During his medical and public health studies at the University of Miami, Christopher J. Dy, MD, MPH, became interested in learning about how disparities in health care and access to care can impact population groups. This drew him to the field of health services research, an area of study he began pursuing while an orthopaedic surgery resident at the Hospital for Special Surgery in New York City.

“As a surgeon, you are essentially confined to one patient at a time when you’re in the operating room,” said Dr. Dy. “But as a health services researcher, I can try to impact an entire system of care. And, as we push forward with healthcare reform, it is imperative to decrease variations both in the delivery and the cost of care, thereby optimizing patient outcomes.”

Now a surgeon at Washington University School of Medicine in St. Louis, Dr. Dy is continuing his investigations into how the healthcare system impacts the treatment of hip fractures.

“Hip fractures are the biggest public health issue we’ll see as orthopaedic surgeons,” Dr. Dy explained. “There is tremendous variation in the care patients receive. Hip fracture surgeries have a mortality rate of 20 percent after 1 year and significantly increased disability for those who survive. Total costs exceeded $12 billion in 2005 and are projected to grow 49 percent by 2025.”

Previous epidemiologic studies of hip fractures have addressed only a single aspect of healthcare supply, such as surgeon training or case volume, in isolation. This makes it difficult to turn findings into strategies for improvement, especially when many other factors that impact the delivery of care need to be considered.

With funding from a 2013 Orthopaedic Research and Education Foundation (OREF) Young Investigator Award (now the New Investigator Award), Dr. Dy designed a rigorous study to simultaneously evaluate the influence of multiple aspects of healthcare supply on the delivery of care for hip fractures.

Under the mentorship of Stephen Lyman, PhD, Dr. Dy and his research team began analyzing a large database of hip fracture patients in the state of New York over a 13-year period. Their initial findings, which demonstrated race- and insurance-based disparities in delivery of care and complications, were published in The Journal of Bone and Joint Surgery in 2016.

The team is currently researching the influence of healthcare resource availability on the delivery and safety of care for patients within communities throughout the state. This arm of the study has the following two goals:

Measure the influence of healthcare supply on the efficiency of hip fracture care delivery—ie, availability of hospital resources and surgeons, and on-time admission and procedures, a key indicator for survival after hip fracture.
Determine the influence of healthcare supply on complications after hip fracture surgery—ie, the frequency of short-term complications, readmission, and reoperation after hip fracture surgery.

“Hopefully, this work will directly inform administrative and policy changes in healthcare resource allocation to address any disparities that are identified,” said Dr. Dy.

Healthcare disparity
Dr. Dy collected data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) on all discharges from nonfederal acute-care hospitals in New York State. Using International Classification of Diseases, Ninth Revision, and Clinical Modification (ICD-9-CM) codes, Dr. Dy and his team identified records for 197,290 residents in the state who underwent surgery for a hip fracture between 1998 and 2010. The researchers used multivariable regression models to evaluate the association of patient characteristics, social deprivation, and hospital/surgeon volume with time from admission to surgery, in-hospital complications, readmission, and 1-year mortality.

“We expected to find that multiple characteristics of healthcare supply would influence the frequency of adverse events after hip fracture surgery,” said Dr. Dy. “We also anticipated that socioeconomic characteristics within a community, such as pervasiveness of poverty and lower education, would influence the frequency of adverse events.”

Data indicated racial and socioeconomic disparities exist for treatment access and outcomes.
“After adjusting for patient and surgery characteristics, hospital/surgeon volume, social deprivation, and other variables,” reported Dr. Dy, “subgroup analyses showed a greater risk for delayed surgery for black and Asian patients compared with white patients, regardless of social deprivation. There was also a greater risk for readmission for black patients compared with white patients, regardless of social deprivation. And, compared with Medicare patients, Medicaid patients were at increased risk for delayed surgery, whereas privately insured patients were at decreased risk for delayed surgery complications.”

These racial and socioeconomic disparities in the treatment of hip fractures have the potential to substantially affect both hospitals and healthcare providers in an era of value-based payment.

“In addition to identifying and resolving the causes for these disparities in hip fracture care, we need to develop targeted interventions to mitigate the effects of these disparities on patients at greatest risk,” said Dr. Dy. “This could include supply-based strategies for improving care delivery for hip fractures, such as re-routing ambulances carrying patients with hip fractures to higher-volume hospitals or to specifically trained surgeons, or coordinating surgeon on-call schedules across facilities to ensure that surgeons experienced with hip fractures are on-call at peak times or locations.

“I think it’s essential that we as an orthopaedic surgery community embrace the fact that we’re going to need to steer our path going forward for healthcare reform,” Dr. Dy continued. “I’d like to improve the system of care so we can continue to provide reliable and effective outcomes for our entire patient population.”

OREF boosts credibility
Dr. Dy said that the OREF grant has helped him in many ways.

“Funding from an organization like OREF gives us credibility among our peers,” he said. “It shows that the orthopaedic community supports our research and understands its importance. My mentors have told me seeking research funding through a mechanism like OREF is essential to getting further funding. Recognition by our specialty shows that our research is valued, and makes us competitive with other specialties when applying for funding from the National Institutes of Health and other large funding mechanisms.”

Mark Crawford is a contributing writer for OREF. He can be reached at communications@oref.org

© Orthopaedic Research and Education Foundation (OREF)