Research suggests some hip fracture surgery patients experience better outcomes after the procedure with a longer post-acute stay. Recovery also is easier when these patients do not have to engage in intensive physical therapy initiated immediately after surgery.1
Investigators reviewed outcomes and data from Medicare patients in post-acute care settings, including four inpatient rehabilitation and seven skilled nursing facilities, reports Alison Cogan, OTR/L, co-author and adjunct assistant professor of health, human function, and rehabilitation sciences at George Washington University.
These patients needed additional care after surgery. “I can’t speak to the settings where surgery was conducted, but they were discharged to post-acute care facilities,” Cogan notes.
Cogan and colleagues found discharging many patients before 21 days in a post-acute care setting had elapsed likely transferred burden of care to family and caregivers, home health, and outpatient services. CMS encourages quality care that also is cost-effective. From that perspective, it makes sense to provide more therapy in the early days after surgery, and to discharge patients home faster. But Cogan and colleagues found this approach does not result in the best patient outcomes.
“We need to identify patients who are going to be OK with home discharge and a lower level of support vs. the patients who need to be sent to an inpatient facility for a post-discharge period and who will benefit from more intensive rehabilitation care,” Cogan suggests.
The authors examined patients’ functional independence measures for mobility and self-care. They grouped patients in different recovery trajectories, including those who recovered quickly and those who took much longer to recover, Cogan explains. “The rate of recovery was strongly associated with how much independence they had with mobility and self-care outcomes at discharge from the post-acute care facility,” she adds. “Also, the length of stay was strongly associated with their functional outcomes.”
Cogan and colleagues did not see data about patients’ functional ability before surgery. However, at admission to post-acute facilities, they were similar in their limitations for self-care, lower body dressing, and getting on and off the toilet, Cogan notes. “Some people improved rapidly; others less so,” she says. “We found that the amount of therapy did not seem to change their trajectory.”
For instance, some patients were prescribed intense physical therapy, which did not lead to faster improvement, Cogan explains. What did seem to work was giving patients more time to heal instead of jumping into rigorous therapy at the beginning of their post-acute care facility stay, Cogan says.
For this study, patients were divided into groups of high performers, medium performers, and low performers. “People in that middle group who had a longer length of stay were discharged with functional independence. Those on higher-intensive therapy regimens still needed assistance with a number of tasks when they were discharged,” Cogan says. “In the inpatient rehab setting, the standard of care is three hours of therapy per day, and the middle group had an average length of stay of 14 days.”
Those who stayed 14 days recorded lower functional scores than those who stayed an extra week and participated in less intensive therapy.
Of note, these authors collected data from the 2005-2010 period. Since then, the trend of home discharge has grown, Cogan observes. “It all comes down to cost effectiveness and getting people the right care without doing too much,” she says. “There is a trend toward the kinds of surgeries that are discharging people home.”
- Cogan AM, Weaver JA, McHarg M, et al. Association of length of stay, recovery rate, and therapy time per day with functional outcomes after hip fracture surgery. JAMA Netw Open 2020;3:e1919672.