Bundled Payments for Hip Fracture Surgery Are Associated With Improved Access, Quality, and Health Care Utilization, but Higher Costs for Complex Cases: An Interrupted Time Series Analysis.

ABSTRACT

OBJECTIVES: To study the impact of bundled payments for surgically managed hip fractures on care access, care quality, health care resource utilization, clinical impact, and acute care cost. DESIGN: An observational retrospective cohort study using a quasi-experimental design comparing prebundled and postbundled payments through an interrupted time series analysis. SETTING: A public acute care general hospital. PATIENTS Patients 60 years and older, with surgery for an isolated, unilateral, nonpathological hip fracture during 2014-first quarter of 2019 [diagnosis-related group codes I03A, I03B, I08A, and I08B] and transferred to specific rehabilitation institutions were studied. INTERVENTION Bundled payments for funder-to-provider reimbursement. MAIN OUTCOMES MEASUREMENTS Care access, care quality, health care resource utilization, clinical impact, and cost. RESULTS: Of 1477 patients, 811 were assigned to prebundled and 666 to postbundled payments. Although there was an improving trend of ward admission waiting times during postbundled payments [odds ratio (OR) = 1.14; 95% confidence interval (CI) 1.02-1.28], ward admission waiting times were longer when compared with prebundled payments (OR = 0.45; 95% CI 0.23-0.85). Rates of 30-day all-cause readmissions were lower (OR = 0.08; 95% CI 0.01-0.67), and trends of reducing inpatient rehabilitation and overall episode length of stay (OR = 1.26; 95% CI 1.16-1.37 and OR = 1.17; 95% CI 1.07-1.28, respectively) were demonstrated during postbundled payments. Acute care cost for complex cases were higher (OR = 0.49; 95% CI 0.26-0.92) during bundled payments, compared with prebundled payments. CONCLUSIONS: Bundled payments for surgically managed hip fractures were associated with benefits for several outcomes pertinent to clinical improvement initiatives. More work, especially concerning cost-effective surgical implants and better care cost computations, are critically needed to contain the growth of acute medical care cost for these patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.