Reasons for readmission to hospital after hip fracture: Implications for occupational therapy

Abstract

Introduction

The aim of this study was to determine the rate of readmission to hospital after hip fracture. The relationship between readmission to hospital and a range of social and functional variables, including receiving a home visit by an occupational therapist prior to discharge from hospital, was explored.

Method

A retrospective cohort study was conducted of 154 patients returning to community living following hip fracture. Multivariate logistic regression identified variables associated with risk of readmission to hospital.

Results

One in three patients was readmitted to hospital within 12 months after discharge, with 7% readmitted within 30 days. The most common reason for readmission was another fall. A low level of mobility prior to hip fracture was the strongest independent predictor of risk of readmission to hospital. There was no association between receiving a pre-discharge home visit by an occupational therapist and risk of readmission to hospital.

Conclusion

Rates of readmission to hospital are high after hip fracture, and falls are the single most common reason for readmission. Interventions provided by occupational therapists, including home visits, should emphasise and incorporate evidence-based falls prevention strategies.

Keywords

Occupational therapy readmission hip fracture home visit falls discharge planning

Introduction

Hip fractures in older adults are common and substantially increase the risk of long term health problems and premature death. Almost one in five patients with hip fracture are still having assistance with bathing and showering more than 6 months post fracture (Pasco et al., 2005). After a year, more than half of all patients with hip fracture are still unable to walk independently, and only 1 in 10 consider that they have regained their pre-fracture mobility (Pasco et al., 2005).

Hip fracture is the leading orthopaedic discharge diagnosis associated with 30-day readmission to hospital, with rates reported at between 4% and 18% (Goodman et al., 2011; Kates et al., 2015a; Pollock et al., 2015; Weiss et al., 2013). Hospital readmission is costly for patients, hospitals and the community. One study from the United States (US) reported that one in five elderly Medicare patients are readmitted to hospital within 30 days, at an estimated cost of $US 17 billion (Jencks et al., 2009). Readmission following hip fracture has also been associated with prolonged hospitalisation, worsening prognosis and increased mortality (Boockvar et al., 2003; Kates et al., 2015a, 2015b).

In a recent systematic review, patient-related factors such as age, comorbidities and functional status were found to be independent predictors of risk of hospital readmission following hip fracture (Ali and Gibbons, 2017). Social factors, such as socioeconomic status, living situation, home resources and social support, have also been associated with readmission risk following a period of hospitalisation (Calvillo-King et al., 2013). DePalma et al. (2013) found that unmet need for assistance with activities of daily living (ADL) on discharge from hospital was linked to an increased risk of readmission to hospital, particularly amongst patients with recently acquired disabilities.

Discharging patients from hospital is a complex process and the transition from hospital to home has been identified as a high-risk time for patients. There is an acknowledgement of a period of vulnerability to a variety of adverse health events following discharge from hospital as a result of functional impairments and stress from hospitalisation (Krumholz, 2013). Interventions provided in hospital that address deficits in both functional ability and social resources are likely to be effective in getting patients back into their own homes (Ellis et al., 2011; Rogers et al., 2017). McGilton et al. (2016) suggested that if the benefits of inpatient rehabilitation are to persist after discharge then rehabilitation interventions need to be deliverable in the home and customised to the individual.

Occupational therapy is one profession that has a key role in planning for the transition from the hospital environment to home. Interventions commonly provided by occupational therapists include provision of adaptive equipment, health education and active practice of daily living skills in preparation for discharge. In some settings, occupational therapists may complete a home visit prior to discharge to determine whether patients are able to manage their daily occupations in their home environment or provide home modifications and equipment to support patients as they readjust following a period of hospitalisation. A recent systematic review found that pre-discharge home visits by occupational therapists may reduce the risk of readmission to hospital, particularly in patients following orthopaedic trauma (Lockwood et al., 2015). However, we need to better understand the role that home visits play in supporting patients after hip fracture as they transition from hospital to home.

In recent years, there has been an emphasis on keeping people out of hospitals and residential care facilities as long as possible. This is not only more cost effective, it is also the option preferred by the majority of older people themselves (Chappell et al., 2004; Wiles et al., 2011). Early identification of patients who are at high risk of readmission to hospital, combined with targeted actions and risk reduction strategies, may have the potential to keep people in their homes for longer. However, there is little to guide occupational therapists about how to predict which patients are at risk of readmission and subsequently attempt to reduce hospital readmissions.

The aim of this study was to focus on patients returning home to community living after hip fracture and determine the rate of readmission in the 30 days and first 12 months after discharge. We also aimed to explore the relationship between readmission to hospital and a range of social and functional variables, including receiving a home visit by an occupational therapist prior to discharge from hospital.

Method

Study design

A retrospective cohort study of patients admitted to a major metropolitan health service following hip fracture was completed. Data for the study were retrieved from hospital medical records for the initial admission and for any admission for the 12 months after discharge. Approval to analyse the data for the current project was obtained from both the health service and university human research ethics committees. Written informed consent from participants was not required for this study as anonymised data were retrieved from hospital medical records.

Patient population

Patients hospitalised for hip fracture between 1 January 2013 and 31 December 2013, within a large publicly funded metropolitan health service (comprising four acute hospitals and four rehabilitation centres) providing services for close to 800,000 people over a large geographical area, were eligible for the study. Participants were included if they were admitted as an inpatient to an acute hospital in the health service, were over 50 years of age, had a primary diagnosis of hip fracture and were admitted from a private residence and returned to a private residence on discharge from hospital.

Data

Data were collected for all patients using hospital medical records. Data collected included demographic information, comorbidities, functional status, whether or not a home visit was completed during the admission and referral to rehabilitation and support services provided on discharge from hospital. The occurrence and cause for hospital readmissions within 12 months of discharge and the number of overnight stays in hospital were also recorded.

Data analysis

Descriptive statistics were used to describe the characteristics of the sample and causes of readmission to hospital. Univariate analyses were conducted comparing patients who were readmitted to hospital following hip fracture and patients who were not at both 30 days and 12 months. The variables of age (based on a cut off of 85 years), length of stay (based on median length of stay) and comorbidities (based on a cut off of one) were dichotomised for the purposes of the univariate analysis, to enable all comparisons to be expressed as odds ratios. The outcomes of readmission to hospital at 30 days and readmission at 12 months were calculated separately. Explanatory variables having a univariate test with p value cut off point of 0.25 or less were selected as candidates for the multivariate analysis (Bursac et al., 2008). Multivariate logistic regression was conducted using a backward elimination method to identify variables independently associated with readmission to hospital at 12 months following hip fracture. Vittinghoff and McCulloch (2007) suggest that between 5 and 10 events are needed per predictor variable in a logistic regression. The number of readmissions to hospital in the first 30 days after discharge was too small to explore the association with predictor variables using logistic regression and was therefore not included in the multivariate analysis. All analyses were performed using SPSS version 22 (IBM Corp., 2013).

Results

There were 264 patients discharged from hospital following a hip fracture in the 12-month period. Of these patients, 154 returned to a private residence on discharge from hospital. The mean age of the study population was 79.1 (SD: 10.7) years, and 71% (n = 109/154) of the population was female. Prior to their hip fracture, three-quarters of the patients were able to walk independently (76%, n = 117/154) and the majority were independent completing personal care tasks (85%, n = 131/154). On discharge from hospital, 40% (n = 61/154) returned to living alone, with 54 patients (35%) receiving a home visit by an occupational therapist prior to discharge. The median length of stay in hospital, including both acute care and rehabilitation, was 25.0 (SD: 22.9) days. Upon discharge back to their previous residence, only 5% of patients (n = 8/154) were able to walk independently with or without a stick, and approximately half (49%, n = 76/154) were able to complete personal care tasks independently with or without aids. Half of patients discharged home were referred to formal community support services (53%, n = 81/154) and two-thirds were referred for follow up community rehabilitation (69%, n = 106/154). Characteristics of the participants are outlined in Table 1.

Table 1.

Characteristics of patients and association with hospital readmission.

Variables	n (%)	Readmission 30 days	OR (95% CI)	Readmission 12 months	OR (95% CI)
Total	154	11 (7)		47 (31)
Gender			1.1 (0.3–4.4)
Female	109 (71)	8 (7)		36 (33)	1.5 (0.7–3.4)
Male	45 (29)	3 (7)		11 (24)
Age			3.1 (0.9–11.0)		2.1 (1.1–4.3)*
<85 years	95 (62)	4 (4)		23 (24)
≥85 years	59 (38)	7 (12)		24 (41)
Language (Interpreter)			0.6 (0.1–4.5)		0.8 (0.3–2.1)
Yes	23 (15)	1 (4)		6 (26)
No	131 (85)	10 (8)		41 (31)
Living situation			3.2 (0.7–15.2)		1.2 (0.6–2.5)
With others	93 (60)	9 (10)		30 (32)
Alone	61 (40)	2 (3)		17 (28)
History of falls (other than fall resulting in fracture)
Yes	33 (21)	4 (12)	2.2 (0.6–8.2)	14 (42)	2.0 (0.9–4.4)†
No	121 (79)	7 (6)		33 (27)
Documented history of cognitive decline			1.3 (0.3–5.2)		2.0 (0.9–4.6)†
Yes	35 (23)	3 (9)		15 (43)
No	119 (77)	8 (7)		32 (27)
Comorbidities			1.8 (0.2–14.9)		5.5 (1.2–24.5)*
≤1	23 (15)	1 (4)		2 (9)
2+	131 (85)	10 (8)		45 (34)
Premorbid mobility			4.3 (1.2–15.2)*		2.9 (1.3–6.2)*
Independent ± stick	117 (76)	5 (4)		29 (25)
Other aid	37 (24)	6 (16)		18 (47)
Mobility on discharge			0.7 (0–12.9)		0.3 (0–2.6)
Independent ± stick	8 (5)	0 (0)		1 (13)
Other aid	146 (95)	11 (8)		46 (32)
Premorbid ADL status			3.7 (1.0–14.0)*		2.4 (1.0–6.0)*
Independent ± aids	131 (85)	7 (5)		36 (27)
Assistance	23 (15)	4 (17)		11 (48)
Personal ADL status on discharge			0.6 (0.2–2.0)		0.7 (0.3–1.3)
Independent ± aids	76 (49)	4 (5)		20 (26)
Assistance	78 (51)	7 (9)		27 (35)
Formal support services on discharge			1.0 (0.3–3.7)		1.5 (0.7–3.0)
Yes	81 (53)	6 (7)		28 (36)
No	73 (47)	5 (7)		19 (26)
Community rehabilitation post discharge			0.8 (0.2–2.8)		1.0 (0.5–2.0)
Yes	106 (69)	7 (7)		32 (30)
No	48 (31)	4 (8)		15 (31)
Home visit			1.6 (0.5–5.5)		1.2 (0.6–2.5)
Yes	54 (35)	5 (9)		18 (33)
No	100 (65)	6 (6)		29 (29)
LOS, days			3.1 (0.8–12.2)		2.8 (1.3–6.0)*
≤25	80 (52)	3 (4)		18 (22)
26+	74 (48)	8 (11)		29 (39)

LOS: length of stay; ADL: activities of daily living; CI: confidence interval; OR: odds ratio.

p < 0.05

†

p < 0.25

Eleven patients (7%) were readmitted within 30 days of discharge from hospital and 47 patients (31%) were readmitted to hospital within 12 months of discharge. Seven patients (15%) were readmitted more than once. The reasons for readmission are outlined in Table 2. Over the 12-month period, patients were four times more likely to be admitted for medical versus surgical complications (81% [n = 38] versus 19% [n = 9]). Within the 12 months following the initial hospital admission for hip fracture, 9% (n = 14/154) were readmitted to hospital with a fall and close to half of these falls resulted in a fracture (43%, n = 6/14). Four patients (3%) died within 30 days of discharge and seven patients (5%) died within 12 months of discharge. Musculoskeletal conditions (not related to the surgical site) (9%, 4/47) and non-orthopaedic infection (11%, 5/47) were the most common medical complications for readmission during the 12 months after discharge.

Table 2.

Reasons for hospital readmission.

Reasons for readmission	30 days n (%)	12 months n (%)
Fracture
Hip	0 (0)	2 (4)
Other	1 (9)	4 (9)
Fall	1 (9)	8 (17)
Complication of surgery	0 (0)	1 (2)
Other musculoskeletal	0 (0)	4 (9)
Not coping	0 (0)	1 (2)
Cardiac	2 (18)	3 (6)
Neurologic	1 (9)	3 (6)
Neoplasm	0 (0)	3 (6)
Infection
Pneumonia	2 (18)	3 (6)
Skin	1 (9)	2 (4)
Gastrointestinal	2 (18)	3 (6)
Respiratory	1 (9)	2 (4)
Metabolic	0 (0)	3 (6)
Other	0 (0)	5 (11)
Total	11 (100)	47 (100)

The univariate analysis showed that patients older than 85 years were more likely to be readmitted within 12 months (OR 2.1, 95% CI 1.1–4.3), as were patients with more than one co-existing disease (OR 5.5, 95% CI 1.2–24.5) (Table 1). Patients who required greater levels of assistance with their mobility prior to their hip fracture (OR 2.9, 95% CI 1.3–6.2) and patients whose initial hospitalisation was longer than the median length of stay (OR 2.2, 95% CI 1.1–4.5) were also more likely to be readmitted to hospital within the 12 months following discharge. Requiring greater levels of assistance with walking, such as use of a frame or assistance of a carer, was associated with a greater risk of readmission to hospital at 30 days (OR 4.3, 95% CI 1.2–15.2).

Multivariate analysis with 12-month readmission as the dependent variable showed that mobility prior to hip fracture was an independent predictor of readmission to hospital within 12 months of discharge (OR 2.4, 95% CI 1.1–5.3) (Table 3). The seven independent variables in the logistic regression model together accounted for only 10.4% of the explanation for why patients were readmitted to hospital. Receiving a home visit prior to discharge was not associated with risk of readmission to hospital in the univariate analysis and so was not included in the multivariate analysis.

Table 3.

Multivariate logistic regression

Variable	Co-efficient	SE	Wald	Sig.	OR (95% CI)
Premorbid mobility	0.894	0.399	5.025	0.025	2.446 (1.119–5.345)
Comorbidity	1.492	0.771	3.745	0.053	4.446 (0.981–20.146)

Sig: significance; SE: standard error

Discussion and implications

Hospital readmission after hip fracture occurs frequently, even in patients considered well enough to return to living in the community. Results from this study found that approximately one in three patients discharged back to a private residence was readmitted to hospital within the 12 months after discharge, with 7% readmitted within 30 days. The findings of this study are comparable to other studies, with 30 day readmission rates reported between 4% and 18% (Kates et al., 2015a). The rate of readmission to hospital in this study was at the lower end of the range reported in other studies, but this may be because the inclusion criteria for the study was limited to people who returned to living independently in the community. Although few studies have investigated the readmission rate over a 12-month period after hip fracture, the rate of readmission was similar to that reported in other studies (Heyes et al., 2015; Teixeira et al., 2009).

Premorbid mobility was the strongest independent predictor of risk of readmission to hospital, controlling for other factors such as age, comorbidity and length of stay in hospital. Patients with lower levels of mobility prior to their hip fracture had twice the odds of being readmitted to hospital compared to those who were able to walk independently with or without a walking stick (OR 2.4; 95% CI 1.1–5.3). This suggests patients who are fitter and more mobile prior to their hip fracture have a better recovery and fewer complications likely to lead to readmission to hospital. These results are consistent with other studies that have shown that better premorbid functioning is associated with better functional outcomes following hip fracture (Alegre-López et al., 2005; Eastwood et al., 2002; Ganz et al., 2007; Koval et al., 1998; Magaziner et al., 1990).

The results of this study suggest that there are some differences in patients who required readmission to hospital and those who did not. The univariate analysis showed that patients older than 85 years were at a higher risk of readmission to hospital in the 12 months following discharge (OR 2.1; 95% CI 1.1–4.3). Patients who had more than one active medical problem were also more likely to be readmitted to hospital (OR 5.5; 95% CI 1.2–24.5). Similar findings have been reported in other studies and are consistent with the increased frailty and susceptibility to medical illness experienced by the hip fracture population (Kates et al., 2015a). These risk factors could be considered unmodifiable and highlight the need for preventive care in older adults.

This study also found that patients following hip fracture with a longer length of stay in hospital had nearly three times the odds of being readmitted compared to those who were discharged within the median length of stay (25 days for both acute and subacute hospitalisations combined) (OR 2.8; 95% CI 1.3–6.0). This suggests that patients who have fewer complications or interruptions to their recovery while they are in hospital are less likely to be readmitted. Other studies have also reported that prolonged hospitalisation after hip fracture is associated with early mortality (Nikkel et al., 2015). This probably reflects an elderly, fragile population and so, although the trajectory of this population’s long term health may not be able to be altered, there should be a focus on rectifying problems within the health system that contribute to poorer health and quality of life outcomes. However, the variables of longer length of stay, older age and having more than one active medical problem did not make an independent contribution to the risk of readmission when included in the multivariate analysis. Therefore, it is important not to over-interpret their possible contribution to readmission.

In the current study, patients were four times more likely to be readmitted for medical versus surgical complications, and this is consistent with the results of other studies (Boockvar et al., 2003). Musculoskeletal conditions not related to the initial fracture site at the hip and non-orthopaedic infection were the most common reasons for readmission to hospital. This is not surprising given the general frailty and high number of active clinical problems experienced by patients admitted to hospital with a hip fracture. The results suggest that patients are discharged from hospital to return to living in the community, but they remain at high risk. It reinforces the importance of the care provided in the transition from hospital to home. This includes effective discharge planning, effective communication between families and care providers, and ensuring patients and families have the ability to self-manage their health care and advocate for their health needs (Allen et al., 2014; Coleman and Boult, 2003). A seamless transition between hospital and home is important particularly in relation to the timing of the supports and services that are put in place. These supports also need to be available for long enough, with appropriate follow up, so that patients and families can reach the level of independence to manage their day to day activities following their change in health status.

Occupational therapists make a unique contribution to the multi-disciplinary team in consideration of the home environment and how it supports or hinders people in their daily occupations. The current study points to the importance of this role so that occupational therapists can co-produce practical solutions alongside patients to manage the transition from hospital to home and provide a safe and supported environment for patients to resume their everyday activities.

Data from the current study showed that the single most common reason that patients were readmitted to hospital following a hip fracture was a fall. Around one-tenth of patients in this study were readmitted having experienced another fall, and close to half of those falls resulted in another fracture. This is supported by other studies that report that recurrent falls are common after hip fracture (Deandra et al., 2010; Harstedt et al., 2015; Lloyd et al., 2009). There is evidence that falls prevention programmes reduce risk of falls (Hill et al., 2015). The strongest results are found for multifactorial programmes that include patient education, home evaluations and home modifications, and physical activity, vision and medication checks (Chase et al., 2012). Occupational therapy interventions have been shown to be effective in reducing the rate of falls and this is likely to be because the interventions consider how the person interacts with the environment while participating in their occupations (Clemson et al., 2008; Gillespie et al., 2012; Pighills et al., 2011). Occupational therapists should therefore place strong emphasis on providing evidence-based falls prevention strategies linked to the initial hospitalisation for hip fracture. This is particularly important given that knowledge of falls prevention strategies remains low in older people (Hill et al., 2011). Occupational therapists can play a key role in exploring older people’s views about falls and their prevention, discussing potential strategies to improve confidence and getting the person involved in modifying the risk (Ballinger and Brooks, 2013). Occupational therapists can assess the home and advise on modifications, but it is also important to advise on how to incorporate activities to improve strength and balance into daily occupations and routines to find the right balance between participating in everyday activities and safety.

Having an understanding of the patient characteristics that are associated with hospital readmission provides an opportunity for occupational therapists and other clinicians to identify patients at risk and allocate their resources accordingly. Occupational therapists may be in a position to help mitigate these risks by providing targeted falls prevention programmes, facilitating the provision of additional community support services, referring on to home-based rehabilitation providers, or recommending equipment or home modifications to improve safety for patients who were already reporting mobility limitations prior to their hip fracture. An increased awareness of risk factors may also support occupational therapists to have open conversations with patients and families about the risks and benefits of continued independence, and support people to make informed choices.

The results of this study did not show any association between providing a home visit by an occupational therapist prior to discharge from hospital and risk of readmission to hospital after hip fracture. There was also no demonstrated association between providing support services or community rehabilitation services. However, it is possible that only those patients with a higher risk of readmission received a home visit or additional support services and so any potential benefits of these interventions may have been masked by other confounding variables and therefore not reflected in the readmission data. A randomised controlled trial would be required to truly evaluate the benefit of these interventions. However, it is worth considering whether current pre-discharge home visiting practices sufficiently address issues in relation to falls prevention and also whether a post-discharge home visit would be more effective than a pre-discharge home visit. Since having a fall is the most common reason for readmission, this suggests that interventions provided by occupational therapists, including home visits, should emphasise and incorporate evidence-based falls prevention strategies (Chase et al., 2012; Hill et al., 2015).

There are several limitations to our study. Our patient cohort is relatively small, with only 154 patient records reviewed over a 12-month period, but detailed outcomes for patients returning to live independently in the community after hip fracture were reported. Our study was retrospective, which limited measurement of the factors to what was recorded in the medical records. However, data were collected on all patients returning home after hip fracture in a 12-month period and so were representative of the population. Data were collected at a single health service, but it was a large health service with eight sites covering metropolitan, outer metropolitan and regional areas. Data collected on support services and community rehabilitation reflects referrals documented as part of the discharge plan in the medical record. It is possible that there were cases where services were planned but never delivered, but we expect that these would be rare (we know, for example, that more than 99% of patients referred to community rehabilitation after hip fracture during the trial period attended at least one session) and unlikely to impact on the data.

Conclusion

One in three patients discharged home to live independently in the community after a hip fracture was readmitted to hospital within 12 months. The most common reason for readmission to hospital was another fall, with close to half of the falls resulting in another fracture. Mobility prior to hip fracture was the strongest independent predictor of risk of readmission to hospital, with patients with lower levels of mobility having twice the odds of being readmitted compared to those who were able to walk independently with or without a walking stick prior to their hip fracture. Occupational therapists are well positioned to affect the clinical outcome for this group of patients by using their expertise and understanding of how the person, environment and occupation factors can impact on a person’s health and wellbeing and providing education related to risk factors, modifying the environment and facilitating additional services and rehabilitation for these patients as they transition home.

Key findings

Rates of readmission to hospital are high after hip fracture, and falls are the single most common reason for readmission.

Poor mobility prior to hip fracture was the strongest independent predictor of risk of hospital readmission.

Pre-discharge home visits were not associated with risk of readmission.

What the study has added

The areas of focus for occupational therapists working with patients during recovery from hip fracture to reduce the risk of hospital readmission are targeted falls prevention programmes, effective discharge planning and support to transition from hospital to home.

Footnotes

Acknowledgments

Kylee Lockwood is supported by an Australian Government Research Training Program (RTP) scholarship.

Research ethics

Ethics approval was obtained from Eastern Health Human Research Ethics Committee and La Trobe University Human Research Ethics Committee in January 2015, reference no. LR123/ 1314. Written informed consent from participants was not required for this study as anonymised data were retrieved from hospital medical records.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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