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Factors Associated With Primary Hip Arthroplasty After Hip Fracture
Ishveen Chopra, MS; Khalid M. Kamal, PhD; Jayashri Sankaranarayanan, MPharm, PhD; and Gibbs Kanyongo, PhD
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Factors Associated With Primary Hip Arthroplasty After Hip Fracture

Ishveen Chopra, MS; Khalid M. Kamal, PhD; Jayashri Sankaranarayanan, MPharm, PhD; and Gibbs Kanyongo, PhD
Patient, clinical, and hospital factors were associated with receiving primary hip arthroplasty versus no surgery after hip fracture in the United States.
Objectives: To determine patient, clinical, and hospital factors associated with receiving total hip arthroplasty (THA) and hemiarthroplasty (HA) in the United States.

Study Design: Retrospective, cross-sectional study.

Methods: Hospital discharge records with a principal diagnosis of hip fracture and primary hip arthroplasty or no surgery were identified from the 2009 Nationwide Inpatient Sample data set of the Healthcare Cost and Utilization Project. Patient (age, sex, race, income, payer), clinical (comorbidities, severity, fracture type), hospital (region, location, teaching status, bed size, ownership), and outcome (receipt of THA or HA) variables were extracted and weighted for the analyses. Univariate and multivariate analysis were conducted and significance was set at P <.05.

Results: A total of 92,861, 15,489, and 9863 discharges occurred for HA, no surgery, and THA, respectively. Compared with no surgery, THA or HA was significantly more likely in patients who were aged >50 years, white, and female; had >$39,000 income; lived in a medium-metro or noncore county; had comorbidities (anemia, hypertension); and had intracapsular fracture. THA or HA was significantly more likely in urban, privately owned hospitals with >249 beds. Compared with no surgery, THA was significantly more likely in nonteaching hospitals, the Northeast region, and in private insurance or self-pay patients with moderate to severe fractures; HA was more likely in teaching hospitals, in the South and West, and in Medicare patients with minor fractures.

Conclusions: Similarities and differences in patient, clinical, and hospital factors associated with surgical treatments of hip fracture warrant the attention of providers and payers.

Am J Manag Care. 2013;19(3):e74-e84
Patient, clinical, and hospital factors are associated with receiving primary hip arthroplasty versus no surgery after hip fracture in the United States.

  •  Total hip arthroplasty (THA) or hemiarthroplasty (HA) was significantly more likely if these characteristics were present: age >50 years, white, female, >$39,000 income, mediummetro or noncore patient county residence, comorbidities, intracapsular fracture, and urban, privately owned hospital with >249 beds.

  •  THA was significantly more likely in nonteaching hospitals, the Northeast, and private insurance or self-pay patients with moderate-severe illness; HA was more likely in teaching hospitals, the South and West, and Medicare patients with minor illness.
Hip fractures are common, disabling, and expensive. According to the American Academy of Orthopedic Surgeons, hip fractures account for more than 350,000 hospital admissions in the United States each year at an annual cost of more than $5 billion.1,2 The number of hospital admissions is expected to increase to 700,000 by 2050, due to an expected increase in the aging population, life expectancy, and prevalence of osteoporosis.1 The hip fracture rates have been shown to increase exponentially with age, especially in individuals over 50 years of age.3 The risk of hip fractures is about 3 times higher in women, with white women more likely than African American or Asian women to suffer hip fractures.4 Further, the complications related to hip fracture and the long recovery period are associated with a high mortality rate, with an estimated 1 in 4 patients dying within 12 months of hip fracture.3

Hip fractures are serious fall injuries, and treatment options depend on the location and pattern of the fracture, patient characteristics, and the availability of US Food and Drug Administration–approved devices.5 The typical location of fracture includes the femoral neck and the intertrochanteric and subtrochanteric regions. Treatment of displaced, unstable fracture of femoral neck often requires surgical management such as internal fixation and hip arthroplasty.6 Although there is no preferred procedure for the management of hip fractures, recent studies have suggested that arthroplasty has better outcomes than internal fixation for femoral neck fractures.7-16 Earlier, hip arthroplasty was recommended for elderly patients, but it has now been shown to be successful in younger patients as well.17 Hip arthroplasty consists of hemiarthroplasty (HA) and total hip arthroplasty (THA). Hemiarthroplasty is a quick and standardized procedure compared with THA.6 However, THA has shown to have better outcomes than HA and is most commonly used in elderly patients with osteoarthritis and those who are physically active. Further, with advances in surgical techniques and technology, THA-related complications have been significantly reduced. According to the American Academy of Orthopedic Surgeons, about 231,000 THAs are performed each year in the United States.17 After hip fracture, most patients undergo surgical intervention. However, nonsurgical (conservative) management is also used for some patients. Conservative management includes a multimodal approach of medication, activity modification, and physical therapy that comprises bed rest, exercise, and the use of walking aids that help in the healing process by reducing pain and strengthening muscles around the hip joint. In general, the choice of surgical or nonsurgical management of hip fractures depends on clinical factors such as type of hip fracture and the patient’s comorbidities as well as social factors (eg, family, economic status, ethnicity, and location).

The purpose of hip fracture–related surgical treatment is to reduce fracturerelated morbidity and complications, with subsequent improvement in activities of daily living and quality of life.5 A systematic review by the Agency for Healthcare Research and Quality in 2009 suggested that the fracture type was not independently related to patient outcomes such as fracture-related pain, functional status, quality of life, and mortality.5 However, there are no proven guidelines to manage hip fractures. Further, data are limited on the patient, clinical, and hospital factors that affect the decision to provide surgical treatment (arthroplasty) versus no surgical treatment. The present study was undertaken to help understand the factors associated with primary hip arthroplasty in real-world medical practice in the United States. The study objectives were (1) to examine patient, clinical, and hospital factors associated with primary hip arthroplasty (HA or THA) versus no surgical treatment; and (2) to evaluate costs, charges, and length of stay for primary HA, primary THA, and no surgical treatment.


Study Design and Data Source

This is a retrospective cross-sectional study of hospital discharge records from the 2009 Nationwide Inpatient Sample (NIS) data. Part of the Healthcare Cost and Utilization Project (HCUP) database, NIS is the largest source of all payer hospital discharge information in the United States. The Nationwide Inpatient Sample is an approximately 20% stratified sample of US community hospitals (excluding veterans and military hospitals) and contains de-identified records of independent hospital discharges selected from 1050 hospitals across 44 states with stratified, single-stage cluster sampling. Each year, about 5 to 8 million hospital stays are recorded by NIS.18 This study was performed under the NIS Data User Agreement and was approved by the Duquesne University Institutional Review Board.

Selection Criteria

The NIS database contains information on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for primary/secondary diagnosis and procedure codes for each discharge record. Included were the discharge records for individuals aged >18 years with an ICD-9-CM primary diagnosis code for hip fracture (codes 820.00-820.32, 820.8, and 820.9).19 Among hip fracture–related discharges, the discharge records with designated ICD- 9-CM primary procedure codes for HA (81.52) and THA (81.51)19 were compared with the discharge records for hip fracture with no documentation of surgery. Other procedures such as internal fixation with closed/open reduction or without reduction and revision arthroplasty were excluded from the study. The discharge records were then classified based on their procedure types: primary hip arthroplasty (HA or THA) and no surgery (comparison group). The schematic presentation of patient selection is shown in the Figure.

Study Variables

Extracted patient-level variables were age (<50 years, 50- 64 years, 65-79 years, and >80 years), race (white, black, Hispanic, Asian-Pacific Islander, Native American, and other), sex, and primary payer (Medicare, Medicaid, self-pay, private, no charge, and other sources of payment). Patients’ median household income (defined as median household income of the patient’s zip code of residence) was classified into 4 quartiles: $1 to $38,999, $39,000 to $47,999, $48,000 to $62,999, and >$63,000.20 In HCUP a patient’s residing location was based on the National Center of Health Statistics urbanrural designation of the patient’s county of residence and was classified into 6 categories: large central (>1 million population), large fringe (>1 million population), medium metro (250,000-999,999 population), small metro (50,000-249,999 population), micropolitan, and noncore counties.20,21

We also included in the analysis clinical variables such as comorbidities (defined as either present or absent), severity of disease, and type of hip fracture, which predict a decision about primary hip replacement surgery. The severity of illness was assessed using All Patient Refined–Diagnosis Related Groups in the HCUP-NIS data set and was categorized as minor, moderate, major, and extreme. The type of hip fracture was grouped into 3 major categories based on the location of the fracture as indicated by their ICD-9-CM codes. These fracture types were intracapsular (820.00-820.19), extracapsular (820.20-820.32), and other (820.8, 820.9).

Hospital-related variables included geographic region (Northeast, Midwest, West, and South), location (urban and rural), teaching status (teaching and nonteaching), ownership (government, nonfederal; private, nonprofit; and private, investor owned), and hospital bed size (small 1-249 beds, medium 250-449 beds, and large >450 beds).18 The outcome variables were the receipt of either HA or THA versus no surgery. The study also included charges and length of stay attributable to primary hip arthroplasty. Because charges include operating, capital, and other costs, these are usually higher than the true economic costs of medical services. Costto- charge ratios provided in the NIS-HCUP data set were applied to medical service charges to estimate the true costs.

Statistical Analyses

For analyses, we used IBM SPSS Statistics for Windows, version 20 (IBM Corp, Armonk, NY). The differences between the hip arthroplasty (HA or THA) and no-surgery groups were assessed using x2 and independent sample t tests. Multivariate analysis using logistic regression was also conducted, in which all the predictor variables were entered into the model in order to evaluate the association of each predictor variable with the likelihood of undergoing THA or HA while controlling for other variables. Population sampling weights from NIS were applied to all statistical computations to calculate the national estimates for community hospitals across the United States. Significance for all statistical tests was set a priori at P <.05, with all P values being 2 tailed. Missing data were considered to be missing at random, were generally below 5% of the data, and were excluded from the analyses.


A weighted sample of 9863 discharges for THA, 92,861 discharges for HA, and 15,489 discharges for no surgery were identified in the 2009 NIS data set. The mean ages for the patients undergoing THA, HA, and no surgery were 75.62 ± 0.12 years, 81.19 ± 0.03 years, and 80.85 ± 0.10 years, respectively (P <.001).

Table 1 reports several significant factors for THA and HA versus no surgery. Both THA and HA were more likely in whites, patients aged 50 to 79 years (THA) and 50 to 64 years (HA), patients with >$39,000 income, patients residing in the large central and metro counties, patients with comorbidities (rheumatoid arthritis [RA] and chronic blood loss/ anemia), and patients with intracapsular or other fractures. The hospital-related factors (urban location, private/nonprofit ownership, teaching status, and >450 bed size) were more likely to be associated with receiving both THA and HA.

Table 2 presents the multivariate logistic regression analysis results with THA as the outcome variable versus no surgery. Total hip arthroplasty was most likely in patients aged 50 to 64 years (odds ratio [OR] = 2.410; P <.001), followed by patients aged 65 to 79 years (OR = 1.720; P <.001) versus patients younger than 50 years. Women were more likely to undergo THA (OR = 1.147; P <.05). Patients with private insurance (OR = 1.250; P <.001) or self-pay (OR = 1.393; P <.05) versus those with Medicare were significantly more likely to undergo THA; that was also true for patients residing in medium metro (OR = 1.386; P <.001) or noncore (OR = 1.292; P = 0.006) counties versus those residing in large central counties.

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