Improving Hip Fractures Outcomes for COPD Patients

Figures & data

Table 1.  Description of CPT codes.

	Description
CPT code 27125	Hemiarthroplasty not femoral neck fracture
CPT code 27235	Percutaneous fixation of femoral neck fracture
CPT code 27236	Femoral Neck fracture treated with prosthesis or internal fixation
CPT code 27244	Intertrochanteric fractures and sliding hip screw
CPT code 27245	Intertrochanteric fracture treated with Intramedullary rod
CPT code 27130	Total hip arthroplasty

Table 2.  Patient characteristics by COPD status** (1998–2005).

	No COPD	Mild COPD	Severe COPD	P-value*
Number of Cases (n)	6,649	2,736	3,261
Age, years (mean)1	72.8	73.7	74.4	0.11
Age <65 (% of sample)	24	21	15	0.40
Age 65–74 (% of sample)	24	26	30
Age 75–84 (% of sample)	42	44	47
Age 85+ (% of sample)	11	10	8
Race Category1
White (% of sample)	72	76	81	<0.001
Black (% of sample)	12	11	7
Hispanic (% of sample)	5	4	3
Other (% of sample)	1	0	0
Unknown (% of sample)	10	8	8
Current Smoker* (% of sample)1	24	35	43	<0.001
Frequent Alcohol* (% of sample)1	13	15	18	<0.001
Steroid Use (% of sample)1	2	2	10	<0.001
Premorbid Functional Status1
Independent (% of sample)	59	59	51	<0.001
Partial Dependence (% of sample)	32	33	40
Dependent (% of sample)	9	8	9
Other Pre-Fracture Diagnoses:
Count of Co-morbidities (Elixhauser)2	4.3	5.7	5.5	<0.001
Osteoporosis (% of sample)2	2.7	2.9	2.6	0.3
Dementia2	19	18	14	<0.001
Recent Significant weight loss1	3	4	8	<0.001
Diabetes1	22	20	18	<0.001
CHF1	4	6	11	<0.001


*P-values reflect results of Chi-Square tests of differences across categories for discrete measures or ANOVA with post-estimation tests across COPD categories for continuous measures.

** Severe COPD is identified by VASQIP interview as: “emphysema and/or chronic bronchitis resulting in any one or more of the following: functional disability (e.g., dyspnea, inability to perform activities of daily living), hospitalization in the past for treatment of COPD, need for chronic bronchodilator therapy with oral or inhaled agents, or an FEV1 of <75% of predicted on pulmonary function testing”.

Mild COPD are those subjects who had a previous clinic visit or hospitalization with an ICD-9 code for COPD but did not meet the VASQIP criteria.

1 Information derived from the VASQIP data

2 Information derived from patient medical records.

Table 3.  Operative characteristics by COPD status** (1998–2005).

	No COPD	Mild COPD	Severe COPD	P-value*
Number of Cases (n)	6,649	2,736	3,261
Operating Time (mean hours)	1.6	1.5	1.5	<0.001
Work RVU's/complexity (higher -> more complex)	15.8	15.8	15.8	0.795
Wound Class (% of cases)
clean	97.6	97.7	96.7
clean contaminated	2.2	2.1	3.2	0.068
contaminated	0.1	0.1	0.1
infected	0.1	0.1	0.0
general anesthesia (vs. other method) (% of cases)	68	63	55	<0.001
Staff MD (vs. resident) (% of cases)	22	29	25	<0.001
Emergency case	19	20	23	<0.001
ASA Class
1 - Healthy patient	1	0	0	<0.001
2 - mild systemic disease	14	7	3
3 - severe systemic disease	67	66	60
4 - constant threat to life	18	26	36
5 - moribund patient	0	0	1
One or more RBC's given (%)	11.7	11.7	13.2	0.082
Operation Delayed 4+ days (%)	25.8	29.4	31.7	<0.001
Days from Admit to Surgery (avg)	5.1	5.0	4.1	0.85


*P-values reflect results of Chi-Square tests of differences across categories for discrete measures or ANOVA with post-estimation tests across COPD categories for continuous measures.

** Severe COPD is identified by VASQIP interview as: “emphysema and/or chronic bronchitis resulting in any one or more of the following: functional disability (e.g., dyspnea, inability to perform activities of daily living), hospitalization in the past for treatment of COPD, need for chronic bronchodilator therapy with oral or inhaled agents, or an FEV1 of <75% of predicted on pulmonary function testing”.

Mild COPD are those subjects who had a previous clinic visit or hospitalization with an ICD-9 code for COPD but did not meet the VASQIP criteria.

All data for Table 3 was derived from the VASQIP non-cardiac file.

Figure 1.  Outcomes of hip fractures in men. Three major outcomes of hip fractures in men treated within the VAH system were studied in detail: 30 day mortality, one or more perioperative complications and 1 year mortality. Unadjusted percentages for 30 day mortality (A), complications (B) and 1 year mortality (C) are shown. Severe COPD (that required chronic medication or impacted function) was associated with greater mortality and more complications (p<0.0001 for each outcome in both the unadjusted comparisons and the adjusted logistic regression model). In adjusted models there was no significant difference for mild COPD compared to no COPD. Unadjusted comparisons of mild COPD compared to no COPD indicated no significant difference in the 30-day rates of mortality or complications, but a higher 1-year mortality rate for patients with mild COPD (t-test p<0.001).

Table 4.  Complications by COPD status** (1998–2005).

	No COPD	Mild COPD	Severe COPD	P-value*
Number of Cases (n)	6,649	2,736	3,261
Reintubation (% of cases)	2.4	2.9	4.9	<0.001
Failure to Wean (% of cases)	1.3	1.35	3.4	<0.001
Pneumonia (% of cases)	5.5	5.7	9.4	<0.001
Wound Infection (% of cases)	2.4	2.3	3.3	0.009
Sepsis (% of cases)	1.4	1.6	2.8	<0.001
Bleeding requiring >4 units transfusion (% of cases)	0.66	0.44	0.58	0.44
DVT (% of cases)	0.9	1.2	0.6	0.05
CVA (% of cases)	0.5	0.6	0.6	0.85
Cardiac arrest (% of cases)	1.7	1.7	2.4	0.027
MI (% of cases)	0.99	0.91	1.38	0.14


*P-values reflect results of Chi-Square tests of differences across COPD categories.

** Severe COPD is identified by VASQIP interview as: “emphysema and/or chronic bronchitis resulting in any one or more of the following: functional disability (e.g., dyspnea, inability to perform activities of daily living), hospitalization in the past for treatment of COPD, need for chronic bronchodilator therapy with oral or inhaled agents, or an FEV1 of <75% of predicted on pulmonary function testing”.

Mild COPD are those subjects who had a previous clinic visit or hospitalization with an ICD-9 code for COPD but did not meet the VASQIP criteria.

Presence of these complications within 30-days of surgery was derived from the VASQIP non-cardiac data file.

Table 5.  Logistic regression models predicting outcomes (entire sample).

	Mortality within 30 Days		Mortality within 1 year		Complication(s) within 30 Days
	Odds Ratio	p-value*	Odds Ratio	p-value*	Odds Ratio	p-value*
Mild COPD (vs no COPD)	0.95	0.59	0.98	0.80	0.95	0.40
Severe COPD (vs no COPD)	1.34	<0.001	1.43	<0.001	1.25	<0.001
Caucasian Race (vs. other)	1.26	0.01	1.07	0.20	1.26	<0.001
Age 65–74 (vs. under age 65)	1.43	0.01	1.49	<0.001	1.54	<0.001
Age 75–84 (vs. under age 65)	2.26	<0.001	2.18	<0.001	2.11	<0.001
Age 85+ (vs. under age 65)	4.14	<0.001	3.89	<0.001	2.48	<0.001
Current smoker (vs. non-smoker)	1.22	0.03	1.05	0.39	1.00	0.99
Heavy Alcohol use (vs. not)	0.83	0.15	0.85	0.03	1.25	<0.001
Steroid use for Chronic condition (vs. not)	1.47	0.01	1.61	<0.001	1.00	0.97
Dementia (vs. not)1	1.47	<0.001	1.64	<0.001	1.04	0.53
Osteoporosis diagnosis (vs. not)1	0.73	0.24	0.80	0.15	0.66	0.03
Recent Significant Weight Loss (vs. not)	1.93	<0.001	2.45	<0.001	1.30	0.01
Elevated Hematocrit	1.46	<0.001	1.50	<0.001	1.18	0.01
Elevated Sodium	3.43	<0.001	1.76	0.06	1.31	0.38
Poor Renal Function	1.41	<0.001	1.30	<0.001	1.25	<0.001
Partial Functional Dependence (vs. independent)	1.55	<0.001	1.34	<0.001	1.35	<0.001
Functional Dependence (vs. independent)	2.04	<0.001	1.99	<0.001	1.58	<0.001
History of CHF	1.71	<0.001	1.18	0.06	1.31	<0.001
History of Stroke	0.84	0.26	0.94	0.52	1.00	0.98
Count of non-COPD Co-morbidities (Elixhauser)1	1.03	0.03	1.08	<0.001	1.04	<0.001
General anesthesia (vs. other method)	1.22	0.01	0.96	0.33	1.35	<0.001
ASA class 3 (vs. 1 or 2)	1.75	0.01	1.40	<0.001	1.51	<0.001
ASA class 4 (vs. 1 or 2)	3.11	<0.001	2.21	<0.001	1.99	<0.001
Emergency Admission	1.14	0.14	1.01	0.82	1.09	0.18
Attending Surgeon (vs. resident)	0.97	0.73	0.91	0.09	1.01	0.80
Intraoperative Blood transfusions	1.07	0.06	1.08	0.01	1.18	<0.001
Early alive discharge (<2 days after surgery)	0.42	<0.001	0.88	0.17	0.58	<0.001
Operation 4 or more days from admission	1.33	<0.001	1.28	<0.001	1.12	0.04
CPT code 27125 (vs. 27130)	1.12	0.66	1.23	0.19	1.18	0.32
CPT code 27235 (vs. 27130)	0.89	0.68	1.08	0.64	0.82	0.29
CPT code 27236 (vs. 27130)	1.26	0.36	1.34	0.05	1.12	0.49
CPT code 27244 (vs. 27130)	1.12	0.65	1.16	0.32	1.02	0.91
CPT code 27245 (vs. 27130)	1.07	0.82	1.28	0.13	1.10	0.58
C-statistic	0.76		0.74		0.68
Number of Observations	11,798		11,798		11,724


*p-values are based on 95% confidence intervals for odds ratios. Standard errors were calculated using robust regression.

** “Severe” COPD and “Mild” COPD are defined in text but are not based on GOLD criteria. Bolded values highlight variables that are significant with a p-value <0.05.

1 Variable derived from the patient medical record (vs. VASQIP).