# The impact of prior level of care on the course of proximal humeral fractures in older patients: an analysis based on health insurance claims data

## TL;DR

Older patients with hip fractures who had higher levels of care before injury had worse outcomes and were more likely to receive non-surgical treatment.

## Contribution

This study demonstrates how prior care levels significantly influence treatment choices and outcomes in older patients with proximal humeral fractures.

## Key findings

- Higher prior level of care was associated with increased non-operative treatment rates and worse outcomes in older PHF patients.
- Mortality rates rose sharply with increasing prior care levels, reaching 50% for the highest level.
- Multivariable analysis confirmed stronger associations between higher care levels and adverse events like death and complications.

## Abstract

The proximal humeral fracture (PHF) is the third most common fracture in older individuals. Prior level of care (LoC) and associated comorbidities may have an impact on patient outcome and prognosis.

Retrospective German health insurance data from patients with PHF aged 65 years and older between 01/17 to 09/22 were analysed. The primary endpoints included overall survival (OS), major adverse events (MAEs), thromboembolic events (TEs), and surgery- or injury-related complications. All endpoints were analysed using multivariable models.

A total of 55,798 patients (median age 79 years; 84% female) were included. Prior to PHF, 68% had no LoC (LoC I 3%, LoC II 12%, LoC III 11%, LoC IV 6%, LoC V 1%), and 8% were living in a nursing home. With increasing LoC, the proportion of patients receiving non-operative treatment (no LoC 52%, LoC I 53%, LoC II 62%, LoC III 64%, LoC IV 71%, LoC V 76%) and the likelihood of a worse outcome increased. Both, mortality rates (1-year mortality: no LoC 4%, LoC I 12%, LoC II 19%, LoC III 29%, LoC IV 41%, LoC V 50%) and rates of MAEs increased drastically with increasing LoC. Multivariable analyses confirmed that increasing LoC was associated with a greater risk of death, MAEs, and TEs (all p < 0.001).

Prior LoC has a significant effect on the course of PHF and the choice of treatment method in older individuals. This should be considered when making treatment decisions.

Level III, retrospective comparative study.

The online version contains supplementary material available at 10.1186/s12913-026-14024-0.