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, MPH3

1VISN-8 Patient Safety Center of Inquiry, James A Haley VAMC2VA Cooperative Studies Program Coordinating Center at Perry Point, MD and University of Maryland School of Medicine 3UCLA David Geffen School of Medicine and VA Greater Los Angeles Healthcare System Geriatric Research, Education and Clinical Center

HERC Cyber SeminarJuly 25, 2007

OutlineOutline

Brief overview of previous literatureBrief overview of previous literature Data sourcesData sources Model, including comorbidity Model, including comorbidity

adjusteradjuster Mortality outcomesMortality outcomes Cost outcomesCost outcomes ImplicationsImplications

BackgroundBackground

Why hip fractures are a real Why hip fractures are a real problem in the elderlyproblem in the elderly– Usually includes inpatient stay and Usually includes inpatient stay and

rehabrehab– Leads to other clinical issuesLeads to other clinical issues– High rates of mortalityHigh rates of mortality

Previous researchPrevious research– Used small samplesUsed small samples– Used mostly female samplesUsed mostly female samples– What’s going on in the VA?What’s going on in the VA?

GoalsGoals

establish risk-adjusted mortality establish risk-adjusted mortality rates for elderly veterans who rates for elderly veterans who sustained a hip fracture over a 12 sustained a hip fracture over a 12 month time periodmonth time period

confirm gender differenceconfirm gender difference estimate costs to Medicareestimate costs to Medicare

Data sourcesData sources

Medicare (Standard Analytical Files and Medicare (Standard Analytical Files and Denominator File) for veterans supplied Denominator File) for veterans supplied by the VA Information Resource Center by the VA Information Resource Center (VIReC): 4.7 million individuals(VIReC): 4.7 million individuals– VHA-eligibleVHA-eligible– enrolled in the VHAenrolled in the VHA– use VHA careuse VHA care– receive compensation from the receive compensation from the

Department of Veterans AffairsDepartment of Veterans Affairs Covers enrollment phase Covers enrollment phase and and follow-up follow-up

period for fracture patients in 1999-2002 period for fracture patients in 1999-2002 (2003) to address right-censoring (VIREC (2003) to address right-censoring (VIREC now has data through 2004)now has data through 2004)

MethodsMethods

Retrospective, incident-hip fracture Retrospective, incident-hip fracture cohort analysis of veterans aged 65+cohort analysis of veterans aged 65+

Patients selected by a “first-ever” Patients selected by a “first-ever” admitting diagnosis of hip fracture admitting diagnosis of hip fracture (ICD-9-CM codes 820-820.9 or 905.3) (ICD-9-CM codes 820-820.9 or 905.3) to a Medicare facility from 1999-2002to a Medicare facility from 1999-2002

Mortality viewed at several time Mortality viewed at several time points up to 1 yearpoints up to 1 year

Costs defined as Medicare paymentsCosts defined as Medicare payments Selection of comorbidity adjusterSelection of comorbidity adjuster

Comorbidity adjusterComorbidity adjuster

What are the options?What are the options? Why an Elixhauser?Why an Elixhauser?

Model & Methods:Model & Methods:365-day Mortality365-day Mortality

ModelModel

Mortality= f(age, gender, comorbidity Mortality= f(age, gender, comorbidity adjuster)adjuster)

Statistical Analysis: Cox’s proportional hazardStatistical Analysis: Cox’s proportional hazard

Duration(t)*Death = age, gender, Duration(t)*Death = age, gender, comorbiditiescomorbidities

Model & Methods:Model & Methods:365-day Costs365-day Costs

ModelModel

Total Costs= f(age, gender, inpatient Total Costs= f(age, gender, inpatient length of stay, death within one year, length of stay, death within one year,

comorbidity adjuster)comorbidity adjuster)

Statistical Analysis: OLS regression (no Statistical Analysis: OLS regression (no transformation after testing several functional transformation after testing several functional forms)forms)

Total Medicare payments* = age, gender, Total Medicare payments* = age, gender, length of stay, death, comorbiditieslength of stay, death, comorbidities

*beginning with first admission date*beginning with first admission date

ResultsResults

Demographics (n=43,165)Demographics (n=43,165)

87% male87% male

94% Caucasian94% Caucasian

80 mean age80 mean age

7 days median length of stay7 days median length of stay

49% discharged to a skilled nursing 49% discharged to a skilled nursing facility (SNF)facility (SNF)

Results: mortalityResults: mortality

Unadjusted one year mortality ratesUnadjusted one year mortality rates

(30 days = 9.7%, 90 days = 17.5%, (30 days = 9.7%, 90 days = 17.5%, 180 days = 24%, 365 days = 32.2%)180 days = 24%, 365 days = 32.2%)

were approximately 10% higher than were approximately 10% higher than the adjusted rates (30 days = 8.9%, the adjusted rates (30 days = 8.9%, 90 days = 15.6%, 180 days = 90 days = 15.6%, 180 days = 21.8%, one year = 29.9%).21.8%, one year = 29.9%).

Results: mortalityResults: mortalityFigure 1. 12 Month Survival Analysis for Hip Fracture Patients (Age 65+)

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0 50 100 150 200 250 300 350 400

Days to mortality

Od

ds o

f m

ort

ali

ty

n= 43,165 Data source: Medicare Inpatient SAF and Denominator File 1999-2003

Results: mortalityResults: mortality

Big differences by gender: the Big differences by gender: the mortality odds for women 12 mortality odds for women 12 months after hip fracture were months after hip fracture were 18%, compared to 32% for men. 18%, compared to 32% for men.

In other words, men were about In other words, men were about twice as likely to die within one twice as likely to die within one year of the hip fracture compared year of the hip fracture compared to women. to women.

Results: mortalityResults: mortalityFigure 2. 12 Month Survival Analysis for Hip Fracture Patients by Gender (Age 65+)

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0 50 100 150 200 250 300 350 400

Days to mortality

Od

ds

of

mo

rtal

ity

males

females

n= 43,165 Data source: Medicare Inpatient SAF and Denominator File 1999-2003

Results: mortalityResults: mortality

The comorbidity adjustment coefficients suggest The comorbidity adjustment coefficients suggest that:that:

metastasic cancer increased the risk of death by metastasic cancer increased the risk of death by almost four times (hazard ratio 3.57) 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 Contrary to expectation, hypertension and alcohol abuse were negatively correlated with one-year abuse were negatively correlated with one-year mortality. mortality.

Results: Medicare paymentsResults: Medicare payments

Medicare spent nearly $3 billion Medicare spent nearly $3 billion for patients in this cohort from for patients in this cohort from 1999-20031999-2003

70% of total annual Medicare 70% of total annual Medicare payments for all services occurred payments for all services occurred within the first 30 days following within the first 30 days following hospital admission hospital admission

Hospital and physician Hospital and physician reimbursements were reimbursements were approximately 3/4 of paymentsapproximately 3/4 of payments

Results: Medicare paymentsResults: Medicare paymentsService useService use

InpatientInpatient 100%100%

PhysicianPhysician 99.1%99.1%

Outpatient care Outpatient care 83.6% 83.6%

Skilled nursing facilities Skilled nursing facilities 64.1% 64.1%

Durable Medical Equipment Durable Medical Equipment 57.2% 57.2%

Home Health AgencyHome Health Agency 45.8% 45.8%

Hospice Hospice 2.7%2.7%

With the exception of DME and hospice (70.1% for DME, 8.4% for With the exception of DME and hospice (70.1% for DME, 8.4% for hospice), these percentages showed only a modest increase at the hospice), these percentages showed only a modest increase at the end of 365 days. end of 365 days.

Results: Medicare paymentsResults: Medicare paymentsAverage Medicare Payments within 365 Days for Hip Fracture

Patients 1999-2003 (N=43,104)

Provider Type Mean ($) 99% Confidence Interval ($)

Inpatient 26,884 26,545-27,223Carrier 24,401 23,895-24,906SNF 12,208 12,058-12,358Hospice 7,073 6,605-7,541Home Health Agency 5,249 5,146-5,352DME 4,447 4,217-4,676Outpatient 3,200 3,085-3,315

Total All Services 69,389 68,539-70,239

SOURCE: Medicare SAFs 1999-2003.

Results: Medicare paymentsResults: Medicare payments

Cost function (OLS regression):Cost function (OLS regression):

VariableVariable Coefficient estimate Coefficient estimate ($)($)

Age (years)Age (years) -575 -575Gender (1=female)Gender (1=female) -3,557-3,5571 year mortality (1=died)1 year mortality (1=died) 3,270 3,270Inpatient LOS (days)Inpatient LOS (days) 1,944 1,944

SOURCE: Medicare SAFs 1999-2003

Results: Medicare paymentsResults: Medicare payments

VariableVariable Coefficient estimate ($)Coefficient estimate ($)

Renal failureRenal failure 52,04352,043LymphomaLymphoma 47,18547,185Metastastic cancerMetastastic cancer 35,35935,359Diabetes w/complicationsDiabetes w/complications 34,33234,332

Alcohol abuseAlcohol abuse -15,193-15,193

More common comorbidities (COPD, CHF & More common comorbidities (COPD, CHF & arrhythmias added between $6,200-arrhythmias added between $6,200-$10,000)$10,000)

SOURCE: Medicare SAFs 1999-2003.

LimitationsLimitations

Did not control for provider Did not control for provider characteristicscharacteristics

Risk adjuster for broad patient Risk adjuster for broad patient populationpopulation

Varying levels of comorbiditiesVarying levels of comorbidities Unable to fully explain gender Unable to fully explain gender

difference in mortality and costs, difference in mortality and costs, alcohol effect and why older alcohol effect and why older patients cost lesspatients cost less

Concluding RemarksConcluding Remarks

Economic implications:Economic implications: High loss of life (downward spiral)High loss of life (downward spiral) Resource use intenseResource use intense What to do? Clinical intervention What to do? Clinical intervention

strategies such asstrategies such as– gait and balance testinggait and balance testing– osteoporosis diagnosisosteoporosis diagnosis– medication reviewmedication review– use of hip protectors use of hip protectors

Tips for VA-Medicare projectsTips for VA-Medicare projects

Apply for Medicare data from Apply for Medicare data from VIReC as soon as possibleVIReC as soon as possible

Contact ResDAC frequentlyContact ResDAC frequently Have a good data managerHave a good data manager Include researchers with varied Include researchers with varied

backgroundsbackgrounds

Contact InformationContact Information

Elizabeth BassElizabeth Bass

VA Patient Safety Center of InquiryVA Patient Safety Center of Inquiry

Tampa, FLTampa, FL

Elizabeth.Bass@va.govElizabeth.Bass@va.gov

813-558-3908813-558-3908