Differences in Opioid Use After Hip Fracture by Race and Post-acute Care Use Among U.S. Older Adults

Background: Suboptimal pain management after a hip fracture can hinder post-fracture rehabilitation and potentially interfere with recovery of function and independence. Black patients generally receive lower opioid doses than White patients. It is unknown whether this disparity persists among patients with a hip fracture or if it varies by post-acute care (PAC) utilization.

Objectives: To examine whether the receipt and dose of opioids differs between Black and White patients after hip fracture hospitalization stratified on institutional PAC use.

Methods: Using Medicare claims data for a 20% random sample of fee-for-service beneficiaries (2012—2018) aged ≥66 years, we identified patients with a primary hospital discharge code for hip fracture. We separated this population into those with and without care in an institutional PAC setting (e.g., skilled nursing facility) for rehabilitation after hospitalization. The follow-up period was the 90 days after discharge from the hospital for those without PAC, or the 90 days after PAC discharge. Patients were censored at death, re-fracture, disenrollment, or hospice entry. We used cause-specific Cox proportional hazards regression models to compare opioid use, accounting for the competing risk of death, age, sex, Combined Comorbidity Index, and length of hospital stay for patients without PAC or length of PAC stay. We used linear regression models to compare the cumulative 90-day morphine milligram equivalent (MME) dose between groups.

Results: We identified 877,329 eligible patients with a hip fracture (364,029 without PAC [90% White, 15% opioid use during follow-up], 513,300 PAC patients [92% White, 14% opioid use]). Black and White patients had a similar history of opioid exposure in the 12 months before fracture (6-8% prevalence; standardized mean difference [SMD] for no PAC group: 0.03; SMD for PAC group: 0.01). In patients without a PAC stay, we found no difference in opioid receipt post-discharge (Hazard Ratio [HR] 1.00 [95% CI 0.96 to 1.04]), but Black patients received slightly lower MMEs (-42 mg [95% CI -64 to -20]). In contrast, Black patients discharged from a PAC stay were less likely than White patients to receive an opioid (HR 0.96 [0.92 to 0.99]) and had lower MMEs (-76 mg [-103 to -50]).

Conclusions: Black patients with a PAC stay after hip fracture were less likely than White patients to receive an opioid after discharge and had lower opioid doses. Future research should examine whether differences in quality of rehabilitation during the PAC stay explain these disparities.