324

ORIGINAL
Characteristics of rehabilitation services in high-FIM efficiency
hospitals after hip fracture
Daichi Asanumaa, and Ryo MomosakibaDepartment of Rehabilitation, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan, bDepartment of
Rehabilitation Medicine, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa, Japan

Abstract : Characteristics of rehabilitation services probably explain a large proportion of the variation inclinical outcomes following hip fracture. The aim of this study was to clarify rehabilitation characteristics ofhigh-performance hospitals after hip fracture. This is a retrospective observational study using the Japan Rehabilitation Database for the period 2005–2015. We divided facilities into high-FIM efficiency and low-FIM efficiency hospitals by using the mean of Functional Independence Measure efficiency for each hospital. We comparedrehabilitation characteristics between high- and low-FIM efficiency hospitals. We identified 1247 patients withhip fracture from 12 hospitals who were eligible for analysis after applying exclusion criteria. Using one-to-one
random matching on admission Functional Independence Measure, 880 pairs of patients were included for final
analysis. More patients were discharged home in the high-FIM efficiency hospitals compared with low-FIM efficiency hospitals. High-FIM efficiency hospitals had significantly shorter length of stay. Patients in high-FIM
efficiency hospitals received higher amounts of daily rehabilitation, early rehabilitation, and preoperative rehabilitation. Patients in high-FIM efficiency hospitals engaged in more weekend exercise and self-exercise. Ourdata suggested that the amount, timing, and type of rehabilitation are essential indicators of performance inacute hip fracture. J. Med. Invest. 66 : 324-327, August, 2019
Keywords : activities of daily living, aged, hip fracture, pay-for-performance, quality indicator

INTRODUCTION

PATIENTS AND METHODS

Hip fracture is the most common fracture among the older individuals and its incidence is rising in developed countries alongside population aging (1). Rehabilitation plays an important rolein mitigating the diminished ability to perform activities of dailyliving among these patients (2).
Facility characteristics explain a large proportion of the variation in clinical outcomes following hip fracture. A previous cohort
study using Medicare data showed facility size, ownership by afacility organization, hospital market concentration, percent ofpatients who have multiple problems, and occupancy rate weresignificant facility characteristics affecting outcomes after hip
fracture (3). We focused on variation of rehabilitation services
as a facility characteristic ; for instance, type and amount of
rehabilitation. We could change characteristics of rehabilitation
services easier than other facility characteristics. Another cohort
study using the Uniform Data System for Medical Rehabilitation
Database did not show any significant correlation of rehabilitation characteristics with gains in motor and cognitive function(4). In addition, if significant characteristics of rehabilitation services are clarified, we could use these characteristics as quality
indicators of rehabilitation in each hospital.
This retrospective observational study aimed to clarify characteristics of rehabilitation services in high-performance hospitals after acute hip fracture.

This study was approved by the Institutional Review Boardof the Japanese Association of Rehabilitation Medicine. The
requirement of informed patient consent was waived because
anonymized data from the association’s database were used foranalysis.
The Japan Rehabilitation Database was established withfinancial support from the Ministry of Health, Labour andWelfare of Japan. Comprehensive clinical data was accumulated
for rehabilitation in continuous patients discharged from participating hospitals from 2005. The database comprises solely
voluntary hospital samples, not random hospital with unique
identifiers for the specific patient data. Baseline data were collected at admission ; time-dependent variables and outcome data
were collected at discharge. The data were then submitted to theJapan Association of Rehabilitation Database. All personal data
were coded and deidentified by deleting all personal identifying
information.
In this study, we included patients with hip fracture admitted
to acute care hospital from the database. We excluded patients
admitted to hospitals that registered less than 10 patients, those
not admitted within the day after onset, and patients with missing Functional Independence Measure (FIM) data.
Data extracted from the database and forwarded to us foranalysis are listed below : Number of patients in each hospital,
FIM scores (from 18 [totally dependent] to 126 [totally independent]) (5) on admission and discharge, length of stay, days fromonset, amount of daily rehabilitation, rehabilitation onset day
from admission, preoperative rehabilitation, self-exercise without medical staff, weekend exercise, fracture type, pre-injury
bedridden degree, whether the patient underwent surgery.
The 18-item FIM scale assesses independence in common
activities of daily living, and FIM scores are familiar to mostrehabilitation staff in Japan. Each item is assessed on a 7-point

Received for publication February 26, 2019 ; accepted August 1, 2019.
Address correspondence and reprint requests to Ryo Momosaki,
Department of Rehabilitation Medicine, Teikyo University School of
Medicine University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu,
Kawasaki, Kanagawa 213-8507, Japan and Fax : +81-44-844-3201.

The Journal of Medical Investigation Vol. 66 2019

325

The Journal of Medical Investigation Vol. 66 August 2019
ordinal scale, with higher scores reflecting greater independence. The FIM is grouped into a 13-item motor subscale (eating,grooming, bathing, upper-body dressing, lower-body dressing,
personal hygiene, bladder management, bowel management,
bed-to-chair transfer, toilet transfer, shower transfer, walk or
wheel-chair and stairs) and a 5-item cognitive subscale (com-prehension, expression, social interaction, problem solving andmemory). The motor subscale score ranges from 13 to 91 (motor
FIM). Therapists evaluated FIM on the ward using ADL performance. Even if patients could not walk, they could performseveral ADLs in a subcategory of FIM, such as eating, grooming,
upper-body dressing, and personal hygiene. FIM gain was calculated as : (FIM score on discharge – FIM score on admission).
FIM efficiency was calculated as (FIM score on discharge – FIM
score on admission) /length of stay in days (6).
All patients with hip fracture participated in rehabilitation
programs that focused on gait- and exercise-related to activities
of daily living, typically involving 40–60 min of rehabilitation
per weekday. Weekend exercise is rehabilitation therapy provided by therapists on Saturdays and Sundays. Weekend rehabilitation is usually provided at the discretion of the attending
physician based on their prescription of rehabilitation therapy
and the setup of rehabilitation therapy services (7). Self-exercise
was performed with the instructions of a therapist, nurse, or physician. Self-exercise supplemented formal therapy by repeating
the activity or motion. Self-exercise varied in terms of content
and load, and although the details were not clear for every acutehospital, a survey of some of the facilities indicated that self-exercise was planned under the guidance of a therapist and thatthe primary focus was on standing training, transfer training,and gait training (8).
Bedridden degree, which is used to judge the level of long-termcare. This indicates the level of independence of elderly patientsin ADL, ranging from fully independent to completely bedridden
as follows : independent (fully independent), J1 and J2 (independent with some disability), A1 and A2 (moving around indoors
independently, but requiring some assistance when they go out),
B1 and B2 (mostly bedridden), or C1 and C2 (completely bedridden). In the present study, we divided this range of independence
into four variables : independent (independent, J1 or J2), homebound (A1 or A2), mostly bedridden (B1 or B2), or completely
bedridden (C1 or C2).
We used FIM efficiency as a performance index of in-hospital
rehabilitation services. We divided facilities into high-FIM efficiency and low-FIM efficiency hospitals by using the median of
FIM efficiency. Before and after one-to-one random matching on
admission FIM, rehabilitation characteristics were compared
between high-FIM efficiency and low-FIM efficiency hospitals using the chi-square test for categorical variables and theunpaired t-test for continuous variables. We used SPSS 19.0
software (IBM SPSS Inc., Armonk, NY) for all analyses, withstatistical significance set at p < 0.05.

RESULTSA total of 3088 patients with hip fracture were identified in 32
acute hospitals for the study period. Of these, we excluded 841
patients who were admitted to hospitals that registered less than
10 patients ; 621 were not admitted within the day after onset
and 379 had missing data on FIM. This left 1247 patients from
12 acute hospitals eligible for analysis (Figure 1). FIM efficiency
for each hospital are shown in Table 1. Median of FIM efficiency
in all patients was 0.5. We defined high-FIM efficiency hospitals
as facilities with median of FIM efficiency over 0.5 and identified
6 high-FIM efficiency hospitals (50%) with 589 patients (47.2%).

Using one-to-one matching on admission FIM, 880 pairs ofpatients were included for final analysis. Table 2 shows the comparison between the high-FIM efficiency and low-FIM efficiency
hospitals. High-FIM efficiency hospitals had significantly higher
FIM efficiency and FIM gain scores than the control group,
and a significantly shorter length of stay in both matched andunmatched groups. More patients engaged in early rehabilitation, high amounts of rehabilitation, preoperative rehabilitation, self-exercise, and weekend rehabilitation in the high-FIM
efficiency hospitals compared with low-FIM efficiency hospitals
before and after matching.

Figure 1. Flow chart of patient selection

Table 1. Number of patients and FIM efficiency for each hospital
Hospital

FIM efficiency
Mean ± standard deviation

Median [Interquartile range]A

0.44 ± 0.25

0.40 [0.24, 0.62]

B

1.26 ± 0.85

1.10 [0.69, 1.74]

C

0.64 ± 0.47

0.57 [0.20, 1.04]

D

0.59 ± 0.55

0.49 [0.24, 0.79]

E

0.62 ± 0.59

0.51 [0.23, 0.74]

F

0.94 ± 0.67

0.82 [0.41, 1.35]

G

1.17 ± 0.69

1.12 [0.59, 1.79]

H

0.61 ± 0.56

0.44 [0.15, 1.05]

I

0.35 ± 0.25

0.28 [0.17, 0.51]

J

0.52 ± 0.39

0.42 [0.25, 0.69]

K

0.37 ± 0.33

0.28 [0.09, 0.54]

L

0.99 ± 1.90

0.58 [0.26, 1.00]

FIM, Functional Independence Measure.

326

D. Asanuma and R. Momosaki Rehabilitation features in hip fracture

Table 2. Differences between patients in high-FIM efficiency and low-FIM efficiency hospitals
Unmatched groups
Patients in highFIM efficiency
hospitals
Number of patients

Patients in lowFIM efficiency
hospitals

Matched groups using admission FIM
p-value

Patients in highFIM efficiency
hospitals

Patients in lowFIM efficiency
hospitals

p-value

589

658

440

440

462 (78.4)

526 (79.9)

0.514

338 (76.8)357 (81.1)

0.136

< 64

52 (8.8)

45 (6.8)

0.014

31 (7.0)32 (7.3)

0.466

65-74

78 (13.2)

55 (8.4)

50 (11.4)

36 (8.2)

75-84

193 (32.8)

226 (34.3)

145 (33.0)

148 (33.6)

90-

266 (45.2)

332 (50.5)

214 (48.6)

224 (50.9)

Female (%)
Age (%)

Comorbidities (%)
Cerebrovascular disease72 (12.2)

59 (9.0)

0.065

62 (14.1)

43 (9.8)

Orthopedic disease

93 (15.8)

101 (15.3)

0.831

64 (14.5)

63 (14.3)

0.924

Dementia

211 (35.8)

258 (39.2)

0.220

180 (40.9)

153 (34.8)

0.071

Non-operative (%)

34 (5.8)30 (4.6)

0.369

25 (5.7)

17 (3.9)

0.268

Fracture type (%)

0.001

0.061

0.001

Femoral neck186 (31.6)

128 (19.5)

123 (28.0)

Trochanteric231 (39.2)

139 (21.1)

175 (39.8)

94 (21.4)

Missing

172 (29.2)

391 (59.4)

142 (32.3)

261 (59.3)

Independent

182 (30.9)

209 (31.8)

100 (22.7)

141 (32.0)

Homebound

128 (21.7)

164 (24.9)

104 (23.6)

102 (23.2)

Mostly bedridden

79 (13.4)

79 (12.0)

71 (15.9)

43 (9.8)

Completely bedridden

23 (3.9)27 (4.1)

19 (4.3)

17 (3.9)

Missing

177 (30.1)

179 (27.2)

147 (33.4)

137 (31.1)

FIM score on admission ± SD

53.1 ± 20.3

45.6 ± 19.6

< 0.00148.2 ± 18.1

48.2 ± 18.1

1

Motor FIM score on admission ± SD

28.7 ± 13.9

24.4 ± 13.2

< 0.00125.6 ± 11.9

25.3 ± 12.4

0.716

Pre-injury bedridden degree (%)

85 (19.3)

0.588

0.080

Cognitive FIM score on admission ± SD

24.3 ± 9.8

21.1 ± 9.2< 0.001

22.6 ± 9.74

22.9 ± 9.0

0.635

FIM score on discharge ± SD

85.2 ± 29.4

72.0 ± 30.9

< 0.001

79.9 ± 28.9

75.9 ± 29.6

0.045

FIM gain ± SD

32.1 ± 19.2

26.3 ± 20.3

< 0.00130.9 ± 19.7

27.4 ± 20.2

0.044

FIM efficiency ± SD

1.06 ± 0.93

0.56 ± 0.50

< 0.001

0.94 ± 0.72

0.62 ± 0.52

< 0.001

Home discharge (%)

303 (51.4)

189 (28.7)< 0.001204 (46.4)

130 (29.5)< 0.001

Length of stay (days) ± SD

39.7 ± 24.9

54.1 ± 30.6

< 0.001

41.9 ± 25.4

54.2 ± 30.8

< 0.001

Rehabilitation starting day from admission ± SD

2.8 ± 22.1

5.3 ± 4.8

< 0.001

3.3 ± 21.8

5.5 ± 4.6

0.043

Amount of daily rehabilitation (min) ± SD

58.0 ± 22.7

43.3 ± 34.7

< 0.001

57.1 ± 23.5

43.8 ± 34.9

< 0.001

Preoperative rehabilitation (%)

244 (41.4)

140 (21.3)< 0.001176 (40.0)

91 (20.7)< 0.001

Self-exercise (%)

172 (29.2)

35 (5.3)< 0.001103 (23.4)

18 (4.1)< 0.001

Weekend rehabilitation (%)

311 (52.8)

10 (1.5)< 0.001217 (49.3)

6 (1.4)< 0.001

FIM, Functional Independence Measure ; SD, standard deviation.

DISCUSSION
This study used a large rehabilitation inpatient database
to clarify rehabilitation characteristics in high-FIM efficiency
hospitals after hip fracture. Patients in the high-FIM efficiency
hospitals received early rehabilitation and more amounts of rehabilitation. Also, high-FIM efficiency hospitals provided more
preoperative rehabilitation, self-exercise, and weekend exercise.
A cohort study demonstrated that participation of rehabilitation specialists, conference execution rate, amount of exercise perday, self-exercise without therapists, and exercise in wards weresignificant characteristics in recovery among stroke patients (9).
In the present study, timing, amount, and type of rehabilitation
were associated with hospital performance ; we obtained similar
results as in the previous study. In addition, a systematic review
reported the effect of intensive and early rehabilitation for hip
fracture (10). Self-exercise and weekend exercise may contributeto improving physical ability by increasing the amount of exercise and variety of rehabilitation after hip fracture (7, 8).
High-FIM efficiency hospitals had significantly shorter
lengths of stay. However, high-FIM efficiency hospitals provided
longer rehabilitation time for patients. The difference in length of

The Journal of Medical Investigation Vol. 66 August 2019
stay was 12 days on average between the two groups. The additional provision of rehabilitation services totally costs on average
about 14800 Japanese yen. We think this cost is reasonable.
Pay-for-performance initiatives provide financial benefits orconsequences to individual health care providers, groups of providers, or institutions based on their performance in measures ofquality (11). Pay-for-performance was found to improve quality
and efficiency of cardiac rehabilitation (12). Also, a pay-for-performance model was associated with improved quality of carefor older patients with hip fracture (13). Thus, rehabilitation
characteristics of this study could be used as quality indicators
and assessment criteria for pay-for-performance. Further research is required to clarify whether these indices could be usedin pay-for-performance evaluation with a larger amount of data.
We recognize a certain limitation in this study. First, theJapan Rehabilitation Database solely contains data provided voluntarily, not random samples, from participating hospitals, andso generalization of our findings to all hospitals may be limited.
Second, the low-FIM efficiency hospitals had more missing datacompared with high-FIM efficiency hospitals. This suggests that
low-FIM efficiency hospitals probably did not make concerted
efforts in data collection.
In conclusion, we have clarified the characteristics of highFIM efficiency hospitals in acute hip fracture rehabilitation. Ourdata suggested that amount, timing, and type of rehabilitation
are essential indicators of performance in acute hip fracture
rehabilitation.

CONFLICT OF INTERESTS
No conflict of interest to declare.

ACKNOWLEDGMENTS
This study gratefully acknowledges the Japan Association of
Rehabilitation Database for providing the data analyzed in thisstudy. Discussion of the results of this study represent the viewsof the authors and not the official views of the Japan Associationof Rehabilitation Database.

REFERENCES
1.

Johnell O, Kanis JA : An estimate of the worldwide prevalence and disability associated with osteoporotic fractures.

327

Osteoporos Int 17 : 1726-1733, 2006
Radosavljevic N, Nikolic D, Lazovic M, Jeremic A : Hip
fractures in a geriatric population – rehabilitation based on
patient’s needs. Aging Dis 5 : 177-182, 2014
3. Neuman MD, Silber JH, Passarella MR, Werner RM : Comparing the contributions of acute and postacute care facility
characteristics to outcomes after hospitalization for hip
fracture. Med Care 55 : 411-420, 2017
4. Johnston MV, Wood KD, Fiedler R : Characteristics of effective and efficient rehabilitation programs. Arch Phys Med
Rehabil 84 : 410-418, 2003
5. Hetherington H, Earlam RJ : Measurement of disability
after multiple injuries : the functional independence measure. Clinical review. Eur J Surg 161 : 549-555, 1995
6. Koh GC, Chen CH, Petrella R, Thind A : Rehabilitation impact indices and their independent predictors : a systematic
review. BMJ Open 3 : e003483, 2013
7. Kinoshita S, Momosaki R, Kakuda W, Okamoto T, Abo
M : Association between 7 days per week rehabilitation andfunctional recovery of patients with acute stroke : a retrospective cohort study based on the Japan Rehabilitation
Database. Arch Phys Med Rehabil 98 : 701-706, 2017
8. Shiraishi N, Suzuki Y, Matsumoto D, Jeong S, Sugiyama
M, Kondo K : Effects of a self-exercise program on activities
of daily living in patients after acute stroke : a propensity
score analysis based on the Japan Association of Rehabilitation Database. Arch Phys Med Rehabil 98 : 434-441, 2017
9. Jeong S, Kondo K, Shiraishi N, Inoue Y : An evaluation of
the quality of post-stroke rehabilitation in Japan. ClinicalAudit 2 : 59-66, 2010
10. Chudyk AM, Jutai JW, Petrella RJ, Speechley M : Systematic review of hip fracture rehabilitation practices in theelderly. Arch Phys Med Rehabil 90 : 246-262, 2009
11. Mendelson A, Kondo K, Damberg C, Low A, Motúapuaka
M, Freeman M, Kansagara D : The effects of pay-for-performance programs on health, health care use, and processesof care : a systematic review. Ann Intern Med 166 : 341-353,
2017
12. Mead H, Grantham S, Siegel B : Improving cardiovascularcare through outpatient cardiac rehabilitation : an analysis
of payment models that would improve quality and promoteuse. J Cardiovasc Nurs 29 : 158-164, 2014
13. Colais P, Pinnarelli L, Fusco D, Davoli M, Braga M, Perucci
CA : The impact of a pay-for-performance system on timing
to hip fracture surgery : experience from the Lazio Region(Italy). BMC Health Serv Res 13 : 393, 20132.