Association between postoperative rehabilitation pathway, dose, and three-year mortality in older adults with hip fracture: A nationwide retrospective cohort study

Objective To quantify the long-term survival associations of different rehabilitation pathways and dosages in older adults after hip fracture within a health system characterised by ultra-short hospital stays (seven to 10 days). Design A nationwide, population-based, retrospective cohort study. Setting Taiwan's National Health Insurance Research Database (2005–2013). Participants A total of 10,142 older adults [mean age 79.8 (SD 7.0) years; 62.7% (n = 6361) female] undergoing first surgical repair for fragility hip fracture. Interventions Participants were categorised based on postoperative rehabilitation receipt (users versus non-users), delivery pathway (inpatient only, outpatient only, or integrated inpatient-to-outpatient), and intensity (dosage, defined as administrative billing sessions: one to three sessions versus four or more sessions). Main measures The primary outcome was three-year all-cause mortality (33.2%, n = 3363 out of 10,142). Multivariable Cox proportional hazards models were used to estimate adjusted hazard ratios, controlling for potential confounders. Results A substantial care gap was identified, with 55.8% ( n = 5659) of participants receiving no postoperative rehabilitation. Any rehabilitation was associated with a 17% lower mortality risk (adjusted hazard ratio 0.83; 95% confidence interval 0.77 to 0.89). The strongest association was observed in the integrated inpatient-to-outpatient pathway (0.67; 0.57–0.79). A dose–response pattern was observed, with participants receiving four or more sessions achieving a significantly lower mortality risk (0.71; 0.64–0.80) compared to those receiving no rehabilitation. Conclusions In a system emphasising early discharge, lack of rehabilitation is common and associated with higher mortality. Integrated, higher-dose rehabilitation was consistently associated with lower mortality.