Background
Methods
Data sources
Study design and population
PAC setting
Outcomes
Follow-up
Participant and hospital characteristics
Statistical analyses
Sensitivity analysis
Software
Results
Study population
Characteristics | Overall (N = 624,631) | SNF (n = 423,347) | IRF (n = 100,411) | HHC (n = 100,873) |
---|---|---|---|---|
Demographics | ||||
Age, mean (SD), years | 82.70 (8.26) | 83.76 (8.15) | 80.59 (7.95) | 80.33 (8.13) |
Female Sex | 468,247 (74.96) | 322,011 (76.06) | 72,672 (72.37) | 73,564 (72.93) |
Race/ethnicity | ||||
Non-Hispanic White | 570,284 (91.30) | 388,748 (91.83) | 91,014 (90.64) | 90,522 (89.74) |
Non-Hispanic Black | 24,482 (3.92) | 16,048 (3.79) | 3,897 (3.88) | 4,537 (4.50) |
Hispanic | 11,032 (1.77) | 6,450 (1.52) | 2,325 (2.32) | 2,257 (2.24%) |
Othera | 17,004 (2.72) | 11,038 (2.61) | 2,825 (2.81) | 3,141 (3.11) |
Unknown | 1,829 (0.29) | 1,063 (0.25) | 350 (0.35) | 416 (0.41) |
Dual Medicare/Medicaid enrollment | 161,103 (25.79) | 123,662 (29.21) | 18,724 (18.65) | 18,717 (18.56) |
Calendar year of fracture | ||||
2012 | 81,465 (13.06) | 54,452 (12.86) | 14,703 (14.64) | 12,310 (12.20) |
2013 | 85,178 (13.66) | 57,482 (13.58) | 14,425 (14.37) | 13,271 (13.16) |
2014 | 94,679 (15.16) | 63,700 (15.05) | 16,049 (15.98) | 14,930 (14.80) |
2015 | 93,624 (14.99) | 63,429 (14.98) | 14,862 (14.80) | 15,333 (15.20) |
2016 | 88,836 (14.22) | 60,397 (14.27) | 13,343 (13.29) | 15,096 (14.97) |
2017 | 93,329 (14.94) | 62,805 (14.84) | 13,837 (13.78) | 16,687 (16.54) |
2018 | 87,520 (14.01) | 61,082 (14.43) | 13,192 (13.14) | 13,246 (13.13) |
Conditionsb | ||||
Acute myocardial infarction | 4,924 (0.79) | 3,589 (0.85) | 745 (0.74) | 590 (0.59) |
Acute phlebitis, thrombophlebitis, or thromboembolism | 2,440 (0.39) | 1,730 (0.41) | 3,564 (3.55) | 356 (0.35) |
Anemia | 207,434 (33.21) | 143,277 (33.84) | 34,957 (34.81) | 29,200 (28.95) |
Asthma | 16,211 (2.60) | 10,579 (2.50) | 3,009 (3.00) | 2,623 (2.60) |
Cancer | 60,901 (9.75) | 40,772 (9.63) | 10,903 (10.86) | 9,226 (9.15) |
Cardiac dysrhythmias | 96,617 (15.47) | 68,536 (16.19) | 15,780 (15.72) | 12,301 (12.19) |
Cerebrovascular disease | 22,610 (3.62) | 16,052 (3.79) | 3,611 (3.60) | 2,947 (2.92) |
Chronic kidney disease | 47,418 (7.59) | 33,261 (7.86) | 7,088 (7.06) | 7,069 (7.01) |
Chronic obstructive pulmonary disease and bronchiectasis | 58,283 (9.33) | 39,628 (9.36) | 10,026 (9.98) | 8,629 (8.55) |
Coronary atherosclerosis and other heart diseases | 37,778 (6.05) | 26,337 (6.22) | 5,939 (5.91) | 5,502 (5.45) |
Dementia, delirium, and other cognitive disorders | 100,408 (16.07) | 83,212 (19.66) | 7,288 (7.26) | 9,908 (9.82) |
Diabetes mellitus | 157,873 (25.27) | 106,761 (25.22) | 26,596 (26.49) | 24,516 (24.30) |
Gout and other crystal arthropathies | 10,399 (1.66) | 7,036 (1.66) | 1,858 (1.85) | 1,505 (1.49) |
Heart valve disorders | 41,128 (6.58) | 29,093 (6.87) | 6,907 (6.88) | 5,128 (5.08) |
Hypertension | 256,381 (41.05) | 173,440 (40.97) | 44,140 (43.96) | 38,801 (38.47) |
Liver disease | 7,048 (1.13) | 4,741 (1.12) | 1,276 (1.27) | 1,031 (1.02) |
Low back pain | 4,433 (0.71) | 2,817 (0.67) | 721 (0.72) | 895 (0.89) |
Other musculoskeletal pain | 13,758 (2.20) | 9,405 (2.22) | 2,078 (2.07) | 2,275 (2.26) |
Obesity | 15,294 (2.45) | 9,979 (2.36) | 2,796 (2.78) | 2,519 (2.50) |
Opioid-related disorders | 7,646 (1.22) | 5,504 (1.30) | 993 (0.99) | 1,149 (1.14) |
Osteoarthritis | 58,690 (9.40) | 39,377 (9.30) | 10,310 (10.27) | 9,003 (8.93) |
Peripheral and visceral atherosclerosis | 19,765 (3.16) | 13,190 (3.12) | 2,952 (2.94) | 3,622 (3.59) |
Phlebitis, thrombophlebitis, and thromboembolism | 15,675 (2.51) | 11,083 (2.62) | 2,721 (2.71) | 1,871 (1.85) |
Pulmonary heart disease | 21,492 (3.44) | 15,464 (3.65) | 3,469 (3.45) | 2,559 (2.54) |
Rheumatoid arthritis and related disease | 9,375 (1.50) | 6,179 (1.46) | 1,621 (1.61) | 1,575 (1.56) |
Schizophrenia and other psychotic disorders | 7,806 (1.25) | 6,281 (1.48) | 817 (0.81) | 708 (0.70) |
Thyroid disorder | 81,155 (12.99) | 56,267 (13.29) | 13,489 (13.43) | 11,399 (11.30) |
Frailty indexc | ||||
Robust | 162,414 (26.00) | 90,007 (21.26) | 34,219 (34.08) | 38,188 (37.86) |
Prefrail | 411,929 (65.95) | 292,117 (69.00) | 61,959 (61.71) | 57,853 (57.35) |
Mildly-to-severely frail | 50,288 (8.05) | 41,223 (9.74) | 4,233 (4.22) | 4,832 (4.79) |
Gagne comorbidity score, mean (SD)d | 3.02 (2.32) | 3.21 (2.36) | 2.66 (2.22) | 2.56 (2.12) |
Medication use before the hip fracture hospitalizatione | ||||
Opioids | 70,034 (11.06) | 50,297 (11.88) | 9,350 (9.31) | 10,387 (9.51) |
NSAIDs | 20,061 (3.17) | 13,637 (3.22) | 2,999 (2.99) | 3,425 (3.14) |
Gabapentinoids | 30,674 (4.85) | 22,410 (5.29) | 3,952 (3.94) | 4,312 (3.95) |
Benzodiazepines | 42,617 (6.73) | 31,745 (7.50) | 4,903 (4.88) | 5,969 (5.47) |
Hip fracture hospitalization characteristics | ||||
Length of stay, mean, days | 5.15 (2.92) | 5.27 (2.99) | 4.87 (2.60) | 4.93 (2.93) |
Hospital complications | ||||
Urinary tract infections | 114,237 (18.29) | 85,262 (20.14) | 14,567 (14.51) | 14,408 (14.28) |
Pressure ulcer of skin | 6,090 (0.97) | 4,722 (1.12) | 658 (0.66) | 710 (0.70) |
Pneumonia | 22,445 (3.59) | 16,713 (3.95) | 2,921 (2.91) | 2,811 (2.79) |
Fracture managementf | ||||
Partial or total joint replacement | 203,080 (32.51) | 133,697 (31.58) | 36,280 (36.13) | 33,103 (32.81) |
Internal fixation (any) or external fixation (open or percutaneous approach) | 333,871 (53.45) | 228,016 (53.86) | 52,391 (52.18) | 53,464 (53.00) |
Other surgical management | 1,503 (0.24) | 983 (0.23) | 261 (0.26) | 259 (0.27) |
Non-surgical management | 307,812 (49.28) | 214,702 (50.72) | 48,281 (48.08) | 44,829 (44.44) |
ICU use during hip fracture hospitalization | 92,067 (14.74) | 64,688 (15.28) | 15,541 (15.48) | 11,838 (11.74) |
Characteristics | Overall (N = 624,631) | SNF (n = 423,347) | IRF (n = 100,411) | HHC (n = 100,873) |
---|---|---|---|---|
Number of beds | ||||
< 50 + Missinga | 24,807 (3.98) | 20,575 (4.86) | 1,369 (1.36) | 2,888 (2.87) |
50–100 | 48,320 (7.75) | 35,936 (8.49) | 5,389 (5.37) | 7,055 (7.00) |
101–200 | 122,765 (19.68) | 85,902 (20.29) | 17,552 (17.48) | 19,467 (19.30) |
> 200 | 427,841 (68.59) | 280,934 (66.36) | 76,101 (75.79) | 71,463 (70.85) |
Medical school affiliation | ||||
Major | 123,538 (19.78) | 85,306 (20.15) | 18,092 (18.02) | 20,140 (19.97) |
Limited | 117,496 (18.81) | 77,889 (18.40) | 20,801 (20.72) | 18,806 (18.64) |
Graduate | 29,532 (4.73) | 19,090 (4.51) | 5,703 (5.68) | 4,739 (4.70) |
No Affiliation + Missinga | 354,064 (56.68) | 241,062 (56.94) | 55,815 (55.59) | 57,188 (56.69) |
Urban/Rural | ||||
Urban | 523,639 (83.83) | 346,416 (81.83) | 88,109 (87.75) | 89,114 (88.34) |
Rural + Missinga | 100,992 (16.17) | 76,931 (18.17) | 12,302 (12.25) | 11,759 (11.66) |
Region | ||||
Northeast | 118,521 (18.97) | 83,398 (19.90) | 19,659 (19.58) | 15,464 (15.33) |
Midwest | 148,527 (23.78) | 113,295 (26.80) | 15,770 (15.71) | 19,462 (19.29) |
South | 250,829 (40.16) | 158,856 (37.45) | 51,490 (51.28) | 40,483 (40.13) |
West | 106,677 (17.08) | 67,782 (15.83) | 13,461 (13.41) | 25,434 (25.21) |
Other + Missinga | 77 (0.01) | 16 (0.00) | 31 (0.03) | 30 (0.03) |
Ownership | ||||
Government-owned | 72,930 (11.68) | 50,271 (11.89) | 11,857 (11.81) | 10,802 (10.71) |
For-profit | 90,264 (14.45) | 55,005 (13.00) | 19,546 (19.48) | 15,713 (15.58) |
Not-for-profit | 447,290 (71.61) | 308,313 (72.79) | 66,716 (66.40) | 72,261 (71.64) |
Missing | 14,147 (2.26) | 9,758 (2.30) | 2,292 (2.28) | 2,097 (2.08) |
One-year cumulative incidences and incidence rates
SNF (n = 423,347) | IRF (n = 100,411) | HHC (n = 100,873) | |
---|---|---|---|
FRIs | |||
Events, n | 32,577 | 8,024 | 7,899 |
Crude cumulative incidence, % | 7.70 | 7.99 | 7.83 |
Follow-up time, person-years | 267,301 | 76,405 | 88,629 |
Crude incidence rate (95% CLs), per 1,000 person-years | 123 (121, 123) | 105 (102, 107) | 89 (87, 91) |
Hospital Readmissions | |||
Events, n | 148,712 | 35,999 | 32,518 |
Crude cumulative incidence, % | 35.13 | 35.85 | 32.24 |
Follow-up time, person-years | 238,875 | 66,918 | 77,756 |
Crude incidence rate (95% CLs), per 1,000 person-years | 623 (619, 626) | 538 (532, 544) | 418 (414, 423) |
Death | |||
Events, n | 45,142 | 3,665 | 4,963 |
Crude cumulative incidence, % | 10.66 | 3.65 | 4.92 |
Follow-up time, person-years | 270,301 | 77,451 | 90,620 |
Crude incidence rate (95% CLs), per 1,000 person-years | 167 (165, 169) | 47 (46, 49) | 55 (53, 56) |
SNF (n = 423,347) | IRF (n = 100,411) | HHC (n = 100,873) | |
---|---|---|---|
Hip Fracture | |||
Events, n | 14,478 | 3,759 | 3,791 |
Crude cumulative incidence, % | 3.42 | 3.74 | 3.76 |
Follow-up time, person-years | 269,644 | 77,142 | 90,118 |
Crude incidence rate (95% CLs), per 1,000 person-years | 54 (53, 55) | 49 (47, 50) | 42 (41, 43) |
Lower Extremity Fracture | |||
Events, n | 6,530 | 1,524 | 1,524 |
Crude cumulative incidence, % | 1.54 | 1.52 | 1.51 |
Follow-up time, person-years | 269,677 | 77,267 | 90,069 |
Crude incidence rate (95% CLs), per 1,000 person-years | 24 (24, 25) | 20 (19, 21) | 17 (16, 18) |
Axial Fracture | |||
Events, n | 7,071 | 1,653 | 1,644 |
Crude cumulative incidence, % | 1.67 | 1.65 | 1.63 |
Follow-up time, person-years | 269,209 | 77,107 | 90,059 |
Crude incidence rate (95% CLs), per 1,000 person-years | 26 (26, 27) | 21 (20, 23) | 18 (17, 19) |
Upper Extremity Fracture | |||
Events, n | 2,485 | 629 | 612 |
Crude cumulative incidence, % | 0.59 | 0.63 | 0.61 |
Follow-up time, person-years | 270,002 | 77,344 | 90,386 |
Crude incidence rate (95% CLs), per 1,000 person-years | 9 (9, 10) | 8 (8, 9) | 7 (6, 7) |
Intracranial Bleeding | |||
Events, n | 1,953 | 493 | 452 |
Crude cumulative incidence, % | 0.46 | 0.49 | 0.45 |
Follow-up time, person-years | 267,000 | 77,359 | 90,472 |
Crude incidence rate (95% CLs), per 1,000 person-years | 7 (7, 8) | 6 (6, 7) | 5 (5, 5) |