Racial and Socioeconomic Disparities in Hip Fracture Care

Abstract

Background: Despite declines in both the incidence of and mortality following hip fracture, there are racial and socioeconomic disparities in treatment access and outcomes. We evaluated the presence and implications of disparities in delivery of care, hypothesizing that race and community socioeconomic characteristics would influence quality of care for patients with a hip fracture.

Methods: We collected data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS), which prospectively captures information on all discharges from nonfederal acute-care hospitals in New York State. Records for 197,290 New York State residents who underwent surgery for a hip fracture between 1998 and 2010 in New York State were identified from SPARCS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multivariable regression models were used to evaluate the association of patient characteristics, social deprivation, and hospital/surgeon volume with time from admission to surgery, in-hospital complications, readmission, and 1-year mortality.

Results: After adjusting for patient and surgery characteristics, hospital/surgeon volume, social deprivation, and other variables, black patients were at greater risk for delayed surgery (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.42, 1.57), a reoperation (hazard ratio [HR] = 1.21; CI = 1.11, 1.32), readmission (OR = 1.17; CI = 1.11, 1.22), and 1-year mortality (HR = 1.13; CI = 1.07, 1.21) than white patients. Subgroup analyses showed a greater risk for delayed surgery for black and Asian patients compared with white patients, regardless of social deprivation. Additionally, there was a greater risk for readmission for black patients compared with white patients, regardless of social deprivation. Compared with Medicare patients, Medicaid patients were at increased risk for delayed surgery (OR = 1.17; CI = 1.10, 1.24) whereas privately insured patients were at decreased risk for delayed surgery (OR = 0.77; CI = 0.74, 0.81), readmission (OR = 0.77; CI = 0.74, 0.81), complications (OR = 0.80; CI = 0.77, 0.84), and 1-year mortality (HR = 0.80; CI = 0.75, 0.85).

Conclusions: There are race and insurance-based disparities in delivery of care for patients with hip fracture, some of which persist after adjusting for social deprivation. In addition to investigation into reasons contributing to disparities, targeted interventions should be developed to mitigate effects of disparities on patients at greatest risk.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1

Patient characteristics associated with delayed hip fracture surgery (multivariable logistic regression model adjusted for characteristics shown and age, Deyo Comorbidity Index, type of surgery, osteoporosis diagnosis present on admission, number of hospitals in hospital service area, number of beds at treating hospital, urban or rural type of treating hospital, teaching status of treating hospital, hospital volume of hip fracture cases, surgeon volume of hip fracture cases, and Area Deprivation Index). *P < 0.05; ^p < 0.01; †p < 0.001.

Fig. 2

Patient characteristics associated with readmission within 90 days after hip fracture surgery (multivariable logistic regression model adjusted for characteristics shown and age, Deyo Comorbidity Index, type of surgery, osteoporosis diagnosis present on admission, number of hospitals in hospital service area, number of beds at treating hospital, urban or rural type of treating hospital, teaching status of treating hospital, hospital volume of hip fracture cases, surgeon volume of hip fracture cases, and Area Deprivation Index). *P < 0.05; ^p < 0.01; †p < 0.001.

Fig. 3

Patient characteristics associated with a reoperation within 1 year after hip fracture surgery (multivariable logistic regression model adjusted for characteristics shown and age, Deyo Comorbidity Index, type of surgery, osteoporosis diagnosis present on admission, number of hospitals in hospital service area, number of beds at treating hospital, urban or rural type of treating hospital, teaching status of treating hospital, hospital volume of hip fracture cases, surgeon volume of hip fracture cases, and Area Deprivation Index). *P < 0.05; ^p < 0.01; †p < 0.001.

Fig. 4

Patient characteristics associated with inpatient mortality within 1 year after hip fracture surgery (multivariable logistic regression model adjusted for characteristics shown and age, Deyo Comorbidity Index, type of surgery, osteoporosis diagnosis present on admission, number of hospitals in hospital service area, number of beds at treating hospital, urban or rural type of treating hospital, teaching status of treating hospital, hospital volume of hip fracture cases, surgeon volume of hip fracture cases, and Area Deprivation Index). *P < 0.05; ^p < 0.01; †p < 0.001.