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BACKGROUND: Large regional hospitals achieve good outcomes for patients with complex conditions. However, recent studies have suggested that some patient groups might not benefit from treatment in higher-level trauma centers. OBJECTIVE: To test the hypothesis that older adults with isolated hip fractures experience delayed surgical treatment and worse clinical outcomes when treated in higher-level trauma centers. RESEARCH DESIGN: Retrospective cohort study using a statewide longitudinal database that captured 98% of inpatients within California (2007-2011). SUBJECTS: All older adults (aged 65 y and above) admitted with an isolated hip fracture who did not require interhospital transfer. MEASURES: Days to operation, length of stay, inhospital mortality, 30-day risk of unplanned readmission, 30-day venous thromboembolism, decubitus ulcers, and pneumonia. RESULTS: There were 91,401 patients, 6.1% of whom were treated in a level 1 trauma center (L1TC), 17.7% in a level 2 trauma center (L2TC), and 70.2% in a nontrauma center (NTC). Within multivariable logistic and generalized linear regression models, patients treated in L1TCs underwent surgery later (predicted mean difference: 0.30 d; 95% CI, 0.08-0.53), had prolonged inpatient stays (0.99 d, 0.40-1.59), and had higher odds of both 30-day readmission (aOR=1.62; 95% CI, 1.35-1.93) and venous thromboembolism (aOR=1.32, 1.01-1.74) relative to NTCs. There were no differences in mortality, decubitus ulcers, or pneumonias. L2TCs were not different from NTCs across any of the measured outcomes. CONCLUSIONS: Older adults with hip fractures may be disadvantaged in L1TCs. Further research should aim to develop our understanding of this disparity to ensure that all patient groups benefit from the resources and expertise available within these hospitals.

Original publication




Journal article


Med care

Publication Date





616 - 622


Age Factors, Aged, 80 and over, California, Female, Hip Fractures, Hospital Mortality, Humans, Length of Stay, Male, Patient Readmission, Postoperative Complications, Quality of Health Care, Retrospective Studies, Trauma Centers, Treatment Outcome