Regional variation of care dependency after hip fracture in Germany: A retrospective cohort study using health insurance claims data

OBJECTIVE: To investigate variation of care dependency after hip fracture across German regions based on the assessment by the German statutory long-term care insurance.

DATA SOURCES/STUDY SETTING: Patient-level statutory health and long-term care insurance claims data from 2009-2011 and official statistical data from Germany.

STUDY DESIGN: We performed a retrospective cohort study. Investigated multinomial outcome categories were increase in care dependency (new onset or a higher care dependency than pre-fracture), no change as reference and death as competing risk in the quarterly period following hip fracture (follow-up 3 months). Regional variation was operationalized with the variance of regional-level random intercepts based on generalized linear mixed models. We adjusted for patient and regional characteristics.

PRINCIPAL FINDINGS: The study included 122,887 hip fracture patients in 95 German postal code regions. Crude outcomes were 30.87% increase in care dependency and 14.35% death. Results indicated modest variation on regional level. Male sex, increasing age, increasing comorbidity, pertrochanteric and subtrochanteric fracture site compared to femoral neck, time from hospital admission to surgery of 3 or more days, as well as increasing inpatient length of stay, non-participation in rehabilitation and regions with lower hospital density were positively associated with an increase in care dependency.

CONCLUSIONS: Several characteristics on patient and regional level associated with the outcome were identified. Variation in the increase in care dependency after hip fracture appeared to be attributable primarily to patient characteristics. Variation on regional level was only modest.