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Original Investigation |

Survival and Functional Outcomes After Hip Fracture Among Nursing Home Residents ONLINE FIRST

Mark D. Neuman, MD, MSc1,2; Jeffrey H. Silber, MD, PhD1,2,3,4,5; Jay S. Magaziner, PhD6; Molly A. Passarella, MS3; Samir Mehta, MD7; Rachel M. Werner, MD, PhD2,8
[+] Author Affiliations
1Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
2Leonard Davis Institute for Health Economics, the University of Pennsylvania, Philadelphia
3Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia
4Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
5Health Care Management Department, the Wharton School, the University of Pennsylvania, Philadelphia
6Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
7Department of Orthopedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
8Division of General Internal Medicine, Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
JAMA Intern Med. Published online June 23, 2014. doi:10.1001/jamainternmed.2014.2362
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Importance  Little is known regarding outcomes after hip fracture among long-term nursing home residents.

Objective  To describe patterns and predictors of mortality and functional decline in activities of daily living (ADLs) among nursing home residents after hip fracture.

Design, Setting, and Participants  Retrospective cohort study of 60 111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009.

Main Outcomes and Measures  Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture.

Results  Of 60 111 patients, 21 766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ≤75 years: hazard ratio [HR], 2.17; 95% CI, 2.09-2.26 [P < .001]), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 [P < .001]), and advanced comorbidity (Charlson score of ≥5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 [P < .001]). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk [RR], 1.66; 95% CI, 1.56-1.77 [P < .001]), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 [P < .001]), and patients older than 90 years (vs ≤75 years: RR, 1.42; 95% CI, 1.37-1.46 [P < .001]).

Conclusions and Relevance  Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population.

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Figure 1.
Survival at up to 365 Days Among 60 111 US Long-term Care Residents Hospitalized With Hip Fracture Between July 1, 2005, and June 30, 2009

Male patients demonstrate a lower probability of survival than women at all time points after fracture (P < .001 by log-rank test).

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Figure 2.
Survival to 180 Days and Within-Residents Changes in Locomotion Self-performance Among 59 749 Nursing Home Residents Hospitalized With Hip Fractures Between July 1, 2005, and June 30, 2009

For individuals within a given category of baseline locomotion self-performance, the corresponding horizontal bar shows the fraction of patients who died within 180 days, along with the distribution of postfracture locomotion scores at the last available assessment within 180 days among survivors. The bold vertical line intersecting each bar demarcates the fraction of individuals within a baseline locomotion category who both survived to 180 days and regained or exceeded their baseline level of locomotion self-performance at the latest available assessment within 180 days after fracture.

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