Early Rehabilitation at Home of Elderly Patients with Hip Fractures and Consumption of Resources in Primary Care

From 1976 onwards an active rehabilitation programme has been applied to elderly patients with fresh hip fractures at the Department of Orthopaedics in Lund in Southern Sweden. This involves early mobilisation in the hospital (internal fixation and immediate weight-bearing) and at home, rehabilitation in cooperation with primary health care personnel from the time of the patient's admission.

The purposes of this investigation were to evaluate the effect of this programme in primary care and to assess the consumption of resources for rehabilitation at home of patients with cervical or trochanteric hip fractures.

One hundred of 161 consecutive patients returned home directly on discharge from the hospital and were followed up until four months after the fracture by the home care unit (a primary health care centre). Most patients regained their previous functions within four months of their fractures. Patients with cervical fractures consumed less resources for rehabilitation than patients with trochanteric fractures. The total cost per patient was ten times higher for care at a convalescent-home than for rehabilitation at home through primary care.

Early at home rehalibitation of elderly patients with hip fractures gives good results at a minimal cost and is thus of advantage both to the patient and to the community.     

延伸护理在老年髋部骨折患者术后康复中的应用

目的:探讨延伸护理服务在老年髋部骨折术后康复中的应用效果。方法:将42例老年髋部骨折患者随机分为观察组22例和对照组20例,对照组患者出院时给予健康指导,观察组患者给予建立出院家庭访视档案,分别于出院后1周和出院后1,2,3个月进行家庭访视,给予心理护理、下肢功能锻炼、生活自理能力指导,3个月后比较两组患者焦虑发生率、下肢功能活动情况及生活自理能力等。结果:观察组患者焦虑发生率低于对照组(P0.05),下肢活动情况、生活自理能力均优于对照组(P均0.05)。结论:对老年髋部骨折患者出院后进行家庭访视康复指导,能延伸健康教育及提供优质护理服务,提高患者出院后康复治疗依从性及生活自理能力,减少并发症,从而促进患者康复。     

Continuity,assessment and feedback in orthopaedic nursing care practice is cost-effective

Hip fracture treatment and rehabilitation are often considered as separate issues and generally performed in different locations. The rapidly increasing proportion of patients that is old and very old now calls for a new approach. This is a prospective study of 909 consecutive hip fracture patients, over 64 years old, admitted to hospital from an independent living situation. In a specialized hip fracture unit, 256 patients were given an early and intense rehabilitation program. It focused on continuity, feedback, reorientation and continuous monitoring of cognitive function and activities of daily living (ADL). Eighty-five percent of the patients could return directly to their own home after the initial treatment period. The mean total utilization of health care resources during the first 4 months after the injury was lower (28 institutional days) than in 286 historical controls given conventional rehabilitation (39 days, p < 0.05). At 4 months, 81% of the patients still lived in their own home vs. 72% of the controls and the 1-year mortality was 14% (21% in the controls, p < 0.05). After the project had been completed 297 patients formed an additional control group. In this group the proportion discharged to their own home decreased to 44% and the number of bed-days during the first 4 months returned to the pre-study level (39 days). It thus appears to be cost-effective to allocate sufficient rehabilitation resources early in the treatment of elderly patients with hip fractures. Annual savings in the catchment area due to the intervention were calculated to approximately 5,000,000 SEK. Continuous assessment and adequate continuity gives the staff emotional feedback, which promotes their personal commitment.     

Outcome after hip fracture in different health care districts. Rehabilitation of 837 consecutive patients in primary care 1986-88.

The social and functional outcome for 837 consecutive hip fracture patients rehabilitated in primary care was studied during 1986-1988. Of patients coming from their own home (59%) the majority (76%) were back at home four months after fracture and had a good functional status, while 9% were dead. Predictors of managing ADL (dressing/personal hygiene) four months after hip fracture were age, type of fracture, sex, and having regular social contacts outside the home before fracture. Health care districts differed in the incidence of hip fractures, the patients hospital stay, housing, type of fracture, and age. These differences had consequences on costs. Total costs per patient were lowest in districts where most of the patients were discharged to their own homes. No significant differences in fracture incidence were seen between rural and urban primary health care districts.     

老年髋部骨折患者围手术期的护理

目的总结老年髋部骨折患者围手术期的护理要点。方法 2010年6月~2013年9月对本院收治的95例老年髋部骨折患者进行人工关节置换术或内固定术,护士配合做好术前、术后围手术期护理工作。结果 95例患者术后均康复出院,住院时间11 d~28 d,平均(17.5±2.5)d,术后1例患者发生肺炎,1例患者发生切口感染,经治疗护理后治愈。结论住院期间,护士应积极做好老年患者围手术期护理,根据其心理、生理特点,做好心理护理工作,有针对性地预防和处理术后并发症,指导患者进行康复训练,其可促进患者尽快增强日常生活能力,促进康复。     

Inpatient mortality of hip fracture patients in the Veterans Health Administration.

Hip fractures among elderly people frequently result in permanent disabilities, nursing home placement, and death. The bulk of hip fracture research focuses on elderly women. Within the Veterans Health Administration (VHA), the majority of patients are men. There are no published national reports on hip fractures with large male samples, or on related inpatient mortality among veterans. This retrospective study of 13,546 veterans with hip fracture discharges from 1998-2002 found unadjusted mortality rates are higher in the VHA, compared with the general population. VHA patients tend to be older men in poor health who stay in the hospital longer Increased knowledge about the risks and outcomes associated with hip fractures in men could lead to improved primary and secondary injury-prevention programs. Rehabilitation nurses in acute care can be catalysts in proactively incorporating protective devices, screening for osteoporosis, and initiating lifestyle changes in their plans of care to optimize outcomes for hip fracture patients.     

Hip fractures in primary health care. Evaluation of a rehabilitation programme

The routine follow-up of hip fracture patients was transferred from the Orthopaedic Department, Lund University Hospital, to the primary health care districts in 1985. The medical state and social functions of all 298 patients during the first 12 months of the follow-up rehabilitation programme were registered. Before fracture, 61% lived in their own homes, 22% in old people's homes, and 14% in geriatric hospitals or nursing homes. Four months after fracture, 13% were dead, 47% were living in their own homes, 14% were in old people's homes, 25% in geriatric hospitals or nursing homes, while the rest were in other types of institutional residence. Of patients coming from their own homes, 75% were back at home four months after fracture and their social and functional status were as good as before fracture. The study has shown that routine check-ups at the orthopaedic department can be omitted. Follow-up in primary health care without radiography and orthopaedic expertise gives equally good functional results as in previous studies, provided that patients with pain and walking problems from the hip are guaranteed rapid specialist treatment.     

住院老年髋部骨折术后患者康复护理需求的调查分析

目的 了解老年髋部骨折术后患者康复护理及模式需求程度、需求满足度。方法 对我院2012年1月至2012年12月行骨科手术治疗的41位老年髋部骨折患者进行问卷调查。结果 康复需求10 个维度中他人支持、出院后续康复及功能训练指导位居前3 位,护士与治疗师相结合的康复模式,也是患者最需要的。结论 护士早期给予针对性的康复训练指导和健康教育是患者迫切的需求; 康复需求程度高者, 相应需求满足率低, 其生活质量及髋关节功能恢复应成为干预的重点。     

Patient and caregiver outcomes 12 months after home-based therapy for hip fracture: a randomized controlled trial

OBJECTIVE: To compare the effect of early discharge and home-based therapy with conventional hospital rehabilitation on patient and caregiver outcomes at 12 months after hip fracture. DESIGN: Randomized controlled trial. SETTING: Acute and subacute care with follow-up in a community setting in Australia. PARTICIPANTS: Sixty-six older adults admitted to acute care after hip fracture who were assessed as needing rehabilitation. INTERVENTIONS: Eligible patients were randomized to either home-based (n=34) or hospital (n=32) rehabilitation. Patients assigned to the home-based group were discharged home within 48 hours of randomization. Patients assigned to hospital rehabilitation received usual care. MAIN OUTCOME MEASURES: Modified Barthel Index (MBI), timed up and go (TUG) test, Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and Caregiver Strain Index. RESULTS: At 12 months, 56 of 66 (85%) participants were available for follow-up assessment. Both groups achieved significant improvements in MBI and TUG test scores. Patients in both groups had a significant decline in the physical score of the SF-36 and there were no differences between groups. Caregivers of patients allocated to receive home-based therapy reported a reduction in burden after 12 months. Over that period, there was a significant reduction in the burden for caregivers of those patients who received home rehabilitation (P=.020). CONCLUSION: For patients who were previously functionally independent and living in the community, early return home with increased involvement of caregivers after hip fracture resulted in similar patient outcomes (home vs hospital) and less caregiver burden at 12 months.     

Impact on Health Care Consumption of an Experimental Daycare Intervention

The purpose of the present study was to assess the impact on health care utilization of a controlled intervention programme for geriatric daycare patients. Sixty-five patients referred to daycare were allocated to an intervention and control group respectively. The 12-week programme was added to the ordinary daycare agenda and was designed in active collaboration with the patients in order to counteract passivity and enhance active patient involvement. Evaluations were made before and after 6 and 12 weeks of intervention, as well as 3 and 9 months after the conclusion of the programme. No extra resources were allocated to either the intervention or the control group. During the intervention period there were no changes in the utilization of home care for either group during the whole study period. Noticeably, there was a significant difference in the number of patients readmitted to hospital between the intervention and control groups (13/33 and 21/32 respectively). There was also a significant difference in favour of the intervention group concerning mean length of hospital stay (22.1 and 61.9 days respectively). The mean corresponding saving for each 12-week intervention patient during a one-year follow-up was calculated at 57 500 SEK. Even if our calculations are tentative and do not cover all aspects of the total cost, they indicate the importance of further studies of elderly patients discharged from daycare units and institutional settings.     

早期强化家庭康复锻炼对老年股骨粗隆间骨折患者术后生活质量的影响

目的 探讨早期强化家庭康复锻炼对老年股骨粗隆间骨折患者术后生活质量的影响。方法 选取2017年1月至2018年12月南京市六合区人民医院收治的老年股骨粗隆间骨折患者104例进行研究，依据入院顺序单双数分组，52例单数入院者为对照组术后施予常规护理，52例双数入院者为观察组术后行早期强化家庭康复护理，对比两组的护理干预效果。结果 观察组患者康复效果优良率高于对照组；术后3个月、6个月比较，观察组患者髋关节功能（Harris评分）、日常生活活动能力（Barthel指数）及生活质量（SF-36）均好于对照组，住院时间短于对照组，护理满意度高于对照组，差异均有统计学意义（均P<0.05）。结论 予以老年股骨粗隆间骨折患者术后早期强化家庭康复锻炼干预可促进患者髋关节功能改善，并有利于提高患者日常生活活动能力及生活质量。     

出院后家庭康复指导对老年髋部骨折术后患者日常生活能力的影响

目的了解出院后家庭康复指导对老年髋部骨折术后出院患者日常生活能力的影响。方法将60例老年髋部骨折出院后的恢复期患者,按照出院先后次序分为干预组和对照组,每组各30例。干预组由社区护士在患者出院后1、3、6个月进行家访实施康复指导;对照组采用传统的家庭疗养方法。比较两组患者出院后1、3、6个月Barthel指数评分的差异。结果干预组患者出院后第1、3、6个月日常生活能力优于对照组,两组Brathel指数评分比较,均P<0.05,差异具有统计学意义。结论实施家庭康复指导可提高老年髋部骨折术后出院患者的日常生活能力,此服务模式具有可操作性和实用性,值得临床推广应用。     

Medical care of elderly patients with hip fractures

Medical morbidity associated with hip fractures in the elderly population is considerable. The all-cause mortality rate is 24% at 12 months. The functional limitations of survivors can be pronounced. As the American population ages, hip fractures will substantially affect the utilization of hospital resources. Several issues, including preoperative clearance and related surgical timing, deep venous thrombosis prophylaxis, delirium, nutrition, and urinary tract management, are important in the care of these patients. A close partnership between orthopedic surgeons and clinicians provides the best strategy of care for the subset of patients with multisystemic complications.     

Nursing attitudes to the care of elderly patients at risk of continuing hospital care

This study assesses changes in nurses' attitudes to the process of decision-making regarding the care of elderly patients identified as being at risk of continuing (long-term) hospital care It was undertaken during the course of an evaluation of an intervention programme which involved a new approach to decision-making concerning the long-term care of dependent elderly patients Complementary components of the intervention programme were (a) an early discharge planning service, and (b) an extended home care programme The programme involved close liaison of specially trained community health nurses with staff members of the general medical wards of a large general hospital At the onset of the evaluation, it was perceived by management that the staff of the general medical wards favoured continuing hospital care for very dependent elderly patients rather than community care It was hypothesized that the intervention programme would result in a change in ward staffs' attitudes concerning the feasibility of home-based care and how decisions about care should be made To test this, attitude changes of community health nurses and ward nurses were assessed over the period of implementation of the programme Following the introduction of the programme, the study found that some of the ward nurses' attitudes became closer to those of community health nurses There was a shift in ward nurses' attitudes away from a professional approach to decisions about the care and placement of very dependent elderly patients to a 'patient choice' approach Nurses felt more strongly that they had an important role in patient care Implications of the research are considered in relation to the process of discharge planning     

Costs and consequences of hip fracture occurrence in old age: an economic perspective

PURPOSE: To summarize the reported short- and long-term costs associated with hip fracture occurrence in old age, based on a systematic literature review of published studies. A further aim is to provide a clinician-oriented discussion of the different types of economic evaluations, with an emphasis on studies that examined potential determinants of the costs of care after hip fracture. METHOD: Literature review. MAIN RESULTS: Even after the initial hospitalization, hip fractures continue to generate significant costs throughout the one-year period after discharge, but particularly during the first three months. Cost estimates based on data obtained prospectively from hip-fracture patients and matched controls showed that the costs associated with the treatment of hip-fracture patients are about three times greater than those resulting from the treatment of age and residence-matched controls without a fracture. Two-fifths of these excess costs are incurred during the first three months following hospital discharge. Increasing age at the time of injury and living in an institution before the fracture are among the most important determinants of an increased cost of care after hospital discharge. Programs that focus on continuity of care, adopt a multidisciplinary approach, and accelerate rehabilitation have shown to be able to reduce the cost of care after hip fracture. CONCLUSIONS: This review emphasizes the importance of current and future interventions to decrease the incidence of hip fracture. While the current review cannot provide definite answers to the questions of cost containment, our review provides critically important evidence about the need to base health policy decisions on empirical observations. Comprehensive economic analyses of financial costs and health outcomes are needed to develop cost-effective strategies.     

加速康复外科理念下信息化延续护理在老年髋部脆性骨折患者中的应用

目的探讨基于加速康复外科(ERAS)理念的信息化延续护理在老年髋部脆性骨折患者中的应用效果。方法采用便利抽样法,选择2018年5—12月北京积水潭医院收治的186例老年髋部脆性骨折患者为对照组,采用ERAS理念下常规延续护理,选择2019年5—12月北京积水潭医院收治的193例老年髋部脆性骨折患者为试验组,采用ERAS理念下信息化延续护理,依托微信多元化、信息化平台,组建ERAS多学科协作团队,实施多元化、精准化、连续性的信息化延续护理。采用t检验、χ²检验和Fisher精确检验比较干预后两组患者延续护理依从性和延续护理效率指标。结果试验组主动寻求建议、康复训练、按时复诊、规范用药及合理饮食依从率均高于对照组,差异均有统计学意义(χ²值分别为50.846、37.408、6.916、14.108、17.111;P<0.01)。出院6个月后试验组患者Harris髋关节功能评分量表得分为(89.3±5.1)分、骨质疏松药物正确使用率为99.0%(191/193)、患者满意度为97.9%(189/193),均高于对照组,差异均有统计学意义(t/χ²值分别为29.598、50.746、11.017;P<0.01);试验组患者二次骨折发生率为1.6%(3/193)、并发症发生率为5.2%(10/193),均低于对照组,差异有统计学意义(χ²值为4.177、9.369;P<0.05)。结论基于ERAS理念的信息化延续护理能提高老年髋部脆性骨折患者居家护理的依从性,利于患者加速康复。     

Rehabilitation after a hip fracture. Special needs of the elderly

Hip fractures are one of the most common and potentially devastating injuries in the geriatric population. The incidence, morbidity, and health care costs associated with hip fracture among older persons are well recognized. Because of the complex health care needs of the elderly, rehabilitation after a hip fracture can present a challenge at a time when the nursing workforce and health care funding are declining. Aggressive rehabilitation focusing on continuity of care and attention to the cognitive as well as physiologic status results in effective and cost-effective rehabilitation.     

Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: A systematic review.

BACKGROUND: While hip fractures are an important cause of disability, dependency and death in older adults, the benefit of multi-disciplinary rehabilitation for people who have sustained hip fracture has not been demonstrated. METHODS: Systematic review of randomized controlled trials which compare co-ordinated multi-disciplinary rehabilitation with usual orthopaedic care in older people who had sustained a hip fracture. Outcome measures included: mortality, return home, "poor outcome", total length of hospital stay, readmissions and level of function. RESULTS: We identified 11 trials including 2177 patients. Patients who received multi-disciplinary rehabilitation were at a lower risk (Risk Ratio 0.84, 95% CI 0.73-0.96) of a "poor outcome" - that is dying or admission to a nursing home at discharge from the programme, and showed a trend towards higher levels of return home (Risk Ratio 1.07, 95% CI 1.00-1.15). Pooled data for mortality did not demonstrate any difference between multi-disciplinary rehabilitation and usual orthopaedic care. CONCLUSION: This is the first review of randomized trials to demonstrate a benefit from multi-disciplinary rehabilitation; a 16% reduction in the pooled outcome combining death or admission to a nursing home. This result supports the routine provision of organized care for patients following hip fracture, as is current practice for patients after stroke.     

Health care and social welfare costs in home-based and hospital-based rehabilitation after stroke

During the 1990s most western European and Organization of Economic Cooperation and Development (OECD) countries experienced financial difficulties and were forced to cut back on or restrain health care expenditures. Home rehabilitation has received attention in recent years because of its potential for cost containment. Often forgotten, however, is the redistribution of costs from one caregiver to another. The aim of this study was to analyse whether a redistribution of costs occurs between health care providers (the County councils) and social welfare providers (the municipalities) in a comparison of home-based rehabilitation and hospital-based rehabilitation after stroke. The study population included 123 patients, 53 in the home-based rehabilitation group and 68 in the hospital-based rehabilitation group. The patients were followed up at 6 and 12 months after onset of stroke. Resource use over a 12-month period included acute hospital care, in-hospital rehabilitation, home rehabilitation and use of home-help service as well as nursing home living. The hospital-based rehabilitation group had significantly fewer hospitalization days after a decision was made about rehabilitation at the acute care ward and consequently the cost for the acute care period was significantly lower. The cost for the rehabilitation period was significantly lower in the home-based rehabilitation group. However, the cost for home help service was significantly higher in the home-based rehabilitation group. The total costs for the care episode did not differ between the two groups. The main finding of this study is that there seems to occur a redistribution of costs between health care providers and social welfare providers in home rehabilitation after stroke in a group of patients with mixed degree of impairment.