Highlights
- •The aim of this study was to examine the correlation between patient rurality, socioeconomic status, and outcomes after orthopedic trauma.
- •A nationally representative sample, representing over 1 million patients, was used to build population-weighted logistic regression models.
- •Rural patients with hip fracture were 32% more likely to die than urban patients with hip fracture (P < 0.001).
- •Patients with low income were 23% more likely to die than patients with high income (p = 0.002) in the urban polytrauma group.
- •Objective measures of disparity-sensitive healthcare are needed to ensure optimal care for all orthopedic trauma patients.
Abstract
Introduction
Healthcare disparities linked to patient rurality and socioeconomic status are known
to exist, but few studies have examined the effect of urban versus rural status on
outcomes after orthopedic trauma surgery. The aim of this study was to examine the
correlation between patient rurality, socioeconomic status, and outcomes after orthopedic
trauma.
Materials and methods
This is a retrospective cohort study of patients diagnosed with a hip or long bone
fracture between January 2016 and December 2017. Data were collected from the Nationwide
Inpatient Sample (NIS), a 20% weighted sample of 95% of the U.S. inpatient population.
Patients were stratified into 3 groups: isolated hip fracture, isolated long bone
fracture, and polytrauma. Bivariate analysis was completed using chi-squared tests
for categorical variables and t-tests for continuous variables. Multivariable analysis
was completed using population-weighted logistic regression models, based on a conceptual
model derived selection of covariates.
Results
We included 235,393 patients diagnosed with a hip or extremity fracture. These were
weighted to represent 1,176,965 patients nationally. In the hip fracture group, rural
patient status was associated with higher odds of mortality (OR 1.32, P < 0.001) but not complications (OR 0.95, P = 0.082). In the extremity fracture and polytrauma groups, rural patient status was
not associated with significantly higher odds of mortality or complications. In the
urban polytrauma group, zip code with below-median income was associated with increased
odds of mortality (OR 1.23, P = 0.002) but not complications. In the rural polytrauma group, zip code with below-median
income was not associated with significantly increased odds of mortality or complications.
In the hip fracture and extremity fracture groups, below-median income was not associated
with significantly higher odds of mortality.
Conclusion
We found that rural patients with hip fracture have higher mortality compared to urban
patients and that socioeconomic disparities in mortality after a polytrauma exist
in urban settings. These results speak to the ongoing need to develop objective measures
of disparity-sensitive healthcare and optimize trauma systems to better serve low-income
patients and patients in rural areas.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to InjuryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The national burden of orthopedic injury: cross-sectional estimates for trauma system planning and optimization.J Surg Res. 2020; 249: 197-204
- Current concepts in orthopaedic care disparities.J Am Acad Orthop Surg. 2018; 26: 823-832
- Rurality as a root or fundamental social determinant of health.Dis Mon. 2012; 58: 620-628
- Physicians and rural America.West J Med. 2000; 173: 348-351
- Longitudinal urban-rural discrepancies in the US orthopaedic surgeon workforce.Clin Orthop Relat Res. 2013; 471: 3074-3081
- Association of hospital critical access status with surgical outcomes and expenditures among medicare beneficiaries.JAMA. 2016; 315: 2095-2103
- Differences in rural and urban outcomes: a national inspection of emergency general surgery patients.J Surg Res. 2017; 218: 277-284
- The impact of income on emergency general surgery outcomes in urban and rural areas.J Surg Res. 2020; 245: 629-635
- Concentration and quality of hospitals that care for elderly black patients.Arch Intern Med. 2007; 167: 1177-1182
- The characteristics and performance of hospitals that care for elderly Hispanic Americans.Health Aff (Millwood). 2008; 27: 528-537
- Thirty-day readmission rates for Medicare beneficiaries by race and site of care.JAMA. 2011; 305: 675-681
- Quality of care in hospitals with a high percent of Medicaid patients.Med Care. 2007; 45: 579-583
- Minority trauma patients tend to cluster at trauma centers with worse-than-expected mortality: can this phenomenon help explain racial disparities in trauma outcomes?.Ann Surg. 2013; 258 (discussion 9-81): 572-579
- Association between hospitals caring for a disproportionately high percentage of minority trauma patients and increased mortality: a nationwide analysis of 434 hospitals.Arch Surg. 2012; 147: 63-70
HCUP NIS Description of Data Elements. Healthcare Cost and Utilization Project (HCUP): Agency for Healthcare Research and Quality, Rockville, MD; 2008.
Clark D.E., Osler T.M., Hahn D.R. ICDPIC: stata module to provide methods for translating International Classification of Diseases (Ninth Revision) diagnosis codes into standard injury categories and/or scores. 2009.
- Open-access programs for injury categorization using ICD-9 or ICD-10.Inj Epidemiol. 2018; 511
- An overview of the injury severity score and the new injury severity score.Inj Prev. 2001; 7: 10-13
- Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.Med Care. 2005; 43: 1130-1139
- Delirium as a predictor of mortality in US Medicare beneficiaries discharged from the emergency department: a national claims-level analysis up to 12 months.BMJ Open. 2018; 8e021258
- Prevalence of pulmonary embolism in patients with syncope.JAMA Intern Med. 2018; 178: 356-362
- Predicting occurrence of spine surgery complications using "big data" modeling of an administrative claims database.J Bone Joint Surg Am. 2016; 98: 824-834
- In-hospital outcomes after hemiarthroplasty versus total hip arthroplasty for isolated femoral neck fractures.Arch Bone Jt Surg. 2014; 2: 151-156
- Medicare claims can be used to identify US hospitals with higher rates of surgical site infection following vascular surgery.Med Care. 2014; 52: 918-925
- ICD-10 coding algorithms for defining comorbidities of acute myocardial infarction.BMC Health Serv Res. 2006; 6161
- Sepsis among medicare beneficiaries: 1. The burdens of sepsis, 2012-2018.Crit Care Med. 2020; 48: 276-288
- Trends, predictors, and outcomes of cardiovascular complications associated with polycystic ovary syndrome during delivery hospitalizations: a national inpatient sample analysis (2002-2019).J Am Heart Assoc. 2022; 11 (e025839-e)
- Mortality rates are similar after hip fractures for rural and urban patients.Clin Orthop Relat Res. 2012; 470: 1763-1770
- The effect of hospital type and surgical delay on mortality after surgery for hip fracture.J Bone Joint Surg Br. 2005; 87: 361-366
- Frailty and survival of rural and urban seniors: results from the Canadian Study of Health and Aging.Aging Clin Exp Res. 2007; 19: 145-153
- Frailty and survival of older Chinese adults in urban and rural areas: results from the Beijing Longitudinal Study of Aging.Arch Gerontol Geriatr. 2012; 54: 3-8
- The orthogeriatric comanagement improves clinical outcomes of hip fracture in older adults.Osteoporos Int. 2019; 30: 907-916
- The diverse implementation of geriatrics-orthopedics comanagement programs in the United States.J Am Geriatr Soc. 2020; 68: 1714-1719
- Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system.Am J Med. 2000; 108: 621-626
- Hip fracture outcomes: does surgeon or hospital volume really matter?.J Trauma. 2009; 66: 809-814
- Ninety-day mortality after intertrochanteric hip fracture: does provider volume matter?.J Bone Joint Surg Am. 2010; 92: 799-806
- Utilization and outcomes of inpatient surgical care at critical access hospitals in the United States.JAMA Surg. 2013; 148: 589-596
- National estimates of predictors of outcomes for emergency general surgery.J Trauma Acute Care Surg. 2015; 78 (discussion 90-1): 482-490
- Racial/ethnic disparities in emergency general surgery: explained by hospital-level characteristics?.Am J Surg. 2015; 209: 604-609
- The impact of race on outcomes following emergency surgery: an American College of Surgeons National Surgical Quality Improvement Program assessment.Am J Surg. 2013; 206: 172-179
- Defining rates and risk factors for readmissions following emergency general surgery.JAMA Surg. 2016; 151: 330-336
- The impact of delayed management of fall-related hip fracture management on health outcomes for African American older adults.J Trauma Acute Care Surg. 2021; 90: 942-950
- Race and surgical mortality in the United States.Ann Surg. 2006; 243: 281-286
- A regional assessment of medicaid access to outpatient orthopaedic care: the influence of population density and proximity to academic medical centers on patient access.J Bone Joint Surg Am. 2014; 96e156
- Disparities in access to musculoskeletal care: narrowing the gap: AOA critical issues symposium.J Bone Joint Surg Am. 2019; 101e121
- Advancing health equity by integrating intersectionality into epidemiological research: applications and challenges.J Epidemiol Community Health. 2020; 74: 761-762
- Socioeconomic status and injury mortality: individual and neighbourhood determinants.J Epidemiol Community Health. 2000; 54: 517-524
Article info
Publication history
Published online: November 08, 2022
Accepted:
November 7,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
