BACKGROUND/RATIONALE:
Hip fractures are prevalent, dangerous, impact quality of life and are costly. VA hip fracture patients are younger, more likely to be male, more likely to have been admitted from a nursing home or acute care setting, have longer lengths of stay, are more likely to be discharged directly to the community after hospitalization, and have higher unadjusted in-hospital mortality rates than the Medicare population. Not enough is known about the impact of peri-operative care on long-term outcomes. Variation in hip fracture care and outcomes have not been compared in VA and Medicare.
This research is a first step toward improving clinical practice and care for veterans with hip fracture and includes the three initial steps in the VHA's Quality Enhancement Research Initiative (QuERI) process. The study created a VA cohort with comprehensive, detailed information on many of the peri- and post-operative factors that can influence long-term outcomes by linking VA Surgical Quality Improvement Program (VASQIP) and VA administrative databases. Tracking care and outcomes for a full 12 months for both VA and Medicare patients provided a unique assessment of how these patients fare beyond surgical care, particularly as it relates to understanding the higher unadjusted mortality rates for veterans. This type of evidence is needed to guide improvements in clinical practice for a vulnerable group of patients.

OBJECTIVE(S):
Objective 1: Did post-acute utilization, costs, morbidity, mortality, and community residence at one- year vary for veterans treated for hip fracture in VA between 1998 and 2005?
Hypothesis 1: One-year outcomes of health care utilization, costs, mortality and community residence were influenced by immutable demographic and baseline health risk characteristics along with mutable peri-operative care, post-operative complications, and resources. Veterans who are older, have lower pre-operative health status, experience delayed surgery or post-operative complications, receive care in areas with fewer rehabilitation resources, or receive less post-acute care had higher overall utilization and costs and were less likely to be alive and residing in the community at 12 months.
Secondary Aim 1: Is it possible to accurately measures residential setting for veterans one year following surgery using secondary data sources?
Hypothesis SA1: A short telephone survey confirmed that secondary data accurately captures community residence for 90% of the cases interviewed.
Objective 2: Were post-acute health care utilization, costs, morbidity, mortality, and community residence at one year of veterans treated for hip fracture in VA similar to outcomes for similar Medicare beneficiaries treated for hip fracture outside the VA system between 2003 and 2005?
Hypothesis 2: One-year outcomes of health care utilization, costs, mortality and community residence differed for veterans and Medicare beneficiaries treated for hip fracture. Patients who received surgery and rehabilitation in the VA system had less expensive care trajectories, higher mortality, and lower rates of return to community living compared to a matched sample of Medicare cases.

METHODS:
This retrospective observational research study assessed care patterns, outcomes, and costs for veteran patients age 65 and over with hip fracture; assessed the accuracy of key measures using prospective follow-up for a sub-sample of veterans; and compared VA patients to a matched sample of Medicare hip fracture patients who received surgery in private sector hospitals.
Sample:
Objective 1: A national sample of approximately 12,800 veterans age 65+ who had hip fracture repair surgery in a VA facility, as tracked by the NSQIP registry from 1998-2005.
Secondary Aim: Sub-sample of 109 cases to validate our methodology for determining residential setting one year following discharge from surgery.
Objective 2: A matched sample of 3,000 VA and 3,000 Medicare patients with hip fracture repair during 2003-2005
Outcomes: Mortality, community residence, costs by system at 12 months:
Key Covariates: Demographic characteristics, premorbid health status, peri-operative care, rehabilitation resources in patient's home market area; patient's post-acute care setting, costs and utilization; system of care.

Analysis Descriptive analysis of variables, propensity score methods to adjust for observed confounding, regression analysis, and sensitivity analysis to assess whether findings differ according to the statistical method chosen..

FINDINGS/RESULTS:
Objective 1: Annual mortality rates for hip fracture repair declined over time, particularly between 2003 and 2005. Intramedullary nail use increased from 1998-2005, but did not improve perioperative mortality or comorbidity compared to standard plate-and-screw devices. Nearly half of veterans were discharged directly home after surgery. Patients were more likely to be discharged to non-home settings if they had total function dependence, had American Society of Anesthesiology (ASA) class 4 or 5, had surgical complications prior to discharge, or lived in counties with lower nursing home bed occupancy rates.
Secondary Aim: VA secondary data accurately measures community residence at 1 year. More than 40% of veterans who were surveyed reported ongoing moderate to severe pain 1 year after hip fracture repair.

Objective 2: Mortality rates are higher and average system health care costs lower among patients cared for in VA than among patients cared for under Medicare between 2003 and 2005. These differences persist after adjustment for age, comorbidity, year of surgery, and length of hospital stay.

IMPACT:
This research is a preliminary step toward improving care and outcomes for veterans with hip fracture. It provides VA with information about the impact of care processes on 30-day and one year mortality following hip fracture repairs performed in VHA between 1998 and 2005. Several care processes are amenable to change including surgical delay, type of anesthesia and choice of surgical procedure. Intervention trials to improve these care processes can now be planned. An important finding is that both 30-day and one-year adjusted mortality rates are higher in VA than in a propensity matched cohort of Medicare patients. Because Medicare administrative data lacks the detail available for the VA cohort, it is not possible to know whether this is related to confounding by unknown variables, such as functional status, or to care processes.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Regan EA, Radcliff TA, Henderson WG, Cowper Ripley DC, Maciejewski ML, Vogel WB, Hutt E. Improving hip fractures outcomes for COPD patients. COPD. 2013 Feb 1; 10(1):11-9. [view]
2. Radcliff TA, Regan E, Cowper Ripley DC, Hutt E. Increased use of intramedullary nails for intertrochanteric proximal femoral fractures in veterans affairs hospitals: a comparative effectiveness study. The Journal of Bone and Joint Surgery. 2012 May 2; 94(9):833-40. [view]
3. Hutt E, Fink RM, Nelson-Marten P, Jones J, Kutner JS. Measuring pain perceptions and medication taking behavior at the end of life: a pilot study. The American journal of hospice & palliative care. 2014 Nov 1; 31(7):726-9. [view]
4. Radcliff TA, Henderson WG, Stoner TJ, Khuri SF, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. The Journal of Bone and Joint Surgery. 2008 Jan 1; 90(1):34-42. [view]

Conference Presentations

1. Sursky S, Winter S, Classen S, Yarney A, Monahan M, Lutz A, Platek K, Levy CE. Intermediate-term effects of an occupational therapy driving intervention for combat Veterans. Poster session presented at: Association for Driving Rehabilitation Specialists Annual Conference; 2015 Aug 2; Louisville, KY. [view]
2. Levy CE. Knowledge Now: Update on Mild TBI. Paper presented at: American Academy of Physical Medicine and Rehabilitation Annual Assembly; 2012 Nov 15; Atlanta, GA. [view]
3. Radcliff T, Henderson W, Stoner T, Khuri S, Dohm M, Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems, Acute and Combat-Related Injury
DRE: Epidemiology
Keywords: Falls, Functional status, Quality assessment
MeSH Terms: none