Risk-Adjusted Mortality Rates of Elderly Veterans with Hip Fractures
Introduction
Hip fractures (HFx) in the elderly are substantial sources of morbidity, mortality, and medical costs. Among all types of fall-related injuries, HFxs cause the greatest number of deaths, lead to severe health problems, and reduce quality of life 1, 2. Postfracture mortality is strongly and positively associated with prefracture functional impairment, cognitive impairment, older age, low physical activity, and chronic diseases 3, 4, 5, 6, 7, 8, 9, 10. One year after a HFx, most patients report some restrictions in ordinary living activities (11) and less than one third ever return to previous function levels 12, 13. A higher relative risk of dying is present in-hospital and persists months to years after the fracture 3, 4, 5, 6, 7, 14. While the incidence of HFx is greater among women 15, 16, 17, men who fracture experience higher morbidity and mortality 3, 4, 18, 19, 20. Past research has found that, regardless of the time horizon, men have a greater mortality risk after HFx compared with women 4, 13, 18, 21, but there is some dispute 22, 23; mortality rates for men vary widely from 16.5% to 37.5% 3, 7, 24. The gender difference in mortality rates has not been fully explained, but attributable factors for men may include older age at the time of fracture, increased morbidity, more postoperative complications, and lifestyle factors, such as smoking and alcohol use 3, 4, 5, 25. There is evidence 7, 21 that age and comorbidity burden alone do not eliminate the gender difference.
Although HFxs have been widely studied in women, more robust studies of HFx in men would be useful in resolving this issue. Most previous research into mortality after HFx has employed samples that are chiefly female or contain fewer than 1,000 patients, or both. The Veterans Health Administration (VHA) is the largest healthcare system in the United States with integrated patient data on elderly males, thus providing a large population to study. The goal of this research was to estimate 12-month survival rates for a large sample of elderly veterans post-HFx with a risk-adjusted model and to compare the results of men to those of women.
Section snippets
Data Source
This was a retrospective cohort analysis of veterans aged 65 years or older who sustained an HFx in the time period 1999–2002. The data source was Medicare; specifically, the Medicare Inpatient Standard Analytical File (SAF) and Denominator File for veterans supplied by the VA Information Resource Center (VIReC). VIReC identifies veterans for possible inclusion in their dataset if they are VHA eligible, enrolled in the VHA, use VHA care, or receive compensation from the Department of Veterans
Results
The descriptive statistics of the patient population are found in Table 1. During the study period (1999–2002), we identified 43,165 elderly veterans who were treated in Medicare facilities for their first HFx admission. Men constituted 87% of the study sample from a predominately Caucasian (94%) population. The average age of the sample was 80 years.
Table 2 presents the multivariate Cox proportional hazard estimates. Coefficients are expressed as the log-odds of the mortality rate and not the
Discussion
Elderly men who experience a HFx have a 1 in 3 chance of dying within 1 year after their initial admission date. Mortality risk for men is highest in the first months. The annual risk-adjusted rate and male hazard ratios are similar to those calculated by others 3, 4, 6, 24 and to the unadjusted rate given by Kamel (41) for veterans with HFx treated in the VHA. Our adjusted mortality rates are approximately 10% lower than the unadjusted rates across the 4 time intervals reported (30, 90, 180,
Conclusion
One in 3 elderly males who sustain an HFx dies within 12 months. Our work represents the first large study of HFxs incorporating males and confirms that men do have a higher mortality risk than women when adjusted for comorbidities, as reported by previous researchers who used smaller samples that were mainly female. Fracture patients with metastatic cancer, renal failure, and liver disease have particularly high mortality risk. The adverse outcomes associated with HFx argue for clinical
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This research was supported by the Department of Veterans Affairs, Veterans Health Administration, VISN-8 Patient Safety Center of Inquiry. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.