Inpatient Rehabilitation Outcomes in Medicare Hip Fracture Patients

描述（由申请人提供）：迄今为止，基于轶事报告的政策指令驱动了利用和治疗决策。虽然髋部骨折被医疗保险和医疗补助服务中心（CMS）认为是住院康复设施（IRF）护理的医学上适当的诊断，但很少有证据支持这一假设。在现有证据的基础上，该项目的总体目标是确定哪些客户和系统特征会导致改善的康复结果。使用两个大型国家数据集，CMS住院康复设施-患者评估工具（IRF-PAI）和服务提供者（POS）文件，将构建一个分析文件，以测试回归模型，这些模型可能解释两个时间点（irf入院和出院）之间康复结果的差异。本研究以安徒生健康服务使用模型为概念框架，旨在：(1)确定个体特征（易感因素：年龄、性别、种族）、（使能因素：社会支持）、（需要因素：入院时的功能状态和认知状态，以及合并症）对住院髋部骨折医疗保险受益人康复结果（运动功能、功能状态和出院家）的影响；(2)确定情境特征（类型、大小、位置、所有权和护士配备）对IRF总体康复结果（运动功能、功能状态和出院）的影响，控制IRF中髋部骨折医疗保险受益人总体个体特征（易感、使能和需要）的影响。本研究将为关于哪种类型的患者最适合irf的政策辩论提供信息，并将根据与髋部骨折患者和弱势亚群体（即种族/少数民族、没有足够社会支持的老年人和85岁及以上的老年人）的康复结果相关的特定个体和环境特征，确定irf在提供康复治疗方面的有效性。特别令人关切的是确定证据基础，以表明这种效力将在种族/族裔少数群体中产生积极的结果。鉴于各国对健康差异的关注日益增加，确定基于种族/族裔的结果是否存在差异变得越来越重要。健康差距仍然是国家护理研究所（NINR）的主要研究重点。拟议的研究和随后的分析将通过确定更好地为消除种族/民族差异的干预措施提供信息的特征，从而增加当前的护理知识体系。

DESCRIPTION (provided by applicant): To date, policy directives based on anecdotal reports, drive utilization and treatment decisions. Although hip fracture is considered by Center for Medicare and Medicaid Services (CMS) as a medically appropriate diagnosis for Inpatient Rehabilitation Facility (IRF) care, little evidence is available to support this assumption. Building on sparse existing evidence, the overall objective of this project is to determine which client and system characteristics result in improved rehabilitation outcomes. An analytic file using two large national datasets, the CMS Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) and the Provider of Service (POS) file, will be constructed to test regression models of factors that may explain differences in rehabilitation outcomes between two time points, admission and discharge from IRFs. Using the Andersen's Model for Health Services Use as the conceptual framework, the proposed longitudinal study aims to: (1) determine the influence of individual characteristics (Predisposing: age, gender, race), (Enabling: social support), (Need: functional status and cognitive status on admission, and comorbidities) on rehabilitation outcomes (motor functioning, functional status and discharged home) for Medicare beneficiaries with hip fracture in IRFs; and (2) determine the influence of contextual characteristics (type, size, location, ownership and nurse staffing) on IRF aggregate rehabilitation outcomes (motor functioning, functional status, and discharge home), controlling for the influence of aggregate individual characteristics (Predisposing, Enabling and Need) of Medicare beneficiaries with hip fracture in IRFs. This study will inform the policy debate on which types of patients are most appropriate for IRFs and will determine the effectiveness of IRFs in delivering rehabilitative treatment based on specific individual and contextual characteristics associated with rehabilitative outcomes among hip fracture patients and vulnerable subgroups (i.e., racial/ethnic minorities, older adults without adequate social support and those 85 years and older). Of particular concern is determining the evidence base to indicate that such effectiveness will result in positive outcomes among racial/ethnic minorities. Given the growing national interest in health disparities, it becomes increasingly important to determine if there are differences in outcomes based on race/ethnicity. Health disparities remain a major research focus of the National Institute of Nursing Research (NINR). The proposed research and subsequent analysis will add to the current body of nursing knowledge by identifying characteristics that better inform interventions that look to eliminate racial/ethnic disparities. PUBLIC HEALTH RELEVANCE: The Centers for Disease Control and Prevention estimate that more than 350,000 hip fractures occur annually in the US with a lifetime attributable cost of $81,300 from a hip fracture, including care provided during acute hospitalization and across the post-acute continuum (inpatient rehabilitation, skilled nursing and home health). For many older adults, the personal costs of a fractured hip results in chronic disability and complications, loss of independent ambulation, functional dependence and death. With the growing numbers of older adults and the complexity of their health conditions, appropriate and effective geriatric rehabilitation services are needed. The nation's baby boomers will be turning age 65 in 2011 and will bring about major demographic changes which will certainly influence the delivery of health care. Consequently, in order to effectively care for an aging population with increasing rates of injury and chronic diseases, nurses and other health care providers require the evidence base indicating "what" is effective and "why." Outcomes from the proposed study may be used in systematic reviews and meta-analyses to inform policy decisions about the appropriateness of care which looks to optimize outcomes based on valid clinical endpoints.