabilitation. Few Veterans (0.8%) were discharged with home health, with higher proportions discharged to a nursing home (15%), outpatient rehabilitation (19%), or inpatient rehabilitation (17%).
• Veterans with higher comorbidity scores were less likely to be discharged to inpatient rehabilitation.
• Veterans were more likely to be discharged to non-home settings if they had total functional dependence, had high American Society of Anesthesiology (ASA) class scores, had one or more surgical complications, or lived in counties with lower nursing home bed occupancy rates. Thus, it appeared that the most vulnerable patients were provided inpatient care.
• Surgical complications were the most significant predictor of discharge setting, but the availability of community resources also was an important predictor.

LIMITATIONS:

• A limited number of Veterans were discharged to home health; this may have limited the power to detect clinically meaningful differences in some variables.
• These data did not capture rehabilitation care that was covered under non-VA auspices (e.g., Medicare), which may have been used by a subgroup of cases assigned to the "home" setting.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 04-173); Dr. Maciejewski also was supported by an HSR&D Career Scientist Award. Dr. Maciejewski is part of HSR&D's Center for Health Services Research in Primary Care in Durham, N.C.

Maciejewski M, Radcliff T, Henderson W, et al. Determinants of Post-Surgical Discharge Setting for Hip Fracture Patients. Journal of Rehabilitation Research & Development January 2014;50(9):1267-76.