1. US Department of Veterans Affairs Hip Fractures in VA/Medicare-Eligible Veterans: Mortality and Costs Elizabeth Bass, PhD, 1 Dustin D. French, PhD, 1 Douglas D. Bradham, DrPH, 2 Laurence Z. Rubenstein, MD, MPH 3 1 VISN-8 Patient Safety Center of Inquiry, James A Haley VAMC 2 VA Cooperative Studies Program Coordinating Center at Perry Point, MD and University of Maryland School of Medicine 3 UCLA David Geffen School of Medicine and VA Greater Los Angeles Healthcare System Geriatric Research, Education and Clinical Center HERC Cyber Seminar July 25, 2007

2. Outline Brief overview of previous literature Brief overview of previous literature Data sources Data sources Model, including comorbidity adjuster Model, including comorbidity adjuster Mortality outcomes Mortality outcomes Cost outcomes Cost outcomes Implications Implications

3. Background Why hip fractures are a real problem in the elderly Why hip fractures are a real problem in the elderly –Usually includes inpatient stay and rehab –Leads to other clinical issues –High rates of mortality Previous research Previous research –Used small samples –Used mostly female samples –What’s going on in the VA?

4. Goals establish risk-adjusted mortality rates for elderly veterans who sustained a hip fracture over a 12 month time period establish risk-adjusted mortality rates for elderly veterans who sustained a hip fracture over a 12 month time period confirm gender difference confirm gender difference estimate costs to Medicare estimate costs to Medicare

5. Data sources Medicare (Standard Analytical Files and Denominator File) for veterans supplied by the VA Information Resource Center (VIReC): 4.7 million individuals Medicare (Standard Analytical Files and Denominator File) for veterans supplied by the VA Information Resource Center (VIReC): 4.7 million individuals –VHA-eligible –enrolled in the VHA –use VHA care –receive compensation from the Department of Veterans Affairs Covers enrollment phase and follow-up period for fracture patients in 1999-2002 (2003) to address right-censoring (VIREC now has data through 2004) Covers enrollment phase and follow-up period for fracture patients in 1999-2002 (2003) to address right-censoring (VIREC now has data through 2004)

6. Methods Retrospective, incident-hip fracture cohort analysis of veterans aged 65+ Retrospective, incident-hip fracture cohort analysis of veterans aged 65+ Patients selected by a “first-ever” admitting diagnosis of hip fracture (ICD-9-CM codes 820-820.9 or 905.3) to a Medicare facility from 1999-2002 Patients selected by a “first-ever” admitting diagnosis of hip fracture (ICD-9-CM codes 820-820.9 or 905.3) to a Medicare facility from 1999-2002 Mortality viewed at several time points up to 1 year Mortality viewed at several time points up to 1 year Costs defined as Medicare payments Costs defined as Medicare payments Selection of comorbidity adjuster Selection of comorbidity adjuster

7. Comorbidity adjuster What are the options? What are the options? Why an Elixhauser? Why an Elixhauser?

8. Model & Methods: 365-day Mortality Model Mortality= f(age, gender, comorbidity adjuster) Statistical Analysis: Cox’s proportional hazard Duration(t)*Death = age, gender, comorbidities

9. Model & Methods: 365-day Costs Model Total Costs= f(age, gender, inpatient length of stay, death within one year, comorbidity adjuster) Statistical Analysis: OLS regression (no transformation after testing several functional forms) Total Medicare payments* = age, gender, length of stay, death, comorbidities *beginning with first admission date

10. Results Demographics (n=43,165) 87% male 94% Caucasian 80 mean age 7 days median length of stay 49% discharged to a skilled nursing facility (SNF)

11. Results: mortality Unadjusted one year mortality rates (30 days = 9.7%, 90 days = 17.5%, 180 days = 24%, 365 days = 32.2%) (30 days = 9.7%, 90 days = 17.5%, 180 days = 24%, 365 days = 32.2%) were approximately 10% higher than the adjusted rates (30 days = 8.9%, 90 days = 15.6%, 180 days = 21.8%, one year = 29.9%).

12. Results: mortality

13. Big differences by gender: the mortality odds for women 12 months after hip fracture were 18%, compared to 32% for men. In other words, men were about twice as likely to die within one year of the hip fracture compared to women.

14. Results: mortality

15. The comorbidity adjustment coefficients suggest that: metastasic cancer increased the risk of death by almost four times (hazard ratio 3.57) metastasic cancer increased the risk of death by almost four times (hazard ratio 3.57) congestive heart failure increased risk by 63% congestive heart failure increased risk by 63% renal failure increased risk by 95% renal failure increased risk by 95% lymphoma increased risk by 63% lymphoma increased risk by 63% weight loss increased risk by 90% weight loss increased risk by 90% Contrary to expectation, hypertension and alcohol abuse were negatively correlated with one-year mortality.

16. Results: Medicare payments Medicare spent nearly $3 billion for patients in this cohort from 1999-2003 Medicare spent nearly $3 billion for patients in this cohort from 1999-2003 70% of total annual Medicare payments for all services occurred within the first 30 days following hospital admission 70% of total annual Medicare payments for all services occurred within the first 30 days following hospital admission Hospital and physician reimbursements were approximately 3/4 of payments Hospital and physician reimbursements were approximately 3/4 of payments

17. Results: Medicare payments Service use Inpatient100% Physician99.1% Outpatient care 83.6% Skilled nursing facilities 64.1% Skilled nursing facilities 64.1% Durable Medical Equipment 57.2% Durable Medical Equipment 57.2% Home Health Agency45.8% Home Health Agency45.8% Hospice 2.7% With the exception of DME and hospice (70.1% for DME, 8.4% for hospice), these percentages showed only a modest increase at the end of 365 days.

18. Results: Medicare payments Average Medicare Payments within 365 Days for Hip Fracture Patients 1999-2003 (N=43,104) Provider Type Mean ($) 99% Confidence Interval ($) Inpatient26,88426,545-27,223 Carrier 24,401 23,895-24,906 SNF12,20812,058-12,358 Hospice 7,073 6,605-7,541 Home Health Agency 5,249 5,146-5,352 DME 4,447 4,217-4,676 Outpatient 3,200 3,085-3,315 Total All Services 69,38968,539-70,239 SOURCE: Medicare SAFs 1999-2003.

19. Results: Medicare payments Cost function (OLS regression): VariableCoefficient estimate ($) Age (years) -575 Gender (1=female)-3,557 1 year mortality (1=died) 3,270 Inpatient LOS (days) 1,944 SOURCE: Medicare SAFs 1999-2003

20. Results: Medicare payments VariableCoefficient estimate ($) Renal failure52,043 Lymphoma47,185 Metastastic cancer35,359 Diabetes w/complications34,332 Alcohol abuse-15,193 More common comorbidities (COPD, CHF & arrhythmias added between $6,200-$10,000) SOURCE: Medicare SAFs 1999-2003.

21. Limitations Did not control for provider characteristics Did not control for provider characteristics Risk adjuster for broad patient population Risk adjuster for broad patient population Varying levels of comorbidities Varying levels of comorbidities Unable to fully explain gender difference in mortality and costs, alcohol effect and why older patients cost less Unable to fully explain gender difference in mortality and costs, alcohol effect and why older patients cost less

22. Concluding Remarks Economic implications: High loss of life (downward spiral) High loss of life (downward spiral) Resource use intense Resource use intense What to do? Clinical intervention strategies such as What to do? Clinical intervention strategies such as –gait and balance testing –osteoporosis diagnosis –medication review –use of hip protectors

23. Tips for VA-Medicare projects Apply for Medicare data from VIReC as soon as possible Apply for Medicare data from VIReC as soon as possible Contact ResDAC frequently Contact ResDAC frequently Have a good data manager Have a good data manager Include researchers with varied backgrounds Include researchers with varied backgrounds

24. Contact Information Elizabeth Bass VA Patient Safety Center of Inquiry Tampa, FL Elizabeth.Bass@va.gov 813-558-3908