To date, policy directives based on anecdotal reports, drive utilization and treatment decisions. Although hip fracture is considered by Center for Medicare and Medicaid Services (CMS) as a medically appropriate diagnosis for Inpatient Rehabilitation Facility (IRF) care, little evidence is available to support this assumption. Building on sparse existing evidence, the overall objective of this project is to determine which client and system characteristics result in improved rehabilitation outcomes. An analytic file using two large national datasets, the CMS Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) and the Provider of Service (POS) file, will be constructed to test regression models of factors that may explain differences in rehabilitation outcomes between two time points, admission and discharge from IRFs. Using the Andersen's Model for Health Services Use as the conceptual framework, the proposed longitudinal study aims to: (1) determine the influence of individual characteristics (Predisposing: age, gender, race), (Enabling: social support), (Need: functional status and cognitive status on admission, and comorbidities) on rehabilitation outcomes (motor functioning, functional status and discharged home) for Medicare beneficiaries with hip fracture in IRFs;and (2) determine the influence of contextual characteristics (type, size, location, ownership and nurse staffing) on IRF aggregate rehabilitation outcomes (motor functioning, functional status, and discharge home), controlling for the influence of aggregate individual characteristics (Predisposing, Enabling and Need) of Medicare beneficiaries with hip fracture in IRFs. This study will inform the policy debate on which types of patients are most appropriate for IRFs and will determine the effectiveness of IRFs in delivering rehabilitative treatment based on specific individual and contextual characteristics associated with rehabilitative outcomes among hip fracture patients and vulnerable subgroups (i.e., racial/ethnic minorities, older adults without adequate social support and those 85 years and older). Of particular concern is determining the evidence base to indicate that such effectiveness will result in positive outcomes among racial/ethnic minorities. Given the growing national interest in health disparities, it becomes increasingly important to determine if there are differences in outcomes based on race/ethnicity. Health disparities remain a major research focus of the National Institute of Nursing Research (NINR). The proposed research and subsequent analysis will add to the current body of nursing knowledge by identifying characteristics that better inform interventions that look to eliminate racial/ethnic disparities.

Public Health Relevance

The Centers for Disease Control and Prevention estimate that more than 350,000 hip fractures occur annually in the US with a lifetime attributable cost of $81,300 from a hip fracture, including care provided during acute hospitalization and across the post-acute continuum (inpatient rehabilitation, skilled nursing and home health). For many older adults, the personal costs of a fractured hip results in chronic disability and complications, loss of independent ambulation, functional dependence and death. With the growing numbers of older adults and the complexity of their health conditions, appropriate and effective geriatric rehabilitation services are needed. The nation's baby boomers will be turning age 65 in 2011 and will bring about major demographic changes which will certainly influence the delivery of health care. Consequently, in order to effectively care for an aging population with increasing rates of injury and chronic diseases, nurses and other health care providers require the evidence base indicating what is effective and why. Outcomes from the proposed study may be used in systematic reviews and meta-analyses to inform policy decisions about the appropriateness of care which looks to optimize outcomes based on valid clinical endpoints.

National Institute of Health (NIH)
National Institute of Nursing Research (NINR)
Predoctoral Individual National Research Service Award (F31)
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National Institute of Nursing Research Initial Review Group (NRRC)
Program Officer
Banks, David
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University of Virginia
Schools of Nursing
United States
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Goode, Victoria; Crego, Nancy; Cary Jr, Michael P et al. (2017) Improving Quality and Safety Through Use of Secondary Data: Methods Case Study. West J Nurs Res 39:1477-1501
Cary Jr, Michael P; Baernholdt, Marianne; Merwin, Elizabeth I (2016) Changes in Payment Regulation and Acute Care Use for Total Hip Replacement: Trends in Length of Stay, Costs, and Discharge, 1997-2012. Rehabil Nurs 41:67-77
Cary Jr, Michael P; Merwin, Elizabeth I; Oliver, M Norman et al. (2016) Inpatient Rehabilitation Outcomes in a National Sample of Medicare Beneficiaries With Hip Fracture. J Appl Gerontol 35:62-83
Cary, Michael P; Baernholdt, Marianne; Anderson, Ruth A et al. (2015) Performance-based outcomes of inpatient rehabilitation facilities treating hip fracture patients in the United States. Arch Phys Med Rehabil 96:790-8