Changing Patterns of Hip Fracture Care Before and After Implementation of the Prospective Payment System

Abstract

We tested the hypothesis that since the implementation of the prospective payment system (PPS), elderly patients hospitalized for hip fractures receive shorter, less care-intensive hospitalizations and are more frequently institutionalized. In blinded fashion, we reviewed the charts of elderly patients with hip fractures admitted to a municipal hospital from 1981 through 1985. Demographic and clinical characteristics of patients treated before implementation of the PPS were similar to patients treated thereafter. After implementation of the PPS, the mean length of hospitalization fell from 16.6 to 10.3 days, and the mean number of physical therapy sessions received decreased from 9.7 to 4.9. Concomitantly, the proportion of patients discharged to a nursing home increased (21% to 48%), as did the proportion receiving nursing home care at six months after discharge (13% to 39%). This increase in long-term nursing home placement suggests that the quality of care for elderly patients with hip fractures may have deteriorated.

Comparison of lengths of hospital stay after surgery and mortality in elderly hip fracture patients between Japan and the United States – the relationship between the lengths of hospital stay after surgery and mortality

“…The increase in the number of patients remaining in nursing homes 1 year after the fracture suggests that the overall quality of care may have deteriorated although neither in-hospital mortality nor 1-year mortality changed significantly [5]. There are few studies that analyzed the effect of reducing LOS on outcomes in the US.…”

“…In the US, the Diagnostic Related Groups were instituted in 1983 for the purpose of reducing costs from over-utilization of health services [5]. The Japanese government has also tried to reduce the LOS to save costs by introducing a fixed payment plan and by separating care provided in rehabilitation hospitals from that provided in acute care hospitals, similar to what was done in the US.…”

Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia

“…About half of the patients in these hospitals are in long term institutional care. In the United States the mean length of hospital stay decreased from 21.9 to 12.6 days between 1981 and 1986 17. Shorter stays were associated with less inpatient treatment and an increase in placement in long term nursing home.…”

“…Shorter stays were associated with less inpatient treatment and an increase in placement in long term nursing home. 17 18…”

Challenge of aging.

“…Experience from the US warns that under the contractual prepayment system of the reformed NHS, one way that managers will seek to trim hospital costs will be by withdrawing rehabilitation from older patients. 3 The brief paragraph dealing specifically with older people is ambiguous and possibly misconceived (box). Although the importance of a healthier old age is recognised, the document offers no programme for ensuring good health in elderly people and age associated disability is not suggested as a key area.…”