1. In Hospital Hip Fracture Mortality Colleen McLaughlin, MPH, PhD Division of Quality and Patient Safety

2. 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

3. 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

4. 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

5. Risk adjustment coefficients (national data) APR-DRG risk of mortality 1=minor 2=moderate 3=major 4=extreme

6. 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

7. 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

8. Statewide Observed Hip Fracture Mortality, 2006-2011

9. Hip Fracture Mortality by ED Type, NYS, 2011 Statewide rate

10. Hip Fracture Mortality by ED Type, NYS, 2010 Statewide rate

11. Hip Fracture Mortality by ED type, 2011

12. Hip Fracture Mortality by ED type, 2010

13. Odds ratios for in hospital death among hip fracture patients, NYS, 2011 patientsdeaths case fatality (%)OR 95% Confidence Intervals Age (yrs) 65-69801131.61(reference) 70-741181201.71.00.52.1 75-791936562.91.71.03.4 80-843121782.51.50.82.9 85+70223244.62.91.75.4 Gender Male36261714.71(reference) Female1043653200.30.70.60.9 Type of ED Trauma center42631333.11.0(reference) Large ED32391113.41.00.81.3 Other facilities65592473.81.00.81.3

14. Odds ratios for in hospital death among hip fracture patients, NYS, 2011 patientsdeaths case fatality (%)OR 95% Confidence Intervals femur fracture 121652.32.60.96.5 femur fracture 25336311.813.58.422.2 femur fracture 32335724.534.020.757.2 femur fracture 4603050.0111.958.4218.8 hip replacement 1/23666722.02.21.43.6 hip replacement 3651517.84.32.67.2 hip replacement 453713.215.65.936.6 hip surgery/trauma 12822240.91.0(reference) hip surgery/trauma 24273902.12.21.43.6 hip surgery/trauma 31103444.04.32.67.2 hip surgery/trauma 41371913.916.58.731.1 other dx 1-2223177.631.911.483.0 other dx 37379.642.112.4129.6 other dx 418527.8162.839.3634.5

15. 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 ROMOR95% CI minor1.10.62.2 moderate1.10.81.4 major1.20.81.8 extreme0.50.30.9 OR contrasting all other facilities to trauma centers, NYS 2010 ROMOR95% CI minor1.30.72.5 moderate1.10.81.6 major0.90.61.3 extreme1.40.73.1

16. Percent of Patients seen at Trauma Centers by Risk Adjustment Variables APR-DRG ROM 1=minor 2=moderate 3=major 4=extreme

17. 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