High-volume facilities better for nursing hip fractures

The sweeping new analysis shows that the most experienced skilled nursing facilities were more than twice as likely as the least experienced to successfully discharge patients back to the community within 30 days of breaking a hip. The results, led by Brown University researchers, appear in the Journal of the American Geriatrics Society.

"While volume is not a direct measure of post-acute care quality, it appears that it is a good proxy that captures hard-to-measure aspects of quality, like the expertise of the staff, that are clearly associated with an outcome that patients care about: returning home soon and in a condition that allows them to remain at home without further institutionalization in a hospital or a nursing home," said lead author Pedro Gozalo, associate professor (research) of health services, policy and practice in the Brown University School of Public Health.

Gozalo and his colleagues reviewed records of more than 512,000 patients age 75 and older who sought care at more than 15,400 skilled nursing facilities between 2000 and 2007. The researchers measured the volume of cases at each of the facilities in the 12 months leading up to each admission and noted whether the patient was discharged to the community within 30 days.

In all, about 31 percent of people were able to return home within a month, but that rate varied widely among facilities of different experience. The rate of successful discharge from facilities with more than 24 cases in the prior year was 43.7 percent, but it was only 18.8 percent at facilities with one to six cases a year.

To check whether this could be for some reason other than volume, Gozalo and his colleagues statistically accounted for a large number of attributes of the patients and of the facilities, such a nurse and therapist staffing levels.

"Even adjusting for a long list of patient risk factors and for important facility characteristics, facilities that had cared for more than two dozen hip fracture patients in the last 12 months were more than twice as likely to successfully discharge patients in a timely manner compared to facilities that had three or less hip fracture admissions," Gozalo said.

You better shop around

The study also revealed that many patients are not going to higher-volume facilities, even though they could. According to the records, more than 70 percent of people who went to a lower-volume facility could have found a higher-volume facility within 10 miles.

That finding, Gozalo said, suggests that people don't have much information about quality. The Centers for Medicare and Medicaid Services make some information available, but that can be hard for many families to access and interpret. Hospital discharge planners also vary widely in what information they provide to families.

"Based on our results, it would seem that in addition to any other sources of information and recommendations the family can get, they should definitely ask each facility they are considering what was the number of hip fractures they cared for in the last year," Gozalo said. "It's a basic but very informative predictor of how well their loved one may fare at that facility."