, Volume 471, Issue 3, pp 1047-1053
Date: 16 Jan 2013

Fee-based Care is Important for Access to Prompt Treatment of Hip Fractures Among Veterans

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Hip fracture is a medical emergency for which delayed treatment increases risk of disability and death. In emergencies, veterans without access to a Veterans Administration (VA) hospital may be admitted to non-VA hospitals under fee-based (NVA-FB) care paid by the VA. The affect of NVA-FB care for treatment and outcomes of hip fractures is unknown.


This research seeks to answer three questions: (1) What patient characteristics determine use of VA versus NVA-FB hospitals for hip fracture? (2) Does time between admission and surgery differ by hospital (VA versus NVA-FB)? (3) Does mortality differ by hospital?


Veterans admitted for hip fractures to VA (n = 9308) and NVA-FB (n = 1881) hospitals from 2003 to 2008 were identified. Primary outcomes were time to surgery and death. Logistic regression identified patient characteristics associated with NVA-FB hospital admissions; differences in time to surgery and death were evaluated using Cox proportional hazards regression, controlling for patient covariates.


Patients admitted to NVA-FB hospitals were more likely to be younger, have service-connected disabilities, and live more than 50 miles from a VA hospital. Median days to surgery were less for NVA-FB admissions compared with VA admissions (1 versus 3 days, respectively). NVA-FB admissions were associated with 21% lower relative risk of death within 1 year compared with VA hospital admissions.


For veterans with hip fractures, NVA-FB hospital admission was associated with shorter time to surgery and lower 1-year mortality. These findings suggest fee-based care, especially for veterans living greater distances from VA hospitals, may improve access to care and health outcomes.

Level of Evidence

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

The institution of one or more of the authors (KKR, MV-S, PC, PJK) has received, during the study period, funding from the U.S. Department of Veterans Affairs. This study was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, Veterans Rural Health Resource Center-Central Region, and the Health Services Research and Development Service, Department of Veterans Affairs, Comprehensive Access & Delivery Research and Evaluation (CADRE) Center at the Iowa City VAMC (REA 09-220). The authors do not have any conflicts of interest or financial relationships related to the content of this manuscript. The authors had full access to and take full responsibility for the integrity of the data. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
This work was performed at the Comprehensive Access & Delivery Research and Evaluation Center, Iowa City VA Healthcare System, Iowa City, IA, USA