# Presentation: 713986

## 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 VAMC
- 2VA 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 Seminar
- July 25, 2007

## Outline

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

## Background

*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*
- Used small samples
- Used mostly female samples
- What’s going on in the VA?

## Goals

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

## Data sources

- 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)

## Methods

- 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
- Mortality viewed at several time points up to 1 year
- Costs defined as Medicare payments
- Selection of comorbidity adjuster

## Comorbidity adjuster

- What are the options?
- Why an Elixhauser?

## Model  & Methods:365-day Mortality

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

## 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

## 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)

## Results: mortality

- Unadjusted one year mortality rates
-  (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%).

## Results: mortality

## Results: mortality

- 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.

## Results: mortality

## Results: mortality

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

## Results: Medicare payments

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

## Results: Medicare payments

***Service use***
- 			Inpatient			100%
- 			Physician			99.1%
- 			Outpatient care 			83.6%
- 		            Skilled nursing facilities 		64.1%
- 		           Durable Medical Equipment 	57.2%
- 		           Home Health Agency		45.8%
- 			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.

## Results: Medicare payments

- Average Medicare Payments within 365 Days for Hip Fracture Patients 1999-2003 (N=43,104)
*Provider Type **	**	**Mean ($)  99% Confidence Interval ($)*
- Inpatient		26,884		26,545-27,223
- Carrier 			24,401	    	23,895-24,906
- SNF			12,208		12,058-12,358
- 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	 69,389		68,539-70,239
- SOURCE: Medicare SAFs 1999-2003.

## Results: Medicare payments

- Cost function (OLS regression):
*Variable**	**	**	**Coefficient 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

## Results: Medicare payments

*Variable**	**	**	**Coefficient estimate ($)*
- Renal failure			52,043
- Lymphoma				47,185
- Metastastic cancer		35,359
- Diabetes w/complications	34,332
- Alcohol abuse			-15,193
- More common comorbidities (COPD, CHF & arrhythmias added between $6,200-$10,000)
- SOURCE: Medicare SAFs 1999-2003.

## Limitations

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

## Concluding Remarks

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

## Tips for VA-Medicare projects

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

## Contact Information

- Elizabeth Bass
- VA Patient Safety Center of Inquiry
- Tampa, FL
- _[Elizabeth.Bass@va.gov](mailto:Elizabeth.Bass@va.gov)_
- 813-558-3908