Scientific Articles   |    
Ninety-Day Mortality After Intertrochanteric Hip Fracture: Does Provider Volume Matter?
Mary L. Forte, PhD, DC1; Beth A. Virnig, PhD, MPH2; Marc F. Swiontkowski, MD3; Mohit Bhandari, MD, MSc, FRCSC4; Roger Feldman, PhD2; Lynn E. Eberly, PhD2; Robert L. Kane, MD2
1 Departments of Orthopaedics and Epidemiology, University of Maryland, 22 South Greene Street, S11B, Baltimore, MD, 21202. E-mail address: mforte@umoa.umm.edu
2 Divisions of Health Policy and Management (B.A.V., R.L.K., and R.F.) and Biostatistics (L.E.E.), School of Public Health, University of Minnesota, MMC 197 (B.A.V., R.L.K., and R.F.) and MMC 303 (L.E.E.), 420 Delaware Street S.E., Minneapolis, MN 55455
3 Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Minneapolis, MN 55454
4 Division of Orthopedic Surgery, McMaster University, Hamilton General Hospital, 7 North, Suite 727, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Centers for Medicare and Medicaid Services (contract to ResDAC). In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (Medtronic and United Health Group).

A commentary by J. Lawrence Marsh, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at the University of Minnesota, Minneapolis, Minnesota

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Apr 01;92(4):799-806. doi: 10.2106/JBJS.H.01204
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Research on the relationship between orthopaedic volume and outcomes has focused almost exclusively on elective arthroplasty procedures. Geriatric patients who have sustained an intertrochanteric hip fracture are older and have a heavier comorbidity burden in comparison with patients undergoing elective arthroplasty; therefore, any advantage of provider volume in terms of mortality could be overwhelmed by the severity of the hip fracture condition itself. This study examined the association between surgeon and hospital volumes of procedures performed for the treatment of intertrochanteric hip fractures in Medicare beneficiaries and inpatient through ninety-day postoperative mortality.


The Medicare 100% files of hospital and physician claims plus the beneficiary enrollment files for 2000 through 2002 identified beneficiaries who were sixty-five years of age or older and who underwent inpatient surgery for the treatment of an intertrochanteric hip fracture with internal fixation. Provider volumes of intertrochanteric hip fracture cases were calculated with use of unique surgeon and hospital provider numbers in the claims. Fixed effects regression analysis using generalized estimating equations was used to model the association between hospital and surgeon intertrochanteric hip fracture volume and inpatient through ninety-day mortality, controlling for age, sex, race, Charlson comorbidity score, subtrochanteric fracture, prefracture nursing home residence, Medicaid-administered assistance, surgical device, and year. The unadjusted inpatient, thirty, sixty, and ninety-day mortality rates and adjusted relative risks are reported.


Between March 1, 2000, and December 31, 2002, 192,365 claims met inclusion criteria and matched with provider information. The unadjusted inpatient, thirty-day, sixty-day, and ninety-day mortality rates were 2.91%, 7.92%, 12.34%, and 15.19%, respectively. Patients managed at lower-volume hospitals had significantly higher (10% to 20%) adjusted risks of inpatient mortality than those managed at the highest-volume hospitals. By sixty days postoperatively, the increased mortality risk persisted only among patients managed at the lowest-volume hospitals (six cases per year or fewer). Patients who were managed by surgeons who treated an average of two or three cases per year had the highest mortality risks when compared with patients managed by the highest-volume surgeons.


Only the highest-volume hospitals showed an inpatient mortality benefit for Medicare patients with intertrochanteric hip fractures. Unlike the situation with elective arthroplasty procedures, our findings do not indicate a need to direct patients with routine hip fractures exclusively to high-volume centers, although the higher mortality rates found in the lowest-volume hospitals warrant further investigation.

Level of Evidence: 

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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