Cost-effectiveness analysis of surgical proximal femur fracture prevention in elderly: a Markov cohort simulation model.

BACKGROUND: Hip fractures are a common and costly health problem, resulting in significant morbidity and mortality, as well as high costs for healthcare systems, especially for the elderly. Implementing surgical preventive strategies has the potential to improve the quality of life and reduce the burden on healthcare resources, particularly in the long term. However, there are currently limited guidelines for standardizing hip fracture prophylaxis practices. METHODS: This study used a cost-effectiveness analysis with a finite-state Markov model and cohort simulation to evaluate the primary and secondary surgical prevention of hip fractures in the elderly. Patients aged 60 to 90 years were simulated in two different models (A and B) to assess prevention at different levels. Model A assumed prophylaxis was performed during the fracture operation on the contralateral side, while Model B included individuals with high fracture risk factors. Costs were obtained from the Centers for Medicare & Medicaid Services, and transition probabilities and health state utilities were derived from available literature. The baseline assumption was a 10% reduction in fracture risk after prophylaxis. A sensitivity analysis was also conducted to assess the reliability and variability of the results. RESULTS: With a 10% fracture risk reduction, model A costs between $8,850 and $46,940 per quality-adjusted life-year ($/QALY). Additionally, it proved most cost-effective in the age range between 61 and 81 years. The sensitivity analysis established that a reduction of ≥ 2.8% is needed for prophylaxis to be definitely cost-effective. The cost-effectiveness at the secondary prevention level was most sensitive to the cost of the contralateral side's prophylaxis, the patient's age, and fracture treatment cost. For high-risk patients with no fracture history, the cost-effectiveness of a preventive strategy depends on their risk profile. In the baseline analysis, the incremental cost-effectiveness ratio at the primary prevention level varied between $11,000/QALY and $74,000/QALY, which is below the defined willingness to pay threshold. CONCLUSION: Due to the high cost of hip fracture treatment and its increased morbidity, surgical prophylaxis strategies have demonstrated that they can significantly relieve the healthcare system. Various key assumptions facilitated the modeling, allowing for adequate room for uncertainty. Further research is needed to evaluate health-state-associated risks.

Impact of structural and economic factors on hospitalization costs, inpatient mortality, and treatment type of traumatic hip fractures in Switzerland.

The assessment of structural and potentially economic factors determining cost, treatment type, and inpatient mortality of traumatic hip fractures are important health policy issues. We showed that insurance status and treatment in university hospitals were significantly associated with treatment type (i.e., primary hip replacement), cost, and lower inpatient mortality respectively. INTRODUCTION: The purpose of this study was to determine the influence of the structural level of hospital care and patient insurance type on treatment, hospitalization cost, and inpatient mortality in cases with traumatic hip fractures in Switzerland. METHODS: The Swiss national medical statistic 2011-2012 was screened for adults with hip fracture as primary diagnosis. Gender, age, insurance type, year of discharge, hospital infrastructure level, length-of-stay, case weight, reason for discharge, and all coded diagnoses and procedures were extracted. Descriptive statistics and multivariate logistic regression with treatment by primary hip replacement as well as inpatient mortality as dependent variables were performed. RESULTS: We obtained 24,678 inpatient case records from the medical statistic. Hospitalization costs were calculated from a second dataset, the Swiss national cost statistic (7528 cases with hip fractures, discharged in 2012). Average inpatient costs per case were the highest for discharges from university hospitals (US$21,471, SD US$17,015) and the lowest in basic coverage hospitals (US$18,291, SD US$12,635). Controlling for other variables, higher costs for hip fracture treatment at university hospitals were significant in multivariate regression (p < 0.001). University hospitals had a lower inpatient mortality rate than full and basic care providers (2.8% vs. both 4.0%); results confirmed in our multivariate logistic regression analysis (odds ratio (OR) 1.434, 95% CI 1.127-1.824 and OR 1.459, 95% confidence interval (CI) 1.139-1.870 for full and basic coverage hospitals vs. university hospitals respectively). The proportion of privately insured varied between 16.0% in university hospitals and 38.9% in specialized hospitals. Private insurance had an OR of 1.419 (95% CI 1.306-1.542) in predicting treatment of a hip fracture with primary hip replacement. CONCLUSION: The seeming importance of insurance type on hip fracture treatment and the large inequity in the distribution of privately insured between provider types would be worth a closer look by the regulatory authorities. Better outcomes, i.e., lower mortality rates for hip fracture treatment in hospitals with a higher structural care level advocate centralization of care.

Reimbursement of care for severe trauma under SwissDRG.

QUESTIONS: Treatment of patients with severe injuries is costly, with best results achieved in specialised care centres. However, diagnosis-related group (DRG)-based prospective payment systems have difficulties in depicting treatment costs for specialised care. We analysed reimbursement of care for severe trauma in the first 3 years after the introduction of the Swiss DRG reimbursement system (2012-2014). MATERIAL/METHODS: The study included all patients with solely basic insurance, hospital admission after 01.01.2011 and discharge in 2011 or 2012, who were admitted to the resuscitation room of the University Hospital of Zurich, aged ≥16 years and with an injury severity score (ISS) ≥16 (n = 364). Clinical, financial and administrative data were extracted from the electronic medical records. All cases were grouped into DRGs according to different SwissDRG versions. We considered results to be significant if p ≤0.002. RESULTS: The mean deficit decreased from 12 065 CHF under SwissDRG 1.0 (2012) to 2 902 CHF under SwissDRG 3.0 (2014). The main reason for the reduction of average deficits was a refinement of the DRG algorithm with a regrouping of 23 cases with an ISS ≥16 from MDC 01 to DRGs within MDC21A. Predictors of an increased total loss per case could be identified: for example, high total number of surgical interventions, surgeries on multiple anatomical regions or operations on the pelvis (p ≤0.002). Psychiatric diagnoses in general were also significant predictors of deficit per case (p<0.001). CONCLUSION: The reimbursement for care of severely injured patients needs further improvement. Cost neutral treatment was not possible under the first three versions of SwissDRG.

Quantitative and qualitative MR-imaging assessment of vastus medialis muscle volume loss in asymptomatic patients after anterior cruciate ligament reconstruction.

BACKGROUND: To quantitatively and qualitatively assess vastus medialis muscle atrophy in asymptomatic patients with anterior cruciate ligament reconstruction, using the nonoperated leg as control. METHODS: Prospective Institutional Review Board approved study with written informed patient consent. Thirty-three asymptomatic patients (men, 21; women,12) with ACL-reconstruction underwent MR imaging of both legs (axial T1-weighted spin-echo and 3D spoiled dual gradient-echo sequences). Muscle volume and average fat-signal fraction (FSF) of the vastus medialis muscles were measured. Additionally, Goutallier classification was used to classify fatty muscle degeneration. Significant side differences were evaluated using the Wilcoxon test and, between volumes and FSF, using student t-tests with P-value < 0.05 and < 0.025, respectively. RESULTS: The muscle volume was significantly smaller in the operated (mean ± SD, 430.6 ± 119.6 cm(3) ; range, 197.3 to 641.7 cm(3) ) than in the nonoperated leg (479.5 ± 124.8 cm(3) ; 261.4 to 658.9 cm(3) ) (P < 0.001). Corresponding FSF was 6.3 ± 1.5% (3.9 to 9.2%) and 5.8 ± 0.9% (4.0 to 7.4%), respectively, with a nonsignificant (P > 0.025) difference. The relative muscle-volume and FSF differences were -10.1 ± 8.6% (7.1 to -30.1%) and 10.9 ± 29.4% (39.7 to 40.1%). The qualitative assessment revealed no significant differences (P > 0.1). CONCLUSION: A significant muscle volume loss of the vastus medialis muscle does exist in asymptomatic patients with ACL-reconstruction, but without fatty degeneration.

Cross-sectional area measurements versus volumetric assessment of the quadriceps femoris muscle in patients with anterior cruciate ligament reconstructions.

OBJECTIVE: Our aim was to validate the use of cross-sectional area (CSA) measurements at multiple quadriceps muscle levels for estimating the total muscle volume (TMV), and to define the best correlating measurement level. METHODS: Prospective institutional review board (IRB)-approved study with written informed patient consent. Thighs of thirty-four consecutive patients with ACL-reconstructions (men, 22; women, 12) were imaged at 1.5-T using three-dimensional (3D) spoiled dual gradient-echo sequences. CSA was measured at three levels: 15, 20, and 25 cm above the knee joint line. TMV was determined using dedicated volumetry software with semiautomatic segmentation. Pearson's correlation and regression analysis (including standard error of the estimate, SEE) was used to compare CSA and TMV. RESULTS: The mean ± standard deviation (SD) for the CSA was 60.6 ± 12.8 cm(2) (range, 35.6-93.4 cm(2)), 71.1 ± 15.1 cm(2) (range, 42.5-108.9 cm(2)) and 74.2 ± 17.1 cm(2) (range, 40.9-115.9 cm(2)) for CSA-15, CSA-20 and CSA-25, respectively. The mean ± SD quadriceps' TMV was 1949 ± 533.7 cm(3) (range, 964.0-3283.0 cm(3)). Pearson correlation coefficient was r = 0.835 (p < 0.01), r = 0.906 (p < 0.01), and r = 0.956 (p < 0.01) for CSA-15, CSA-20 and CSA-25, respectively. Corresponding SEE, expressed as percentage of the TMV, were 15.2%, 11.6% and 8.1%, respectively. CONCLUSION: The best correlation coefficient between quadriceps CSA and TMV was found for CSA-25, but its clinical application to estimate the TMV is limited by a relatively large SEE. KEY POINTS: • Cross-sectional area was used to estimate QFM size in patients with ACL-reconstruction • A high correlation coefficient exists between quadriceps CSA and volume • Best correlation was seen 25 cm above the knee joint line • A relatively large standard error of the estimate limits CSA application.