Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes.

CONTEXT: Hip fracture is a common clinical problem that leads to considerable mortality and disability. A need exists for a practical means to monitor and improve outcomes, including function, for patients with hip fracture. OBJECTIVES: To identify and compare the importance of significant prefracture predictors of functional status and mortality at 6 months for patients hospitalized with hip fracture and to compare risk-adjusted outcomes for hospitals providing initial care. DESIGN: Prospective study with data obtained from medical records and through structured interviews with patients and proxies. SETTING AND PARTICIPANTS: A total of 571 adults aged 50 years or older with hip fracture who were admitted to 4 New York, NY, metropolitan hospitals between August 1997 and August 1998. MAIN OUTCOME MEASURES: In-hospital and 6-month mortality; locomotion at 6 months; and adverse outcomes at 6 months, defined as death or needing assistance to ambulate, compared by hospital, adjusting for patient risk factors. RESULTS: The in-hospital mortality rate was 1.6%. At 6 months, the mortality rate was 13.5%, and another 12.8% needed total assistance to ambulate. Laboratory values were strong predictors of mortality but were not significantly associated with locomotion. Age and prefracture residence at a nursing home were significant predictors of locomotion (P =.02 for both) but were not significantly associated with mortality. Adjustment for baseline characteristics either substantially augmented or diminished interhospital differences in outcomes. Two hospitals had 1 outcome (functional status or mortality) that was significantly worse than the overall mean while the other outcome was nonsignificantly better than average. CONCLUSIONS: Mortality and functional status ideally should be considered both together and individually to distinguish effects limited to one or the other outcome. Hospital performance for these 2 measures may differ substantially after adjustment, probably because different processes of care are important to each outcome.

Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury--1990-1997.

OBJECTIVES: To describe changes in acute and rehabilitation length of stay (LOS) for persons with traumatic spinal cord injury (SCI), describe predictors of LOS, and explore year-1 anniversary medical and social outcomes. DESIGN: Longitudinal, exploratory study of patients with SCI. SETTING: Eighteen Model Spinal Cord Injury Centers across the United States. SAMPLE: A total of 3,904 persons discharged from the Model Systems between 1990 and 1997 who had follow-up interviews at 1 year postinjury. MAIN OUTCOME MEASURES: Rehabilitation LOS; injury anniversary year-1 presence of pressure ulcers; incidence of rehospitalization; community or institutional residence; and days per week out of residence. RESULTS: Acute rehabilitation LOS declined from 74 days to 60 days. Discharges to nursing homes and rehospitalizations increased between 1990 and 1997. Linear regression showed that lower admission motor Functional Independence Measure (FIM) scores, year of discharge from the Model System, method of bladder management, tetraplegia, race, education, marital status, discharge disposition, and age were related to longer LOS. At first anniversary, logistic regressions revealed that lower discharge motor FIM, injury level, and age were related to the presence of pressure ulcers, rehospitalization, residence, and time spent out of residence. Of those discharged to nursing homes, 44% returned to home by year 1, and these individuals had higher functional status and were younger. DISCUSSION: High functional status is associated with shorter LOS, discharge to the community, and time spent out of residence, indicating efficiency in the system. For 44.4% of individuals one or more of the following outcomes were observed by first year anniversary: rehospitalization; residing in a skilled nursing facility; having pressure ulcers; or infrequently leaving one's residence.

Direct observation nursing: adverse patient behaviors and functional outcomes.

The authors describe a study at a rehabilitation facility that was designed to enhance understanding of which patient behaviors and cognitive problems were predictive of the need for 1:1 or 1:2 full-time staff direct observation (DO). The costs associated with such 1:1 monitoring are substantial, having been estimated at $6,000 for a typical 3 week LOS, or $78,000 per year for each patient so monitored. Traumatic brain injury, stroke, and poor mental status had previously been associated with impulsivity, patient falls, and other adverse events, and thus such patients were frequently subjected to medical immobilization (restraints). Such immobilization has serious negative consequences for rehabilitation patients, so nursing assistants would frequently be assigned to stay with, observe, and redirect such patients around the clock. This study, which was designed to ascertain the significant differences between the patients who were placed on physician-ordered direct observation status when compared with those not needing DO, encompassed all patients admitted to a 36-bed rehabilitation unit between October 1995 and April 1996.

Functional status and its uses in rehabilitation medicine.

BACKGROUND: Over the past decade and a half, rehabilitation medicine has developed and implemented standardized measures of functional status. Standardized measures of functional status are important for four reasons: (1) clinicians need them to determine whether interventions produce the expected outcomes; (2) managed care companies use them to decide which rehabilitation services and equipment will be paid for; (3) accreditation bodies such as the Commission on the Accreditation of Rehabilitation Facilities (CARF) require empirical functional status and functional outcome measures; and (4) public policy is moving toward a case-based payment system derived from patient need, and type and severity of impairment. METHODS: Review of the literature. CONCLUSIONS: While researchers, clinicians, managed care, accrediting bodies, and federal regulation have each influenced rehabilitation as conceptualized, measured, and practiced, lack of coordination among these groups has hampered agreement on appropriate tools for functional assessment and outcome. Rehabilitation providers, however, will be increasingly accountable to government regulations and managed care companies.

Skills acquisition among matched samples of institutionalized and community-based persons with mental retardation.

Clients who had been moved from an institution to community settings were compared with matched clients who remained in the institution. Matching variables included age, sex, level of mental retardation, self-preservation, mobility, blindness, daily living skills, social and cognitive skills, and secondary disabilities (cerebral palsy, epilepsy, physical disability, neurological impairment, and impairment related to aging). Results demonstrated that community clients surpassed institutional clients in social and cognitive skills, but not in daily living skills. Gains in social and cognitive skills by the community sample were conditioned by baseline skill levels and the presence of secondary disabilities. The nonimpaired clients and those with the fewest skills when relocated made the greatest gains. Institutional sample members' gains were uniform across all client conditions and may have been the effect of rater bias.