Nonoperative care for hip fracture in the elderly: the influence of race, income, and comorbidities

Abstract

Context: Hip fracture occurs in 340,000 older adults each year. Operative repair is the standard of care, maximizing the chances of functional recovery. Not receiving operative care may condemn patients to a lifetime of pain and potential immobility.

Objective: To measure the incidence of nonoperative treatment for first-time hip fracture in a population-based cohort and to measure the odds of nonoperative treatment of hip fracture among patients of differing race and income.

Design, setting, and participants: Retrospective cohort study of 165,861 Medicare beneficiaries admitted for hip fracture between March 31, 2002 and December 31, 2006 to hospitals in New York, Illinois, and Texas.

Main outcome measures: Odds of nonoperative management of hip fracture, adjusted for fracture characteristics, comorbidities, source of admission, age, sex, race, income, and individual hospital effects.

Results: Nonoperative management occurred in 6.2% of patients (N = 10,283). After adjustment, black patients had a 79% increase in the odds of nonoperative management as compared with whites (OR 1.79, 95% CI 1.64-1.95). Low income itself was not associated with a change in the odds of nonoperative care. Among patients not receiving operative repair, blacks demonstrated lower mortality than whites at 7 days (7.96% vs. 20.17%, P < 0.0001) and 30 days (24.14% vs. 38.22%, P < 0.0001).

Conclusions: Black race predicts an increased odds of nonoperative care for hip fracture. Among patients receiving nonoperative care, black patients demonstrated increased survival compared with whites. These results are consistent with differential selection of operative candidates by patient race.

Figure 1. Kaplan-Meier Survival Curves, By Race

Upper panel: survival curves for the full patient sample. Lower panel: survival curves for patients receiving operative or non-operative care. See text for description.