Our study demonstrates, in a prospective study of patients receiving a unified in-hospital protocol, that the addition of post-discharge care from a “Patient-Centered Medical Home” program, including a nurse case manager for primary care-based follow-up, was successful in significantly reducing mortality in the 6 months following hip fracture and showed evidence of benefits to hip pain and function as well. While it may be unrealistic to expect that such a post-discharge program would eliminate mortality/morbidity, this study makes a promising case for utilizing PCMH programs for a focused, limited period following discharge. Although significant benefits in reduced admissions, emergency department visits or medication utilization and costs were not seen, the two cohorts remained similar in these respects, suggesting that the aggressive follow-up by the PCMH program did not substantially drive up healthcare utilization or costs. Future larger-scale studies should help to better define the optimal patient population for such programs and refinements that would provide further benefits for patients undergoing hip fracture surgery. We note that, while we found more published estimates of 1-year mortality than 6-month mortality, our control group's 6-month and 12-month mortality rates of 26 and 30%, respectively, appear to be consistently in the range of the published findings of Johnston et al.  and others who have followed operative treatment of hip fractures.
Mortality and morbidity after hip fracture in elderly patients remains a serious problem; however, there is growing evidence to suggest that patient factors and specific details of the approach to post-fracture treatment can impact mortality and quality of life. As noted by Johnston et al., many studies report mortality following hip fracture as a simple percentage and do not take into account age, gender and other factors . In a recent systematic review, Butler et al. concluded that while neither implant type nor surgical approach were associated with differences in mortality rates, patient factors such as age, sex, pre-fracture functioning, and cognitive impairment were directly related to mortality and functional outcomes . This literature suggested that the main mortality risk for elderly women is in the 6 weeks following surgery, while the risk for men is higher near 6 months, with comorbidities and age impacting different subgroups. In a study that complements our current results in a different population, Rahme et al. retrospectively reviewed 11,326 patients receiving hemiarthroplasty for hip fracture and showed that the small percentage of those (16%) who received post-discharge home care had a lower mortality rate at 3 months than those who received no home care . While the data collected for this study do not allow us to pinpoint the exact reason why the PCMH program influenced the 6-month mortality rate in our study, we believe that by providing reinforcement during the critical 4 weeks following discharge, the primary care PCMH team may be able to better engage, activate and educate patients as well as identify and resolve issues that may otherwise be missed or caused by care gaps during the transition from hospital to home.
The main strengths of our study are its population and statistical design. We were able to use patients in an integrated health system where electronic health records were available for the hip fracture population to quantify mortality, inpatient admissions, emergency department visits and other healthcare utilization. Furthermore, we were able to take advantage of the fact that a PCMH program was in the middle of being implemented such that patients would naturally be assigned to either an intervention group (PCMH) or control group for post-discharge care. Finally, we employed robust statistical methods to identify and balance confounding variables in the two cohorts through matching. The chief limitations of the study are the modest sample size and the fact that it was a non-randomized study, though we took steps to address biases due to confounding through the matched study design. Nevertheless, not all subjects could be appropriately matched to controls, resulting in a further reduced sample size. We note, for example, that the number of deaths between 6 and 12 months was small, and with a larger sample size, some of the nonsignificant findings here may also have reached statistical significance. For the secondary outcomes of cost and functional questionnaires, we also note that not all subjects responded to the telephone questionnaire or had the appropriate insurance provider that allowed us to measure costs. Finally, the questionnaires were administered at 12 months only and we did not collect preoperative scores, though we expect that acute injury patients would have both EQ-5D and functional scores similar to the general population in their own age range, on average. While we took advantage of the data collection methods of an integrated health system (EHR tracking, claims data, survey center) to perform this investigation, we note that standardized protocols and PCMH models are increasingly being adopted across the U.S. and we believe that these results should be highly translatable to a variety of healthcare settings.
Increasingly, society, patients and payors are demanding measurable quality outcomes. The biggest social impacts may be made by improving the outcome of patient groups whose injuries significantly affect society, such as the elderly patients who sustain hip fractures. Given the multitude of different implant studies which have shown little difference in one-year outcomes for this common yet socially-disruptive injury, studies like this one suggest that the patient care that takes place outside the operating room may ultimately have the biggest impact on improved outcomes. The biggest improvements thus far in hip fracture care have not come from changes in implant technology (e.g., switching to a locked side plate or to an intramedullary device) , but from multidisciplinary management of these patients in the acute setting; longer-term benefits of these in-hospital interventions, however, have not been widely demonstrated [32–34]. It is our hope that the current study provides new evidence regarding important patient outcomes and costs, comparing an intrinsic control group with an experimental group, and that future work will support compelling arguments to government and private payors that the most cost-effective standard of care also gives the highest quality outcome. We recognize that the majority of care-coordination efforts thus far have focused on chronic diseases such as congestive heart failure or diabetes, and that evidence of effectiveness has been mixed, depending on the specific features of the intervention [35–38]. Future work should determine which specific conditions yield high-value results in order to avoid the error of a one-size-fits-all approach.