Exposing the Care Conundrum of Low-Energy Pelvic Ring Fractures in Older Adults: A Review of 322 Patients.

Abstract

A care conundrum for low-energy pelvic ring fracture patients in which they face financial burden after not qualifying for an inpatient stay of 3days or more has been noted in the literature. The purpose of this study was to identify factors that lead to inpatient length of stay (IP LOS) ≥3days in older adults with nonoperative pelvic ring fragility fractures and to highlight the challenging financial decision-making of those with IP LOS <3days in the context of the Medicare 3-day rule. This was a retrospective review of 322 patients aged ≥65 presenting from March 2016 and February 2019 to either of 2 emergency departments (EDs) after a ground-level fall resulting in a pelvic ring fracture. Patient demographic, IP LOS, and mortality data were extracted. Case management notes were analyzed to summarize financial decision-making for patients with IP LOS <3days. Multivariate logistic regression analysis was conducted to identify factors that predicted IP LOS ≥3days and mortality. IP LOS ≥3days was associated with presentation to level I hospital (OR .30 [.19, 0.50]) and being single (OR 2.50 [1.10, 5.68]). 70.3% required a post-acute skilled nursing facility (SNF) stay. Of patients with LOS <3days, 25.0% were financially responsible for their SNF stay, while 7.9% elected home care due to financial reasons. Overall 30-day, 90-day, and 1-year mortality were 2.5%, 8.1%, and 20.8%, respectively. For patients with LOS <3days, returning to assisted living compared to discharging to a SNF increased 90-day mortality risk (HR 8.529, P = .0451). Having Medicare trended towards increased 90-day mortality risk compared to commercial insurance (HR 4.556, P = .0544). The current system is failing older adult patients who sustain nonoperative low-energy pelvic ring fractures in terms of financial coverage of necessary post-acute treatment. This care conundrum has yet to be solved.