Utah geriatric hip fracture and in-hospital death

1. Utah Geriatric Hip Fracture
and In-Hospital Death
From Utah Statewide Trauma Registry 2008-2015
June 12, 2017 - Trauma System Advisory Committee Meeting
Yukiko Yoneoka, BEMSP, Utah Department of Health

2. Geriatric Hip Fracture and In-Hospital Death:
Why analyze Utah Statewide Trauma Registry (UTR) data?
To find out
 Prevalence of geriatric hip fracture in Utah
 Characteristics of hip fracture patients
 Who is at risk of dying after hip fracture

3. Geriatric Hip Fracture: Definition
• Primary cause Ecode 880-888 (Accidental fall)
• In ICD9_1 to ICD9_10 fields: 733.14, 733.15, 733.81, 733.82, 733.96, 808,
808.1, 820, 820.01, 820.02, 820.03, 820.09, 820.10, 820.11, 820.12,
820.13, 820.19, 820.20820.21, 820.22, 820.30, 820.31, 820.32, 820.8,
820.9 (Specified by Centers for Medicare and Medicaid Services)
• Age 65+

4. Prevalence of Geriatric Hip Fracture in Utah
• Census estimate for 2015 Utah population is 2,995,919.
• Of those, estimated proportion for geriatric population (age 65+) is 10.3%.
• Fall data was included in UTR in 2008.
• There are 93,826 patients in UTR between 2008 and 2015.
• 35.7% (33,522) of them are geriatric patients.
• 86.8% (29,110) of geriatric patients in UTR had a fall.
• 96.8% (28,187) of geriatric falls in UTR are accidental falls.
• 38.4% (10,818) of UTR geriatric patients who had falls had hip fracture.
• Of those, 2.5% (274) died in hospital.

5. Hip Fracture Patients: Hip fracture incidents
and deaths by age
0
100
200
300
400
500
600
65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103
Number of geriatric hip fracture patients and in-hospital death by age
Hip Fracture Death
Hip fractures
most frequently
happen
between age 80-90.
Peak around
age 84-86.
But more deaths
happen at
age 85 and there
after. Peak around
age 88-92.

6. Hip Fracture Patients: Outcome by sex
97.9%
96.5%
2.1%
3.5%
95%
96%
97%
98%
99%
100%
Female Male
Hip Fracture Outcome by Sex
Alive Dead
More males
seem to die
after hip
fracture

7. Hip Fracture Patients: All and deceased
Mean Age, ISS, and TRISS
Deceased Hip Fracture PatientsAll Hip Fracture Patients
Male Female
Mean Age 81.2 82.7
Mean ISS 9.3 9.3
Mean
TRISS
96.4% 96.5%
Male Female
Mean age 84.8 85.4
Mean ISS 9.7 10.1
Mean
TRISS
95.3% 95.9%
Males are slightly younger than females Deceased males are slightly younger than
females with lower mean ISS
Deceased
patients are
older than
all patients

8. Hip Fracture Patients: All and deceased - ISS by sex
ISS distributions are not so different

9. Hip Fracture Patients: All and deceased - Comorbidity by sex
Deceased females had more comorbidities
All patients Deceased patients

10. Hip Fracture Patients: Outcome by trauma center level
Level 1 vs. level 2 (comparable two) : Level 2 – Less patients, but more deaths?
97.9%
96.8%
97.7%
96.8%
100%
98.4% 98.5%
2.1%
3.2%
2.3%
3.2%
1.6% 1.5%
95%
96%
97%
98%
99%
100%
Level 1 Level 2 Level 3 Level 4 Level 5 CAH Resource
Outcome by Trauma Center Level Alive DeadTotal #
Patients 2,098 3,771 1,826 1,381 45 128 1,552
Total #
Hospital 2 4 5 12 3 6 14
1049
patients
per
hospital
942
patients
per
hospital
365
patients
per
hospital

11. Hip Fracture Patients: All and deceased
- Percentage of transferred-in patients
Level 2 – Less transferred-in patients, more transferred-in deaths?
18.7%
14.8%
2.1%
8.2%
0.0%
2.3%
0.6%
20.5%
23.5%
4.8%
15.9%
0% 0% 0%
2.3%
5.0% 5.3% 6.2%
0% 0% 0%
0%
20%
Level 1 Level 2 Level 3 Level 4 Level 5 CAH Resource
Percentage of transferred-in patients in all and deceased hip fracture patients per trauma center level
plus percentage of deaths within transferred-in patients
% Transferred-in of all HF patients % Transferred-in of deceased HF patients % Death within all transferred in HF patients
Level 1 had more transferred-in patients than level 2.
Transferred-in patients consisted 20.5% of all death after hip fracture
for level 1, and 23.5% for level 2. Within the transferred-in patients,
level 2 had twice as many death than level1.

12. Hip Fracture and In-Hospital Death: Who is at risk?
Variables used for logistic regression
Dependent variable
• Outcome: Alive or Dead
Independent variables
• Age (old 65-74, older 75-84, oldest 85+ )
• Sex (female, male)
• ISS (not severe 1-15, sever 16-75)
• TRISS score ( <=50%, >50% )
• Transfer (transferred, not-transferred)
• Trauma center level (level 1 to level 5, CAH, resource, obsolete)

13. Hip Fracture and In-Hospital Death: Who is at risk?
Variables used for logistic regression (cont.)
Independent variables (cont.)
• Comorbidity from risk_type1 to risk_type3 fields
ADD_ADHD ALCOHOL NEED_ASSIST BLEEDING
BLOOD_CIRC HYPERTENSION CONGENITAL DEMENTIA
DNR DRUG_ABUSE ESOPHVAR FLUID_ACCU
HEART_DISEASE
(included CHF, MI, Angina)
CANCER
(included Chemo therapy)
KIDNEY_DISEASE
(included dialysis)
LIVER_DISEASE
OBESE OTHER_RISK PSYCHIATRIC RESPIRATORY
SENSORIUM SMOKER STEROIDS STROKE

14. Hip Fracture and In-Hospital Death: Who is at risk?
Final model – 12 risk factors affect death (P < 0.05)

15. Hip Fracture and In-Hospital Death: Who is at risk?
Final model – Odds ratio for 12 risk factors
• Odds ratio (Estimate) 1 = No difference
• More than 1 = Increased risk
• Less than one = Protective against death
• 95% confidence intervals should not contain
1 in between to be statistically significant
* Level 4 - 12 hospitals and 44 deaths.
Level 2 - 4 hospitals and 119 deaths.
We take Level 2 seriously and disregard level 4.

16. *
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17. Hip Fracture and In-Hospital Death: Who is at risk?
Findings 1-4 of 12
• Females are 40% less likely to die after hip fracture compared to males.
• Oldest age group (85+) is about 2.6 times more likely to die after hip fracture compared
to old age group (65-74).
• Those who had severe injury (ISS > 15) are about 3.7 times more likely to die after hip
fracture, compared to those who did not have severe injury (ISS <= 15). (Note: TRISS had
no effect on predicting death after hip fracture.)
• Transferred patients are about 40% more likely to die after hip injury compared to not-
transferred patients. (Note: This may reflect severity of injury.)

18. Hip Fracture and In-Hospital Death: Who is at Risk?
Findings 5-8 of 12
• Hip fracture patients are 80% more likely to die at level 2 trauma centers
compared to level 1 trauma centers.
• Those who needed assistance in daily activities are about 2.2 times more likely
to die after hip fracture than those who did not need assistance.
• Those who had DNR in their advanced directive are about 3.7 times more likely
to dies after hip injury compared to those who did not have DNR. (Note: This
makes sense. The older, the more DNR they had.)
• Those who had heart disease are about 2.2 times more likely to die after hip
fracture compared to those who did not have heart disease.

19. Hip Fracture and In-Hospital Death: Who is at risk?
Findings 9-12 of 12
• Those who had kidney disease are 90% more likely to die after hip fracture than those
who did not have kidney disease.
• Those who had liver disease are about 13.6 times more likely to die after hip fracture
compared to those who did not have liver disease. (Note: There were 19 patients with
liver disease out of 10818 hip fracture patients - about 0.2% of all hip fracture patients.
21.1% of the patients - 4 out of 19- died after hip fracture).
• Those who had respiratory disease are about 2.2 times more likely to die after hip
fracture compared to those who did not have respiratory disease.
• Those who had cerebrovascular disease are about 2.2 times more likely to die after hip
fracture compared to those who did not have cerebrovascular disease.

20. Hip Fracture and In-Hospital Death: Who is at risk?
Summary
Patient risk factors
• Age 85 and older
• Male (Conundrum!)
• Severe injury (ISS >15)
• Need assistance in daily activities
• Have heart disease, kidney
disease, liver disease, respiratory
disease, and cerebrovascular
disease
Other risk factors
• DNR
• Transferred
• Level 2 (Need more investigation.)

21. Questions?
• Yukiko Yoneoka
• Data Analyst
• Bureau of Emergency Medical Services and Preparedness
(BEMSP)
• Utah Department of Health
• yyoneoka@utah.gov