title: Post-acute pathways among hip fracture patients: a system-level analysis.
abstract: Hip fractures among older adults are one of the leading causes of hospitalization and result in significant morbidity, mortality, and health care use. Guidelines suggest that rehabilitation after surgery is imperative to return patients to pre-morbid function. However, post-acute care (which encompasses rehabilitation) is currently delivered in a multitude of settings, and there is a lack of evidence with regards to which hip fracture patients should use which post-acute settings. The purpose of this study is to describe hip fracture patient characteristics and the most common post-acute pathways within a 1-year episode of care, and to examine how these vary regionally within a health system.
  
  
  
  This study took place in the province of Ontario, Canada, which has 14 health regions and universal health coverage for all residents. Administrative health databases were used for analyses. Community-dwelling patients aged 66 and over admitted to an acute care hospital for hip fracture between April 2008 and March 2013 were identified. Patients' post-acute destinations within each region were retrieved by linking patients' records within various institutional databases using a unique encoded identifier. Post-acute pathways were then characterized by determining when each patient went to each post-acute destination within one year post-discharge from acute care. Differences in patient characteristics between regions were detected using standardized differences and p-values.
  
  
  
  Thirty-six thousand twenty nine hip fracture patients were included. The study cohort was 71.9 % female with a mean age of 82.9 (±7.5SD). There was significant variation between regions with respect to the immediate post-acute discharge destination: four regions discharged a substantially higher proportion of their patients to inpatient rehabilitation compared to all others. However, the majority of patient characteristics between those four regions and all other regions did not significantly differ. There were 49 unique post-acute pathways taken by patients, with the largest proportion of patients admitted to either community-based or short-term institutionalized rehabilitation, regardless of region.
  
  
  
  The observation that similar hip fracture patients are discharged to different post-acute settings calls into question both the appropriateness of care delivered in the post-acute period and health system expenditures. As policy makers continue to develop performance-based funding models to increase accountability of institutions in the provision of quality care to hip fracture patients, ensuring patients receive appropriate rehabilitative care is a priority for health system planning.
authors.affiliation: Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G1V7, Canada. kristen.pitzul@mail.utoronto.ca.
authors.forename: Kristen B
authors.initials: KB
authors.lastname: Pitzul
authors.affiliation: Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G1V7, Canada.|Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario, M5T3M6, Canada.|Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario, M561V7, Canada.
authors.forename: Walter P
authors.initials: WP
authors.lastname: Wodchis
authors.affiliation: Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G1V7, Canada.|Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario, M5T3M6, Canada.|Department of Mechanical and Industrial Engineering, University of Toronto, 5 King's College Road, Toronto, Ontario, M5S3G8, Canada.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Carter
authors.affiliation: Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G1V7, Canada.|Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario, M5T3M6, Canada.|Department of Surgery, University of Toronto, 2075 Bayview Avenue., MG-365, Toronto, Ontario, M4N3M5, Canada.
authors.forename: Hans J
authors.initials: HJ
authors.lastname: Kreder
authors.affiliation: Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario, M5T3M6, Canada.|Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario, M561V7, Canada.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Voth
authors.affiliation: Institute of Health Policy, Management, and Evaluation, University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G1V7, Canada.|Institute for Clinical Evaluative Sciences, 155 College Street, Suite 425, Toronto, Ontario, M5T3M6, Canada.|Toronto Rehabilitation Institute, University Health Network, 160-500 University Avenue, Toronto, Ontario, M561V7, Canada.|Department of Physical Therapy, University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G1V7, Canada.
authors.forename: Susan B
authors.initials: SB
authors.lastname: Jaglal
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006620:Hip Fractures / Q000534:rehabilitation*; D006760:Hospitalization; D006801:Humans; D007297:Inpatients; D008297:Male; D009864:Ontario; D010351:Patient Discharge; D019467:Subacute Care / Q000379:methods*; D013597:Systems Analysis
keywords: Care pathways; Health system planning; Hip fractures; Regional variation; Rehabilitation; Resource allocation