Research Summary
Research topic: Measuring how health care supply influences hip fracture care delivery and complications, and how socioeconomic and demographic characteristics influence care for patients with hip fractures
Research results: Data indicate racial and socioeconomic disparities exist for treatment access and outcomes
Patient care application of results: Development of targeted interventions to mitigate the effects of socioeconomic and racial disparities on hip fracture patients at greatest risk
Simplified patient care application: Providers should strive to provide high-quality, high-value care for all patients with hip fractures, paying particular attention to those at risk for complications.
Improving Standards of Care
OREF grant recipient seeks to improve delivery of care for patients with hip fractures through population-based research
Mark Crawford
During his medical and public health studies at the University of Miami, Christopher J. Dy, MD, MPH, was interested in learning about how disparities in health care and access to care can have dramatic impacts on population groups. This drew him to the field of health services research, an area that he began pursuing while an orthopaedic surgery resident at Hospital for Special Surgery in New York City.
“As a surgeon, you are essentially confined to one patient at a time when you’re in the operating room,” said Dr. Dy. “But as a health services researcher, I can try to impact an entire system of care. And, as we push forward with health care reform, it is imperative to decrease variations both in the delivery and the cost of care, thereby optimizing patient outcomes.”
Now a surgeon at Washington University School of Medicine in St. Louis, Dr. Dy is continuing his investigations into how the health care system impacts the treatment of hip fractures. (
See Dr. Dy talk about his research on OREF TV.)
“Hip fractures are the biggest public health issue we’ll see as orthopaedic surgeons,” Dr. Dy explained. “There is tremendous variation in the care patients receive. Hip fracture surgeries have a mortality rate of 20 percent after one year and significantly increased disability for those who survive. Total costs exceeded $12 billion in 2005 and are projected to grow 49 percent by 2025.”
Previous epidemiologic studies of hip fractures have addressed only a single aspect of health care supply, such as surgeon training or case volume, in isolation. This makes it difficult to turn findings into strategies for improvement, especially when it is apparent that there are so many other impacts on the delivery of care that need to be considered.
Under a 2013 OREF Young Investigator Award (now the New Investigator Award), Dr. Dy designed a rigorous study to simultaneously evaluate the influence of multiple aspects of health care supply on the delivery of care for hip fractures.
Under the mentorship of Stephen Lyman, PhD, Dr. Dy and their research team are continuing their analysis of a large database of hip fracture patients in New York State over a 13-year period. Their initial findings demonstrated race- and insurance-based disparities in delivery of care and complications and were published in The Journal of Bone and Joint Surgery in 2016. They are currently expanding on these findings by researching the influence of health care resource availability within communities on the delivery and safety of care for patients throughout New York State.
“Hopefully this work will directly inform administrative and policy changes in health care resource allocation to address any disparities that are identified,” said Dr. Dy.
Health care disparity
With this study, Dr. Dy aims to accomplish two main goals:
Goal 1. Measure the influence of health care supply on the efficiency of hip fracture care delivery—for example, availability of hospital resources and surgeons, and on-time admission and procedures, a key indicator for survival after hip fracture.
Goal 2. Determine the influence of health care supply on complications after hip fracture surgery—for example, frequency of short-term complications, readmission and reoperation after hip fracture treatment.
Dr. Dy collected data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) on all discharges from nonfederal acute-care hospitals in New York State. Using International Classification of Diseases, Ninth Revision, and Clinical Modification (ICD-9-CM) codes, Dr. Dy and his team identified records for 197,290 New York State residents who underwent surgery for a hip fracture between 1998 and 2010. The researchers used multivariable regression models to evaluate the association of patient characteristics, social deprivation and hospital/surgeon volume with time from admission to surgery, in-hospital complications, readmission and one-year mortality.
“We expected to find that multiple characteristics of health care supply would influence the frequency of adverse events after hip fracture surgery,” said Dr. Dy. “We also anticipated that socioeconomic characteristics within a community, such as pervasiveness of poverty and lower education, would influence the frequency of adverse events.”
Patients at risk
Data indicated racial and socioeconomic disparities exist for treatment access and outcomes.
“After adjusting for patient and surgery characteristics, hospital/surgeon volume, social deprivation and other variables, we discovered black patients were at greater risk for delayed surgery than white patients,” reported Dr. Dy. “Subgroup analyses showed a greater risk for delayed surgery for black and Asian patients compared with white patients, regardless of social deprivation. There was also a greater risk for readmission for black patients compared with white patients, regardless of social deprivation. And, compared with Medicare patients, Medicaid patients were at increased risk for delayed surgery whereas privately insured patients were at decreased risk for delayed surgery complications.”
These racial and socioeconomic disparities in the treatment of hip fractures have the potential to substantially affect both hospitals and health care providers in an era of value-based payment.
“In addition to identifying and resolving the causes for these disparities in hip fracture care, we need to develop targeted interventions to mitigate the effects of these disparities on patients at greatest risk,” said Dr. Dy. “This could include supply-based strategies for improving care delivery for hip fractures, such as re-routing ambulances carrying patients with hip fractures to higher-volume hospitals or to specifically trained surgeons, or coordinating surgeon on-call schedules across facilities to ensure that surgeons experienced with hip fractures are on-call at peak times or locations.”
“I think it’s essential that we as an orthopaedic surgery community embrace the fact that we’re going to need to steer our path going forward for health care reform,” Dr. Dy continued. “I’d like to improve the system of care so we can continue to provide reliable and effective outcomes for our entire patient population.”
OREF boosts credibility
Dr. Dy said that the OREF grant helped him in many ways.
“Funding from an organization like OREF gives us credibility among our peers,” he said “It shows that the orthopaedic community supports our research and understands its importance. My mentors have told me seeking research funding through a mechanism like OREF is essential to getting further funding. Recognition by our specialty shows that our research is valued, and makes us competitive with other specialties when applying for funding from the National Institutes of Health and other large funding mechanisms.”
Mark Crawford is a contributing writer for OREF. He can be reached at communications@oref.org