Am. Kramer et al., OUTCOMES AND COSTS AFTER HIP FRACTURE AND STROKE - A COMPARISON OF REHABILITATION SETTINGS, JAMA, the journal of the American Medical Association, 277(5), 1997, pp. 396-404
Objective.-To assess whether outcomes and costs differ for elderly pat
ients admitted to rehabilitation hospitals, subacute nursing homes, an
d traditional nursing homes. Design.-Inception cohort stratified by pr
ovider type and followed prospectively for 6 months. Setting.-A total
of 92 hospital-based units and freestanding facilities from 17 states.
Patients.-A total of 518 randomly selected patients with hip fracture
and 485 stroke patients admitted from November 1991 to February 1994.
Main Outcome Measures.-At 6 months comparing community residence, rec
overy to premorbid levels in 5 activities of daily living (ADLs), Medi
care costs, and the number of therapy and physician visits. Outcomes w
ere adjusted for premorbid residence and function, caregiver availabil
ity, comorbid illness, admission function, cognition, depression, sens
ory deficits, and mobility impairments. Results.-On admission, rehabil
itation hospital patients were more likely (P<.001) to have caregivers
and better cognitive and physical function. Hip fracture patients adm
itted to rehabilitation hospitals did not differ from patients admitte
d to nursing homes in returning to the community (adjusted odds ratio
[OR], 1.3; 95% confidence interval [Cl], 0.6-2.6) or in the number of
ADLs recovered to premorbid level (difference, 0.09 ADL; 95% Cl, -0.27
-0.44), but stroke patients admitted to rehabilitation hospitals were
more likely to return to the community (adjusted OR, 3.3; 95% Cl, 1.5-
7.2) and recover ADLs (difference, 0.63 ADL; 95% CI, 0.201.07). Subacu
te nursing home patients with stroke were more likely than traditional
nursing home patients to return to the community (adjusted OR, 6.8; 9
5% Cl, 2.2-21 .4), there was no difference in return to the community
for patients with hip fracture (adjusted OR, 1.6; 95% Cl, 0.7-3.6), an
d there were no differences in recovery of ADLs for either condition.
Medicare costs were greater (P<.001) for rehabilitation hospital patie
nts than for subacute nursing home patients, and the costs for subacut
e nursing home patients were greater (P=.03 for stroke and .009 for hi
p fracture) than for traditional nursing home patients. Conclusions.-S
tudy findings are consistent with enhanced outcomes for elderly patien
ts with stroke treated in rehabilitation hospitals but not for patient
s with hip fracture. Subacute nursing homes were more effective than t
raditional nursing homes in returning patients with stroke to the comm
unity, despite comparable functional outcomes.