In Hospital Hip Fracture Mortality

Colleen McLaughlin, MPH, PhDDivision of Quality and Patient Safety

Background

• STAC request to examine in hospital mortality among hip fracture patients– Is trauma center status associated with risk of in

hospital death– Are higher risk patients more likely to be treated

at trauma centers– What are the trends in hip fracture inpatient

mortality

Methods

• AHRQ Inpatient Quality Indicator IQI19 Hip Fracture Mortality

• National Quality Forum (NQF) Endorsed Measure (NQF #354)

• Risk adjusted using All Patient Refined DRG and Risk of Mortality (APR-DRG- ROM)– ROM is based on comorbidities

IQI19 Hip fracture mortality definition

• Denominator: All discharges, age 65 years and older, with principal diagnosis code for hip fracture (risk set)– Excludes patients with any diagnosis of

periprosthetic fracture or who were transferred to another short-term hospital

• Numerator: In hospital deaths among risk set

Risk adjustment coefficients(national data)

APR-DRG risk of mortality1=minor2=moderate3=major4=extreme

Sample Risk of Mortality

• Minor: 84 yrs old – Pertrochanteric fracture, closed, Intertrochanteric

section; & other wounds– Sinusitis; hypertension; degenerative disc disease

• Extreme: 94 yr old– Same fracture– Acute renal failure; Pulmonary collapse;

Congestive heart failure; other comorbidities

New York Data

• SPARCS inpatient discharge data– Stratified analysis

• by trauma center, large ED (100+ visits per day), and all other facilities

• by facility

– Risk factors for mortality based on NY data

Statewide Observed Hip Fracture Mortality, 2006-2011

Hip Fracture Mortality by ED Type, NYS, 2011

Statewide rate

Hip Fracture Mortality by ED Type, NYS, 2010

Statewide rate

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Hip Fracture Mortality by ED type, 2011

Each dot represents one facility

Truama Center

Large ED (100+ visits/day)

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Hip Fracture Mortality by ED type, 2010

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Odds ratios for in hospital death among hip fracture patients, NYS, 2011

patients deathscase fatality

(%) OR95% Confidence

IntervalsAge (yrs)65-69 801 13 1.6 1 (reference)70-74 1181 20 1.7 1.0 0.5 2.175-79 1936 56 2.9 1.7 1.0 3.480-84 3121 78 2.5 1.5 0.8 2.985+ 7022 324 4.6 2.9 1.7 5.4

GenderMale 3626 171 4.7 1 (reference)Female 104365 320 0.3 0.7 0.6 0.9

Type of EDTrauma center 4263 133 3.1 1.0 (reference)Large ED 3239 111 3.4 1.0 0.8 1.3Other facilities 6559 247 3.8 1.0 0.8 1.3

Odds ratios for in hospital death among hip fracture patients, NYS, 2011

patients deathscase fatality

(%) OR95% Confidence

Intervalsfemur fracture 1 216 5 2.3 2.6 0.9 6.5femur fracture 2 533 63 11.8 13.5 8.4 22.2femur fracture 3 233 57 24.5 34.0 20.7 57.2femur fracture 4 60 30 50.0 111.9 58.4 218.8hip replacement 1/2 3666 72 2.0 2.2 1.4 3.6hip replacement 3 651 51 7.8 4.3 2.6 7.2hip replacement 4 53 7 13.2 15.6 5.9 36.6hip surgery/trauma 1 2822 24 0.9 1.0 (reference)hip surgery/trauma 2 4273 90 2.1 2.2 1.4 3.6hip surgery/trauma 3 1103 44 4.0 4.3 2.6 7.2hip surgery/trauma 4 137 19 13.9 16.5 8.7 31.1other dx 1-2 223 17 7.6 31.9 11.4 83.0other dx 3 73 7 9.6 42.1 12.4 129.6other dx 4 18 5 27.8 162.8 39.3 634.5

Does being treated at a trauma center improve the outcomes for patients with

high Risk of Mortality?OR contrasting all other facilities to trauma centers, NYS 2011ROM OR 95% CIminor 1.1 0.6 2.2moderate 1.1 0.8 1.4major 1.2 0.8 1.8extreme 0.5 0.3 0.9

OR contrasting all other facilities to trauma centers, NYS 2010ROM OR 95% CIminor 1.3 0.7 2.5moderate 1.1 0.8 1.6major 0.9 0.6 1.3extreme 1.4 0.7 3.1

Percent of Patients seen at Trauma Centers by Risk Adjustment Variables

APR-DRG ROM1=minor2=moderate3=major4=extreme

Conclusion

• Treatment in a trauma center is generally not associated with statistically significantly improved in hospital mortality risk

• Other than those with multiple significant trauma, hip fracture patients are not more likely to be treated in a trauma center compared to patients with other conditions