Discharge destination and patient‐reported outcomes after inpatient treatment for isolated lower limb fractures

In reply: We thank Chung and Haran for their interest in our article. We acknowledge some of the limitations they present and, in fact, did mention them in our publication.1 These include limitations inherent to registry‐based studies such as the lack of access to the precise reasons for decision making and the unmeasured confounders including psychological issues, frailty and complications among others. We believe that concerns in regards to housing and home hazards, which may be present at discharge and lead to an inpatient rehabilitation (IPR) admission, should not affect longer term outcomes at 12 months.

In regards to the balance of covariates and the inverse probability weighting (IPTW) approach used, we agree with Chung and Haran that the validity of the estimates obtained from this approach (and all other regression‐based approaches) relies on the groups being compared having overlapping attributes. We showed that patients treated at home and in IPR had balanced covariates, as shown by the standardised differences about weighting using IPTW displayed in Box 3 and Box 4 in our article.1 We acknowledged in our review that assumptions about unmeasured attributes could not be made. We performed an analysis to assess the sensitivity of our conclusions to the possibility of unmeasured differences between the two groups of patients (figure 3 in the Supporting Information document in our article).2 This sensitivity analysis permits readers to consider whether the magnitude of the impact of unmeasured confounders that is sufficient to change conclusions about the effect of discharge destination on outcomes is plausible and adjust their interpretation of our results accordingly.

We also agree that patients discharged directly home had less than optimal outcomes. Outcomes of patients with orthopaedic trauma have been presented in other research, and increasing our understanding of how to improve these patient outcomes is paramount. Our study particularly focused on the comparison of discharge destination rather than the overall outcome following lower limb fracture.

Unfortunately, we did not have access to other domains of the World Health Organization’s International Classification of Functioning, Disability and Health or other scores at this time. However, further research into the outcomes of home discharge compared with IPR is being considered, and we will expand our outcome measures accordingly to provide a greater understanding of the patient cohorts.