Association between additional weekend rehabilitation and functional outcomes in patients with hip fractures: Does age affect the effectiveness of weekend rehabilitation ?

doi:10.21203/rs.3.rs-3403452/v1

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Research Article

Association between additional weekend rehabilitation and functional outcomes in patients with hip fractures: Does age affect the effectiveness of weekend rehabilitation ?

https://doi.org/10.21203/rs.3.rs-3403452/v1

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Journal Publication

published 04 May, 2024

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Purpose

Rehabilitation after hip fracture surgery is crucial for improving physical function. Additional rehabilitation over the weekend or after working hours is reportedly associated with improved physical function; however, this may not apply to an aging population, including patients aged > 90 years. This study aimed to investigate the association between additional weekend rehabilitation and functional outcomes in different age groups.

Methods

This study analysed a cohort of patients aged ≥ 60 years who had hip fractures and were operated on from 2013 to 2018. Data were extracted from a nationwide multicentre database. Functional outcomes at discharge were compared between patients who underwent rehabilitation on weekdays only and those who underwent rehabilitation on both weekdays and weekends. The patient groups were selected using propensity score matching analysis. Furthermore, a sub-analysis was conducted on patients in their 60s, 70s, 80s, and 90s.

Results

A total of 411,056 patients underwent surgery during the study period. After matching, each group comprised 129,583 patients. Patients who underwent weekend rehabilitation exhibited improved physical function in transferring, walking, and stair climbing at discharge, as compared with patients who did not (odds ratio [95% confidence interval]: 1.17 [1.15–1.19], 1.17 [1.15–1.2], and 1.06 [1.03–1.08], respectively). Except for stair climbing, the positive association between weekend rehabilitation and patient function was observed across all age groups.

Conclusion

Weekend rehabilitation was significantly associated with improved physical function. Given the limited healthcare resources, high-demand activities such as stair climbing may be reserved for younger age groups to optimise rehabilitation therapy.

Functional outcomes

Hip fractures

Propensity score matching

Rehabilitation

Aim To investigate the association between additional weekend rehabilitation and functional outcomes among different age groups.

Findings After matching 411 056 cases, a significantly higher correlation was found between patients who had received weekend rehabilitation and improved physical function at discharge compared with those who had not received weekend rehabilitation (odds ratio, OR [95% confidence interval, CI]: 0·84 [0·8–0·89], p<0·001).

Message Weekend rehabilitation was significantly associated with improved physical function. To optimise rehabilitation therapy given limited healthcare resources, low demand activity can be more effective in older age groups, whereas high demand activity should be aimed at younger age groups.

Recovery of activities of daily living (ADL) after a hip fracture largely depends on rehabilitation after surgery. Previous studies have reported the benefits of additional weekend rehabilitation sessions. We performed a PubMed search using the terms ‘hip fracture’, ‘additional rehabilitation’, ‘weekend rehabilitation’, and ‘physical function’; this search was repeated regularly for articles published in English through July 2023. Previous randomised controlled trials have confirmed that additional weekend rehabilitation could shorten the length of hospital stay and improve the ADL. However, ADL evaluations are often based on composite scores, and previous studies have mainly assessed a broad integrated mobility score that emphasises several mobile functions, such as transferring, walking, and stair climbing. Thus, the possible impact of additional weekend rehabilitation on different physical functions of post-femoral fracture patients, such as their ability to transfer, walk, and climb stairs at acute hospital discharge, is not yet understood.

Added value of this study

A propensity score matching analysis was performed using data from a nationwide Japanese database, including 129,583 pairs of patients who underwent hip fracture surgery. Our study revealed that weekend rehabilitation was significantly associated with improved physical function at discharge and that weekend rehabilitation showed a stronger association with less demanding physical functions, such as transferring, particularly among older subgroups. As for more demanding physical functions, such as stair climbing, rehabilitation displayed a weaker association with functional status at discharge among older subgroups.

Implications of all available evidence

Weekend rehabilitation was significantly associated with improved physical function. Given the limited healthcare resources, low-demand activities may be more effective for older age groups, whereas high-demand activities may be aimed at younger age groups to optimise rehabilitation therapy. Further prospective studies or randomised trials with a relatively larger number of participants should investigate more robust causal relationships between additional weekend rehabilitation and improvements in physical function.

The number of patients with hip fractures is increasing each year, reflecting population ageing[.¹] Patients with hip fractures often experience impairment in their activities of daily living (ADL), with 30–60% of these patients not returning to their pre-fracture ADL levels, leading to an increase in care burden.[^{2, 3}] Furthermore, hip fractures impose a considerable healthcare burden with respect to extended hospital stays and rehabilitation requirements.⁶ High ADL levels are crucial for continuing outpatient visits aimed at preventing refracture through osteoporosis treatment,[⁴] and ADL recovery after hip fracture often involves post-surgical rehabilitation[.⁵] []Thus, it is essential to effectively restore the patients’ ADL after hip fracture surgery by efficiently utilising medical resources.

As patients tend to be less active over weekends, rehabilitation sessions are therefore crucial for maintaining their activity levels.⁷ Several studies have evaluated the benefits of additional weekend rehabilitation sessions. In particular, previous randomised controlled trials have shown that additional weekend rehabilitation could shorten the length of hospital stay and improve the ADL[.^8–10] However, ADL evaluations are often based on composite scores, and previous studies have only assessed broad mobility categories such as transferring, walking, and stair climbing. Moreover, basic research has suggested potential muscle loss due to overtraining.[¹¹] Thus, the impact of additional weekend rehabilitation on patients’ ability to transfer, walk, and climb stairs upon acute hospital discharge after hip fracture surgery is not yet understood, and it also remains unclear whether additional weekend rehabilitation is always beneficial for older patients with hip fractures.

The present study aimed to investigate the effects of additional weekend rehabilitation on the ability of elderly patients to independently perform ADL after a hip fracture using data from a national Japanese database. In this study, ADL were categorised according to the physical demands of transferring, walking, and stair climbing, and the patients’ ability to independently perform each movement at hospital discharge was evaluated. Furthermore, a subgroup analysis was conducted to explore the relationship between independent ADL and different age groups and to determine how the impact of additional weekend rehabilitation varied by age. Given that medical resources are limited on weekends compared with weekdays, optimising these resources is vital. Determining which patients will benefit the most from additional weekend rehabilitation sessions is of considerable importance.

Data source and study population

This study utilised data from the Japanese Diagnosis Procedure Combination (DPC) inpatient database, a nationwide database that includes discharge abstracts and administrative claims data from over 1500 hospitals in Japan. Patients’ baseline characteristics, primary diagnoses at admission, ADL score, existing comorbidities at admission, surgical procedures, complications after admission, and length of hospital stay were recorded in this database. Medical diagnoses, comorbidities, and complications were described using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes recorded in the database[ 11 ](Appendix 1). A previous validation study reported a sensitivity of approximately 80% and specificity of 90% for the diagnostic and procedural records [12]. This study was approved by the institutional review board (M2000-788), and the requirement for the acquisition of informed consent from individual patients was waived because the data were anonymised.

The study participants were consecutive patients who were hospitalised with a primary diagnosis of femoral neck fracture (ICD-10 code S7200), trochanteric fracture (ICD-10 code S7210), or subtrochanteric fracture (ICD-10 code S7220) and underwent open reduction and internal fixation or hemiarthroplasty from 1 April 2010 to 31 March 2018. Patients aged ≥ 60 years were included in the investigation on acute elderly patients with hip fractures.

Main exposure and clinical outcomes

The patients were divided into two groups—namely, (i) the plus-weekends group, which comprised patients who underwent rehabilitation on Saturdays, Sundays, or both days within one week of surgery and (ii) the weekdays-only group, which consisted of patients who did not undergo rehabilitation on either Saturdays or Sundays. The weekend rehabilitation data were collected from patient claims records in the DPC database, which recorded each daily prescription for musculoskeletal rehabilitation sessions performed by a physical or occupational therapist. Healthcare insurance reimbursed the cost of each rehabilitation session, which involved exercises for 20 min, including exercise therapy, practical gait training, and ADL training tailored to each individual case to achieve independence in practical ADL through the recovery of basic movement skills (Appendix 2). The type of physical rehabilitation provided by the therapist was not determined by the insurers and varied according to the hospital involved. The primary outcome was physical function, including the ability to independently transfer, walk, and climb stairs at discharge. Additionally, a subgroup analysis was performed to evaluate the association between weekend rehabilitation and outcomes among different age groups.

Covariates

Based on previous literature, we analysed the following patient characteristics: age, sex, body mass index (BMI), smoking history, comorbidities at admission, preoperative anticoagulant use, ADL score measured by the Barthel Index, waiting time for surgery, type of anaesthesia, year of admission, and whether admission was through the emergency department on a weekday or weekend.[^12–15] Furthermore, hospital characteristics such as hospital status (teaching or standard), bed capacity, and annual volume of hip fracture surgeries were evaluated. Annual surgical volume was defined as the annual number of patients who underwent hip fracture surgery at each hospital. BMI was categorised as follows: <18.5, 18.5–24.9, 25.0–29.9, and > 30.0 kg/m². The following Charlson Comorbidity Index (CCI) components were recorded for each patient: congestive heart failure, peripheral vascular disease, myocardial infarction, heart failure, stroke, dementia, pulmonary disorders, peptic ulcer, mild-to-moderate or severe liver disease, diabetes with or without complications, hemiplegia, renal failure, cancer, metastatic cancer, and human immunodeficiency virus infection.[^{16, 17}] In addition to these CCI components, Parkinson’s disease, stable angina, hypertension, and anaemia were also included. ADL was assessed based on the Barthel Index, which is an ordinal scale that measures ADL performance.¹⁸ The patients’ mental status was evaluated using the Japan Coma Scale, which is a metric used for examining consciousness and is highly correlated with the Glasgow Coma Scale[.¹⁹]

Statistical analyses

A cohort of patients with similar baseline characteristics was identified via a propensity score matching analysis to consider differences in these characteristics between the plus-weekends and weekdays-only rehabilitation groups. The propensity score, which pertained to the conditional probability of receiving a specific intervention (e.g., weekend rehabilitation) after adjustment for a set of measured baseline covariates,[^{20, 21}] was estimated using a multivariable logistic regression analysis, with the probability of receiving weekend rehabilitation being calculated with adjustment for all baseline characteristics listed in Table 1. Subsequently, the patients were matched based on the propensity score between the plus-weekends and weekdays-only rehabilitation groups using a 1:1 matching protocol without patient replacement. To achieve balance within the cohort, the calliper width was set at 20% of the standard deviation of the logit of the propensity score. The baseline characteristics of the two groups were checked by comparing the standardised differences for all baseline covariates before and after matching. Standardised differences equal to or less than 10% for a given baseline set of covariates were considered to be indicative of a relatively balanced matching.[²²]

Table 1

Patient characteristics before and after matching
			Before matching			After matching
		Total	Weekends	Only weekdays	SMD	Weekdays-only group	Plus-weekends group	SMD
Total		390 713	234 477	156 236		129 583	129 583
Age, mean (SD)	60-	26 627 (6·8%)	16 320 (7·0%)	10 307 (6·6%)	0·045	8560 (6·6%)	8717 (6·7%)	0·009
	70-	78 397 (20·1%)	48 216 (20·6%)	30 181 (19·3%)		25 119 (19·4%)	25 432 (19·6%)
	80-	191 985 (49·1%)	115 210 (49·1%)	76 775 (49·1%)		63 860 (49·3%)	63 615 (49·1%)
	90-	90 878 (23·3%)	53 111 (22·7%)	37 767 (24·2%)		31 065 (24·0%)	30 858 (23·8%)
	100-	2826 (0·7%)	1620 (0·7%)	1206 (0·8%)		979 (0·8)	961 (0·7)
Sex, n (%)	Male	78 022 (20·0%)	48 021 (20·5%)	30 001 (19·2%)	0·032	25 164 (19·4%)	25 589 (19·7%)	0·008
	Female	312 691 (80·0%)	186 456 (79·5%)	126 235 (80·8%)		104 419 (80·6%)	103 994 (80·3%)
BMI, n (%)	< 18·5	113 174 (29·0%)	67 641 (28·8%)	45 533 (29·1%)	0·009	37 894 (29·2%)	37 669 (29·1%)	0·007
	18·5–25	235 375 (60·2%)	141 354 (60·3%)	94 021 (60·2%)		77 875 (60·1%)	77 897 (60·1%)
	25–30	37 143 (9·5%)	22 485 (9·6%)	14 658 (9·4%)		12 193 (9·4%)	12 327 (9·5%)
	≥ 30	5021 (1·3%)	2997 (1·3%)	2024 (1·3%)		1621 (1·3%)	1690 (1·3%)
Smoking history, n (%)	Never smoker	346 449 (88·7%)	207 218 (88·4%)	139 231 (89·1%)	0·023	115 319 (89·0%)	115 049 (88·8%)	0·007
	Smoker	44 264 (11·3%)	27 259 (11·6%)	17 005 (10·9%)		14 264 (11·0%)	14 534 (11·2%)
Coronary heart disease, n (%)		5306 (1·4%)	3323 (1·4%)	1983 (1·3%)		1652 (1·3%)	1688 (1·3%)	0·002
Heart failure, n (%)		32 015 (8·2%)	18 940 (8·1%)	13 075 (8·4%)		10 699 (8·3%)	10 663 (8·2%)	0·001
Peripheral vascular disease, n (%)		1968 (0·5%)	1230 (0·5%)	738 (0·5%)		587 (0·5%)	636 (0·5%)	0·006
Stroke, n (%)		41 273 (10·6%)	24 461 (10·4%)	16 812 (10·8%)		13 692 (10·6%)	13 775 (10·6%)	0·002
Dementia, n (%)		72 703 (18·6%)	41 372 (17·6%)	31 331 (20·1%)		25 152 (19·4%)	25 083 (19·4%)	0·001
Pulmonary disorders, n (%)		15 121 (3·9%)	9088 (3·9%)	6033 (3·9%)		4938 (3·8%)	5030 (3·9%)	0·004
Connective tissue disease, n (%)		926 (0·2%)	598 (0·3%)	328 (0·2%)		273 (0·2%)	285 (0·2%)	0·002
Peptic ulcer, n (%)		11 186 (2·9%)	7390 (3·2%)	3796 (2·4%)		3403 (2·6%)	3452 (2·7%)	0·002
Mild liver disease, n (%)		1954 (0·5%)	1254 (0·5%)	700 (0·4%)		591 (0·5%)	608 (0·5%)	0·002
Mild-to-moderate diabetes, n (%)		58 976 (15·1%)	35 608 (15·2%)	23 368 (15·0%)		19 281 (14·9%)	19 522 (15·1%)	0·005
Diabetes with complications, n (%)		9738 (2·5%)	6521 (2·8%)	3217 (2·1%)		2865 (2·2%)	2964 (2·3%)	0·005
Hemiplegia, n (%)		21 (0·0%)	19 (0·0%)	2 (0·0%)		3 (0·0%)	2 (0·0%)	0·002
Renal failure, n (%)		16 681 (4·3%)	10 994 (4·7%)	5687 (3·6%)		4959 (3·8%)	5161 (4·0%)	0·008
Cancer, n (%)		18 147 (4·6%)	11 692 (5·0%)	6455 (4·1%)		5601 (4·3%)	5742 (4·4%)	0·005
Metastatic cancer, n (%)		1739 (0·4%)	1198 (0·5%)	541 (0·3%)		471 (0·4%)	503 (0·4%)	0·004
Sever liver disease, n (%)		94 (0·0%)	71 (0·0%)	23 (0·0%)		21 (0·0%)	23 (0·0%)	0·001
HIV infection, n (%)		26 (0·0%)	18 (0·0%)	8 (0·0%)		9 (0·0%)	7 (0·0%)	0·002
Hypertension, n (%)		142 684 (36·5%)	82 627 (35·2%)	60 057 (38·4%)		48 334 (37·3%)	48 112 (37·1%)	0·004
Stable angina, n (%)		28 188 (7·2%)	17 701 (7·5%)	10 487 (6·7%)		8818 (6·8%)	9062 (7·0%)	0·007
Parkinson disease, n (%)		9508 (2·4%)	5642 (2·4%)	3866 (2·5%)		3174 (2·4%)	3164 (2·4%)	< 0·001
Anaemia, n (%)		13 467 (3·4%)	8316 (3·5%)	5151 (3·3%)		4359 (3·4%)	4435 (3·4%)	0·003
Anticoagulation use before surgery, n (%)		16 730 (4·3%)	9358 (4·0%)	7372 (4·7%)		5765 (4·4%)	5731 (4·4%)	0·001
Hospitalisation through the emergency department, n (%)		360 396 (92·2%)	212 800 (90·8%)	147 596 (94·5%)		121 861 (94·0%)	121 552 (93·8%)	0·010
Hospitalisation on weekends, n (%)		86 437 (22·1%)	43 080 (18·4%)	43 357 (27·8%)		32 396 (25·0%)	31 796 (24·5%)	0·011
Japan Coma Scale, n (%)	0	335 993 (86·0%)	203 057 (86·6%)	132 936 (85·1%)	0·050	110 881 (85·6%)	110 864 (85·6%)	0·006
	1	24 332 (6·2%)	14 247 (6·1%)	10 085 (6·5%)		8185 (6·3%)	8279 (6·4%)
	2	16 774 (4·3%)	9576 (4·1%)	7198 (4·6%)		5830 (4·5%)	5790 (4·5%)
	3	12 002 (3·1%)	6597 (2·8%)	5405 (3·5%)		4168 (3·2%)	4107 (3·2%)
	10	1259 (0·3%)	773 (0·3%)	486 (0·3%)		412 (0·3%)	425 (0·3%)
	20	222 (0·1%)	147 (0·1%)	75 (0·0%)		69 (0·1%)	73 (0·1%)
	30	131 (0·0%)	80 (0·0%)	51 (0·0%)		38 (0·0%)	45 (0·0%)
Fracture type, n (%)	Trochanteric fracture	194 949 (49·9%)	118 980 (50·7%)	75 969 (48·6%)	0·044	63 311 (48·9%)	63 662 (49·1%)	0·007
	Neck fracture	187 073 (47·9%)	110 199 (47·0%)	76 874 (49·2%)		63 416 (48·9%)	62 989 (48·6%)
	Subtrochanteric fracture	8691 (2·2%)	5298 (2·3%)	3393 (2·2%)		2856 (2·2%)	2932 (2·3%)
Waiting time before surgery	≤ 48 hours	159 546 (40·8%)	75 133 (32·0%)	84 413 (54·0%)	0·455	62 184 (48·0%)	59 849 (46·2%)	0·036
	> 48 hours	231 167 (59·2%)	159 344 (68·0%)	71 823 (46·0%)		67 399 (52·0%)	69 734 (53·8%)
Anaesthesia, n (%)	General anaesthesia	214 584 (54·9%)	123 515 (52·7%)	91 069 (58·3%)	0·115	72 191 (55·7%)	71 304 (55·0%)	0·014
	Spinal anaesthesia	165 377 (42·3%)	103 979 (44·3%)	61 398 (39·3%)		54 109 (41·8%)	54 910 (42·4%)
	General and epidural	9541 (2·4%)	6132 (2·6%)	3409 (2·2%)		2971 (2·3%)	3024 (2·3%)
	Spinal and epidural	1211 (0·3%)	851 (0·4%)	360 (0·2%)		312 (0·2%)	345 (0·3%)
Types of surgery	Hemiarthroplasty	140 259 (35·9%)	86 401 (36·8%)	53 858 (34·5%)	0·050	45 263 (34·9%)	45 421 (35·1%)	0·003
	Open reduction and internal fixation	250 454 (64·1%)	148 076 (63·2%)	102 378 (65·5%)		84 320 (65·1%)	84 162 (64·9%)
Hospital volume, bed, n (%)	< 100	67 630 (17·3%)	41 223 (17·6%)	26 407 (16·9%)	0·032	21 769 (16·8%)	21 388 (16·5%)	0·016
	100–200	124 882 (32·0%)	74 259 (31·7%)	50 623 (32·4%)		41 550 (32·1%)	40 968 (31·6%)
	200–300	92 483 (23·7%)	55 886 (23·8%)	36 597 (23·4%)		30 101 (23·2%)	30 359 (23·4%)
	300–400	49 982 (12·8%)	29 978 (12·8%)	20 004 (12·8%)		17 131 (13·2%)	17 504 (13·5%)
	400–500	28 451 (7·3%)	16 531 (7·1%)	11 920 (7·6%)		9819 (7·6%)	9943 (7·7%)
	> 500	27 285 (7·0%)	16 600 (7·1%)	10 685 (6·8%)		9213 (7·1%)	9421 (7·3%)
Annual procedure volume, n (%)	~ 30 cases/year	24 623 (6·3%)	17 800 (7·6%)	6823 (4·4%)	0·281	6356 (4·9%)	6485 (5·0%)	0·014
	30–100 cases/year	163 957 (42·0%)	108 005 (46·1%)	55 952 (35·8%)		50 624 (39·1%)	51 410 (39·7%)
	~ 100 cases/year	202 133 (51·7%)	108 672 (46·3%)	93 461 (59·8%)		72 603 (56·0%)	71 688 (55·3%)
Teaching hospital, n (%)		7287 (1·9%)	6305 (2·7%)	982 (0·6%)		1025 (0·8%)	982 (0·8%)	0·004
Barthel Index, mean (SD)		17·48 (26·62%)	17·89 (27·19%)	16·87 (25·72%)	0·039	17·08 (26·80%)	17·25 (25·96%)	0·007
Values are presented as the number of patients, with the percentage of the cohort in parentheses, except for age and Barthel Index, which are expressed as mean and standard deviation.
BMI, body mass index; HIV, human immunodeficiency virus; N, number of patients; SMD, standardised mean difference.

The primary and secondary outcomes were examined using logistic regression. Subgroup analysis was conducted to identify the association between weekend rehabilitation and outcomes in the 60–69-year, 70–79-year, 80–89-year, and > 90-year age groups. Type I error probability was set at 0.05 for all analyses. All statistical analyses were performed using Stata version 16.1 (StataCorp, College Station, TX, USA).

Study population

A total of 557,456 patients (mean age: 83.5 ± 8.1 years) were included in this study; of these patients, 79.0% (n = 440,341) were female. Overall, 79.0% (n = 440,341) underwent hemiarthroplasty, whereas 51.5% (n = 287,185) underwent weekend rehabilitation (Fig. 1, Table 1). Slightly aged male patients, those with a higher BMI or higher CCI, or those who were admitted on Monday or Tuesday were more likely to undergo weekend rehabilitation (Table 1, Appendix 3). The waiting time for surgery was longer in the plus-weekend group (> 72 hours; 63.8% vs. 54.0%). Teaching hospitals and hospitals with fewer beds (< 200; 49.0% vs. 47.7%) and mid-range annual surgical volumes (30–100; 47.5% vs. 37.9%) were more likely to provide weekend rehabilitation. No significant difference in comorbidities was observed between the two groups.

Outcomes after matching

A significant relationship between weekend rehabilitation and improvements in all aspects of ADL (namely, transferring, walking, and stair climbing) at discharge was found (Fig. 2). With respect to independence in transferring at discharge, the plus-weekend group performed significantly better than the weekdays-only group (38,329 vs. 34,241; odds ratio [OR]: 1.17; 95% confidence interval [CI]: 1.15–1.19; p < 0.001). As for the ability to walk independently at discharge, the plus-weekend group again significantly outperformed the weekdays-only group (30,223 vs. 26,675; OR: 1.17, 95% CI: 1.15–1.2; p < 0.001). Regarding independent stair climbing at discharge, the plus-weekend group was also significantly better than the weekdays-only group (19,206 vs. 18,342; OR: 1.06, 95% CI: 1.03–1.08; p < 0.001).

Subgroup analysis stratified by age

The subgroup analysis stratified by age revealed a significant relationship between weekend rehabilitation and the independent ability to transfer and walk across all age groups. However, in the case of independent stair climbing, a significant relationship was observed across all age groups except for those aged > 90 years (Fig. 3).

With respect to the independent ability to transfer, the association with weekend rehabilitation strengthened as age increased. Specifically, for patients in their 60s, 70s, 80s, and > 90s, the ORs were 1.11, 1.17, 1.19, and 1.23, respectively (all p < 0.001). Independent walking was consistently and significantly associated with weekend rehabilitation across all age groups (all p < 0.001).

Conversely, the association between independence in stair climbing and weekend rehabilitation weakened as age increased. For patients in their 60s, 70s, 80s, and > 90s, the ORs were 1.1 (p = 0.002), 1.05 (p = 0.01), 1.04 (p = 0.015), and 1.02 (p = 0.52), respectively.

In the present study, a propensity score matching analysis was performed using data from a nationwide Japanese database, including 129,584 pairs of patients who underwent hip fracture surgery. The large sample size ensured that the study possessed sufficient statistical power. This study revealed (i) that weekend rehabilitation was significantly associated with improved physical function at discharge and (ii) that weekend rehabilitation had a stronger association with less demanding physical functions such as transferring in older subgroups but showed a weaker association with more demanding physical functions such as stair climbing in older subgroups.

Weekend rehabilitation and ability to independently perform ADL

Consistent with the findings of previous studies, our results indicated that additional weekend rehabilitation during the acute phase after femoral fracture occurrence contributed to the patients’ ability to independently perform ADL at the time of hospital discharge, specifically in terms of transferring, walking, and stair climbing.

Peiris et al. reported that additional weekend rehabilitation led to improvements both in the total Functional Independence Measure (FIM) score and in the FIM mobility score,⁹ which comprehensively evaluates transferring, walking, and stair climbing without assessing each motion individually. Their randomised controlled trial involving 996 patients aged 75 years on average with various conditions, including orthopaedic, neurological, and other disabling impairments, compared the FIM mobility score and total FIM score between the additional weekend rehabilitation group and weekdays-only rehabilitation group. The results indicated that patients undergoing additional weekend rehabilitation displayed a statistically significant improvement of 1.0 point (average) for the FIM mobility score and 2.3 points (average) for the total FIM score, as compared with those undergoing only weekday rehabilitation. Thus, additional weekend rehabilitation improved the ADL at discharge. However, because the FIM mobility score does not evaluate individual movements and the study was not limited to femoral fractures, it was unclear whether additional weekend rehabilitation was effective for individual independence in transferring, walking, and stair climbing.

Peiris et al. also reported that additional weekend rehabilitation increased the number of steps and upright time during hospitalisation.⁷ In another trial involving 105 patients aged 74 years on average who had conditions such as fractures and other lower-limb fractures and underwent total hip replacement, total knee replacement, or amputation, they compared the in-hospital steps and upright time resulting from additional weekend and weekdays-only rehabilitations. The results suggested that patients undergoing additional weekend rehabilitation showed a 57% increase in steps and a 50% increase in upright time, as compared with those undergoing weekdays-only rehabilitation. Therefore, additional weekend rehabilitation could improve habitual activity during hospitalisation in patients with orthopaedic lower-limb conditions. Nevertheless, its effectiveness in patients in their 80s or older with femoral fractures remains uncertain.

In a retrospective study on 469 Japanese patients with hip fractures aged 82.5 years on average, Hasebe et al. compared the length of stay and discharge FIM efficiency between the additional weekend and weekdays-only rehabilitation groups. They reported that additional weekend rehabilitation improved the FIM efficiency at discharge and that patients undergoing additional weekend rehabilitation had an average of 22 fewer days of hospital stay and an increase of 0.33 in FIM efficiency, as compared with weekdays-only patients.⁸ Thus, in the same average-aged 80s population, additional weekend rehabilitation increases FIM efficiency; however, its effect on individual function remains unclear.

In our study, we propensity score-matched 259,166 hip fracture cases in patients aged 84 years on average and compared their ability to independently transfer, walk, and climb stairs when they underwent additional weekend rehabilitation, as opposed to weekdays-only rehabilitation, during the postoperative acute phase. Our results showed that patients undergoing additional weekend rehabilitation had a significantly higher independence rate for all activities—namely, transferring, walking, and stair climbing (OR: 1.17, 1.17, and 1.06, respectively). Hence, in patients with hip fractures in their 80s, additional weekend rehabilitation during the acute phase significantly contributed to independence in all activities.

Additional weekend rehabilitation after acute hospital discharge contributed to independence in transferring, walking, and stair climbing. However, compared to transferring and walking, the improvement in stair mobility was relatively small, which may be attributable to the fact that the hip function required for stair mobility is particularly demanding in elderly individuals with sustained hip fractures. A few of these individuals could navigate stairs even before their hip fracture, and only a limited number regained sufficient hip function to manage stairs even after surgery. Even if they regain their ability, recovery of postoperative hip function would take time.

Tang et al. evaluated the walking and stair climbing abilities before injury and at 6 months after surgery in 733 patients with hip fractures aged 84 years on average who were registered in the nationally representative Health and Retirement Study using linked Medicare claims.[²³ ]With respect to pre-hip fracture ADLs, the proportion of patients who could navigate stairs without resting was 30% less than those who could walk. Postoperatively, the proportion of patients who regained stair mobility was 25% less than those who regained walking ability. The results showed that 48.7% could navigate stairs before the injury, whereas only 29% could do so at 6 months after surgery. Meanwhile, 78.% of patients could walk indoors before the injury, and 54% maintained this ability at 6 months after surgery. Fewer patients with hip fractures were, therefore, able to independently navigate stairs before and after surgery, as compared to walking.

Beckmann et al. prospectively studied 207 patients with hip fracture averaging 82.6 years of age from a single facility and investigated their walking and stair mobility recovery upon discharge and at 3 and 12 months postoperatively. They reported that no patients with hip fracture regained stair mobility upon discharge and that regaining stair mobility took longer than walking at 3-month and 12-month follow-ups.[²⁴] After hip fracture surgery, acquiring stair mobility took longer than walking. At 3 months after surgery, stair mobility started to improve and continued until the 12th month. The stair-climbing test, an assessment involving eight rapidly ascending and descending steps[²⁵], was not performed by any patient upon discharge. In contrast, all patients regained their walking ability by discharge and their walking ability further improved between 3 and 12 months after surgery. Hence, the smaller effect of additional weekend rehabilitation on stair independence at acute hospital discharge might be attributed to the challenges and time required for recovery, as compared to transferring and walking.

In line with previous reports, this study of 259,166 hip fracture cases in patients with an average age of 84 years and an average hospital stay of 32 days suggests a shorter time frame during the acute postoperative period for patients to achieve stair independence, as compared to transferring or walking. Additional weekend rehabilitation in acute-phase hospitals for patients after hip fracture surgery contributed to independence in transferring, walking, and stair climbing. However, its impact was significantly more pronounced for transferring and walking than for stair climbing, possibly because of the longer time required to regain stair mobility during the acute phase, as evidenced in a previous study.

Limitations

The present study had some limitations. First, regarding the definition of rehabilitation, our database did not include precise information on the types of physical rehabilitation provided at each hospital. Information regarding rehabilitation was recorded based on health insurance codes encompassing a range of activities provided by physical and occupational therapists. Therefore, our results are not applicable to other countries because the content of rehabilitation sessions is likely to vary across different countries and regions. Second, our database did not include information on each surgeon’s skills and experience, which affect the risk of postoperative complications. Nevertheless, data on annual surgical volume were included as a proxy under the assumption that hospitals with higher surgical volumes would have more skilled and experienced surgeons than those with lower surgical volumes. Furthermore, our database did not include details on the severity of surgical complications.

Weekend rehabilitation was significantly associated with improved physical function. Given the limited healthcare resources, low-demand activities can be more effective in older age groups, whereas high-demand activities should be aimed at younger age groups to optimise rehabilitation therapy. Further prospective studies or randomised trials with a relatively larger number of participants should investigate more robust causal relationships between additional weekend rehabilitation and improvements in physical function.

Author contributions The authors confirm their contributions to the paper as follows: study conception and design: TO, RO, and HS; data collection: KF; analysis and interpretation of results: TO, RO, HS, HS, and MTK; manuscript draft preparation: TO, RO, HS, HS, and MTK; supervision: MTK, TY, and TJ. All authors reviewed the results and approved the final version of the manuscript.

Competing interests The authors have no conflict of interest to declare. All authors have read and agreed to the published version of the manuscript.

Funding None.

Data availability statement The Diagnosis Procedure Combination (DPC) database cannot be made available to comply with data governance agreements with the respective management authorities. The data can only be obtained through applications to authorised research institutions.

Ethical review committee statement

The study protocol was approved by the institutional review boards of Tokyo Medical and Dental University. (M2000-788-14)

A statement of the location where the work was performed

All research work has been performed in Tokyo Medical and Dental University.

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Association between additional weekend rehabilitation and functional outcomes in patients with hip fractures: Does age affect the effectiveness of weekend rehabilitation ?

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Weekend rehabilitation and ability to independently perform ADL

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