Why Didn’t That Hip Get Fixed?
Race and Variations in Operative and Nonoperative Treatment for Hip Fracture
Mark D. Neuman, MD
University of Pennsylvania
Robert Wood Johnson Foundation Clinical Scholars Program
Department of Anesthesiology and Critical Care Medicine
Background
• Hip fracture is a disease of older adults
• Most fractures occur due to a combination of
osteoporosis and low-velocity trauma (i.e.
falls)
• 340,000 events in US each year
• 20-30% 1 year mortality; 40% do not return to
pre-fracture level of walking
• Higher mortality & worsened mobility among
non-white patients at 6 months
Background
• Hospital admission
indicated for all patients
with hip fracture
• Operative repair is the
standard of care
• Non-operative repair
only if moribund,
refusing surgery, or no
chance of functional
recovery
Parker, M. et al. BMJ 2006;333:27-30
Aims
1. Estimate the frequency of operative and nonoperative management for hip fracture in a
population-based sample
2. Assess associations between patient race,
income, and comorbidities and the odds of
non-operative management
Data sources
• Inpatient Medicare claims
• Obesity and Surgical Outcomes (OBSOS) Study
• New York, Illinois, Texas 2002-2006
• 3,975,666 patients; 12,103,966 admissions
• Hip fracture defined by ICD-9-CM diagnosis
codes
• 3-Month look-back to exclude re-admissions
Methods
• Operative care defined by presence of 104
ICD-9-CM procedure codes within 1 month
• 60 Patient-level variables
• Univariate analyses: chi-square, t-test
• Predictive models for operative or nonoperative care: multivariable logistic
regression
• Survival analyses: Kaplan-Meier, MantelHanszel analyses
Hip fracture care in NY, TX, and IL: 2002-2006
Number
Percent
Operative management*
155,178
93.8%
Non-operative management
10,283
6.2%
Total
165,861
100%
*Operative care defined as presence of any of 104 ICD-9-CM
procedure codes for surgery on proximal femur or hip joint within one
month of admission
Selected patient variables: operative vs non-operative*
Variable
Operative
Non-operative
Age: 85 and over (%)
43.6
49.7
Median # of comorbidities
4.3
4.6
CHF (%)
29.0
39.6
COPD (%)
26.0
29.0
Renal failure (%)
10.2
18.2
Alzheimer’s disease (%)
32.8
38.2
Race: white (%)
92.0
88.3
Race: black (%)
3.7
7.3
* P<0.0001 For all comparisons (χ2)
Predictors of non-operative management (selected)*
Parameter
Odds Ratio 95% CI
P
Age 85 and over (vs. 65-74)
1.36
1.28, 1.46
<0.0001
CHF
1.46
1.40, 1.53
<0.0001
COPD
1.13
1.08, 1.18
<0.0001
Renal failure
1.66
1.56, 1.76
<0.0001
Alzheimer’s disease
1.17
1.12, 1.22
<0.0001
Race: black (vs. white)
1.80
1.65, 1.96
<0.0001
Income: below 25th
percentile (vs. above 75th)
1.02
0.96, 1.08
0.525
*Full model controlled for 39 patient variables including age,
comorbidities, sex, source of admission, fracture location, injury
characteristics, race, income, and 21 significant interactions.
Hypothesis (1): Black patients with hip
fracture receive care at hospitals that are
more likely to pursue non-operative
management.
Odds of non-operative care within individual hospitals:
conditional logistic regression*
Parameter
Odds Ratio
95% CI
P
Race: Black (vs. white)
1.53
1.38, 1.66
<0.0001
Income: Below 25th
Percentile (vs. above 75th)
1.10
1.01, 1.19
0.028
*Full model controlled for individual hospital effects, 39 patient variables
including age, comorbidities, sex, source of admission, fracture location,
injury characteristics, race, income, and 21 significant interactions.
Hypothesis (2): Black patients with hip
fracture are more acutely ill than whites.
I. Non-operative patients: survival to 7 days
Alive (Row %)
Dead (Row %)
Black
694 (92%)
60 (8.0%)
White
7249 (73.7%)
1831 (18.6%)
II. Odds of survival to 7 days: black vs. white
Odds Ratio
95% CI
Unadjusted
2.92
2.23, 3.82
Adjusted for hospital
2.44
1.79, 3.34
(Mantel-Hanszel)
1.0
Operative
0.9
SURVIVAL
0.8
0.7
Non-Operative
0.6
0.5
0.4
0
30
60
90
120
DAYS AFTER ADMISSION
Black
White
150
180
Conclusions
• Black race associated with 80% increased
odds of non-operative treatment
• Controlled for comorbidities, source of admission,
fracture characteristics, and income
• Controlling for hospital, odds of non-operative
treatment increased 57% among black
patients
• Pattern not explained by acuity of illness, as
black patient survival exceeds white patient
survival in non-operative cases
Implications
• Clinical model allows for examination of
differences in care delivered to a large
sample of patients with similar indications for
intervention
• Further research needed to validate and
describe causes of this potential disparity
• Identification of patient-level factors and
socio-environmental effects that may
influence patterns of operative care
Collaborators
• Lee A. Fleisher, MD (PENN
• Orit Even-Shoshan, MS (Center for Outcomes
Research, CHOP)
• Lanyu Mi, MS (Center for Outcomes Research,
CHOP)
• Jeffrey H. Silber, MD, PhD (Center for Outcomes
Research, CHOP; PENN)
• Funding: NIDDK #R01 DK073671 (JHS); RWJFCSP (MDN)