Among US women 65 years and older, the annual

Trends in Mortlity Following Hip Frcture in Older Women CLINICAL Jon C. Lo, MD; Sowmy Srinivsn, MD; Mlini Chndr, MS, MBA; Mry Ptton, MD; Amer Budyr, MD; Lucy H. Liu, MD; Gene Lu, MD; nd Christopher D. Grimsrud, MD, PhD Among US women 65 yers nd older, the nnul incidence of hip frctures is estimted t 793 per 100,000 women, bsed on Medicre clims dt from 2005. 1 While hip frctures constitute only 14% of ll osteoporotic frctures, 2 they result in substntil morbidity nd mortlity, 1-6 with short-term mortlity risk 2- to 8-fold higher thn tht of ge-mtched controls. 4,7,8 One-yer mortlity rtes re in the rnge of 22%, 1 with excess mortlity Mnged Cre & Helthcre Communictions, LLC risk highest during the first 3 to 6 months following hip frcture. 4,7 Given the projected increse of the ging US popultion over the next 2 decdes 9 prticulrly mong those over 65 yers old nd those of nonwhite rce/ethnicity, 9,10 in whom less is known regrding contemporry frcture outcomeship frctures remin significnt public helth concern. Numerous risk fctors contribute to hip frcture mortlity in women, including ge, frcture type, functionl sttus, comorbidities, post frcture cre, nd rehbilittion. 1,7,11-13 Exmintion of 20-yer trends since 1985 demonstrted ntionl declines in 1-yer mortlity following hip frcture, lrgely due to mortlity reduction prior to 1998. 1 These findings my be potentilly ttributble in prt to dvnces in surgicl nd post opertive medicl cre. 1 Survivl rtes following hip frcture lso vry by rce/ethnicity, with historicl mortlity rtes slightly higher for blcks compred with whites. 14 Few studies hve exmined differences in mortlity following hip frcture mong US women of other rce/ ethnicities. After experiencing hip frcture, only subset of women will regin their pre-frcture qulity of life, while mny suffer permnent deficits in ctivities of dily living 6,15 ; it is estimted tht up to 17% of remining post frcture life my be spent in nursing fcility. 6 Hospitl redmission rtes re high following hip frcture nd hve been mostly ttributble to nonorthopedic/nonsurgicl conditions. 3,16 In one study, infections (21%), followed by crdic conditions (12%), were the leding cuses of redmission within ABSTRACT Objectives: To exmine contemporry trends in mortlity following hip frcture mong older postmenopusl women in n integrted helthcre delivery system. Study Design: Retrospective cohort study of 13,550 women ged 65 yers with hip frcture during 2000 to 2010. Methods: Demogrphic fctors, comorbidity index score, frcture history, erly rehospitliztion, nd ll-cuse mortlity within 1 yer following hip frcture were exmined using helth pln dtbses nd records. Temporl trends, risk fctors, nd the ssocition of rce/ethnicity nd mortlity within 1 yer post frcture were exmined using multivrible logistic regression. Results: Among 13,550 women with hip frcture, 84.6% were ged 75 yers: 83.6% were white, 2.8% blck, 5.6% Hispnic, 4.5% Asin, nd 3.5% of other/unknown rce. Following hip frcture, 2.4% died during the index hospitliztion, while 12.3% were rehospitlized within 30 dys of dischrge. Infection, pneumoni, nd crdiovsculr conditions were the most common nonorthopedic indictions for redmission. Mortlity rtes t 6 months (17%) nd 1 yer (22.8%) following hip frcture were high nd incresed with ge. Greter comorbidity nd erly rehospitliztion were ssocited with incresed mortlity risk, while Asin nd Hispnic rce/ethnicity were ssocited with lower mortlity risk (vs white). Temporl trends demonstrted smll but significnt reduction in mortlity risk during 2004 to 2010. Conclusions: While hip frcture morbidity nd mortlity remin high, temporl trends suggest recent declines in mortlity risk, with risk of deth following hip frcture lower for Asin nd Hispnic women. Future studies should exmine potentil benefits of trgeted interventions within integrted helthcre settings nd fctors contributing to observed rcil/ethnic differences in post frcture survivl. Am J Mng Cre. 2015;21(3):e206-e214 e206 n www.jmc.com n MARCH 2015

Hip Frcture Mortlity in Older Women the first 6 months, while surgicl complictions ccounted for only 11% of redmissions. 16 Rehospitliztion following hip frcture hs lso been shown to be n independent predictor of dverse morbidity nd mortlity outcome. 3,5,16 In the contemporry er, limited dt pertining to hip frcture morbidity nd mortlity exist in lrge community-bsed prctice settings serving demogrphiclly diverse popultions. This study exmines erly rehospitliztion nd mortlity outcome following hip frcture during 2000 to 2010 within northern Cliforni integrted helthcre delivery system, with specific focus on rcil/ethnic differences nd temporl trends in mortlity risk. METHODS Kiser Permnente Northern Cliforni (KPNC) is lrge, integrted helthcre delivery system providing cre to over 3 million members. There re more thn 150 medicl offices nd 20 hospitls providing cre, with centrlized dtbses of ll network nd nonnetwork hospitliztion dischrge dignoses, mbultory visit dignoses, nd phrmcy records. The Kiser Foundtion Reserch Institute s Institutionl Review Bord pproved the study nd wiver of informed consent ws obtined due to the nture of the study. Cohort Identifiction Using helth pln dtbses, we identified ll femle helth pln members 65 yers or older with principl hospitl dischrge dignosis of proximl femur frcture between Jnury 1, 2000, nd December 31, 2010. A proximl femur (hip) frcture ws defined by frcture of the femorl neck (Interntionl Clssifiction of Diseses, Ninth Revision, Clinicl Modifiction [ICD-9-CM] codes 820.00-820.03, 820.09, 820.8) or pertrochnteric region (ICD-9-CM 820.20, 820.21), excluding open frctures nd those ssocited with mjor trum (ICD-9- CM E800-E848). The finl cohort ws estblished by scertining the first qulifying hip frcture per womn. Women without continuous helth pln membership in the yer prior to hip frcture were excluded from these nlyses in order to define cohort with ongoing membership nd to llow for scertinment of bseline covrites. Temporl trends nd rce/ethnic differences in femur frcture mong KPNC women hve been seprtely reported. 17 Tke-Awy Points While hip frcture mortlity remins high, significnt declines in mortlity risk nd importnt rcil/ethnic differences were seen following hip frcture in older women receiving cre within lrge integrted helthcre delivery system. n Older ge, incresed comorbidity, nd erly rehospitliztion were ssocited with n incresed risk of deth within 1 yer following hip frcture. n Rcil/ethnic differences in post frcture survivl were lso seen; compred with women of white rce, Asin nd Hispnic women hd lower mortlity risk during the first yer. n Temporl trends demonstrted smll but significnt mortlity risk reduction, where the potentil benefits of trgeted helthcre interventions should be further exmined. Ptient Chrcteristics Age nd self-reported rce/ethnicity (clssified s non- Hispnic white, blck, Hispnic, Asin, or other/unknown) were obtined from dministrtive dtbses. A clinicl comorbidity index score ws clculted bsed on dignosis nd procedure codes obtined from ll hospitliztion, emergency, nd mbultory visits in the prior yer (including the index frcture dmission) using modifiction of the Chrlson Comorbidity Index estblished by Deyo nd collegues. 18 Frcture history (frctures occurring fter ge 40 nd prior to hip frcture) ws obtined by identifying prior outptient nd hospitliztion dignoses of frctures involving the spine, trunk, upper nd lower extremities (ICD-9-CM 805, 807-815, 817-825, 827-829), excluding open frctures, frctures ssocited with spinl cord injury, frctures of the hed/fingers/toes, nd hospitlized frctures ssocited with high-energy trum (ICD- 9-CM E800-E848). Rehospitliztion Outcomes Erly rehospitliztion ws defined s rehospitliztion within 1 to 30 dys following dischrge from the initil hip frcture hospitliztion (sme- or next-dy redmissions or trnsfers with principl dignosis of hip frcture were considered prt of the initil hospitliztion, ffecting only 0.8% of the cohort). The principl dignosis ssigned to the rehospitliztion event ws ctegorized s follows: 1) crdiovsculr condition: hypertension, ischemic hert disese, crdiomyopthy, hert filure, crdiogenic shock, conduction disorder, dysrhythmi, or tchycrdi (ICD-9-CM 401-405, 410-414, 425-428, 785.0, 785.51); 2) venous embolism/ thrombosis, pulmonry embolism (ICD-9-CM 415.1, 453); 3) cerebrovsculr disese: hemorrhge, occlusion, ischemi, lte effects (ICD-9-CM 430-438); 4) pneumoni, pneumonitis, influenz, respirtory insufficiency or filure (ICD-9-CM 480-488, 507, 518.81-84); 5) chronic obstructive pulmonry disese/sthm/bronchitis (ICD-9-CM 466.0, 490-493, 496, 519.11); 6) urinry trct infection (ICD-9-CM 599.0); 7) cog- VOL. 21, NO. 3 n THE AMERICAN JOURNAL OF MANAGED CARE n e207

CLINICAL nitive impirment or ltered mentl sttus (ICD-9-CM 290-298, 331, 348.3, 780.0-1, 780.97); 8) cute or chronic kidney disese/filure (ICD-9-CM 584-586); 9) gstritis, gstrointestinl ulcers/hemorrhge (ICD-9-CM 531-535, 526.12-13, 578.9); 10) glucose-, electrolyte-, or fluid-relted disorder (ICD-9-CM 249-251, 275.2-4, 276); 11) Clostridium difficile infection (ICD-9-CM 8.45); 12) skin infection, ulcer, gngrene, or wound infection (ICD-9-CM 681-682, 686, 707, 785.4, 998.5); 13) bcteremi/septicemi, sepsis, septic shock (ICD- 9-CM 038, 790.7, 785.52, 995.91-92); 14) mlignnt neoplsm (ICD-9-CM 140-208); 15) nonpelvic, nonhip/femur frcture (ICD-9-CM 800-807, 809-819, 822-829); 16) pelvic- or femurrelted frcture/ftercre (ICD-9-CM 733.14-15, 808, 820, 821, V54.13, V54.14, V43.64, V54.13, V54.23, V54.8-9); nd 17) surgicl implnt or hrdwre-relted issue (ICD-9-CM 996.4-996.6, 996.70, 996.77-996.79, V43.64). Mortlity Ascertinment For scertinment of deth from ny cuse, women were followed up to 1 yer fter frcture, through December 31, 2011. Only 3.1% hd membership cesstion prior to 1 yer without n scertined deth outcome (nd were presumed live); sensitivity nlyses were conducted with exclusion of these women. All-cuse mortlity ws ssessed t 30, 90, 180 nd 365 dys following hip frcture, using helth pln nd dministrtive dtbses (updted with informtion from stte deth certifictes nd Socil Security Administrtion files). These included mortlity outcomes previously reported for subset of women who experienced hip frcture during 2007 nd 2008. 19 Sttisticl Anlysis Differences between subgroups (eg, by ge nd rce/ ethnicity) were compred using the χ 2 test. Multivrible logistic regression ws used to evlute the ssocition of rce/ethnicity, clendr yer, nd erly rehospitliztion with mortlity outcome, djusting for confounders ssocited with both the predictor nd outcome of interest. We did not specificlly exmine for potentil interctions. Clendr yer ws represented s ctegoricl vrible (using the yer 2000 or 2004 s reference) nd s continuous vrible when evluting for liner trend. A 2-sided P vlue of <.05 ws used s the criterion for sttisticl significnce. All nlyses were performed using SAS 9.3 (SAS Institute, Cry, North Crolin). RESULTS We initilly identified 14,059 femle helth pln members 65 yers nd older who suffered low-trum hip frcture in the femorl neck or pertrochnter during 2000 to 2010. After excluding 509 women without continuous helth pln membership in the yer prior to frcture, the finl cohort included 13,550 women, with men ge of 82.5 ± 7.4 yers nd 84.6% ged 75 yers or over. The cohort ws predominntly white (83.6%), with 2.8% blck, 5.6% Hispnic, 4.5% Asin, nd 3.5% of other/unknown rce. During the index hospitliztion, 2.4% died, including slightly higher proportion mong women 85 yers nd older (3.3%) compred with women ged 65 to 74 nd 75 to 84 yers (both 1.8%; P <.001). Among the 13,221 (of 13,550 women) who suffered hip frcture nd were dischrged live, 1624 (12.3%) were rehospitlized within 30 dys following initil dischrge. These included 212 (10.3%) mong women ged 65 to 74 yers, 671 (11.7%) mong women ged 75 to 84 yers, nd 741 (13.6%) mong women 85 yers nd older. The most common indictions for rehospitliztion (excluding 11.9% for orthopedic conditions) were pneumoni (11.6%), other infection-relted conditions (14.9% including sepsis/ bcteremi, urinry trct infection, nd Clostridium difficile infection), nd crdiovsculr disese (9.7%), s shown in Tble 1. In ddition, 12.6% (204 of 1624) of rehospitlized women experienced more thn 1 rehospitliztion event during the 30-dy redmission window. Incresing ge, comorbidity sttus, nd prior frcture were ll ssocited with 30-dy redmission following the initil hip frcture dischrge, wheres frcture type ws not (dt not shown). Erly rehospitliztion rtes were similr cross rcil/ ethnic subgroups except for higher proportion mong blck compred with white women (Tble 2). The overll rte of deth from ny cuse ws 6.3%, 12.7%, 17%, nd 22.8% t 1, 3, 6, nd 12 months, respectively. These included 2.4% who died during the index hospitliztion nd n dditionl 1.5% who died during subsequent rehospitliztion occurring within 30 dys of initil dischrge. Among the 1624 women rehospitlized within 30 dys of dischrge, the 1-yer mortlity rte ws substntilly higher t 43.4%. Women who died during the first yer following hip frcture were somewht more likely to hve hd prior frcture (40.5% vs 36.6%; P <.001) nd to hve experienced pertrochnteric frcture (46.1% vs 43.5%; P =.01) compred with women who survived; they were lso much more likely to hve comorbidity score 3 (31.0% vs 19.2%; P <.001). The strong ssocition of older ge nd mortlity is shown in Figure 1, with women 85 yers nd older nerly twice s likely to die compred with women ged less thn 85 yers during the ensuing 6 months (23.9% vs 12.1%; P <.001) nd 1 yer (31.4% vs 16.7%; P <.001) following hip frcture. e208 n www.jmc.com n MARCH 2015

Hip Frcture Mortlity in Older Women Hip frctures remin mjor public helth burden due to persistently high mortlity nd ssocited disbility. 7,20 While severl recent reports demonstrte tht ge-djustn Tble 1. Principl Dignosis Ctegory for Women Rehospitlized Within 30 Dys After Dischrge From the Index Hip Frcture Hospitliztion (column percentges presented) Principl dignosis ctegory for the first rehospitliztion event within 1-30 dys fter initil dischrge b Totl (N = 1624) b Aged 65-74 yers (N = 212) Aged 75-84 yers N = 671) Aged 85 yers (N = 741) Pneumoni/respirtory distress 189 (11.6%) 15 (7.1%) 87 (13.0%) 87 (11.7%) COPD/sthm/bronchitis 40 (2.5%) 9 (4.3%) 18 (2.7%) 13 (1.8%) Crdiovsculr condition 157 (9.7%) 19 (9.0%) 60 (8.9%) 78 (10.5%) Sepsis/bcteremi 95 (5.9%) 10 (4.7%) 33 (4.9%) 52 (7.0%) Urinry trct infection 84 (5.2%) 9 (4.3%) 38 (5.7%) 37 (5.0%) Glucose/electrolytes/fluid disorder 59 (3.6%) 6 (2.8%) 21 (3.1%) 32 (4.3%) GI ulcer/gstritis/bleeding 57 (3.5%) 2 (0.9%) 15 (2.2%) 40 (5.4%) Venous thromboembolism 52 (3.2%) 8 (3.8%) 29 (4.3%) 15 (2.0%) Cerebrovsculr disese 58 (3.6%) 6 (2.8%) 25 (3.7%) 27 (3.6%) Altered cognition/mentl sttus 37 (2.3%) 7 (3.3%) 15 (2.2%) 15 (2.0%) Clostridium difficile infection 62 (3.8%) 11 (5.2%) 24 (3.6%) 27 (3.6%) Skin infection/ulcer/gngrene 52 (3.2%) 9 (4.3%) 25 (3.7%) 18 (2.4%) Kidney disese or filure 24 (1.5%) 1 (0.5%) 8 (1.2%) 15 (2.0%) Cncer (mlignnt neoplsm) 15 (0.9%) 6 (2.8%) 6 (0.9% 3 (0.4%) Frcture (nonfemur/pelvis frcture) 13 (0.8%) 0 8 (1.2%) 5 (0.7%) Pelvic/femur frcture or ftercre 92 (5.7%) 15 (7.1%) 27 (4.0%) 50 (6.8%) Surgicl/frcture compliction 88 (5.4%) 9 (4.3%) 35 (5.2%) 44 (5.9%) Other conditions not included bove 450 (27.7%) 70 (33.0%) 197 (29.4%) 183 (24.7%) COPD indictes chronic obstructive pulmonry disese; GI, gstrointestinl. See Methods section of text for conditions included within ech dignostic ctegory. b Among 1624 women rehospitlized within 30 dys fter dischrge, 204 (12.6%) hd more thn 1 rehospitliztion within the 30 dys (N = 30, ged 65-74 yers; N = 91, ged 75-84 yers; N = 83, ged 85 yers). One-yer mortlity lso vried by rce/ethnicity (Tble 3), with crude mortlity rtes significntly higher mong whites (23.6%) compred with Hispnics (19%) nd Asins (15.6%; P <.01), but not significntly different from blcks (22.1%). Among women 85 yers nd older (41.5% of the frcture cohort), the 1-yer mortlity ws 32.5% in whites, lso significntly higher thn tht of Hispnics (24.1%) nd Asins (19%), but similr to tht of blcks (31.8%). Tble 2 shows the distribution of ge, bseline comorbidity, frcture history, nd ntomic frcture site by rce/ethnicity, where significnt differences were seen in ge (Hispnic nd Asins compred with whites), comorbidity index score (higher comorbidity mong ll rces/ethnicities compred with whites), prior frcture, nd frcture type. In multivrible nlyses djusting for these confounders (Tble 3), both Asin rce nd Hispnic ethnicity were ssocited with significntly lower odds of deth t 1 yer compred with white rce, djusting for ge, comorbidity index score, prior frcture, frcture subtype, nd frcture yer (odds rtio [OR], 0.64; 95% CI, 0.51-0.80 for Asin; nd OR, 0.75; 95% CI, 0.62-0.91 for Hispnic). These findings were unchnged fter excluding the 3.1% of women without deth outcome whose helth pln membership ended prior to 1 yer (dt not shown). Hving t lest 1 rehospitliztion within 30 dys of dischrge ws lso ssocited with greter thn 3-fold incresed odds of deth t 1 yer (OR, 3.41; 95% CI, 3.04-3.82, djusting for ge, rce/ethnicity, nd comorbidity index score). Given evidence of potentil reduction in mortlity risk fter the yer 2004 (Tble 3), we next exmined temporl trends in the risk of deth t 6 months nd 1 yer post frcture between 2004 nd 2010 s shown in Figure 2. Compred with 2004, the djusted odds of deth in 2010 were significntly lower t 6 months (OR, 0.73; 95% CI, 0.59-0.90) nd 1 yer (OR, 0.70; 95% CI, 0.57-0.85), djusting for ge, rce/ ethnicity, comorbidity index score, nd prior frcture, with smll but significnt declining trend in the djusted odds of deth during this intervl (P <.01, test for liner trend). DISCUSSION VOL. 21, NO. 3 n THE AMERICAN JOURNAL OF MANAGED CARE n e209

CLINICAL n Tble 2. Bseline Chrcteristics, In-Hospitl Mortlity, nd Erly Rehospitliztion by Rce/Ethnicity Among Older Women Following Hip Frcture (column percentges presented) Age group 65-74 yers 75-84 yers 85 yers White N = 11,323 1660 (14.7%) 4854 (42.9%) 4809 (42.5%) Blck N = 381 68 (17.8%) 165 (43.3%) 148 (38.9%) Hispnic N = 758 144 (19.0%) 336 (44.3%) 278 (36.7%) Asin N = 615 131 (21.3%) 284 (46.2%) 200 (32.5%) Other/Unknown N = 473 89 (18.8%) 199 (42.1%) 185 (39.1%) Comorbidity index Score 0 Score 1-2 Score 3 4891 (43.2%) 4084 (36.1%) 2348 (20.7%) 141 (37.0%) 137 (36.0%) 103 (27.0%) b 283 (37.3%) 254 (33.5%) 221 (29.2%) b 241 (39.2%) 212 (34.5%) 162 (26.3%) b 163 (34.5%) 178 (37.6%) 132 (27.9%) b Frcture type, N (%) Femorl neck Pertrochnteric 6321 (55.8%) 5002 (44.2%) c 222 (58.3%) 159 (41.7%) 389 (51.3%) 369 (48.7%) c 368 (59.8%) 247 (40.2%) c 278 (58.8%) 195 (41.2%) Prior frcture 4340 (38.3%) 97 (25.5%),c 277 (36.5%) 171 (27.8%),c 200 (42.3%) d In-hospitl deth 289 (2.6%) e 11 (2.9%) e 16 (2.1%) 7 (1.1%) 6 (1.3%) Rehospitlized in 30 dys 1345 (11.9%) 59 (15.5%) 97 (12.8%) 69 (11.2%) 54 (11.4%) P <.05 compred with whites. b P <.01 comorbidity index score (0-2 vs 3) compred with whites. c P <.05 compred with Hispnics. d P <.05 compred with blcks, Hispnics, Asins. e P <.05 for the index hip frcture dmission, compred with Asins. The letters t the top of the column refer to the overll c 2 comprison (multiple ctegory comprison). n Figure 1. Age-Specific Mortlity t 1, 3, 6, nd 12 Months Following Hip Frcture 35 1-month mortlity 3-month mortlity,b 31.4% 30 6-month mortlity 12-month mortlity,b 25 23.9%,b 20 17.5% 18.3% % 15 10 10.0% 14.2% 9.4% 12.8%,b 3.8% 7.1% 5 3.8% 4.4% 0 Aged 65-74 Yers N = 2092 Aged 75-84 Yers N = 5838 Aged 85 Yers N = 5620 P <.01 compred with women ged 65-74 yers. b P <.01 compred with women ged 75-84 yers. e210 n www.jmc.com n MARCH 2015

Hip Frcture Mortlity in Older Women hip frcture dmission is ssocited with significntly incresed mortlity. 3,5,16 Furthermore, consistent with published literture, our study demonstrtes tht surgicl nd frcture-specific complictions ccount for only smll proportion of repet dmissions compred with medicl comorbidity or complictions, 3,16 where infection nd pulmonry- nd crdiovsculr-relted conditions were identified s the most common indictions for erly redmission. These findings hve importnt implictions for short-term mngement of older women experiencing n cute hip frcture, prticulrly with regrd to the importnce of ggressive mngement of medicl comorbidities. Within our frcture cohort of more thn 13,000 women, 82% were white, reflecting the predominnt rcil subgroup within our helth pln for this femle ge group (66% white) nd the known higher risk of hip frcture sn Tble 3. Bseline Demogrphic nd Clinicl Predictors of Mortlity Outcome Following Hip Frcture 6-Month Mortlity 12-Month Mortlity Rte per 100 Undjusted OR Adjusted OR Rte per 100 Undjusted OR Adjusted OR Age 1.07 (1.07-1.08) 1.08 (1.07-1.09) 1.07 (1.06-1.08) 1.08 (1.07-1.09) Age group 65-74 yers 75-84 yers 85 yers Rce/ethnicity White Blck Hispnic Asin Other/unknown 10.0 12.8 23.9 17.7 17.6 14.5 9.6 12.7 1.32 (1.12-1.55) 2.81 (2.41-3.28) 0.99 (0.76-1.30) 0.79 (0.64-0.97) 0.49 (0.38-0.65) 0.68 (0.51-0.89) 1.37 (1.16-1.62) 3.15 (2.68-3.69) 0.98 (0.74-1.29) 0.79 (0.64-0.98) 0.52 (0.40-0.69) 0.66 (0.50-0.88) 14.2 17.5 31.4 23.6 22.1 19.0 15.6 18.4 1.29 (1.12-1.49) 2.78 (2.43-3.19) 0.91 (0.72-1.17) 0.76 (0.63-0.91) 0.60 (0.48-0.75) 0.73 (0.58-0.92) 1.34 (1.17-1.55) 3.13 (2.72-3.60) 0.90 (0.70-1.16) 0.75 (0.62-0.91) 0.64 (0.51-0.80) 0.71 (0.56-0.91) Comorbidity index 1.17 (1.15-1.20) 1.23 (1.20-1.26) 1.18 (1.16-1.20) 1.24 (1.21-1.27) Comorbidity index Score 0 Score 1-2 Score 3 13.2 16.7 24.6 1.32 (1.19-1.47) 2.15 (1.92-2.40) 1.38 (1.24-1.54) 2.63 (2.33-2.96) 18.0 22.7 32.2 1.34 (1.22-1.47) 2.17 (1.96-2.40) 1.41 (1.27-1.55) 2.67 (2.40-2.98) Prior frcture 18.2 1.14 (1.04-1.25) 1.04 (0.95-1.15) 24.6 1.18 (1.09-1.28) 1.08 (0.99-1.18) Frcture subtype Femorl neck Pertrochnteric Yer of frcture 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 16.2 17.9 14.9 17.7 15.3 16.8 18.3 17.4 18.2 17.1 17.4 17.0 16.1 0.89 (0.81-0.97) 1.23 (0.99-1.54) 1.03 (0.82-1.30) 1.16 (0.93-1.44) 1.29 (1.04-1.60) 1.21 (0.97-1.51) 1.28 (1.03-1.59) 1.19 (0.95-1.48) 1.21 (0.97-1.51) 1.17 (0.94-1.46) 1.10 (0.88-1.38) 0.99 (0.90-1.09) 1.27 (1.01-1.60) 1.02 (0.81-1.29) 1.15 (0.91-1.44) 1.21 (0.97-1.51) 1.11 (0.88-1.39) 1.13 (0.91-1.42) 1.01 (0.80-1.27) 0.96 (0.76-1.21) 0.92 (0.73-1.16) 0.88 (0.69-1.11) 22.0 23.8 21.0 22.5 22.0 22.5 24.6 23.6 23.5 23.2 23.2 22.9 21.2 0.90 (0.83-0.98) 1.09 (0.90-1.33) 1.07 (0.87-1.30) 1.10 (0.90-1.33) 1.23 (1.01-1.49) 1.17 (0.96-1.41) 1.16 (0.96-1.41) 1.14 (0.93-1.38) 1.14 (0.94-1.39) 1.12 (0.92-1.36) 1.01 (0.83-1.24) 1.00 (0.92-1.09) 1.12 (0.91-1.38) 1.05 (0.85-1.29) 1.08 (0.88-1.32) 1.15 (0.94-1.41) 1.06 (0.87-1.30) 1.02 (0.84-1.25) 0.97 (0.79-1.19) 0.90 (0.73-1.11) 0.87 (0.71-1.07) 0.80 (0.65-0.99) OR indictes odds rtio. ORs re presented with 95% CI; djusted for ge, rce/ethnicity, yer of frcture, comorbidity index score, frcture subtype, nd prior frcture. Age nd comorbidity index score re included in the model s continuous vribles except where indicted. ed hip frcture rtes hve declined in older women, 1,21,22 the verge ge of women sustining hip frcture hs incresed, 20,22 nd the number of frcture events is expected to rise with the ging US popultion. 1 In this study, we exmined dt from more thn 13,000 women experiencing hip frcture within n integrted helthcre delivery system, nd found tht 1-yer mortlity post frcture ws 23% nd incresed significntly with gepproching 32% for women 85 yers nd older. These estimtes re in the rnge of, or somewht lower thn, other popultion cohorts exmined in different cre settings. 7,23 Following dischrge from the initil hip frcture hospitliztion, pproximtely 1 in 8 women experienced erly rehospitliztion within the ensuing 30 dys, ssocited with substntilly higher 1-yer mortlity risk. Others hve lso found tht rehospitliztion following the initil VOL. 21, NO. 3 n THE AMERICAN JOURNAL OF MANAGED CARE n e211

CLINICAL differences were seen in mortlity risk when compring white nd blck women. While it is possible tht these findings my reflect rcil/ethnic differences in mortlity within the generl bckground popultion nd the fct tht older Asins 25,26 nd US immigrnts 27 hve been ren Figure 2. Liner Trend in the Adjusted Odds of Deth t 6 Months nd 1 Yer Post Hip Frcture During 2004-2010 2 6-month mortlity outcome Undjusted Adjusted (95% CI) Odds Rtio 1 0 2004 2005 2006 2007 2008 2009 2010 2 1-yer mortlity outcome Undjusted Adjusted (95% CI) Odds Rtio 1 0 2004 2005 2006 2007 2008 2009 2010 P <.01 when exmining for liner trend (clendr yer s continuous vrible). Odds rtios re represented by clendr yer compred with 2004 (ctegoricl vrible), undjusted nd djusted for ge, rce/ethnicity, comorbidity index score, nd prior frcture. socited with white rce. 24 However, we noted tht post frcture mortlity vried significntly by rce/ethnicity, with mortlity risk following hip frcture being lowest for women of Asin rce followed by women of Hispnic ethnicity. In contrst to historicl studies, 14 no significnt e212 n www.jmc.com n MARCH 2015

Hip Frcture Mortlity in Older Women ported to hve higher life expectncy compred with other US subgroups, the extent to which our findings reflect rcil/ethnic disprities in hip frcture or helth survivl rtes, 25-28 modifible risk fctors, 29,30 disese mngement, socil reltionships, 31 or socioeconomic fctors is uncler. These considertions re likely to become incresingly relevnt with the nticipted growing subset of nonwhite women in the ging US popultion. 9,10 Although lrge proportion of deths following hip frcture relte to the frcture itself, 32 ptient comorbidity clerly remins n importnt contributor towrd excess mortlity. 12,33,34 Implementing multidisciplinry or medicl co-mngement of hospitlized hip frcture ptients hs been shown to decrese inptient postopertive complictions, subsequent redmission, nd/or mortlity rtes, 35-39 s hs osteoporosis tretment, vitmin D supplementtion, nd fll-prevention efforts post hip frcture. 40,41 Within our helth pln, number of these fctors my hve contributed to the smll but significnt observed reduction in mortlity risk. Incresed screening nd tretment of vitmin D deficiency 42 nd implementtion of regionl progrms trgeting osteoporosis therpy for primry nd secondry frcture prevention during the pst 10 yers my hve lso contributed to the overll decline in hip frctures observed within our helth pln, in which the ge-djusted incidence of hip frcture fell from 281 to 240 per 100,000 women between 2006 nd 2012. 17 Greter interdisciplinry collbortion between orthopedic surgeons nd hospitlists surrounding the cute hip-frcture dmission hs been incresingly evident t both the hospitl nd fcility level, with joint focus on optimizing inptient medicl cre in this high-risk popultion. Bsed upon this tem pproch, region-wide progrms re now underwy to formlize hip frcture mngement pthwys, nd they re nticipted to result in n even greter reduction of mortlity risk following hip frcture. Limittions First, we were unble to scertin functionl sttus, frilty, nd qulity of lifeimportnt fctors tht require qulittive ssessment beyond the scope of this retrospective study. It is ssumed tht the mjority of women were community-dwelling individuls lthough we were not ble to determine how mny were in ssisted living or institutionl cre t the time of hip frcture. Second, dt pertining to specific surgicl interventions, postopertive medicl mngement, nd receipt of subsequent cre in noncute settings were not exmined. Third, mortlity outcome my hve been incomplete for members who left the helth pln nd relocted out of stte, lthough our findings were unchnged fter excluding the 3.1% with erly membership cesstion who were presumed live t 1 yer. Finlly, we did not exmine bckground mortlity trends within our helth pln, so we cnnot exclude the possibility tht the temporl decline in mortlity risk reflects temporl trends in mortlity cross our helth pln popultion, irrespective of hip frcture sttus. As such, these dt represent findings from n ging insured popultion of older women with ccess to helthcre nd my not necessrily reflect morbidity nd mortlity rtes in other cre settings. Nonetheless, our results provide contemporry estimtes tht my be generlizble to similr popultions, nd provide dt from one of the lrgest contemporry hip frcture cohorts within single helthcre system. Our findings lso point to the need for further studies exmining contemporry trends nd disprities in post frcture morbidity nd mortlity outcome, including the role of multidisciplinry cre, complex comorbidity mngement, post opertive nutrition, nd other interventions. CONCLUSIONS While mortlity rtes remin high mong older women post hip frcture, significnt temporl reduction in djusted mortlity risk ws observed during the pst decde, coincident with multidisciplinry efforts within our helth pln to improve clinicl outcomes in ptients with osteoporosis nd post frcture. We lso found tht rce/ ethnicity ws n importnt predictor of outcome, with Asin women, nd to lesser extent Hispnic women, demonstrting lower mortlity risk over 1 yer compred with white women. Future investigtions should focus on potentil explntions for these differences nd the ssocited cost benefit of trgeted interventions, in which strtegies to prevent hip frctures nd reduce dverse helth outcomes re nticipted to hve substntil public helth implictions. Acknowledgments The uthors thnk Joel Gonzlez for ssistnce with mnuscript preprtion nd literture review. Author Affilitions: Division of Reserch, Kiser Permnente Northern Cliforni (JCL, MC), Oklnd, CA; Deprtment of Orthopedics (CDG) nd Deprtment of Medicine (JCL, SS, MP, AB, LHL), Kiser Permnente Oklnd Medicl Center, Oklnd, CA; Deprtment of Medicine, Kiser Permnente Sn Frncisco Medicl Center (GL), Sn Frncisco, CA. Source of Funding: This study ws funded in prt by the Kiser Permnente Community Benefit Progrm. Author Disclosures: Drs Lo nd Chndr hve received prior reserch funding from Amgen, Inc. Drs Srinivsn, Ptton, Budyr, Liu, Lu, nd Grimsrud report no reltionship or finncil interest with ny entity tht would pose conflict of interest with the subject mtter of this rticle. VOL. 21, NO. 3 n THE AMERICAN JOURNAL OF MANAGED CARE n e213

CLINICAL Authorship Informtion: Concept nd design (JCL, SS, MC); cquisition of dt (MC); nlysis nd interprettion of dt (JCL, SS, MC, MP, AB, LHL, GL, CDG); drfting of the mnuscript (JCL, SS, MC, MP, AB, LHL, CDG); criticl revision of the mnuscript for importnt intellectul content (JCL, SS, MC, MP, AB, LHL, GL, CDG); sttisticl nlysis (MC); obtining funding (JCL); supervision (JCL); study cohort definition (JCL, CDG). Address correspondence to: Jon C. Lo, MD, Division of Reserch, Kiser Permnente Northern Cliforni, 2000 Brodwy, Oklnd, CA 94612. E-mil: Jon.C.Lo@kp.org. REFERENCES 1. Bruer CA, Coc-Perrillon M, Cutler DM, Rosen AB. Incidence nd mortlity of hip frctures in the United Sttes. JAMA. 2009;302(14): 1573-1579. 2. Burge R, Dwson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence nd economic burden of osteoporosis-relted frctures in the United Sttes, 2005-2025. J Bone Miner Res. 2007;22(3): 465-475. 3. French DD, Bss E, Brdhm DD, Cmpbell RR, Rubenstein LZ. 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