Search

The objectives of this study were to examine longitudinal patterns of Department of Veterans Affairs (VA)-only use, dual VA and Medicare use, and Medicare-only use by veterans with dementia. Data on VA and Medicare use were obtained from VA administrative datasets and Medicare claims (1998-2001) for 2,137 male veterans who, in 1997, used some VA services, had a formal diagnosis of Alzheimer's disease or vascular dementia in the VA, and were aged 65 and older. Generalized ordered logit models were used to estimate the effects of patient characteristics on use group over time. In 1998, 41.7% of the sample were VA-only users, 55.4% were dual users, and 2.9% were Medicare-only users. By 2001, 30.4% were VA-only users, 51.5% were dual users, and 18.1% were Medicare-only users. Multivariate results show that greater likelihood of Medicare use was associated with older age, being white, being married, having higher education, having private insurance or Medicaid, having low VA priority level, and living in a nursing home or dying during the year. Higher comorbidities were associated with greater likelihood of dual use as opposed to any single system use. Alternatively, number of functional limitations was associated with greater likelihood of Medicare-only use and less likelihood of VA-only use. These results imply that different aspects of veterans' needs have differential effects on where they seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure that patients receive high-quality care, especially patients with multiple comorbidities.

OBJECTIVES: To examine unidentified heterogeneity in hip fracture patients that may predict variation in functional outcomes. DESIGN: Observational, longitudinal, multisite cohort study. SETTING: Three separate cohorts from five hospitals in the metropolitan New York area and eight hospitals in Baltimore. PARTICIPANTS: Two thousand six hundred ninety-two hip fracture patients treated at one of 13 hospitals and followed for 6 months postfracture. MEASUREMENTS: A mobility measure with three categories (independent (walks independently or with a device), limited independence (needs human assistance or supervision to walk 150 feet or one block or able only to walk indoors), and unable to walk) was developed for use with all three cohorts. A similar measure was developed for the other activities of daily living (ADLs): bathing, dressing, feeding, and using the toilet. Cluster analysis was used to form homogenous groups of patients based on baseline demographic characteristics, comorbid conditions, and baseline mobility and ADL independence. RESULTS: Seven homogeneous subgroups were identified based on prefracture age, health, and functional status, with measurably different 6-month functional outcomes. At least 90% of patients could be correctly classified into the seven groups using simple decision rules about age, ADLs, and dementia status at baseline. Dementia was the only comorbid condition that segmented the groups. CONCLUSION: The heterogeneous hip fracture population can be grouped into homogenous patient clusters based on prefracture characteristics. Differentially targeting services and interventions to these subgroups may improve functional status outcomes.

Outcomes of hip fracture, which occurs in approximately 340,000 adults annually,1 are poor, despite most patients having access to an extended period of post-hospital care and rehabilitation covered by Medicare. In recent studies, 44% of patients developed one or more new permanent activity of daily living (ADL) limitations within 3 months after hip fracture,2 and mortality was 13.5% by 6 months after hip fracture.3 Fragmentation in care delivery after hip fracture may be a barrier to achievement of optimal outcomes. Patients receive care at multiple sites, in part influenced by Medicare payment policies. Short hospital lengths of stay result in a substantial proportion of patients being discharged with active clinical problems,4 and the majority of hip fracture patients are discharged to rehabilitation hospitals and nursing facilities.3 Many patients subsequently undertake an additional residential transition to home or to another setting for long-term care. Fluctuations in patients’ medical and functional status over time further exacerbate care fragmentation. Nearly one-third of hip fracture patients experience an acute illness that requires hospital readmission within 6 months of initial hospital discharge.5 Although hip fracture patients experience transitions between multiple care sites, including hospitals, rehabilitation units, nursing home units, and home, the incidence and patterns of relocation associated with hip fracture have not been well characterized. Studies have examined outcomes of hip fracture patients discharged to different postacute care locations,6–8 but studies that describe patterns of relocation during an episode of care are limited.9,10 The American Geriatrics Society11 and others12–14 have identified the care transition as a frequently poorly executed process with potentially harmful consequences for patients, and others have documented gaps in preventive care after hip fracture that care fragmentation might influence.15,16 Examination of patterns of care transitions is an important first step in identifying and preventing adverse consequences of transitions between care sites. The objectives of this study were to describe the incidence and patterns of relocation during the care of patients with hip fracture, identify factors associated with patient relocation, and examine possible adverse effects of relocation on outcomes after hip fracture. It was hypothesized that patient relocation is common after hip fracture and that it occurs in recognizable patterns. If relocations have the potential to cause harm, an association between number or pattern of relocations and physical function or mortality may be detectable. Finally, a subgroup of patients with greater risk of relocation may be a candidate group to target with intensive care coordination and care planning interventions.

OBJECTIVES To examine the relationship between early physical therapy (PT), later therapy, and mobility 2 and 6 months after hip fracture.

BACKGROUND: Anemia and transfusion are common among elderly patients requiring surgery. The effects of transfusion on morbidity and mortality are controversial. The influence of transfusion on risk-adjusted mortality, readmissions, and functional mobility was examined. STUDY DESIGN AND METHODS: A consecutive cohort of 551 patients undergoing surgery for hip fracture at four hospitals was prospectively studied. Outcomes were death, readmission, and functional independence measure-locomotion scores within 60 days of discharge. The trigger Hb level was defined as the lowest value before the first postoperative transfusion. Multivariate analyses adjusted for a validated, hip-fracture-specific risk model and predictors of transfusion. RESULTS: Overall, 54.4 percent of patients received transfusions after surgery. Seventy-two percent of patients with a lowest postoperative Hb level of less than 10.0 g per dL received transfusions compared to 19.6 percent of those whose lowest measurement was at least 10.0 g per dL (p < 0.0001). In the 60 days after discharge, 3.8 percent of patients died and 16.9 percent were readmitted. Transfusion was associated with lower risk-adjusted odds of readmission (OR, 0.54; 95% CI, 0.30-0.97), but it did not influence mortality or mobility functioning. In subgroups analyses, the benefit of transfusion on readmission rates appeared to be concentrated among patients with a trigger Hb level of less than 10.0 g per dL. For patients with a trigger Hb level of at least 10.0 g per dL, transfusion did not affect risk-adjusted rates of death or readmission, but was associated with better risk-adjusted functional mobility scores (p < 0.01). CONCLUSIONS: Postoperative transfusion reduced the risk of readmission but did not decrease mortality or improve mobility. Randomized controlled trials of different transfusion strategies will be needed to clarify the true benefits and risks of transfusion in surgical patients.