title: Fee-based care is important for access to prompt treatment of hip fractures among veterans.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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?
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
authors: Comprehensive Access & Delivery Research and Evaluation Center, Iowa City VA Healthcare System, Mailstop 152, 601 Highway West, Iowa City, IA 52246, USA.
authors: Kelly K
authors: KK
authors: Richardson
authors: Peter
authors: P
authors: Cram
authors: Mary
authors: M
authors: Vaughan-Sarrazin
authors: Peter J
authors: PJ
authors: Kaboli
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D004630:Emergencies; D004636:Emergency Service, Hospital / Q000191:economics; D018588:Fee-for-Service Plans / Q000191:economics*; D005260:Female; D005592:Fracture Fixation / Q000191:economics*; D017048:Health Care Costs; D006297:Health Services Accessibility / Q000191:economics*; D006620:Hip Fractures / Q000191:economics* / Q000401:mortality / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010343:Patient Admission / Q000191:economics; D016016:Proportional Hazards Models; D012111:Residence Characteristics; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment / Q000191:economics; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs / Q000191:economics*; D014728:Veterans