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Outcomes/Effectiveness Research

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Hip fracture study calls for assessing patients' risks of both functional impairment and death

A recent study supported in part by the Agency for Healthcare Research and Quality (HS09459) could help acute and postacute care medical staff improve patient outcomes for the approximately 350,000 hip fractures that occur annually in the United States by focusing efforts on reducing the risk of complications that often leave patients unable to walk or lead to death.

Currently, four of every ten patients are unable to walk without total assistance by 6 months after the fracture, and one-fourth of patients die within a year. In addition to pain and suffering, hip fracture and its consequences have a large economic impact, with hospital charges alone totaling roughly $6 billion a year. The challenge has been to identify characteristics that put patients at higher risk for these adverse outcomes.

The researchers' analysis of data on hip fracture patients in four New York City hospitals between August 1997 and August 1998 found that when patients required moderate to total assistance for walking or stair climbing prior to admission, there was a higher likelihood of poor postfracture functional ability. Limited locomotion prior to the fracture combined with the presence of chronic medical conditions increased the risk of death. Of the 571 elderly patients studied, nearly 2 percent died while in the hospital, and roughly equal percentages—about 13 percent—either died within 6 months or needed total assistance to walk or use a wheel chair.

The researchers identified risk factors that accurately predicted the loss of locomotion and/or death. Although previous studies have identified patient factors related to either the recovery of hip fracture patients or to death, most looked at function or mortality independently. None of the earlier studies reported on how risk-adjusted outcomes could be obtained to assess the effectiveness or quality of care in a hospital or postacute care setting.

Hip fracture patients, most of whom are elderly, are first admitted to acute care hospitals where rehabilitative services generally exist to improve functional mobility and where there are nursing services for preventing or treating common postoperative complications, such as thrombophlebitis (inflammation of a vein and formation of a clot), surgical site infection, and delirium. After hospital discharge, the typical hip fracture patient receives postacute rehabilitative services in a skilled nursing facility, acute rehabilitative unit, home health program, or a combination of these.

Details are in "Mortality and locomotion 6 months after hospitalization for hip fracture. Risk factors and risk-adjusted hospital outcomes," by Edward L. Hannan, Ph.D., Jay Magaziner, Ph.D., Jason J. Wang, M.A., M.S., and others, in the June 6, 2001 Journal of the American Medical Association 285(21), pp. 2736-2742.

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