Elevated Distressed Community Index Score is Associated With Adverse Outcomes Following Hip Fracture Surgery in the Medicare Population.

Abstract

Despite advances in surgical care, disparities in functional recovery and mortality following hip fracture directly relate to racial, ethnic, and economic factors. Without a comprehensive method to model patients' diverse socioeconomic factors, researchers rely on proxies such as race and insurance status. The Distressed Community Index (DCI) score is a validated means of holistically estimating a patient's socioeconomic status, incorporating variables including community median income, unemployment, housing vacancies, education, business growth, and poverty rates. The 2012-2014 100% Medicare Standard Analytical Files was queried, identifying patients surgically treated for isolated hip fractures. Individual socio-economic status was determined by linking residential ZIP codes with the DCI score. The study cohort was divided into 5 distinct tiers based on the DCI score: [0-20] (prosperous), [21-40] (comfortable), [41-60] (mid-tier), [61-80] (at risk), and >80 (distressed). Multi-variate logistic regression analyses were used to assess the impact of increasing DCI score on 90-day complications, readmissions, and mortality. A total of 364 074 patients met inclusion criteria. Patients with lower DCI scores were more likely to receive care at teaching hospitals (13.1%) in urban settings (97.6%) than the Distressed tier (8.7% and 73.6%, respectively). The distressed group was at a significantly higher risk of urinary tract infections (OR 1.12; <i>P</i> < 0.001), pneumonia (OR 1.18; <i>P</i> < 0.001), and pressure ulcers (OR 1.09; <i>P</i> < 0.001). Patients in the distressed group were more likely to have emergency department visits (OR 1.12; <i>P</i> < 0.001) and had higher odds of mortality (OR 1.14; <i>P</i> < 0.001). With elevated DCI score there were lower rates of readmission (OR 0.91-0.95; <i>P</i> < 0.001) but this was not significant in the DCI >80 group. Patients living in ZIP codes with high DCI score had higher risks of post-operative complications, including death, after hip fracture surgery. Integration of the DCI score into clinical practice may help to mitigate adverse outcomes in this vulnerable patient population.