Volume matters: Returning home after hip fracture

Objectives To examine the effect of the relationship between volume (number of hip fracture admissions during the 12 months before participant's fracture) and other facility characteristics on outcomes. Design Prospective observational study. Setting U.S. skilled nursing facilities (SNFs) admitting individuals discharged from the hospital after treatment for hip fracture between 2000 and 2007 (N = 15,439). Participants Community-dwelling fee-for-service Medi-care beneficiaries aged 75 and older admitted to U.S. hospitals for their first hip fracture and discharged to a SNF for postacute care from 2000 to 2007 (N = 512,967). Measurements Successful discharge from SNF to community, defined as returning to the community within 30 days of hospital discharge to the SNF and remaining in the community without being institutionalized for at least 30 days, was examined using Medicare administrative data, propensity score matching, and instrumental variables. Results The overall rate of successful discharge to the community was 31%. Of the 15,439 facilities, the facility interquartile range varied from 0% (25th percentile) to 42% (75th percentile). An important determinant of variation in discharge rate was SNF volume of hip fracture admissions. Unadjusted successful discharge from SNF to community was 43.7% in high-volume facilities (>24 admissions/year), versus 18.8% in low-volume facilities (1-6 admissions/year). This facility volume effect persisted after adjusting for participant and facility characteristics associated with outcomes (e.g., adjusted odds ratio = 2.06, 95% confidence interval = 1.91-2.21 for volume of 25 vs 3 admissions per year). Conclusion In community-dwelling persons with their first hip fracture, successful return to the community varies substantially according to SNF provider volume and staffing characteristics.