Nonoperative versus operative management of frail institutionalized older patients with a proximal femoral fracture: a cost-utility analysis alongside a multicenter prospective cohort study.

Hip fractures are associated with significant healthcare costs. In frail institutionalized patients, the costs of nonoperative management are less than operative management with comparable short-term quality of life. Nonoperative management of hip fractures in patients at the end of life should be openly discussed with SDM. PURPOSE: The aim was to describe healthcare use with associated costs and to determine cost-utility of nonoperative management (NOM) versus operative management (OM) of frail institutionalized older patients with a proximal femoral fracture. METHODS: This study included institutionalized patients with a limited life expectancy aged ≥ 70 years who sustained a proximal femoral fracture in the Netherlands. Costs of hospital- and nursing home care were calculated. Quality adjusted life years (QALY) were calculated based on EuroQol-5D-5L utility scores at day 7, 14, and 30 and at 3 and 6 months. The incremental cost-effectiveness ratio (ICER) was calculated from a societal perspective. RESULTS: Of the 172 enrolled patients, 88 (51%) patients opted for NOM and 84 (49%) for OM. NOM was associated with lower healthcare costs at 6 months (NOM; €2425 (SD 1.030), OM; €9325 (SD 4242), p < 0.001). The main cost driver was hospital stay (NOM; €738 (SD 841) and OM; €3140 (SD 2636)). The ICER per QALY gained in the OM versus NOM was €76,912 and exceeded the threshold of €20,000 per QALY. The gained QALY were minimal in the OM group in patients who died within 14- and 30-day post-injury, but OM resulted in more than triple the costs. CONCLUSION: OM results in significant higher healthcare costs, mainly due to the length of hospital stay. For frail patients at the end of life, NOM of proximal femoral fractures should be openly discussed in SDM conversations due to the limited gain in QoL. TRIAL REGISTRATION: Netherlands Trial Register (NTR7245; date 10-06-2018).

Burden of illness of hip fractures in elderly Dutch patients.

Patients with hip fractures experience reduced health-related quality of life and have a reduced life expectancy. Patients' utilization of healthcare leads to costs to society. The results of the study can be used in future economic evaluations of treatments for hip fractures. PURPOSE: Hip fractures are associated with high mortality, reduced quality of life, and increased healthcare utilization, leading to an economic burden to society. The purpose of this study is to determine the burden of illness of hip fractures in elderly Dutch patients for specific time periods after surgery. METHODS: Patients with a hip fracture above the age of 65 were included in the study. In the 1-year period after surgery, patients were asked to complete a set of questionnaires pre-injury (retrospectively), and 1 week, 1 month, 3 months, 6 months and 12 months after surgery. The set of questionnaires included the Euroqol 5D (EQ-5D-3L), the iMTA Medical Consumption Questionnaire (iMCQ) and iMTA Productivity Cost Questionnaire (iPCQ). Health-related quality of life was calculated using Dutch tariffs. Costs were calculated using the methodology described in the Dutch costing manual. RESULTS: Approximately 20% of patients with a hip fracture died within 1 year. Health-related quality of life was significantly reduced compared to pre-injury values, and patients did not recover to their pre-injury values within 1 year. Total costs in the first year after injury were €27,573, of which 10% were due to costs of the procedure (€2706). Total follow-up costs (€24,876) were predominantly consisting of healthcare costs. Monthly costs decreased over time. CONCLUSIONS: Hip fractures lead to a burden to patients, resulting from mortality and health-related quality of life reductions, and to society, due to (healthcare) costs. The results of this study can be used in future economic evaluations.

The value of nonoperative versus operative treatment of frail institutionalized elderly patients with a proximal femoral fracture in the shade of life (FRAIL-HIP); protocol for a multicenter observational cohort study.

BACKGROUND: Proximal femoral fractures are strongly associated with morbidity and mortality in elderly patients. Mortality is highest among frail institutionalized elderly with both physical and cognitive comorbidities who consequently have a limited life expectancy. Evidence based guidelines on whether or not to operate on these patients in the case of a proximal femoral fracture are lacking. Practice variation occurs, and it remains unknown if nonoperative treatment would result in at least the same quality of life as operative treatment. This study aims to determine the effect of nonoperative management versus operative management of proximal femoral fractures in a selected group of frail institutionalized elderly on the quality of life, level of pain, rate of complications, time to death, satisfaction of the patient (or proxy) and the caregiver with the management strategy, and health care consumption. METHODS: This is a multicenter, observational cohort study. Frail institutionalized elderly (70 years or older with a body mass index < 18.5, a Functional Ambulation Category of 2 or lower pre-trauma, or an American Society of Anesthesiologists score of 4 or 5), who sustained a proximal femoral fracture are eligible to participate. Patients with a pathological or periprosthetic fractures and known metastatic oncological disease will be excluded. Treatment decision will be reached following a structured shared decision process. The primary outcome is quality of life (Euro-QoL; EQ-5D-5 L). Secondary outcome measures are quality of life measured with the QUALIDEM, pain level (PACSLAC), pain medication use, treatment satisfaction of patient (or proxy) and caregivers, quality of dying (QODD), time to death, and direct medical costs. A cost-utility and cost-effectiveness analysis will be done, using the EQ-5D utility score and QUALIDEM score, respectively. Non-inferiority of nonoperative treatment is assumed with a limit of 0.15 on the EQ-5D score. Data will be acquired at 7, 14, and 30 days and at 3 and 6 months after trauma. DISCUSSION: The results of this study will provide insight into the true value of nonoperative treatment of proximal femoral fractures in frail elderly with a limited life expectancy. The results may be used for updating (inter)national treatment guidelines. TRIAL REGISTRATION: The study is registered at the Netherlands Trial Register (NTR7245; date 10-06-2018).

Predicting health status in the first year after trauma.

BACKGROUND: Although mortality rates following major trauma are continuing to decline, a growing number of patients are experiencing long-term disability. The aim of this study was to identify factors associated with health status in the first year following trauma and develop prediction models based on a defined trauma population. METHODS: The Brabant Injury Outcome Surveillance (BIOS) study was a multicentre prospective observational cohort study. Adult patients with traumatic injury were included from August 2015 to November 2016 if admitted to one of the hospitals of the Noord-Brabant region in the Netherlands. Outcome measures were EuroQol Five Dimensions 5D-3L (EQ-5D™ utility and visual analogue scale (VAS)) and Health Utilities Index (HUI) 2 and 3 scores 1 week and 1, 3, 6 and 12 months after injury. Prediction models were developed using linear mixed models, with patient characteristics, preinjury health status, injury severity and frailty as possible predictors. Predictors that were significant (P < 0·050) for one of the outcome measures were included in all models. Performance was assessed using explained variance (R2 ). RESULTS: In total, 4883 patients participated in the BIOS study (50·0 per cent of the total), of whom 3366 completed the preinjury questionnaires. Preinjury health status and frailty were the strongest predictors of health status during follow-up. Age, sex, educational level, severe head or face injury, severe torso injury, injury severity, Functional Capacity Index score, co-morbidity and duration of hospital stay were also relevant in the multivariable models predicting health status. R2 ranged from 35 per cent for EQ-VAS to 48 per cent for HUI 3. CONCLUSION: The most important predictors of health status in the first year after trauma in this population appeared to be preinjury health status and frailty.

Prevalence, recovery patterns and predictors of quality of life and costs after non-fatal injury: the Brabant Injury Outcome Surveillance (BIOS) study.

INTRODUCTION: Trauma is a major public health problem worldwide that leads to high medical and societal costs. Overall, improved understanding of the full spectrum of the societal impact and burden of injury is needed. The main purpose of the Brabant Injury Outcome Surveillance (BIOS) study is to provide insight into prevalence, predictors and recovery patterns of short-term and long-term health-related quality of life (HRQoL) and costs after injury. MATERIALS AND METHODS: This is a prospective, observational, follow-up cohort study in which HRQoL, psychological, social and functional outcome, and costs after trauma will be assessed during 24 months follow-up within injured patients admitted in 1 of 10 hospitals in the county Noord-Brabant, the Netherlands. Data will be collected by self-reported questionnaires at 1 week (including preinjury assessment), and 1, 3, 6, 12 and 24 months after injury. If patients are not capable of filling out the questionnaires, proxies will be asked to participate. Also, information about mechanism and severity of injury, comorbidity and indirect and direct costs will be collected. Mixed models will be used to examine the course of HRQoL, functional and psychological outcome, costs over time and between different groups, and to identify predictors for poor or good outcome. RELEVANCE: This study should make a substantial contribution to the international collaborative effort to assess the societal impact and burden of injuries more accurately. The BIOS results will also be used to develop an outcome prediction model for outcome evaluation including, besides the classic fatal, non-fatal outcome. TRIAL REGISTRATION NUMBER: NCT02508675.