• Kelly K Richardson, Peter Cram, Mary Vaughan-Sarrazin, and Peter J Kaboli.
• Comprehensive Access & Delivery Research and Evaluation Center, Iowa City VA Healthcare System, Mailstop 152, 601 Highway West, Iowa City, IA 52246, USA.
• Clin. Orthop. Relat. Res. 2013 Mar 1; 471 (3): 1047-53.

BackgroundHip 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.Questions/PurposesThis 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?MethodsVeterans 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.ResultsPatients 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.ConclusionsFor 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 EvidenceLevel II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

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