Socioeconomic and Demographic Disparities Among Patients with Femoral Neck Fractures
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. Information related to the Center of Excellence designation and Magnet designation of each treating hospital was collected.
Demographic information including age, sex, race, and insurance provider was collected from the SPARCS database on an individual patient level. SPARCS does not provide patient-level data regarding income, education, or other socioeconomic factors. Therefore, the patient’s home zip code was used to approximate socioeconomic status using area-level social determinants of health including Social Deprivation Index (SDI, a validated composite measure of area level deprivation), standardized percent living in poverty, and standardized percent with less than 12 years of education.
Results
A total of 91,804 femoral neck fractures in 88,409 patients were identified during the study period and included in the subsequent analysis.
Demographics
Centers of Excellence Designation
Overall, 83% of femoral neck fractures were treated at hospitals with Center of Excellence designation. A significantly greater proportion of patients in both SDI quintile 1 (least deprived) and SDI quintile 5 (most deprived) were treated at COE hospitals, while a greater proportion of patients in the middle 3 quintiles were treated at non-COE hospitals (p < 0.001). Patients in the first poverty quintile (lowest poverty levels) were more likely to be treated at a COE hospital, while patients in the fifth poverty quintile (highest poverty levels) were more likely to be treated at a non-COE hospital (p < 0.001). Similarly, patients in the first education quintile (lowest percentage with less than 12 years of education) were more likely to be treated at a COE hospital, while patients in the fifth education quintile (highest percentage with less than 12 years of education) were more likely to be treated at a non-COE hospital (p < 0.001).
| Characteristic | Overall, N = 91,8041 | Center of Excellence | p-value2 | |
|---|---|---|---|---|
| No, N = 15,5781 | Yes, N = 76,2261 | |||
| Social Deprivation Index | <0.001 | |||
| Quintile 1 (least deprived) | 19,129 (20.9%) | 2,442 (15.7%) | 16,687 (21.9%) | |
| Quintile 2 | 18,341 (20.0%) | 3,860 (24.8%) | 14,481 (19.0%) | |
| Quintile 3 | 18,057 (19.7%) | 3,423 (22.0%) | 14,634 (19.2%) | |
| Quintile 4 | 18,428 (20.1%) | 3,569 (22.9%) | 14,859 (19.5%) | |
| Quintile 5 (most deprived) | 17,703 (19.3%) | 2,270 (14.6%) | 15,433 (20.3%) | |
| Poverty score | <0.001 | |||
| Quintile 1 (least poverty) | 19,605 (21.4%) | 1,814 (11.7%) | 17,791 (23.4%) | |
| Quintile 2 | 18,067 (19.7%) | 3,588 (23.1%) | 14,479 (19.0%) | |
| Quintile 3 | 17,530 (19.1%) | 2,906 (18.7%) | 14,624 (19.2%) | |
| Quintile 4 | 19,010 (20.7%) | 4,023 (25.8%) | 14,987 (19.7%) | |
| Quintile 5 (most poverty) | 17,446 (19.0%) | 3,233 (20.8%) | 14,213 (18.7%) | |
| Education score | <0.001 | |||
| Quintile 1 (lowest % with < 12 years education) | 18,461 (20.1%) | 2,463 (15.8%) | 15,998 (21.0%) | |
| Quintile 2 | 18,598 (20.3%) | 3,551 (22.8%) | 15,047 (19.8%) | |
| Quintile 3 | 18,184 (19.8%) | 3,893 (25.0%) | 14,291 (18.8%) | |
| Quintile 4 | 18,083 (19.7%) | 3,810 (24.5%) | 14,273 (18.8%) | |
| Quintile 5 (highest % with < 12 years education) | 18,332 (20.0%) | 1,847 (11.9%) | 16,485 (21.7%) | |
| Age (years) | 79.5 +/- 13.1 | 79.4 +/- 12.9 | 79.5 +/- 13.1 | 0.208 |
| Sex | 0.124 | |||
| Female | 64,290 (70.0%) | 10,829 (69.5%) | 53,461 (70.1%) | |
| Male | 27,514 (30.0%) | 4,749 (30.5%) | 22,765 (29.9%) | |
| Race | <0.001 | |||
| White | 75,488 (82.2%) | 14,514 (93.2%) | 60,974 (80.0%) | |
| Black | 4,213 (4.6%) | 344 (2.2%) | 3,869 (5.1%) | |
| Hispanic | 4,376 (4.8%) | 249 (1.6%) | 4,127 (5.4%) | |
| Asian | 2,269 (2.5%) | 56 (0.4%) | 2,213 (2.9%) | |
| Native American | 169 (0.2%) | 42 (0.3%) | 127 (0.2%) | |
| Other or Unknown | 5,289 (5.8%) | 373 (2.4%) | 4,916 (6.4%) | |
| Elixhauser score | 6.9 +/- 7.4 | 7.0 +/- 7.4 | 6.8 +/- 7.4 | 0.001 |
| Insurance | <0.001 | |||
| Private | 15,569 (17.0%) | 2,195 (14.1%) | 13,374 (17.5%) | |
| Medicare | 71,911 (78.3%) | 12,638 (81.1%) | 59,273 (77.8%) | |
| Medicaid | 2,329 (2.5%) | 309 (2.0%) | 2,020 (2.7%) | |
| Worker's Compensation | 1,010 (1.1%) | 217 (1.4%) | 793 (1.0%) | |
| Other | 984 (1.1%) | 219 (1.4%) | 765 (1.0%) | |
| 1 n (%); Mean +/- SD | ||||
| 2 Pearson’s Chi-squared test; Welch Two Sample t-test | ||||
Magnet Designation
Overall, 35.6% of femoral neck fractures were treated at hospitals with Magnet designation. Compared to Centers of Excellence, there was a greater level of demographic and socioeconomic disparity between patients treated at Magnet designation hospitals and non-Magnet designation hospitals. Patients in the first quintiles for SDI, poverty, and education were more likely to be treated at Magnet hospitals, while those associated with the greatest social deprivation, worst poverty, and lowest education were more likely to be treated at non-Magnet hospitals (p < 0.001 for all comparisons). Furthermore, White patients and patients with private insurance were more likely to be treated at Magnet hospitals, while Black and Hispanic patients and patients with Medicaid were more likely to be treated at non-Magnet hospitals (p < 0.001 for all comparisons).
| Characteristic | Overall, N = 91,8041 | Magnet Designation | p-value2 | |
|---|---|---|---|---|
| No, N = 59,1311 | Yes, N = 32,6731 | |||
| Social Deprivation Index | <0.001 | |||
| Quintile 1 (least deprived) | 19,129 (20.9%) | 10,202 (17.3%) | 8,927 (27.4%) | |
| Quintile 2 | 18,341 (20.0%) | 10,410 (17.6%) | 7,931 (24.3%) | |
| Quintile 3 | 18,057 (19.7%) | 11,542 (19.5%) | 6,515 (20.0%) | |
| Quintile 4 | 18,428 (20.1%) | 13,572 (23.0%) | 4,856 (14.9%) | |
| Quintile 5 (most deprived) | 17,703 (19.3%) | 13,326 (22.6%) | 4,377 (13.4%) | |
| Poverty score | <0.001 | |||
| Quintile 1 (least poverty) | 19,605 (21.4%) | 10,683 (18.1%) | 8,922 (27.4%) | |
| Quintile 2 | 18,067 (19.7%) | 9,351 (15.8%) | 8,716 (26.7%) | |
| Quintile 3 | 17,530 (19.1%) | 11,678 (19.8%) | 5,852 (17.9%) | |
| Quintile 4 | 19,010 (20.7%) | 14,235 (24.1%) | 4,775 (14.6%) | |
| Quintile 5 (most poverty) | 17,446 (19.0%) | 13,105 (22.2%) | 4,341 (13.3%) | |
| Education score | <0.001 | |||
| Quintile 1 (lowest % with < 12 years education) | 18,461 (20.1%) | 9,176 (15.5%) | 9,285 (28.5%) | |
| Quintile 2 | 18,598 (20.3%) | 10,931 (18.5%) | 7,667 (23.5%) | |
| Quintile 3 | 18,184 (19.8%) | 12,257 (20.8%) | 5,927 (18.2%) | |
| Quintile 4 | 18,083 (19.7%) | 13,374 (22.6%) | 4,709 (14.4%) | |
| Quintile 5 (highest % with < 12 years education) | 18,332 (20.0%) | 13,314 (22.5%) | 5,018 (15.4%) | |
| Age (years) | 79.5 +/- 13.1 | 79.4 +/- 13.0 | 79.7 +/- 13.2 | 0.001 |
| Sex | 0.039 | |||
| Female | 64,290 (70.0%) | 41,272 (69.8%) | 23,018 (70.4%) | |
| Male | 27,514 (30.0%) | 17,859 (30.2%) | 9,655 (29.6%) | |
| Race | <0.001 | |||
| White | 75,488 (82.2%) | 48,325 (81.7%) | 27,163 (83.1%) | |
| Black | 4,213 (4.6%) | 3,094 (5.2%) | 1,119 (3.4%) | |
| Hispanic | 4,376 (4.8%) | 3,142 (5.3%) | 1,234 (3.8%) | |
| Asian | 2,269 (2.5%) | 1,588 (2.7%) | 681 (2.1%) | |
| Native American | 169 (0.2%) | 119 (0.2%) | 50 (0.2%) | |
| Other or Unknown | 5,289 (5.8%) | 2,863 (4.8%) | 2,426 (7.4%) | |
| Elixhauser score | 6.9 +/- 7.4 | 6.7 +/- 7.3 | 7.1 +/- 7.7 | <0.001 |
| Insurance | <0.001 | |||
| Private | 15,569 (17.0%) | 9,327 (15.8%) | 6,242 (19.1%) | |
| Medicare | 71,911 (78.3%) | 46,664 (78.9%) | 25,247 (77.3%) | |
| Medicaid | 2,329 (2.5%) | 1,759 (3.0%) | 570 (1.7%) | |
| Worker's Compensation | 1,010 (1.1%) | 658 (1.1%) | 352 (1.1%) | |
| Other | 984 (1.1%) | 722 (1.2%) | 262 (0.8%) | |
| 1 n (%); Mean +/- SD | ||||
| 2 Pearson’s Chi-squared test; Welch Two Sample t-test | ||||
