Abstract

Background and objectives: There are few analyses on the ability to live at home with or without help following hip fracture, as one needs complete care pathways in order to classify individuals correctly after discharge. In both Norway and Finland there is an increased interest in transferring patients to home, as this is believed to be less expensive than long term or other institutional care. By collaborating with the municipalities of Oslo and Helsinki, we were able to link all primary and municipal health care to national registers. Two research questions were analyzed: First, whether patients living at home with help prior to the fracture have higher likelihood of being returned to home after discharge, as they are already receiving care and as such included in the care loop, or lower likelihood of being returned to home due to hip fracture having a greater impact for these patients. Second, whether patients of high socio-economic status have higher likelihood of being returned to home than patients of low status, due to structural causes other than better health and resources.

Methods: Data included all patients with hip fracture as main ICD-10 diagnosis residing in Oslo and Helsinki in 2009-2014, in total 6,275 patients, 3,358 from Oslo and 2,917 from Helsinki. Only patients living at home before the hip fracture admission, who were operated on during the admission and discharged from acute care alive were analyzed. The outcome was number of days until transferral to home, with or without help. We studied the effects of number of home nursing, outpatient, specialist and GP visits in the year prior to the hip fracture admission, and the days of rehabilitation and short term care both in the year prior to admission and 90 days following discharge. We adjusted for comorbidities and days in hospital the year prior to admission, length of admission stay, income and education. Cox regression reporting hazard ratios was used, and the combined sample from both cities was analyzed.

Results: Descriptive results showed that more days in short term care or rehabilitation both prior to and after admission, and home nurse visits prior to admission, decreased the likelihood of being returned to home. More GP, specialist or outpatient visits increased the likelihood of being returned to home. The former effects prevailed also after adjusting for health and socio-economic status at admission: HR for transferal to home=0.95 (95%-CI 0.95-0.96) per month on home nursing in year prior to hip admission, HR=0.92 (95%-CI 0.90-0.93) per 10 days in short term stays in year prior to hip admission, HR=0.86 (95%-CI 0.85-0.88) per 10 days on rehabilitation in the 90 days after discharge from acute treatment, whereas the effects of GP visits and outpatient visits disappeared after adjustment, only the effect of specialist vistits prevailed (HR=1.13, 95% CI 1.04-1.22). Likelihood of being transferred to home increased with increasing income. However, this only affected transferral to home without help, not home with help.

Conclusion: Hip fracture has greater consequences for patients on home nursing prior to fracture, and significantly reduce their likelihood of being transferred to home after discharge. The positive effects of increasing number of GP, specialist and outpatient visits probably signifies greater self-sufficiency for these patients. Even though higher income increased the likelihood of being transferred home, the fact that it was only observed for transferral to home without help indicate network, resource and health causes, not structural trends of transferring patients of higher socio-economic status to home instead of institution. Overall, the results indicate that the primary and municipal health care services are adequately allocated in both cities: Patients get the services they need.