Hannan Research Shows that Risk Factors Predict Patient Survival and Ability to Function After Hip Fracture

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Risk factors, including age and residency in a nursing home, can help predict how well a patient will be able to function after breaking a hip, while other risk factors can help predict whether patients will survive a hip fracture, according to an article by UAlbany Professor Edward L. Hannan in the June 6 issue of The Journal of the American Medical Association (JAMA).

Hannan, chair of the Department of Health Policy, Management, and Behavior in UAlbany's School of Public Health, and his colleagues analyzed data on 571 adults, aged 50 and older, who experienced hip fractures and were admitted to four hospitals in New York City between August 1997 and August 1998.

The study, with Hannan as principal investigator, was designed to identify and compare the importance of significant pre-fracture predictors of functional status and mortality at six months, and to compare risk-adjusted outcomes for hospitals providing initial care.

Hip fracture is a common cause of death and disability. According to background information cited in the article, an estimated 350,000 hip fractures occur each year in the U.S., and the total inpatient cost of caring for these patients is nearly $6 billion per year, exclusive of physician charges. Among patients discharged following hospitalization for hip fracture, only 60 percent will have recovered their pre-fracture walking ability by six months, and 24 percent of patients will have died by 12 months.

Recognizing a need exists for a practical means to monitor and improve outcomes, including function, for patients with hip fractures, the authors focused on the death rate (in the hospital and at six months), locomotion (the patient's ability to walk and climb stairs), and adverse outcomes - death, or the patient's need for total assistance to move around.

The results were compared by hospital, and adjusted for patient risk factors. Patient risk factors prior to the fracture included age, sex, race, functional status, dementia, admission from a nursing home, and whether a paid helper was required to care for the patient. A modified APACHE (Acute Physiology and Chronic Health Evaluation) score was used to capture the impact of patients' vital signs, laboratory studies, and mental status, and a modified comorbidity score measured the impact of chronic conditions.

"The in-hospital mortality rate was 1.6 percent," writes Hannan. "At six months, the mortality rate was 13.5 percent, and another 12.8 percent [of patients] needed total assistance to ambulate. Laboratory values were strong predictors of mortality but were not significantly associated with locomotion. Lower pre-fracture locomotion, a higher modified APACHE score, and a paid helper at home prior to the fracture were significantly related to higher mortality at six months.

"Age and pre-fracture residence at a nursing home were significant predictors of locomotion, but were not significantly associated with mortality," the authors continue.

With respect to hospital performance, the study found that performance on one outcome was not necessarily related to performance on another. "This indicates that both mortality and functional status measures are needed to adequately assess hospital performance, and that the processes of care that are associated with lower mortality rates are not identical to the processes associated with better functional status," the authors suggest.

Hannan and his colleagues suggest that their findings have implications for ongoing efforts by clinicians, hospitals, accrediting agencies, employers, and other parties to better understand and improve outcomes of health care. "Specifically, we believe that greater attention needs to be paid, not only to preventing hip fracture, but also to preventing the mortality and morbidity that results once a patient has fractured a hip - an issue that has not been on the quality improvement agenda of most health care organizations."

The authors encourage more clinical research to better understand the efficacy of interventions that might increase survival and improve functional outcomes.

This project was supported by grants from the Agency for Healthcare Research and Quality, the Mary and David Hoar Fellowship of the New York Community Trust and the New York Academy of Medicine, the National Institute on Aging, and the American Federation for Aging Research Paul Beeson Faculty Scholar Award.

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June 5, 2001

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