A Comparative Effectiveness Study. Tiffany A. Radcliff, PhD, Elizabeth Regan, MD, PhD, Diane C. Cowper Ripley, PhD, and Evelyn Hutt, MD

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1 833 COPYRIGHT Ó 2012 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Increase Use of Intrameullary Nails for Intertrochanteric Proximal Femoral Fractures in Veterans Affairs Hospitals A Comparative Effectiveness Stuy Tiffany A. Racliff, PhD, Elizabeth Regan, MD, PhD, Diane C. Cowper Ripley, PhD, an Evelyn Hutt, MD Investigation performe at the Colorao REAP to Improve Care Coorination, VA Eastern Colorao Healthcare System, Denver, Colorao Backgroun: Intrameullary nails for stabilizing intertrochanteric proximal femoral fractures have been available since the early 1990s. The nails are inserte percutaneously an have theoretical mechanical avantages over plates an screws, but they have not been emonstrate to improve patient outcomes. Still, use of intrameullary nails is becoming more common. The goal of this stuy was to examine trens in the use an associate outcomes of intrameullary nailing compare with sliing hip screws in Veterans Affairs (VA) hospitals. Methos: Review of the VA Surgical Quality Improvement Program (VASQIP) ata ientifie 5244 male patients in whom an intertrochanteric proximal femoral fracture ha been treate in a VA hospital between 1998 an The overall sample was use to assess trens in evice use, thirty-ay mortality, thirty-ay surgical complications, an one-year mortality. Next, propensity score matching methos were use to compare 1013 patients ientifie as having been treate with an intrameullary nail with 1013 patients who ha a sliing-screw proceure. Multiple logistic regression moels for the matche sample were use to calculate os ratios for mortality an complications accoring to the choice of internal fracture fixation. Results: Use of intrameullary nails in VA facilities increase from 1998 through 2005 an varie by geographic region. Unajuste mortality an complication percentages were similar for the two proceures, with approximately 8% of patients ying within thirty ays after surgery, 28% ying within one year, an 19% having at least one perioperative complication. While the choice of an intrameullary nail or sliing-screw proceure was relate to the geographic region, year of surgery, surgeon characteristics, an several patient characteristics, it was not associate with thirty-ay outcomes in either the escriptive or the multiple regression analysis. Conclusions: Intrameullary nail use increase from 1998 through 2005 but i not ecrease perioperative mortality or comorbiity compare with stanar plate-an-screw evices for patients treate for intertrochanteric proximal femoral fractures in VA facilities. Level of Evience: Therapeutic Level III. See Instructions for Authors for a complete escription of levels of evience. The choice of fixation evice for treatment of intertrochanteric proximal femoral fractures is controversial 1. While several stuies have inicate better clinical results with intrameullary nails, particularly for patients with unstable fractures 2-4, authors of other ranomize trials an case series examining intrameullary nails have faile to clearly efine a Disclosure: One or more of the authors receive payments or services, either irectly or inirectly (i.e., via his or her institution), from a thir party in support of an aspect of this work. None of the authors, or their institution(s), have ha any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. Also, no author has ha any other relationships, or has engage in any other activities, that coul be perceive to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitte by authors are always provie with the online version of the article. Disclaimer: The opinions expresse are those of the authors an not necessarily those of the Department of Veterans Affairs or the Unite States Government. J Bone Joint Surg Am. 2012;94:

2 834 benefit, reporting either similar outcomes with higher costs or inferior outcomes compare with those of sliing screws 5-8. Stuies have ocumente geographic variation an increase aoption of intrameullary nails compare with sliing hip screws in the Meicare population, but they reveale little relationship between the choice of fixation evice an patientrelate factors 9,10. The U.S. Department of Veterans Affairs (VA) ocuments perioperative care for most major surgical proceures performe in VA meical centers via the VA Surgical Quality Improvement Program (VASQIP). The single previous stuy of hip fracture care an outcomes in which this ata source was use inicate that surgical elays of greater than four ays, higher American Society of Anesthesiologists (ASA) class, preexisting pulmonary isease, an general (not spinal) anesthesia were associate with higher thirty-ay mortality rates following hip fracture fixation proceures 11. In the present stuy, the same ata source was use to (1) assess changing patterns in surgical proceures for intertrochanteric proximal femoral fractures an (2) analyze whether trens in evice use affecte mortality or complication rates in VA hospitals given that the 2009 Cochrane Review recommene the sliing hip screw over intrameullary nails ue to evience of fewer complications with hip screw use an no improvements in fracture fixation with the nail. Materials an Methos Data Sources an Sample Selection Operative an perioperative ata were obtaine from the VASQIP to ientify intertrochanteric proximal femoral fracture surgical proceures performe in any VA meical center between 1998 an These ata were supplemente with aitional ata from VA patient recors to capture mortality, comorbiity, an hospitalization etails. The VASQIP ata-collection methos have been escribe in etail elsewhere In brief, traine nurses collecte information preoperatively, intraoperatively, an thirty ays postoperatively using a stanarize protocol for most major operations requiring anesthesia performe in any of the 132 VA hospitals proviing major surgery services. Nurse abstractors working in each hospital collecte etaile information regaring the first thirtysix consecutive eligible operations in eight-ay cycles, beginning on a ifferent ay of the week for each ata-collection cycle 14. Operation classifications were base on Current Proceural Terminology (CPT) coes. Demographic, health history, prefracture functional status, chronic conitions, laboratory values, an comorbiity information were collecte at the time of surgery. Patient-specific outcomes collecte for the thirty ays after surgery inclue vital status an the presence of one or more postoperative complications. Operative information inclue the uration of the operation, anesthesia technique, ASA class assigne to the patient at the time of surgery, geographic region of the facility, an training status of the primary surgeon, among others. Ientification of Patients with Repair of an Intertrochanteric Proximal Femoral Fracture The stuy sample inclue all male patients assesse by the VASQIP uring fiscal years 1998 through 2005 with CPT coes (treatment of intertrochanteric fracture with open reuction an internal fixation with a sliing compression screw) an CPT (treatment of intertrochanteric fracture with intrameullary nail). Only the first hip fracture repair proceure was selecte for patients who were ientifie as having ha multiple operations uring the sample time frame. These recors were matche, with use of unique patient ientifiers, to other VA recors, incluing the VA inpatient an outpatient treatment recors containing hospitalization an comorbiity ata an the VA Vital Status atabase to obtain aitional mortality outcomes ata. The primary geographic unit was the Veterans Integrate Service Network (VISN), efine as twenty-one non-overlapping geographic areas that reflect both aministrative units an patient referral patterns in the VA system of care. Patients with missing geographic information were exclue from the analytic sample, as were subjects with isseminate cancer prior to fracture. The latter subgroup was exclue to reuce the likelihoo that outcomes woul be largely riven by the primary isease process. Outcome Variables The presence of one or more complications within thirty ays after surgery an mortality within thirty ays an one year in relation to proceure choice were the primaryoutcomevariables.whilethecptcoeassigneatthetimeofsurgery inicate the proceure choice, mortality was ascertaine through a combination of the perioperative outcomes ata an vital status recors to maximize accuracy in ientifying eaths. Chart review ocumente the occurrence of one or more common perioperative complications within thirty ays after the proceure. The stanar ata-collection protocol i not assess proceure-specific outcomes such as malposition of the implant or inability to bear weight, but instea inclue eighteen general postoperative complications recore for all major surgical proceures performe in VA facilities: symptomatic urinary tract infection, pneumonia, reintubation ue to cariac or respiratory failure, systemic sepsis, cariac arrest, failure to wean from a ventilator within forty-eight hours after surgery, myocarial infarction, eep vein thrombosis, superficial surgical site infection, postoperative bleeing requiring more than four units of packe re bloo cells, pulmonary embolism, cerebrovascular accient/stroke, progressive renal insufficiency, eep woun surgical site infection, acute renal failure, coma lasting more than twentyfour hours, woun isruption/ehiscence, an peripheral nerve injury 15. Analysis Trens in evice use an outcomes were assesse escriptively with both parametric an non-parametric tests for trens. Demographic an clinical variables for the two proceures were compare by using chi-square or Fisher exact tests for categorical variables, as appropriate, an a t test or analysis of variance for continuous variables. These preliminary analyses assesse bivariate relationships between key risk factors, perioperative care characteristics, choice of proceure, an outcomes. Next, because patients were not assigne to proceures at ranom, we matche patients using propensity score methos to ensure a balance sample of cases with intrameullary nails an sliing hip screws with respect to baseline an other surgical characteristics 16,17. Specifically, each case with a nail proceure was matche to the most similar case with a sliing hip screw. We use the flexible psmatch2 subroutine in the Stata software package (StataCorp) to calculate propensity scores that ajuste for factors significantly relate to proceure choice, incluing year of surgery, geographic area (VISN), physician status (attening or resient), an key patient characteristics of age an a iagnosis of chronic obstructive pulmonary isease. Relying on recent methoological recommenations for propensity score matching algorithms, we use a caliper matching metho that specifies a nearest-neighbor istance of no more than one-fifth of a stanar eviation in the propensity score estimate 18. Characteristics of the resulting matche sample were then reteste to ensure similarity in the key baseline patient an preoperative characteristics use for the match. The resulting propensity score was entere along with the inicator for proceure choice an other covariates into logistic regression moels preicting thirty-ay mortality an complication outcomes. The covariates inclue variables that were not part of the propensity score but were foun to be significant (p 0.05) preictors of outcomes in an initial analysis of outcome correlates. Finally, moel iscrimination was assesse with a C-inex, an moel fit was evaluate with a Hosmer-Lemeshow test 19. Source of Funing This research was supporte by the Department of Veterans Affairs, Veterans Health Aministration, Office of Research an Development, Health Services Research an Development Service through the Research Enhancement Awar

3 835 Fig. 1 A graphical isplay of the percentage of hip fracture proceures performe with either an intrameullary nail or a plate an sliing screw evice from 1998 through 2005 at VA meical centers as ientifie in the VASQIP atabase. The overall percentage of intertrochanteric proximal femoral fracture proceures was approximately 42% of all VA hip fracture proceures performe uring this time frame, with a slight ecrease in the number of proceures over time. Program an an investigator-initiate grant (IIR ). T.A. Racliff, D. C. Cowper Ripley, an E. Hutt receive salary support from the Veterans Aministration. Investigators receive institutional review boar approval, a waiver of informe consent, an ata use approval from the Veterans Affairs Surgical Quality Data Use Group an Veterans Affairs Office of Patient Care Services prior to access or analysis of any of the ata files. Results The initial ientification of 5805 surgical cases consistent with repair of an intertrochanteric proximal femoral fracture was refine to exclue females (n = 219), cases with isseminate cancer (n = 274), an recors with missing geographic information (n = 84), or any combination of these. Of the 5244 cases in the resulting analytic sample, 1027 ha an intrameullary nail proceure an 4217 ha treatment with a sliing hip screw. The matche propensity score moels inclue 2026 cases: 1013 matche pairs of nail an sliing-screw cases. In the overall sample, mortality within thirty ays was observe in 8.3% of the cases, one or more complications was observe in 18.9%, an mortality within one year was observe in 28.2%. Time Trens an Geographic Variation in Device Use Figure 1 shows trens in proceure use for intertrochanteric proximal femoral fractures over the fiscal years 1998 through Over these eight years, there was a significant ecrease in the percentage of cases treate with sliing screws an an increase in the cases treate with nails (regression t test, p < 0.001). While only one in twelve proceures was one with the nail in 1998, the ratio was one in 1.6 by Table I shows proceure rates accoring to the geographic region (VISN) over time. In the earlier years of the stuy ata (1998 through 2000), the percentage of nail proceures range from <2% of proceures per region to approximately 25%. By 2005, the percentage more than triple nationally, with 15.6% of all VASQIP-capture hip fracture repairs (ata not shown) an over one-thir of VASQIP-capture intertrochanteric repairs (Table I) using this technique. However, even in the later years of the stuy (2003 through 2005), VISNs varie substantially with regar to choice of proceure, with nail use rates ranging from 10% to >70% (chi-square test, p < 0.001). Although the use of nails generally

4 836 TABLE I Geographic Variation in Intrameullary Nail Use in VA Hospitals from 1998 through 2005 Intertrochanteric Hip Fracture Repairs* (1) (2) (3) VISN No. % IM No. % IM No. % IM Change in % from (1) to (3) Change in Nail Use Change in % from (2) to (3) A 59 2% 53 4% 79 10% 8% 6% B 119 6% 82 21% % 32% 17% C 50 6% 22 5% 18 44% 38% 39% D 78 13% 47 19% 69 32% 19% 13% E 66 11% 53 21% 80 48% 37% 27% F 72 25% 40 28% 87 20% 25% 28% G 99 13% 51 29% 47 47% 34% 18% H % 83 4% 97 20% 10% 16% I 139 9% % % 17% 8% J 151 4% % % 20% 10% K % % % 25% 6% L 40 15% 21 19% 59 31% 16% 12% M 89 3% 41 10% 64 28% 25% 18% N 117 8% 69 13% 65 23% 15% 10% O 173 9% % % 62% 42% P 64 11% 44 7% 49 35% 24% 28% Q 109 7% 60 13% 55 18% 11% 5% R 60 7% 52 21% 51 18% 11% 23% S 72 8% 42 7% 49 71% 63% 64% T 161 9% 89 11% % 8% 6% U 85 15% 39 28% 54 24% 9% 24% Overall % % % 24% 15% *Base on intertrochanteric hip fracture cases assesse as CPT coes or by the VA Surgical Quality Improvement Program (VASQIP). CPT coe represents treatment of intertrochanteric fracture with open reuction an internal fixation with a sliing compression screw. CPT coe represents treatment of intertrochanteric fracture with an intrameullary nail that interlocks proximally into the femoral hea. IM = intrameullary nail. Stuy ientifiers were assigne at ranom to each Veterans Integrate Service Network (VISN) to preserve anonymity of specific VA-efine networks. The stuy ientifiers liste in the table o not correspon to geographic ientifiers use for VA or feeral government purposes. increase uring the stuy time frame, three VISNs (labele F, R, an U in Table I) ha a reuction in the percentage use of nails from the mile time frame (2001 through 2002) to the later years (2003 through 2005). Table II presents patient, operative, an outcome characteristics for both the unmatche an the matche sample. The propensity score moel for matching inclue preoperative patient an surgery characteristics. Patient characteristics in the propensity score moel were age at the time of surgery, white race compare with all other races, ASA class, a count of comorbiities with use of the Elixhauser metho 20, percent of the injury that was eeme connecte to military service, patient history of chronic obstructive pulmonary isease, patient history of iabetes, an preoperative hematocrit level. Operative characteristics known prior to the proceure were whether an attening surgeon or a resient performe the surgery, the location of the facility (VISN), whether the operation was one on an emergency basis, whether there was an operative elay of four or more ays, an the year of the surgery. While there were ifferences between the groups of unmatche cases across many of these variables (p < 0.05), there were no significant ifferences in the matche sample. There were ifferences in the matche sample with regar to several other variables that were inclue in the subsequent logistic regression moels after the match. These inclue ifferences in transfusion rates, operating time, an relative value units, or RVUs (a measure of resources require for the proceure). We note little movement in the sample means for the outcomes following the match an no significant ifferences accoring to proceure choice. Examination of specific complications reveale a significant ifference in rates of urinary tract infections that persiste in the matche sample. Specifically, patients who ha been treate with an intrameullary nail ha a higher rate of urinary tract infections (9% versus 6% for the sliing-screw group [p < 0.025] in the matche sample). Statistical

5 837 TABLE II Case Characteristics in the Unmatche Sample an Propensity-Score-Matche Sample* Unmatche Sample Matche Sample CPT 27245: Nail CPT 27244: Sliing Screw P Value CPT 27245: Nail CPT 27244: Sliing Screw P Value Sample size Patient characteristics inclue in propensity score match Mean age (yr) (range, ) White race (%) Mean ASA class (range, 1-5) Mean comorbiity count (range, 0-19) Mean percent injury relate to military service (range, 0-100) History of iabetes (%) History of chronic obstructive pulmonary isease (%) Mean preop. hematocrit < Surgery characteristics inclue in propensity score match Attening surgeon (%) 16 25% < Mean year of surgery (range, 0-7) < VISN of surgery# < Operative elay of 4 ays (%) < Emergency case (%) Other characteristics (not part of propensity score) Partial functional epenence prior to fracture (%) Complete functional epenence prior to fracture (%) History of congestive heart failure (%) History of ementia (%) Substantial recent weight loss (>10% of boy wt.) (%) Contaminate woun (%) Transfusions (mean no. of PRBCs)** < Mean no. of RVUs < <0.01 Mean operative time (hr) < <0.01 Outcomes Mortality within 30 ays (%) Complication(s) within 30 ays (%) Mortality within 1 yr (%) *The one-to-one propensity-score-matche sample was create with use of a nearest-neighbor matching metho. Cases were sorte at ranom prior to matching an inclue only variables that were known prior to surgery (e.g., surgeon experience was known, but operative time was not). Repeate sampling for matching sliing-screw cases to intrameullary nail cases was conucte to ensure consistent p values for the matche comparisons. Representative finings of the matche sample are presente because the matching algorithm inclue ranom sorting of sliingscrew cases prior to nearest-neighbor ientification. Current Proceure Terminology (CPT) coe represents treatment of intertrochanteric fracture with an intrameullary nail that interlocks proximally into the femoral hea. CPT coe represents treatment of intertrochanteric fracture with open reuction an internal fixation with a sliing compression screw. P values reflect the results of t tests of mean ifferences. Values that are significant (p < 0.05) are inicate with bol text. #While the geographic area is not an orinal value, matching patients accoring to the VISN yiele a similar average value for the matche sample. **PRBCs = packe re bloo cells. The time frame for this measure is within seventy-two hours after the operation. RVUs = work relative value units, which were inclue in the VASQIP ata. It shoul be note that the proceure largely ictates the RVUs an CPT is associate with higher RVU values, which will not be affecte by matching patients accoring to proceure choice. This variable was exclue from the regression moels because of the high correlation with treatment choice. Complications efine with use of the clinical efinitions establishe by the Centers for Disease Control an Prevention.

6 838 TABLE III Multiple Logistic Regression Moel Preicting Thirty-Day Outcomes of Intertrochanteric Proximal Femoral Fracture Repair in VA Hospitals from 1998 through 2005* Mortality within 30 Days 1 Complications within 30 Days Mortality within 1 Yr Os Ratio 95% CI Os Ratio 95% CI Os Ratio 95% CI Intrameullary nail use (vs. sliing-screw use) Propensity score General anesthesia (vs. other metho) Operation uration (hr) transfusions (vs. 0) Recent substantial weight loss Partial functional epenence (vs. inepenent) Full functional epenence (vs. inepenent) History of congestive heart failure History of ementia Contaminate woun (vs. clean) No. of observations *The stuy sample inclues VASQIP hip fracture cases with CPT coes (intrameullary nail) matche one to one to a similar case with CPT coe (sliing screw) from 1998 through Matches were etermine with use of a nearest-neighbor propensity score matching metho, with sliing-screw cases sorte at ranom prior to matching. Confience intervals (CIs) were ajuste to reflect robust stanar errors. Bol text inicates os ratios that were significant (p < 0.05). Base on intertrochanteric hip fracture cases assesse as CPT coes or CPT by the VASQIP. CPT coe = treatment of intertrochanteric fracture with open reuction an internal fixation with a sliing compression screw. CPT coe = treatment of intertrochanteric fracture with an intrameullary nail that interlocks proximally into the femoral hea. The propensity score is the preicte value for each observation from the regression moel preicting nail versus sliing screw use. Variables inclue as part of the propensity score are liste in Table II. tests suggeste no significant ifferences in other key perioperative outcomes base on choice of implant. Table III presents the results of the multiple logistic regression analysis of the propensity score matche sample. The moel inclue the choice of proceure, propensity score, an other selecte covariates that were relate to the outcomes but not the choice of proceure. These other covariates are also liste in Table II. Overall, the regression moel fit was acceptable (C-statistics between 0.6 an 0.67 an nonsignificant Hosmer-Lemeshow p values). The regression results confirme the escriptive finings of no significant ifference in outcomes ue to the choice of proceure. Recent substantial weight loss (loss of >10% of boy weight in the six months prior to surgery) was associate with poorer outcomes, as was full functional epenence an a history of congestive heart failure. Partial functional inepenence was associate with higher os ratios for complications an oneyear mortality, whereas a history of ementia was associate with higher os ratios for mortality at both thirty ays an one year. Discussion We stuie approximately 5250 intertrochanteric proximal femoral fractures treate surgically within the VA hospital system between 1998 an 2005 to examine changes in the use of intrameullary nails compare with the use of the stanar proceure with a plate an sliing-screw evice an associations between the type of proceure an perioperative outcomes. We foun significant geographic variation in the use of the two proceures for intertrochanteric hip fractures within the VA health-care system. We i not fin ifferential mortality or postoperative complication rates associate with either proceure. This retrospective observational stuy involve use of both escriptive statistics an propensity-score-matche logistic regression moels. The finings inicate an increase in use of intrameullary nails over time (Fig. 1 an Table I) but faile to show ifferences in mortality or complication rates accoring to proceure choice (Tables II an III). We i not ientify any substantive time trens in mortality or complication rates (ata not shown). A sensitivity analysis was conucte to compare the results in Table III to basic logistic regression moels that exclue the propensity score ajustment. These basic moels inclue aitional covariates that are relate to both proceure choice an outcome (VISN, year of surgery, an other covariates liste in Table II). The results from the basic moels were substantially similar for both thirty-ay outcomes. However, for the one-year mortality moel, we note an os ratio of 1.21 (95% confience interval [CI], 1.02 to 1.44) for the variable inicating use of the nail (versus the sliing screw), confirming the nee to match samples to ensure unbiase comparisons across proceures.

7 839 While this stuy ocumente a significant increase in the use of nails for stabilizing intertrochanteric proximal femoral fractures in VA hospitals from 1998 through 2005, the increase use was not uniform across all geographic regions (Table I). Our finings were consistent with a recent examination of Meicare ata from 2000 to 2002 that showe increase use of nails with notable geographic variation across states 9. In the overall (unmatche) sample, we note that attening surgeons were less likely than resient surgeons to choose nails. Resients may be relatively more comfortable with the newer proceure; this fining suggests that there will be further increases in nail use over time. This stuy provie information from a large sample of patients ientifie as having ha a surgical proceure for an intertrochanteric fracture in a VA hospital. The ata inclue extensive preoperative an postoperative patient characteristics that are not generally available in aministrative ata sets. The sample stuie was all male since the sample i not inclue enough women to permit statistical analyses by sex subgroups. In other care systems, such as Meicare, males with a hip fracture have been reporte to have worse outcomes than females The thirty-ay mortality rate of 8.3% of the sample note in our stuy is within the range previously reporte in other stuies an is comparable with results from a separate stuy of veterans with hip fracture treate in non-va settings uner Meicare auspices 24,25. The overall rate of perioperative complications was approximately 19% an the oneyear mortality rate was approximately 28% in our stuy, reflecting the serious nature of hip fracture repairs an subsequent recovery. The finings from this stuy that pertain to perioperative complications are limite to those available in the ata-collection protocol for surgical quality improvement in general an o not inclue specific orthopaeic outcomes, such as malposition of the implant. Clearly, information regaring implant placement an subsequent settling, the ability to bear weight an walk after surgery, an the risk of refracture woul be esirable aitions to the collecte information, but this stuy was not esigne to measure those parameters. Since the stanar assessment was esigne to collect uniform ata across a variety of proceures that inclue those from orthopaeics an other specialties, the complication ata collecte were fairly general. However, this avantage for comparing perioperative care across various types of surgery also implies that some of the potential functional avantages or isavantages associate with the nails may not have been capture in the ata. Although the ata o not capture subsequent mechanical failure of the implant, we foun no ifference accoring to the proceure choice for other key complications. For both proceures that we stuie, <4% of cases in the matche sample require a return to the operating room, an 1.4% require a return for reasons relate to the inex proceure. Deep vein thrombosis or pulmonary embolism was ientifie in 1.2% of cases in the matche sample, an sepsis was ientifie in <3% of the matche cases (2.6% for nails versus 2.0% for sliing screws). There are several important limitations of the stuy. First, patients were not prospectively ranomize to receive one or the other treatment option. Despite the inclusion of propensity scores to ajust for observe ifferences in baseline case characteristics across the two proceures, other systematic or unobserve ifferences in patient characteristics may remain. Secon, because case ientification relie primarily on CPT coes to ientify intertrochanteric repair proceures, cases with an unstable subtrochanteric fracture may be in the sample an coul introuce surgeon bias. Thir, some cases are not capture in these ata. The VASQIP ata capture 98% of eligible proceures an at least 70% of all VA surgical proceures 13. Since the ata-collection protocol inclues up to thirty-six consecutive eligible proceures in each facility over eight-ay cycles, cases missing from our sample are unlikely to iffer systematically from the inclue cases. Because implanting nails requires a longer operating time an greater resources, the clinical benefits of intrameullary nails nee careful consieration. For this stuy, we lacke ata to etermine fracture-healing or subsequent outcomes other than mortality at one year. Our results confirm that, within the VA system, intrameullary nail use to treat intertrochanteric proximal femoral fractures has increase but has not ecrease perioperative mortality or morbiity. In view of the fragile patient base an complexity of these proceures, ranomize trials that focus on perioperative management strategies may she light on interventions to improve mortality an complication outcomes. n NOTE: The authors acknowlege the VA Surgical Quality Data Use Group (SQDUG) for its role as scientific avisors an for the critical review of ata use an analysis presente in this manuscript. Tiffany A. Racliff, PhD Department of Health Policy an Management, Texas A&M School of Rural Public Health, TAMU MS 1266, College Station, TX aress: Tiffany.Racliff@ucenver.eu Elizabeth Regan, MD, PhD National Jewish Health, 1400 Jackson Street, K706, Denver, CO Diane C. Cowper Ripley, PhD Research Service (151B), Rehabilitation Outcomes Research Center, 1611 Archer Roa, Malcolm Ranall VA Meical Center, Gainesville, FL Evelyn Hutt, MD Research Service (151), Colorao REAP to Improve Care Coorination, VA Eastern Colorao Healthcare System, 1055 Clermont Street, MS 151, Denver, CO 80220

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