Survival and functional outcomes after hip fracture among nursing home residents

Abstract

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.

Figure 1

Survival at up to 365 days among 60,111 U.S. 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<0.001 by log-rank test).

Figure 2

180-day survival and within-subjects 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 post-fracture 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.