In Hospital Hip Fracture Mortality
Colleen McLaughlin, MPH, PhD
Division 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 mortality
1=minor
2=moderate
3=major
4=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
Hip Fracture Mortality
by ED type, 2011
21
20
19
18
17
16
Risk Adjusted Rate per 100
15
Each dot represents one facility
14
Truama Center
Large ED (100+ visits/day)
Other facilities
13
12
11
10
- - - 99% limits   95% limits
9
8
7
6
5
4
3
State rate
2
1
0
0
100
200
Patients at Risk
300
400
Hip Fracture Mortality
by ED type, 2010
15
14
13
12
Each dot represents one facility
Risk Adjusted Rate per 100
11
Truama Center
Large ED (100+ visits/day)
Other facilities
10
9
8
- - - 99% limits   95% limits
7
6
5
4
3
State rate
2
1
0
0
100
200
Patients at Risk
300
400
Odds ratios for in hospital death among hip
fracture patients, NYS, 2011
case fatality
patients deaths
(%)
Age (yrs)
65-69
70-74
75-79
80-84
85+
Gender
Male
Female
Type of ED
Trauma center
Large ED
Other facilities
OR
95% Confidence
Intervals
801
1181
1936
3121
7022
13
20
56
78
324
1.6
1.7
2.9
2.5
4.6
1
1.0
1.7
1.5
2.9
(reference)
0.5
1.0
0.8
1.7
3626
104365
171
320
4.7
0.3
1
0.7
(reference)
0.6
0.9
4263
3239
6559
133
111
247
3.1
3.4
3.8
1.0
1.0
1.0
(reference)
0.8
1.3
0.8
1.3
2.1
3.4
2.9
5.4
Odds ratios for in hospital death among hip
fracture patients, NYS, 2011
femur fracture 1
femur fracture 2
femur fracture 3
femur fracture 4
hip replacement 1/2
hip replacement 3
hip replacement 4
hip surgery/trauma 1
hip surgery/trauma 2
hip surgery/trauma 3
hip surgery/trauma 4
other dx 1-2
other dx 3
other dx 4
patients deaths
216
5
533
63
233
57
60
30
3666
72
651
51
53
7
2822
24
4273
90
1103
44
137
19
223
17
73
7
18
5
case fatality
(%)
2.3
11.8
24.5
50.0
2.0
7.8
13.2
0.9
2.1
4.0
13.9
7.6
9.6
27.8
OR
2.6
13.5
34.0
111.9
2.2
4.3
15.6
1.0
2.2
4.3
16.5
31.9
42.1
162.8
95% Confidence
Intervals
0.9
6.5
8.4
22.2
20.7
57.2
58.4
218.8
1.4
3.6
2.6
7.2
5.9
36.6
(reference)
1.4
3.6
2.6
7.2
8.7
31.1
11.4
83.0
12.4
129.6
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 2011
ROM
OR
95% CI
minor
1.1
0.6
2.2
moderate
1.1
0.8
1.4
major
1.2
0.8
1.8
extreme
0.5
0.3
0.9
OR contrasting all other facilities to trauma centers,
NYS 2010
ROM
OR
95% CI
minor
1.3
0.7
2.5
moderate
1.1
0.8
1.6
major
0.9
0.6
1.3
extreme
1.4
0.7
3.1
Percent of Patients seen at Trauma
Centers by Risk Adjustment Variables
APR-DRG ROM
1=minor
2=moderate
3=major
4=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