Your Patients Live Longer When Discharged with Home Care After Hemiarthroplasty
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP, Clinical Assistant Professor, West Virginia University School of Medicine, Charleston, WV. Dr. Gupta reports no financial relationship to this field of study.
Synopsis: A Canadian study reveals that while a majority of elderly patients undergoing hemiarthroplasty did not receive home care upon discharge, those that did had longer short-term survival.
Source: Rahme E, et al. Short-term mortality associated with failure to receive home care after hemiarthroplasty. CMAJ 2010 Aug 16; Epub ahead of print.
Hemiarthroplasty of the hip is generally recommended for patients with displaced hip fracture who are elderly and in poor general health, or those who may previously have had a debilitating degenerative joint disease or avascular necrosis, or rheumatoid arthritis of the hip. There is a high short-term mortality rate in patients undergoing this procedure.1 Often, the patients are already at risk of complications and death due to pre-existing comorbid conditions. Due to the comorbid conditions, such patients may have a high rate of readmission during the postoperative period as well. It is widely anticipated that in the near future, hospitals will face fierce resistance from third party payers in the reimbursement for such readmission services connected with the initial surgery itself. As a result, more of such elderly and frail patients may be denied services resulting in unanticipated widening of a disparity gap in the geriatric population. It is vital that we explore all methods that would not only lower hospital re-admission rates, but also improve postoperative short-term mortality rates and avoid some of the unintended consequences from the upcoming health care reform law.
While the study mentioned here is from Canada, there are lessons to be learned for us in the United States. In Quebec, post-discharge care rendered to patients who undergo elective hip replacement is quite dissimilar to those undergoing hemiarthroplasty for a hip fracture. People undergoing planned elective surgery also have a planned discharge with home care, which includes nursing, physiotherapy, occupational therapy, nutrition, psychosocial care, and daily housekeeping. This is not always possible for those undergoing unplanned or emergency procedures such as repair of a hip fracture.
Rahme et al conducted a retrospective cohort study using provincial hospital discharge records data. They obtained the administrative data for 11,326 patients (all 65 years and older) who were discharged from hospital after hemiarthroplasty in the province of Quebec during the period 1997-2004. Of 11,326 study patients, 5.6% were discharged home with home care, 29.9% were discharged home without home care, 2.0% were sent to a rehabilitation center, 24.2% were sent to a nursing home, and 38.3% were sent to another hospital. Among patients who were discharged home, those who were less likely to receive home care were older, had osteoarthritis, had an emergent admission, and were admitted to a high-volume hospital. Discharge with home care was most likely among patients admitted to teaching hospitals, those in hospital for more than 7 days, those with atrial fibrillation, and those with acute renal failure. In those discharged home, the rate of death per 100 patient-months was lowest among patients who were discharged with home care.
Another way to interpret the findings may be that the study revealed that in the province of Quebec, more than 84% of the elderly patients discharged home from hospital after hemiarthroplasty did not receive home care after discharge. Patients who did receive home care were at 43% lower risk of death in the first 3 months post-discharge than those sent home without it.
While it has been previously established that patients receiving hemiarthroplasty after a hip fracture have higher mortality rate than those receiving elective arthroplasty, Rahme et al evaluated the impact of post-discharge home care (inclusive of comprehensive services as mentioned above) on short-term mortality in such patients.2 In the context of clinical practice in the United States, a comprehensive post-discharge care model for identified high-risk admissions, such as those undergoing hemiarthroplasty, should become defining criteria for high-rated, superior performing hospitals. It is widely accepted that bending the long-term cost curve will be the cornerstone of reforming our health care system, which will lead to improved quality of care at an affordable price. To control long-term costs, the current health care reform law attempts to utilize a hybrid approach that not only depends upon results of comparative effectiveness research, but also utilizes a system of taxes and penalties to address individual behavior.3 However, it is incumbent upon every health care provider, as a community, to understand that if we are to have a modernized health care system, it must be anchored in good science. The results of studies such as the one above mandate that we continue to advocate for comprehensive patient care models that do not discontinue once the patient leaves the hospital or the physician offices and that such care models are not limited to large metropolitan areas in the nation. The results of this study should be taken as another piece of that puzzle, which has the potential to ultimately lead us in the right direction.
1. Forte ML, et al. Ninety-day mortality after intertrochanteric hip fracture: Does provider volume matter? J Bone Joint Surg Am 2010;92:799-806.
2. Intrator O, Berg K. Benefits of home health care after inpatient rehabilitation for hip fracture: Health service use by Medicare beneficiaries, 1987-1992. Arch Phys Med Rehabil 1998;79:1195-1199.
3. Orszag PR, Emanuel EJ. Health care reform and cost control. N Engl J Med 2010;363:601-603.