Fracture orthopedic risk of non-home discharge score II (FORD-II)

Post-acute placement after fracture trauma is a major driver of hospital length of stay and cost, but discharge needs are often identified late. We developed and validated the Fracture Orthopedic Risk of Non-Home Discharge score, version II (FORD-II), as an admission-time tool to identify adult fracture-trauma patients likely to require post-acute placement.

We performed a retrospective development and held-out validation study using the National Trauma Data Bank from 2019 to 2024. Adults with International Classification of Diseases, Tenth Revision fracture diagnoses and classifiable discharge dispositions were included. The primary outcome was non-home discharge to inpatient rehabilitation, skilled nursing facility, long-term acute care hospital, or intermediate care. FORD-II was derived from 41 admission-time predictors using least absolute shrinkage and selection operator regression, converted to a 0-to-10 integer score, locked after derivation, and validated without recalibration. Discrimination and calibration were compared with the original Fracture Orthopedic Risk of Non-Home Discharge score (FORD-I), Geriatric Trauma Outcome Score II, and Trauma Risk Adjusted In-hospital Geriatric Evaluation Score. A hospital-perspective budget-impact analysis explored the potential cost implications of using FORD-II to trigger early discharge planning.

Among 1952,210 encounters, 1301,473 were assigned to derivation and 650,737 to validation; 39.9% had non-home discharge. FORD-II retained 16 predictors and achieved an area under the receiver operating characteristic curve of 0.8285 (95% confidence interval, 0.8275-0.8295), exceeding FORD-I (0.7749), Geriatric Trauma Outcome Score II (0.7940), and Trauma Risk Adjusted In-hospital Geriatric Evaluation Score (0.7446; all P < .001). Calibration was strong, with intercept 0, slope 1, and Brier score 0.164. Observed non-home discharge increased from 7.29% in low-risk patients to 80.47% in high-risk patients. In the exploratory budget-impact model, FORD-II-guided early discharge planning was projected to save $362.25 per patient.

FORD-II is an admission-time score derived from a United States national trauma registry that accurately stratified risk of non-home discharge after adult fracture trauma. Its high-risk category identifies patients who may benefit from earlier case management, rehabilitation assessment, family counseling, and post-acute placement planning. As a United States-derived tool, FORD-II requires external validation before adoption in other trauma systems.