| Characteristic | Overall, N = 26,7611 | Subspecialty Training | p-value2 | |||
|---|---|---|---|---|---|---|
| Trauma, N = 5,4041 | Arthroplasty, N = 5,1311 | Both, N = 4181 | Other, N = 15,8081 | |||
| Indication | <0.001 | |||||
| Dispaced FNF | 1,784 (6.7%) | 444 (8.2%) | 353 (6.9%) | 40 (9.6%) | 947 (6.0%) | |
| Nondisplaced FNF | 240 (0.9%) | 47 (0.9%) | 32 (0.6%) | 2 (0.5%) | 159 (1.0%) | |
| FNF with unspecified displacement | 24,737 (92.4%) | 4,913 (90.9%) | 4,746 (92.5%) | 376 (90.0%) | 14,702 (93.0%) | |
| Age (years) | 80.4 +/- 10.8 | 80.0 +/- 11.2 | 79.9 +/- 10.9 | 78.4 +/- 12.0 | 80.8 +/- 10.6 | <0.001 |
| Sex | 0.123 | |||||
| Female | 18,669 (69.8%) | 3,744 (69.3%) | 3,539 (69.0%) | 279 (66.7%) | 11,107 (70.3%) | |
| Male | 8,092 (30.2%) | 1,660 (30.7%) | 1,592 (31.0%) | 139 (33.3%) | 4,701 (29.7%) | |
| Race | <0.001 | |||||
| White | 22,073 (82.5%) | 4,291 (79.4%) | 4,119 (80.3%) | 274 (65.6%) | 13,389 (84.7%) | |
| Black | 1,147 (4.3%) | 295 (5.5%) | 243 (4.7%) | 32 (7.7%) | 577 (3.7%) | |
| Hispanic | 1,128 (4.2%) | 291 (5.4%) | 259 (5.0%) | 54 (12.9%) | 524 (3.3%) | |
| Asian | 750 (2.8%) | 182 (3.4%) | 188 (3.7%) | 24 (5.7%) | 356 (2.3%) | |
| Native American | 52 (0.2%) | 9 (0.2%) | 9 (0.2%) | 2 (0.5%) | 32 (0.2%) | |
| Other or Unknown | 1,611 (6.0%) | 336 (6.2%) | 313 (6.1%) | 32 (7.7%) | 930 (5.9%) | |
| Elixhauser score | 7.5 +/- 7.9 | 7.5 +/- 8.2 | 7.4 +/- 7.9 | 6.7 +/- 7.8 | 7.6 +/- 7.7 | 0.066 |
| Insurance | <0.001 | |||||
| Private | 4,020 (15.0%) | 1,093 (20.2%) | 731 (14.2%) | 59 (14.1%) | 2,137 (13.5%) | |
| Medicare | 21,502 (80.3%) | 4,029 (74.6%) | 4,171 (81.3%) | 325 (77.8%) | 12,977 (82.1%) | |
| Medicaid | 706 (2.6%) | 161 (3.0%) | 139 (2.7%) | 21 (5.0%) | 385 (2.4%) | |
| Worker's Compensation | 246 (0.9%) | 54 (1.0%) | 50 (1.0%) | 3 (0.7%) | 139 (0.9%) | |
| Other | 287 (1.1%) | 67 (1.2%) | 40 (0.8%) | 10 (2.4%) | 170 (1.1%) | |
| Follow-up duration (years) | 0.7 +/- 0.8 | 0.7 +/- 0.8 | 0.6 +/- 0.8 | 0.7 +/- 0.8 | 0.7 +/- 0.9 | <0.001 |
| 1 n (%); Mean +/- SD | ||||||
| 2 Fisher’s Exact Test for Count Data with simulated p-value (based on 2000 replicates); One-way ANOVA; Pearson’s Chi-squared test | ||||||
Variations in hip fracture management based on surgeon specialty training
Methods
Summary of included patients
The Statewide Planning and Research Cooperative System (SPARCS) is a comprehensive reporting system that collects data related to inpatient hospitalizations, outpatient visits, ambulatory surgery encounters, and emergency department visits for hospitals, clinics, and nursing homes in New York State. Using ICD codes, The SPARCS database was queried for all patients presenting with a femoral neck fracture within New York State between 2010 and 2020. Initial data query yielded a total of 111,211 cases in 110,180 patients. Revision cases where the corresponding primary case was not found in the database (e.g., because the primary occurred prior to the study period or outside of New York state) were excluded (4,399 cases). Additional cases with illogical or inconsistent data, likely to be the result of medical coding errors, were removed as necessary (e.g., patients with greater than 2 primary THAs or greater than 1 primary THA of the same laterality). Patients who were not treated operatively (e.g., patients who expired prior to definitive treatment) were also excluded. This resulted in a total of 98,307 femoral neck fractures in 90,991 patients identified during the study period. Information related to the treating surgeon was not regularly reported as part of SPARCS until 2017, and for the purposes of this study, cases without data related to the surgeon were excluded. Additionally, patients under 45 years of age were excluded from this analysis.
In addition to demographic and baseline health status information, details regarding operative treatment, hospital length of stay, rate of complications, and rate of revision surgery were collected. The NPI for the treating surgeon was used to obtain information regarding subspecialty fellowship training. The main effect of the treating surgeon’s subspecialty on the type of operative treatment (i.e., fracture fixation versus hemiarthroplasty versus total hip arthroplasty) was evaluated using both a simple comparison and a multivariable logistic regression model to control for the effects of covariates.
Results
Demographics
Operative Treatment
| Characteristic | Subspecialty | p-value2 | |
|---|---|---|---|
| Trauma, N = 5,4041 | Arthroplasty, N = 5,1311 | ||
| Operative Treatment | <0.001 | ||
| Fixation | 2,707 (50.1%) | 1,714 (33.4%) | |
| Hemiarthroplasty | 2,091 (38.7%) | 2,047 (39.9%) | |
| THA | 606 (11.2%) | 1,370 (26.7%) | |
| 1 n (%) | |||
| 2 Pearson’s Chi-squared test | |||
When directly comparing trauma-trained surgeons and arthroplasty-trained surgeons, there was a significant difference in the overall operative treatment for patients with femoral neck fractures (χ^2 = 512.2, p = < 0.001). There was no significant difference between subspecialties in the proportion of patients treated with hemiarthroplasty (p = 0.494), which suggests that there is consistency between surgeons trained in trauma and surgeons trained in arthroplasty with respect to the optimal surgical treatment for lower functional demand patients.
Trauma surgeons treated a significantly greater proportion of their patients with operative fixation compared to arthroplasty surgeons (50.1% versus 33.4%, p = < 0.001). Likewise, arthroplasty surgeons treated a significantly greater proportion of their patients with THA compared to trauma surgeons (26.7% versus 11.2%, p = < 0.001).
However, there was little difference in baseline characteristics or perioperative outcomes between patients treated with either fixation or THA (i.e., excluding patients treated with hemiarthroplasty) between those treated by trauma surgeons and those treated by arthroplasty surgeons (Table). The mean difference in age was only 0.8 years (78.2 +/- 11.9 versus 77.4 +/- 11.4 years, p = 0.001), and there was no difference in sex, Elixhauser score, or the proportion of patients who required discharge to a skilled nursing facility. This suggests that these cohorts were similar in their underlying baseline health despite the significant difference in treatment.
| Characteristic | Subspecialty Training | p-value2 | |
|---|---|---|---|
| Trauma, N = 3,3131 | Arthroplasty, N = 3,0841 | ||
| Age (years) | 78.2 +/- 11.9 | 77.4 +/- 11.4 | 0.001 |
| Sex | 0.324 | ||
| Female | 2,347 (70.8%) | 2,150 (69.7%) | |
| Male | 966 (29.2%) | 934 (30.3%) | |
| Obesity | 208 (6.3%) | 230 (7.5%) | 0.062 |
| DM | 324 (9.8%) | 297 (9.6%) | 0.840 |
| Elixhauser Score | 6.5 +/- 7.9 | 6.2 +/- 7.5 | 0.209 |
| Discharge Disposition | <0.001 | ||
| Home | 896 (27.0%) | 946 (30.7%) | |
| Skilled Nursing Facility | 1,764 (53.2%) | 1,641 (53.2%) | |
| Inpatient Rehabilitation | 565 (17.1%) | 419 (13.6%) | |
| Transfer | 27 (0.8%) | 33 (1.1%) | |
| Against Medical Advice | 5 (0.2%) | 5 (0.2%) | |
| Discharged to Court | 2 (0.1%) | 0 (0.0%) | |
| Hospice | 21 (0.6%) | 14 (0.5%) | |
| Expired | 33 (1.0%) | 26 (0.8%) | |
| ED presentation within 3 months | 716 (21.6%) | 558 (18.1%) | <0.001 |
| Readmission within 3 months | 542 (16.4%) | 472 (15.3%) | 0.248 |
| Readmission within 12 months | 820 (24.8%) | 739 (24.0%) | 0.463 |
| Mortality within 3 months | 99 (3.0%) | 76 (2.5%) | 0.199 |
| Mortality within 12 months | 143 (4.3%) | 112 (3.6%) | 0.162 |
| 1 Mean +/- SD; n (%) | |||
| 2 Wilcoxon rank sum test; Pearson’s Chi-squared test; Fisher’s Exact Test for Count Data with simulated p-value (based on 2000 replicates) | |||
GLM for treatment
Based on multivariable logistic regression, undergoing treatment of a femoral neck fracture with an arthroplasty surgeon was associated with a significantly greater odds of receiving a THA (OR = 3.26, 95% CI [2.91, 3.65]). The effect of subspecialty training persisted when controlling for covariates including fracture displacement, age, sex, Elixhauser score, obesity, and insurance.
| Characteristic | OR1 | 95% CI1 | p-value |
|---|---|---|---|
| Subspecialty training | |||
| Trauma | — | — | |
| Arthroplasty | 3.26 | 2.91, 3.65 | <0.001 |
| Indication | |||
| FNF with unspecified displacement | — | — | |
| Dispaced FNF | 1.27 | 1.05, 1.53 | 0.012 |
| Nondisplaced FNF | 0.14 | 0.04, 0.34 | <0.001 |
| Age (years) | 0.94 | 0.93, 0.94 | <0.001 |
| Sex | |||
| Female | — | — | |
| Male | 1.03 | 0.91, 1.15 | 0.669 |
| Elixhauser score | 0.96 | 0.95, 0.97 | <0.001 |
| Obesity | |||
| No | — | — | |
| Yes | 0.85 | 0.69, 1.04 | 0.122 |
| Insurance | |||
| Private | — | — | |
| Medicare | 0.98 | 0.85, 1.13 | 0.798 |
| Medicaid | 0.56 | 0.41, 0.77 | <0.001 |
| Worker's Compensation | 0.66 | 0.42, 1.04 | 0.080 |
| Other | 1.49 | 0.91, 2.40 | 0.107 |
| 1 OR = Odds Ratio, CI = Confidence Interval | |||
