With hip and knee surgeries growing across the country, measuring quality of care — especially survival — is increasingly important.

But among three hospitals in California with the worst rates of inpatient hip fracture mortality in 2014, two are in San Diego County: Scripps Memorial in La Jolla and Kaiser Permanente San Diego Medical Center, according to data from the Office of Statewide Health Planning and Development. The third is Santa Barbara Cottage Hospital.



The hip fracture death scores, available online, reflect care provided to the 2,566 patients in San Diego County who broke their hips in 2014, usually after a fall, most of whom  were brought to an emergency room or trauma center. Hip fracture patients are generally older, and have severe osteoporosis or bone loss.

The measure reveals the percentage of patients who did not leave the hospital alive and uses a formula that adjusts for patient severity to fairly account for hospitals that took care of patients who were sicker to begin with, and more likely to not survive.

“We leveled the playing field with all of these hospitals as best we can with the risk models,” said Merry Holliday-Hanson, manager of the state health planning department’s administrative data.

The volume of hip fracture patients was high for both hospitals: 359 for Kaiser — which took in the most hip fracture patients of any hospital in the state — and 186 for Scripps Memorial.

All other hospitals in the county had “average” death rates for hip fracture patients except Palomar Hospital in downtown Escondido, which had an above average rating. Palomar subsequently clarified that all hip fracture surgeries performed under Palomar’s license in 2014 were performed at the new Palomar Medical Center. Palomar is in the process of closing its downtown campus.

CalHospitalCompare also scores hospitals for patients who underwent elective hip or knee surgery for rates of readmissions and complications. Data for these measures are derived from the Centers for Medicare & Medicaid Services, which paid claims for surgical procedures performed on people who are 65 or older, blind or disabled.

Two key factors influence lower rates of inpatient death in hip fracture patients, said orthopedic surgeon Dr. Kevin Bozic, co-founder of the California Joint Replacement Registry who now chairs the department of surgery and perioperative care at Dell Medical School in Austin, Texas.

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One, he said, is better patient management by a team that includes geriatricians, internists, nutritionists, orthopedic surgeons and pain management specialists who work well together and quickly when a hip fracture patient arrives. That’s because hip fracture most often occurs when patients have osteoporosis and are often not ready for surgery.

“You need a team of people who are ready to go to manage their co-morbidities (other serious illnesses) and get them through surgery and recovery,” he said. Having a geriatrician, he emphasized, “is very, very important for this population.”

The second factor is speed.

“There’s pretty good evidence that patients with hip fracture who go to surgery within 24 to 48 hours of their arrival have lower mortality than patients who go to the operating room beyond that,” Bozic said.

Dr. Scott Ball, orthopedic surgeon at UCSD, which was reported as having no in-hospital deaths among its hip fracture patients, agreed with Bozic’s points on the necessity for a multidisciplinary team and rapid surgery as essentials for lower mortality.

A surgical team including Dr. Nikita Bezrukov, left, and Dr. Ian Foran, right, performs a hip procedure on a patient at UCSD’s Thornton Hospital on Feb. 3, 2017. UCSD was reported as having no in-hospital deaths among its hip fracture patients. Photo courtesy Dr. Scott Ball

Ball added the importance of bringing cardiologists onto the team “to make sure the patient’s heart is healthy enough to undergo surgery,” as well as the “critical need” for appropriate use of anesthesia, good case management, and physical therapists who get patients moving rather than just letting them lie in bed, which puts them at risk for pneumonia, bed sores and blood clots.

It’s important to make sure patients with osteoporosis, who are at high risk for falling again, take appropriate medications “so you hopefully minimize the risk they ever have to go through this again.”

In response to the high hip fracture mortality data, Scripps officials deferred to a comment letter the hospital system sent to the state. It argued that a lot of patients who arrived for care after a hip fracture had endured a “serious traumatic fall.”

“Although supported by maximum appropriate surgical and medical therapies, many of these patients or their families had chosen palliative or comfort care prior to their deaths, which was honored by our facility,” the letter stated.

Kaiser officials said in an email that its hospital “has identified opportunities and taken measures to improve these outcomes, which have resulted in significant improvement in this area beginning in 2015. We expect the improvement to be reflected in future data released by OSHPD and CalHospitalCompare.”

Asked why Kaiser’s San Diego hospital receives more hip fracture patients than any other hospital in the state, a Kaiser spokeswoman said the region’s 600,000 enrollees make it the largest Kaiser system in California. Of those 600,000, about 90,000 are Medicare beneficiaries, which means they are 65 or older or blind or disabled.

More than 25,000 Californians endure a hip fracture every year and are rushed to hospitals for emergency care. Knowing which hospitals perform better at making sure they leave the hospital alive is a goal for all orthopedic surgery teams, Bozic said.

Cheryl Clark is a contributing healthcare reporter at inewsource. To contact her with questions, tips or corrections, email clarkcheryl@inewsource.org.