All-cause mortality rates of hip fractures treated in the VHA: do they differ from Medicare facilities?

One-year Survival Rates and Functional Recovery in Veterans Who Suffer from Hip Fractures: Evaluation of Commissioned Hospitals' System through Comparison between Veterans Hospitals and Commissioned Hospitals

Purpose

This study was performed to compare the: i) 1-year survival rate of patients with hip fractures, ii) factors affecting mortality in patients with hip fractures, and iii) results of functional recovery at commissioned hospitals (CH) and veterans hospitals (VH) to characterize the quality of care provided in the Korean commissioned hospital system.

Materials and Methods

The study population consisted of 183 veteran patients (84 and 99 treated at a single VH and 39 CH, respectively) who underwent hip fracture surgery between January 2010 and February 2015. This study compared baseline characteristics (i.e., age, comorbidities, fracture types and surgical treatment approaches) of the two groups vs. clinical outcomes, and evaluated the waiting time, length of hospital stay, total medical expenses, mortality rate within one year, and functional recovery at last follow up.

Results

There were no significant differences in age, fracture types, comorbidities, ambulatory status before fracture, waiting time, or length of hospital stay between the two groups, however, the total medical cost was higher in the CH group (P=0.009). There was no significant difference in mortality within one year after hip fracture (P=0.224) or functional recovery at last follow-up (P=0.463) between the two groups.

Conclusion

The results of this study confirm that the Korean commissioned hospitals system is operating in accordance with its purpose. However, further studies are needed to better characterize the medical expenses of CHs vs. veterans hospitals.

What Is Important in Selecting a Designated Hospital for the Korean Veterans with Hip Fractures?

Purpose

The Korea Veterans Health Service (KVHS) implemented the ‘designated hospital system’ so that veterans can receive prompt medical attention at hospitals near their residences when experience medical emergencies, including hip fractures. We analyzed the hospital-selection process of Korean veterans following a hip fracture. We then evaluated (the validity and considerations) for choosing designated hospitals.

Materials and Methods

The study population consisted of 183 veteran patients (84 treated at a single veterans hospital and the remaining 99 treated at 39 designated hospitals) who underwent hip fracture between January 2010 and February 2015 in the Honam region of South Korea. The subjects were divided into the ‘nearest group’ (those who chose the hospital closest to their residences) and the ‘non-nearest group’ (those who did not choose the hospital closest to their residences). We compared the age, ambulatory status, combined disease and fracture type, factors that we speculated may impact hospital choice.

Results

Although the patients had difficulty moving due to hip fractures, 116 (63.4%) patients choose hospitals that were not closest to their residences. Patients with three or more comorbidities (P=0.028) and older ages (P=0.046) were statistically more likely to fall into the non-nearest group. Ambulatory status and fracture type were shown not to significantly impact choice between nearest and non-nearest hospital. Patients in the non-nearest group tended to seek care at larger hospitals.

Conclusion

Korean veterans with hip fractures tended to seek care at larger hospitals, regardless of distance. We must therefore consider the number of beds and departments when choosing designated hospitals.

Patient and system factors of mortality after hip fracture: a scoping review

Background

Several patient and health system factors were associated with the risk of death among patients with hip fracture. However, without knowledge of underlying mechanisms interventions to improve survival post hip fracture can only be designed on the basis of the found statistical associations.

Methods

We used the framework developed by Arksey and O’Malley and Levac et al. for synthesis of factors and mechanisms of mortality post low energy hip fracture in adults over the age of 50 years, published in English, between September 1, 2009 and October 1, 2014 and indexed in MEDLINE. Proposed mechanisms for reported associations were extracted from the discussion sections.

Results

We synthesized the evidence from 56 articles that reported on 35 patient and 9 system factors of mortality post hip fracture. For 21 factors we found proposed biological mechanisms for their association with mortality which included complications, comorbidity, cardiorespiratory function, immune function, bone remodeling and glycemic control.

Conclusions

The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles and with no proposed mechanisms for their effects on mortality. Where reported, underlying mechanisms are often based on a single article and should be confirmed with further study. Therefore, one cannot be certain whether intervening on such factors may produce expected results.

Increasing duration of type 1 diabetes perturbs the strength-structure relationship and increases brittleness of bone

Type 1 diabetes (T1DM) increases the likelihood of a fracture. Despite serious complications in the healing of fractures among those with diabetes, the underlying causes are not delineated for the effect of diabetes on the fracture resistance of bone. Therefore, in a mouse model of T1DM, we have investigated the possibility that a prolonged state of diabetes perturbs the relationship between bone strength and structure (i.e., affects tissue properties). At 10, 15, and 18 weeks following injection of streptozotocin to induce diabetes, diabetic male mice and age-matched controls were examined for measures of skeletal integrity. We assessed 1) the moment of inertia (I(MIN)) of the cortical bone within diaphysis, trabecular bone architecture of the metaphysis, and mineralization density of the tissue (TMD) for each compartment of the femur by micro-computed tomography and 2) biomechanical properties by three-point bending test (femur) and nanoindentation (tibia). In the metaphysis, a significant decrease in trabecular bone volume fraction and trabecular TMD was apparent after 10 weeks of diabetes. For cortical bone, type 1 diabetes was associated with decreased cortical TMD, I(MIN), rigidity, and peak moment as well as a lack of normal age-related increases in the biomechanical properties. However, there were only modest differences in material properties between diabetic and normal mice at both whole bone and tissue-levels. As the duration of diabetes increased, bone toughness decreased relative to control. If the sole effect of diabetes on bone strength was due to a reduction in bone size, then I(MIN) would be the only significant variable explaining the variance in the maximum moment. However, general linear modeling found that the relationship between peak moment and I(MIN) depended on whether the bone was from a diabetic mouse and the duration of diabetes. Thus, these findings suggest that the elevated fracture risk among diabetics is impacted by complex changes in tissue properties that ultimately reduce the fracture resistance of bone.