A multi-outcome prognostic model for older adults admitted to skilled nursing facilities for hip fracture and stroke

TL;DR

This study created models to predict 6-month mortality and successful discharge for older adults in skilled nursing facilities after hip fracture or stroke.

Contribution

The study introduces new prognostic models for two outcomes in older adults admitted to SNFs for hip fracture or stroke.

Findings

15.5% of hip fracture patients and 24.6% of stroke patients died within 6 months.

60.1% of hip fracture patients and 45.4% of stroke patients had successful community discharge.

The models showed good discrimination and calibration for both outcomes in both cohorts.

Abstract

Many hospitalized older adults are discharged to a skilled nursing facility (SNF) for short-term rehabilitation following a hip/femur fracture or stroke. Mortality rates are high, and many never return home (i.e., high risk of “rehabbed to death”). To inform shared decision-making, we developed prognostic models using a 20% Medicare sample from 2017-2019 of community-dwelling adults aged ≥66 admitted to a SNF for hip/femur fracture or stroke. Within each cohort, we developed a prognostic model to predict 2 outcomes: 6-month mortality and “successful community discharge” (discharge to the community without subsequent rehospitalization or death within 30 days). Model predictors were pre-specified based on literature review: age, sex, hospital length of stay, Medicaid status, comorbidities, and hospitalizations in the past year. Model performance was assessed by discrimination (c-statistic) and calibration (calibration plots). Internal validation was performed via bootstrapping. The hip/femur fracture cohort included 52,843 individuals (mean age 83.4 years, 73% female, 3.3% Black), and the stroke cohort included 20,599 individuals (mean age 81.7 years, 60.1% female, 11.4% Black). Overall, in the hip/femur fracture and stroke cohorts, 15.5% and 24.6% died within 6 months and 60.1% and 45.4% experienced a successful community discharge, respectively. For the hip/femur fracture and stroke cohorts, the optimism-corrected c-statistics were 0.74 and 0.70 for 6-month mortality and 0.68 and 0.67 for successful community discharge, respectively. Calibration plots showed that the models were well-calibrated for both outcomes in both cohorts. Risk predictions from these models can help guide shared decision-making and future planning between SNF clinicians, patients, and caregivers.