Author: Chow, Hoi Wan Intonia
Title: Prediction of home discharge in early acute phase of rehabilitation after hip fracture
Advisors: Pang, Marco (RS)
Degree: DHSc
Year: 2020
Subject: Hip joint -- Fractures -- Treatment
Hip joint -- Fractures -- Patients -- Rehabilitation
Hong Kong Polytechnic University -- Dissertations
Department: Faculty of Health and Social Sciences
Pages: 106 pages
Language: English
Abstract: Background: Hip fractures, a major cause of morbidity, inevitably require hospitalization and are increasingly being recognized as a significant public health concern worldwide. According to the report published at the International Osteoporosis Foundation Regionals 4th Asia-Pacific Osteoporosis Meeting held at Hong Kong in December 2013, an exponential increase is expected in the absolute numbers of hip fractures, leading to a significantly high socioeconomic burden on communities and health care systems. Increasing life expectancy and population aging are global phenomena and although they represent medical, social, and economic advances over disease and mortality, they present significant challenges. Following hip fractures, a few elderly patients become dependent and are unable to regain their pre-fracture mobility. These patients cannot adequately perform their activities of daily living, develop permanent disability and cannot return to their pre-fracture residential status despite successful surgery and adequate rehabilitation. Early prediction of rehabilitation potential and discharge disposition in patients with hip fractures is essential along with effective coordination between multidisciplinary health care teams for optimal discharge planning. Patients' pre-fracture functional status, cognition, as well as sociodemographic and psychosocial factors are important predictors of the discharge disposition in patients with hip fractures. Notably, there is lack of conclusive scientific evidence regarding the role of hip pain severity, extent of physiotherapy training, social support and self-efficacy of patients as predictors of the discharge disposition in these patients. This study investigated the rehabilitation potential of patients with hip fractures to identify those who would be best suited for early discharge to their homes and those who might need further inpatient rehabilitation training in convalescent care settings. In this high-quality comprehensive research, we analyzed a wide range of sociodemographic, clinical, functional, and psychosocial variables using standardized and valid outcome measures to quantify the aforementioned predictors. Objectives: To identify potential predictors of home discharge in the early acute phase of postoperative rehabilitation after a hip fracture. These results can help with the following: (i) optimization of recovery of patients after hip fractures by ensuring realistic goal setting for rehabilitation, (ii) ensuring better discharge planning during the phase of acute hospitalization and, (iii) better allocation of rehabilitation resources. Setting: Inpatient physiotherapy orthopedic rehabilitation unit. Participants: This study recruited 143 elderly patients with a unilateral hip fracture. Methodology: This prospective study included 143 consecutive elderly patients (aged ≥65 years) with literacy in Chinese, who were treated surgically for a unilateral hip fracture at Queen Elizabeth Hospital. Following were the exclusion criteria for this study: age <65 years, hip fractures treated conservatively, inability to walk before the fracture, pathological hip fractures or those associated with malignancy, associated injuries such as upper limb or pelvic fractures, concomitant major injuries such as multiple trauma secondary to traffic accidents, rheumatoid arthritis, inability or refusal to provide informed consent, inability to read and write Chinese, hospitalization >24 hours after the hip fracture, and language barrier. Written informed consent was obtained from all patients before study commencement. A standardized integrated multidisciplinary clinical pathway for fragility hip fractures was implemented for the management of all recruited patients. All patients received pre- and postoperative physiotherapy, including chest physiotherapy, pain-relief management, deep vein thrombosis prevention, edema control, mobilization and strengthening exercises, bed mobility and transfer training, ambulatory and functional training, and patient education. The following parameters were documented pre- and postoperatively during hospitalization: sociodemographic data, severity of hip pain during walking training, mobility based on the Elderly Mobility Scale, cognitive function based on the Mini-Mental State Examination (MMSE), self-efficacy based on the Self-Efficacy for Exercise Scale, the extent of physiotherapy training, and availability of caregivers. The final discharge disposition of the recruited patients was confirmed via a 5-minute telephone interview 6 weeks postoperatively. Data Analysis: All information was entered into a Microsoft Excel document (version 2010, Microsoft Corporation) for data entry and retrieval. Descriptive statistics was used to summarize the central tendency and variability of all variables. The dependent variable was dichotomous (i.e., we determined whether or not patients could be discharged to their own home or to their previous residence 6 weeks postoperatively). Univariate logistic regression analysis was initially performed to identify potentially useful predictors. Subsequently, multiple logistic regression analysis using the 'Enter' method was performed to determine significant predictors of the discharge disposition and their respective odds ratios in patients with hip fractures. The significance level (alpha value) was set at 0.05 for statistical analysis.
Results: The study included 143 patients, of which 34 who did not meet the inclusion criteria were excluded (e.g., those who died postoperatively, those residing in old age homes before the hip fracture, and those who were hospitalized at the time of the telephone follow-up 6 weeks postoperatively). Finally, 109 patients were investigated (44 men [40.4%] and 65 women [59.6%]). Multiple logistic regression analysis showed that sex (p=0.042, odds ratio [OR] 2.927, 95% confidence interval [CI] 1.042-8.218), total number of physiotherapy sessions (p=0.032, OR 1.161, 95% CI 1.013-1.332), the preoperative MMSE score (p=0.022, OR 1.103, 95% CI 1.014-1.199), and availability of caregivers (p=0.017, OR 4.531, 95% CI 1.311-15.657) were significant predictors of home discharge in patients with hip fractures. Conclusion: The present study revealed that female sex, more physiotherapy rehabilitation training, better preoperative cognitive function, and availability of caregivers were significant predictors of home discharge after hip fractures. This information is important for clinical decision-making to assess the rehabilitation potential of patients with hip fractures and to identify those who need further inpatient rehabilitation training in convalescent care settings. Our findings would be useful to optimize rehabilitation outcomes and for the efficient utilization of levels of care, thereby ensuring better allocation of health care resources to reduce the financial burden on health care services. These results could serve as guidelines for effective coordination between physiotherapists and other medical professionals to design the discharge pathway and destination for optimal discharge planning.
Rights: All rights reserved
Access: restricted access

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