Cost-effectiveness of dual-mobility components in patients with displaced femoral neck fractures.

AIMS: Total hip arthroplasty (THA) with dual-mobility components (DM-THA) has been shown to decrease the risk of dislocation in the setting of a displaced neck of femur fracture compared to conventional single-bearing THA (SB-THA). This study assesses if the clinical benefit of a reduced dislocation rate can justify the incremental cost increase of DM-THA compared to SB-THA. METHODS: Costs and benefits were established for patients aged 75 to 79 years over a five-year time period in the base case from the Canadian Health Payer's perspective. One-way and probabilistic sensitivity analysis assessed the robustness of the base case model conclusions. RESULTS: DM-THA was found to be cost-effective, with an estimated incremental cost-effectiveness ratio (ICER) of CAD $46,556 (£27,074) per quality-adjusted life year (QALY). Sensitivity analysis revealed DM-THA was not cost-effective across all age groups in the first two years. DM-THA becomes cost-effective for those aged under 80 years at time periods from five to 15 years, but was not cost-effective for those aged 80 years and over at any timepoint. To be cost-effective at ten years in the base case, DM-THA must reduce the risk of dislocation compared to SB-THA by at least 62%. Probabilistic sensitivity analysis showed DM-THA was 58% likely to be cost-effective in the base case. CONCLUSION: Treating patients with a displaced femoral neck fracture using DM-THA components may be cost-effective compared to SB-THA in patients aged under 80 years. However, future research will help determine if the modelled rates of adverse events hold true. Surgeons should continue to use clinical judgement and consider individual patients' physiological age and risk factors for dislocation. Cite this article: Bone Joint J 2021;103-B(12):1783-1790.

Internal fixation versus hemiarthroplasty for displaced femoral neck fractures in the elderly: A cost-effectiveness analysis.

BACKGROUND: There is little information on the cost and outcome of different treatments for femoral neck fractures. This study aimed to evaluate the cost-effectiveness of internal fixation compared with hemiarthroplasty (HA) for elderly patients with displaced femoral neck fractures. MATERIALS AND METHODS: A total of 121 patients ≥ 65 years old were divided into internal fixation (n = 58) or HA group (n = 63). Clinical outcome was evaluated by the EuroQol 5 dimensions (EQ-5D) score at 3, 12, and 24 months. The total costs including medical and non-medical expense were collected through hospitalisation information, cost diaries, and telephone interviews. A cost-utility analysis of the total costs in combination with quality-adjusted life years (QALYs) calculated by EQ-5D and survival time was conducted. Results were expressed in incremental cost-effectiveness ratio (ICER). RESULTS: The mean EQ-5D index score in the HA group were higher at the early follow-up (p<0.05). At 24 months there were no differences in EQ-5D between the 2 treatment groups (p>0.05). Over the 2-year period, patients treated with HA gained 0.09-0.10 more QALYs than those treated with internal fixation, while the mean total costs for internal fixation (CNY 55,676) were significantly lower than for HA (CNY 80,297) (P<0.001). ICER indicated that internal fixation may be more cost-effective than HA. CONCLUSION: HA is associated with better outcome than internal fixation in the treatment of displaced femoral neck fractures in elderly patients. However, internal fixation may be more cost-effective because of less total cost.

The socioeconomic impact of a femoral neck fracture on patients aged 18-50: A population-based study.

BACKGROUND: By linking health and census data, the objective of this study was to determine the effect of a femoral neck fracture on the household income of non-elderly patients. METHODS: All individuals aged 18-50 who underwent internal fixation for a femoral neck fracture during the years 2006-2012 in the Canadian Province of British Columbia were included in the study. Patient-level hospital data was linked with patient's after-tax household income decile, as estimated by Statistics Canada Postal Code Conversion Files. The primary endpoint was a decline of ≥2 income deciles following the index fracture. Kaplan-Meier analysis was performed to estimate the probability of income decline during the study period. A Cox regression model was used to study the association between a ≥2 income decline and patient age, sex, reoperation, and pre-injury income decile. RESULTS: Of the 391 femoral neck fracture patients included, the majority of patients were male (61.6%), with a median age of 43 years (IQR: 35-48), and a pre-injury median income in the fifth decile (IQR: decile 3-8). 27.0% of patients sustained a decline of ≥2 income deciles during the study period, with 16.3% declining ≥2 income deciles within 2-years of injury. A pre-injury household income in the top 4 deciles (mean of deciles: $57,000-170,500) was associated with an increased likelihood of a ≥2 drop in household income (HR: 1.38, 95% CI: 1.06-1.79, p = 0.02). DISCUSSION: Over a quarter of the femoral neck fracture patients in this study sustained a decline of ≥2 deciles in their household income following their injury. The income decline was disproportionately absorbed by patients with baseline incomes in the 6th decile or higher. This suggests that the available incapacity programs are limited in providing income protection to patients with higher incomes.

Conversion of Hemiarthroplasty to THA Carries an Increased Risk of Reoperation Compared With Primary and Revision THA.

BACKGROUND: There is limited information on the complications and costs of conversion THA after hemiarthroplasty for femoral neck fractures. Previous studies have found that patients undergoing conversion THA experience higher risk complications, but it has been difficult to quantify the risk because of small sample sizes and a lack of comparison groups. Therefore, we compared the complications of patients undergoing conversion THA with strictly matched patients undergoing primary and revision THA. QUESTIONS/PURPOSES: (1) What are the risks of complications, dislocations, reoperations, revisions and periprosthetic fractures after conversion THA compared with primary and revision THA and how has this effect changed over time? (2) What are the length of hospital stay and hospital costs for conversion THA, primary THA, and revision THA? METHODS: Using a longitudinally maintained total joint registry, we identified 389 patients who were treated with conversion THA after hemiarthroplasty for femoral neck fractures between 1985 and 2014. The conversion THA cohort was 1:2 matched on age, sex, and year of surgery to 778 patients undergoing primary THA and 778 patients undergoing revision THA. The proportion of patients having at least 5-year followup was 73% in those who underwent conversion THA, 77% in those who underwent primary THA, and 76% in those who underwent revision THA. We observed a significant calendar year effect, and therefore, compared the three groups across two separate time periods: 1985 to 1999 and 2000 to 2014. We ascertained complications, dislocations, reoperations, revisions and periprosthetic fractures from the total joint registry. Cost analysis was performed using a bottom-up, microcosting methodology for procedures between 2003 and 2014. RESULTS: Patients who converted to THA between 1985 and 1999 had a higher risk of complications (hazard ratio [HR], 2.3; 95% confidence interval [CI], 1.7-3.1; p < 0.001), dislocations (HR, 2.3; 95% CI, 1.3-4.2; p = 0.007), reoperations (HR, 1.7; 95% CI, 1.2-2.5, p = 0.005), and periprosthetic fractures (HR, 3.8; 95% CI, 2.2-6.6; p < 0.001) compared with primary THA. However, conversion THAs during the 1985 to 1999 time period had a lower risk of reoperations (HR, 0.7; 95% CI, 0.5-1.0; p = 0.037), revisions (HR, 0.6; 95% CI, 0.5-0.9; p = 0.014), and periprosthetic fractures (HR, 0.6; 95% CI, 0.4-0.9; p = 0.007) compared with revision THA. The risk differences across the three groups were more pronounced after 2000, particularly when comparing conversion THA patients with revision THA. Conversion THA patients had a higher risk of reoperations (HR, 1.9; 95% CI, 1.0-3.4; p = 0.041) and periprosthetic fractures (HR, 1.7; 95% CI, 1.0-2.9; p = 0.036) compared with revision THA, but there were no differences in the complication risk (HR, 1.4; 95% CI, 0.9-2.1; p = 0.120), dislocations (HR, 1.5; 95% CI, 0.7-3.2; p = 0.274), and revisions (HR, 1.4; 95% CI, 0.7-3.0; p = 0.373). Length of stay for conversion THA was longer than primary THA (4.7 versus 4.0 days; p = 0.012), but there was no difference compared with revision THA (4.7 versus 4.5 days; p = 0.484). Similarly, total inpatient costs for conversion THA were higher than primary THA (USD 22,662 versus USD 18,694; p < 0.001), but there was no difference compared with revision THA (USD 22,662 versus USD 22,071; p = 0.564). CONCLUSIONS: Over the 30 years of the study, conversion THA has remained a higher risk procedure in terms of reoperation compared with primary THA, and over time, it also has become higher risk compared with revision THA. Surgeons should approach conversion THA as a challenging procedure, and patients undergoing this procedure should be counseled about the elevated risks. Furthermore, hospitals should seek appropriate reimbursement for these cases. LEVEL OF EVIDENCE: Level III, therapeutic study.

Post-operative mortality rates for neck of femur fracture at Waitemata District Health Board.

AIM: Mortality rates of up to 38% at one year have been reported following surgery for neck of femur fractures. The aim of this review is to evaluate the post-operative mortality rates and trends over time for patients with fractured neck of femur at Waitemata District Health Board. METHOD: A retrospective cohort study of all patients who received surgery following a neck of femur fracture at Waitemata District Health Board between 2009 and 2016. Inpatient data was retrieved from electronic hospital records and mortality rates from the Ministry of Health, New Zealand. Analyses included crude mortality rates and trends over time, and time-to-theatre from presentation with neck of femur fracture. RESULTS: A total of 2,822 patients were included in the study; mean age 81.9 years, 70.4% female and 29.6% male. Overall post-operative crude rates for inpatient, 30-day and one-year mortality were 3.7%, 7.2% and 23.8% respectively. Adjusted analyses showed a statistically significant decrease in mortality rates between 2009 and 2016 at inpatient (p=0.001), 30 days (p=<0.001) and one year (p=<0.001) time periods. There was also a significant association between time-to-theatre and mortality at inpatient (p=0.002), 30 days (p=0.0001), and one year (p=0.0002) time periods. CONCLUSION: Mortality rates following surgery for fractured NOF have significantly improved over recent years at Waitemata District Health Board. Reduced time-to-theatre is associated with decreased inpatient, 30-day and one-year mortality.

[WAITING TIME FOR SURGICAL FIXATION OF FEMORAL NECK FRACTURES: DOES A DIAGNOSIS-RELATED GROUP PAYMENT METHOD MATTER?]

BACKGROUND: Early surgical fixation of femoral neck factures in elderly patients has been suggested to decrease morbidity and mortality and to improve treatment outcome. This study evaluates the effect of the implementation of a diagnosis-related group payment method in our hospital on waiting time for surgery and the short-term outcomes of elderly patients following surgical fixation of hip fractures. METHODS: Demographic and clinical characteristics of 75 consecutive patients, who underwent surgery for hip fracture in our hospital, before the implementation of a diagnosis-related group payment method, were compared with those of 75 consecutive patients, who were operated on after the implementation of the payment system. RESULTS: Demographic characteristics were similar for both groups. Before the implementation of a diagnosis-related group payment method, 84% of the patients waited longer than 48 hours for surgery, compared to only 24% of patients after the implementation (p<0.001). Medical considerations and operation room availability were the main reasons for delaying surgery in both groups. Mortality and morbidity rates during the hospital stay remained similar, regardless of the implementation of the payment method. CONCLUSIONS: The implementation of a diagnosis-related group payment method shortened the waiting time for surgical hip fixation in elderly patients treated in our hospital, with no effect on the mortality and complication rate during the hospital stay.

Hospitalisation cost analysis on hip fracture in China: a multicentre study among 73 tertiary hospitals.

OBJECTIVE: To describe and analyse the hospitalisation cost of patients with hip fracture under the influence of various factors and to provide references for Chinese national medical insurance policy. MATERIALS AND METHODS: All data were collected from the Chinese National Medical Data Centre database, which contained the hospitalisation data of 73 tertiary hospitals from 24 provinces. The included patients were first hospitalised with the main diagnosis of femoral neck or intertrochanteric fracture, and were discharged between 1 January 2014 and 31 December 2015. Secondary hospitalisation, multiple trauma or pathologic fracture (except for osteoporotic fracture) patients or patients with missing data were excluded. The impact of various factors on the cost was investigated using analysis of variance and multivariable linear regression analysis. The Gross Domestic Product per capita and average annual disposable income were obtained from the website of the National Bureau of Statistics. RESULTS: 27 205 cases were included in the study. The mean cost of all patients was ¥53 440. 60-69 years age group had a significantly higher cost compared with 80 years and above age group. The mean cost of femoral neck fractures was lower than that of the patients with intertrochanteric fractures; the mean cost of hip replacement was higher than that of internal fixation, which showed a strong effect of the surgical approach to the cost. Patients in low-income provinces spent less than those in high-income provinces, while the gap between high-income and middle-income provinces were relatively small. CONCLUSION: The hospitalisation cost of hip fracture has become a great burden to the patients' families. The Chinese medical insurance policy may need further consideration of the demographic and economic factors.

Hip Fractures and the Bundle: A Cost Analysis of Patients Undergoing Hip Arthroplasty for Femoral Neck Fracture vs Degenerative Joint Disease.

BACKGROUND: The purpose of this study is to determine whether episode Target Prices in the Bundled Payment for Care Improvement (BPCI) initiative sufficiently match the complexities and expenses expected for patients undergoing hip arthroplasty for femoral neck fracture (FNF) as compared to hip degenerative joint disease (DJD). METHODS: Claims data under BPCI Model 2 were collected for patients undergoing hip arthroplasty at a single institution over a 2-year period. Payments from the index hospitalization to 90 days postoperatively were aggregated by Medicare Severity Diagnosis-Related Group (469 or 470), indication (DJD vs FNF), and categorized as index procedure, postacute services, and related hospital readmissions. Actual episode costs and Target Prices were compared in both the FNF and DJD cohorts undergoing hip arthroplasty to gauge the cost discrepancy in each group. RESULTS: A total of 183 patients were analyzed (31 with FNFs, 152 with DJD). In total, the FNF cohort incurred a $415,950 loss under the current episode Target Prices, whereas the DJD cohort incurred a $172,448 gain. Episode Target Prices were significantly higher than actual episode prices for the DJD cohort ($32,573 vs $24,776, P < .001). However, Target Prices were significantly lower than actual episode prices for the FNF cohort ($32,672 vs $49,755, P = .021). CONCLUSION: Episode Target Prices in the current BPCI model fall dramatically short of the actual expenses incurred by FNF patients undergoing hip arthroplasty. Better risk-adjusting Target Prices for this fragile population should be considered to avoid disincentives and delays in care.

Cost-utility analysis in orthopaedic trauma; what pays? A systematic review.

BACKGROUND: As healthcare systems come under ever-increasing pressure to provide more care with fewer resources, emphasis is being placed on value-based systems that maximise quality and minimize cost. The aim of this study was to determine which interventions in fracture care have been demonstrated to be cost effective. METHODS: A systemic review of cost-utility studies on the management of fractures from 1976 to 2015 was carried out using a search of the Cost-Effectiveness Analysis Registry, National Health Service Economic Evaluation Database (NHS EED) and MEDLINE. RESULTS: 20 studies were included with 15 (75%) studies assessing interventions in lower limb trauma and 8 (25%) studies assessing interventions in upper limb trauma. 50% of studies used a decision tree model and 50% used collected data alongside a randomised clinical trial. Interventions which were shown to be cost effective in lower limb trauma were total hip replacement in displaced femoral neck fractures, the SHS in stable (A1 and A2) fractures and IM nailing for unstable (A3) fractures, salvage treatment for grade IIIB and IIIC open tibial fractures and operative treatment of ankle and calcaneal fractures. For systems-based strategies, there is evidence demonstrating cost effectiveness to treating hip fractures in high volume centres and to having resources in place to facilitate fractures being treated within 48 h of injury. In upper limb trauma there was evidence showing operative treatment of displaced proximal humerus fractures to be neither clinically nor cost effective. There was evidence supporting the operative treatment of non-displaced scaphoid fractures. Overall the quality of the studies was poor with only 50% (10) of studies able to make a treatment recommendation. Reasons for this included poor quality primary source data and poor reporting methodological practices. CONCLUSION: Certain aspects of fracture management have been shown to be cost effective. However, there is a paucity of evidence in this area and further research is required so that value-based interventions are chosen by healthcare providers engaged in orthopaedic trauma care.

Association Between Financial Incentives for Regional Care Coordination and Health Care Resource Utilization Among Older Patients after Femoral Neck Fracture Surgery: A Retrospective Cohort Study Using a Claims Database.

The incidence rates of hip fracture have been increasing in Japan. Length of stay among hip fracture patients in Japan is much longer than other developed countries, and the Japanese government introduced financial incentives for regionally coordinated femoral neck fracture care to reduce health care resource utilization. The objective of this study was to evaluate whether the financial incentives reduce health care resource utilization among patients 75 years or older with femoral neck fracture in Japan. Claims data from the Fukuoka Prefecture Regional Association for Late-Stage Healthcare for Older People were analyzed for the period from April 2010 to March 2016. The authors identified 4641 eligible subjects after femoral neck fracture surgery, and categorized them into groups based on care pathways: coordinated care, integrated care, and other. Length of stay by care phase and total charges were used as measures of health care resource utilization. The models showed that coordinated and integrated care were significantly associated with shorter length of stay during perioperative care: coordinated care, multiplicative effect, 0.90 (P < 0.001); integrated care, 0.77 (P < 0.001). However, only integrated care was associated with shorter rehabilitation and overall length of stay: 0.66 (P < 0.001) in rehabilitation; 0.70 (P < 0.001) in overall duration. Integrated care also was associated with lower total charges: 0.70 (P < 0.001). Current financial incentives for regionally coordinated femoral neck fracture care do not affect health care resource utilization. Further health care reforms should be implemented to promote effective regional care coordination in Japan.

Is Patient Satisfaction Associated with Objective Measures of Geriatric Hip Fracture Care?

BACKGROUND: Patient satisfaction is publicly reported and used as a subjective measure of quality of care in alternative payment reimbursement models. In this study, we evaluated the association between patient satisfaction scores and objective measures of geriatric hip fracture care. Therefore, according to patient satisfaction score, we investigated the differences for geriatric hip fracture admissions in regard to 1. surgical delay during the index admission and 2. mortality within 1 year. METHODS: We identified 65,974 patients between the ages of 60 and 99 years with a primary diagnosis of femoral neck fracture in the New York Statewide Planning and Research Cooperative System database from 2009 to 2014. We evaluated patient satisfaction using annual hospital HCAHPS scores reported on Hospital Compare. Mixed effects regression models controlled for hospital and year of surgery as random effects variables and categorical age, sex, race, insurance, categorical Deyo score, fracture location, and surgical procedure as fixed effects variables. RESULTS: For high compared to low patient satisfaction hospitals, there were shorter surgical delays (ß: -60%, 95% CI: -66% to -52%, p < 0.001) and a lower risk of 1-year mortality (OR: 0.86, 95% CI: 0.78 to 0.93, p < 0.001). For middle compared to low patient satisfaction hospitals, there were shorter surgical delays (ß: -37%, 95% CI: -46% to -26%, p < 0.001), but no significant difference in 1-year mortality (OR: 0.94; 95% CI: 0.87 to 1.01; p = 0.091). CONCLUSIONS: Subjective quality, as measured by HCAHPS patient satisfaction scores, is associated with objective quality and clinical outcomes in geriatric hip fracture care. While these findings support the use of patient experience as a component of quality measurement, it remains unclear whether a superior patient experience in itself can increase the value of health care for patients in the form of superior clinical outcomes or if it will lead to increased strain on hospital resources and increase the cost of services, which would paradoxically decrease the value of care.

Outcomes of Hemiarthroplasty and Total Hip Arthroplasty for Femoral Neck Fracture: A Medicare Cohort Study.

OBJECTIVES: For patients with femoral neck fractures, total hip arthroplasty (THA) demonstrates superior outcomes compared with hemiarthroplasty. However, hemiarthroplasty remains a common treatment for femoral neck fractures and the conversion rates are unknown. We compared the results of the 2 procedures using a Medicare database. METHODS: We assembled a cohort of 70,242 patients 65 to 90 years of age with an ICD9 diagnosis and matching Current Procedure Terminology code for femoral neck fracture between 2008 and 2012. Patients were followed forward for 2 years minimum. Incidences of dislocation and mortality were measured. Reoperation for revision of THA or conversion of hemiarthroplasty to THA was assessed by Current Procedure Terminology code. Groups were compared through proportional hazard models controlling for age, race, sex, and comorbidity index. RESULTS: Hemiarthroplasty represented 95% of the patients treated using arthroplasty for femoral neck fracture. The proportional hazard of reoperation and dislocation were significantly lower for hemiarthroplasty than THA (P < 0.0001 for both). At 2 years, fewer than 2% of hemiarthroplasty patients underwent conversion to total hip replacement. Patients treated with THA were more likely to be alive for 2 years (adjusted hazard ratio = 1.67, 95% confidence interval: 1.59-1.92). CONCLUSION: Patients treated with hemiarthroplasty after femoral neck fractures had significantly lower proportional hazard of reoperation than those treated with THA. THA may be associated with lower mortality. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis.

BACKGROUND: The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ≤65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario. METHODS: A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis. RESULTS: THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs. CONCLUSIONS: Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group. LEVEL OF EVIDENCE: Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Inpatient cost for hip fracture patients managed with an orthogeriatric care model in Singapore.

INTRODUCTION: The estimated incidence of hip fractures worldwide was 1.26 million in 1990 and is expected to double to 2.6 million by 2025. The cost of care for hip fracture patients is a significant economic burden. This study aimed to look at the inpatient cost of hip fractures among elderly patients placed under a mature orthogeriatric co-managed system. METHODS: This study was a retrospective analysis of 244 patients who were admitted to the Department of Orthopaedics of Tan Tock Seng Hospital, Singapore, in 2011 for hip fractures under a mature orthogeriatric hip fracture care path. Information regarding costs, surgical procedures performed and patient demographics was collected. RESULTS: The mean cost of hospitalisation was SGD 13,313.81. The mean cost was significantly higher for the patients who were managed surgically than for the patients who were managed non-surgically (SGD 14,815.70 vs. SGD 9,011.38; p < 0.01). Regardless of whether surgery was performed, the presence of complications resulted in a higher average cost (SGD 2,689.99 more than if there were no complications; p = 0.011). Every additional day from admission to time of surgery resulted in an increased cost of SGD 575.89, and the difference between the average cost of surgery within 48 hours and that of surgery > 48 hours was SGD 2,716.63. CONCLUSION: Reducing the time to surgery and preventing pre- and postoperative complications can help reduce overall costs. A standardised care path that empowers allied health professionals can help to reduce perioperative complications, and a combined orthogeriatric care service can facilitate prompt surgical treatment.

The Frank Stinchfield Award : Total Hip Arthroplasty for Femoral Neck Fracture Is Not a Typical DRG 470: A Propensity-matched Cohort Study.

BACKGROUND: Hip fractures are a major public health concern. For displaced femoral neck fractures, the needs for medical services during hospitalization and extending beyond hospital discharge after total hip arthroplasty (THA) may be different than the needs after THA performed for osteoarthritis (OA), yet these differences are largely uncharacterized, and the Medicare Severity Diagnosis-Related Groups system does not distinguish between THA performed for fracture and OA. QUESTIONS/PURPOSES: (1) What are the differences in in-hospital and 30-day postoperative clinical outcomes for THA performed for femoral neck fracture versus OA? (2) Is a patient's fracture status, that is whether or not a patient has a femoral neck fracture, associated with differences in in-hospital and 30-day postoperative clinical outcomes after THA? METHODS: The National Surgical Quality Improvement Program (NSQIP) database, which contains outcomes for surgical patients up to 30 days after discharge, was used to identify patients undergoing THA for OA and femoral neck fracture. OA and fracture cohorts were matched one-to-one using propensity scores based on age, gender, American Society of Anesthesiologists grade, and medical comorbidities. Propensity scores represented the conditional probabilities for each patient having a femoral neck fracture based on their individual characteristics, excluding their actual fracture status. Outcomes of interest included operative time, length of stay (LOS), complications, transfusion, discharge destination, and readmission. There were 42,692 patients identified (41,739 OA; 953 femoral neck fractures) with 953 patients in each group for the matched analysis. RESULTS: For patients with fracture, operative times were slightly longer (98 versus 92 minutes, p = 0.015), they experienced longer LOS (6 versus 4 days, p < 0.001), and the overall frequency of complications was greater compared with patients with OA (16% versus 6%, p < 0.001). Although the frequency of preoperative transfusions was higher in the fracture group (2.0% versus 0.2%, p = 0.002), the frequency of postoperative transfusion was not different between groups (27% versus 24%, p = 0.157). Having a femoral neck fracture versus OA was strongly associated with any postoperative complication (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.1-3.8]; p < 0.001), unplanned readmission (OR, 1.8; 95% CI, 1.0-3.2; p = 0.049), and discharge to an inpatient facility (OR, 1.7; 95% CI, 1.4-2.0; p < 0.001). CONCLUSIONS: Compared with THA for OA, THA for femoral neck fracture is associated with greater rates of complications, longer LOS, more likely discharge to continued inpatient care, and higher rates of unplanned readmission. This implies higher resource utilization for patients with a fracture. These differences exist despite matching of other preoperative risk factors. As healthcare reimbursement moves toward bundled payment models, it would seem important to differentiate patients and procedures based on the resource utilization they represent to healthcare systems. These results show different expected resource utilization in these two fundamentally different groups of patients undergoing hip arthroplasty, suggesting a need to modify healthcare policy to maintain access to THA for all patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Association Between Hospital Length of Stay and 90-Day Readmission Risk for Femoral Neck Fracture Patients: Within a Total Joint Arthroplasty Bundled Payment Initiative.

BACKGROUND: Hip arthroplasty is increasingly performed as a treatment for femoral neck fractures (FNFs). However, these cases have higher complication rates than elective total hip arthroplasties (THAs). The Center for Medicare and Medicaid Services has created the Comprehensive Care for Joint Replacement model to increase the value of patient care. This model risk stratifies FNF patients in an attempt to appropriately allocate resources, but the formula has not been disclosed. The goal of this study was to ascertain if patients with FNFs have different readmission rates compared to patients undergoing elective THA so that the resource utilization can be assessed. METHODS: We analyzed all patients undergoing THA at our institution during a 21-month period. Patients classified by a diagnosis-related group of 469 or 470 were included. Multivariate and survival analyses were performed to determine risk of 90-day readmission. RESULTS: Patients admitted for FNFs were older, had higher body mass indices, longer lengths of stay, and were more likely to be discharged to inpatient facilities than patients who underwent elective THA. Increased American Society of Anesthesiologists scores and FNF were also independent risk factors for 90-day readmission, and these patient were more likely to be readmitted during the latter 60 days following admission. CONCLUSION: Results suggest that patients who undergo an arthroplasty following urgent or emergent FNFs have inferior outcomes to those receiving an arthroplasty for a diagnosis of arthritis. Fracture patients should either be risk stratified to allow appropriate resource allocation or be excluded from alternative payment initiatives such as Comprehensive Care for Joint Replacement.

Total medical costs of treating femoral neck fracture patients with hemi- or total hip arthroplasty: a cost analysis of a multicenter prospective study.

UNLABELLED: The aim of this study was to determine the total medical costs for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. The mean total costs per patient at 2 years of follow-up were €26,399. These results contribute to cost awareness. INTRODUCTION: The absolute number of hip fractures is rising and increases the already significant burden on society. The aim of this study was to determine the mean total medical costs per patient for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. METHODS: The population was the Dutch sample of an international randomized controlled trial consisting of femoral neck fracture patients treated with hemi- or total hip arthroplasty. Patient data and health care utilization were prospectively collected during a total follow-up period of 2 years. Costs were separated into costs for hospital care during primary stay, hospital costs for clinical follow-up, and costs generated outside the hospital during rehabilitation. Multiple imputations were used to account for missing data. RESULTS: Data of 141 participants (mean age 81 years) were included in the analysis. The 2-year mortality rate was 19 %. The mean total cost per patient after 10 weeks of follow-up was €15,216. After 1 and 2 years of follow-up the mean total costs were €23,869 and €26,399, respectively. Rehabilitation was the main cost determinant, and accounted for 46 % of total costs. Primary hospital admission days accounted for 22 % of the total costs, index surgery for 11 %, and physical therapy for 7 %. CONCLUSIONS: The main cost determinants for hemi- or total hip arthroplasty after treatment of displaced femoral neck fractures (€26,399 per patient until 2 years) were rehabilitation and nursing homes. Most of the costs were made in the first year. Reducing costs after hip fracture surgery should focus on improving the duration and efficiency of the rehabilitation phase.

Reassessment of osteoporosis-related femoral fractures and economic burden in Saudi Arabia.

UNLABELLED: The current study reassesses the prevalence of fragility fractures and lifetime costs in the Eastern Province of Saudi Arabia. Forty-two percent (391) of the fractures were at the neck of the femur, and 38.6 % (354) were inter-trochanteric fractures. The overall incidence was assessed to be 7528 (1,300,336 population 55 years or older) with the direct cost of SR564.75 million ($150.60 million). A National Fracture Registry and osteoporosis awareness programs are recommended. PURPOSE: Proximal femur fragility fractures are reported to be increasing worldwide due to increased life expectancy. The current study is carried out to assess the incidence of such fractures in the Eastern Province of Saudi Arabia and to assess the costs incurred in managing them annually. Finally, by extrapolating the data, the study can calculate the overall economic burden in Saudi Arabia. METHODS: The data of fragility proximal femur fractures was collected from 24 of 28 hospitals in the Eastern Province. The data included age, sex, mode of injury, type of fracture, prescribed drug (and its cost), and length of hospital stay. Population statistics were obtained from the Department of Statistics of the Saudi Arabian government Web site. RESULTS: Twenty-four hospitals (85 %) participated in the study. A total of 780 fractures were sustained by 681 patients. Length of stay in the hospital averaged 23.28 ± 13.08 days. The projected fracture rate from all the hospitals would be 917 (an incidence of 5.81/1000), with a total cost of SR68.77 million. Further extrapolation showed that the overall incidence could be 7528 (1,300,336 population 55 years or older) with the direct cost of SR564.75 million ($150.60 million). CONCLUSIONS: Osteoporosis-related femoral fractures in Saudi Arabia are significant causes of morbidity besides incurring economic burden. We believe that a National Fracture Registry needs to be established, and osteoporosis awareness programs should be instituted in every part of Saudi Arabia so that these patients can be diagnosed early and treated appropriately to reduce both the number of fractures and the economic burden of the fractures.

The Quality of Cost-Utility Analyses in Orthopedic Trauma.

As health care in the United States transitions toward a value-based model, there is increasing interest in applying cost-effectiveness analysis within orthopedic surgery. Orthopedic trauma care has traditionally underemphasized economic analysis. The goals of this review were to identify US-based cost-utility analysis in orthopedic trauma, to assess the quality of the available evidence, and to identify cost-effective strategies within orthopedic trauma. Based on a review of 971 abstracts, 8 US-based cost-utility analyses evaluating operative strategies in orthopedic trauma were identified. Study findings were recorded, and the Quality of Health Economic Studies (QHES) instrument was used to grade the overall quality. Of the 8 studies included in this review, 4 studies evaluated hip and femur fractures, 3 studies analyzed upper extremity fractures, and 1 study assessed open tibial fracture management. Cost-effective interventions identified in this review include total hip arthroplasty (over hemiarthroplasty) for femoral neck fractures in the active elderly, open reduction and internal fixation (over nonoperative management) for distal radius and scaphoid fractures, limb salvage (over amputation) for complex open tibial fractures, and systems-based interventions to prevent delay in hip fracture surgery. The mean QHES score of the studies was 79.25 (range, 67-89). Overall, there is a paucity of cost-utility analyses in orthopedic trauma; however, the available evidence suggests that certain operative interventions can be cost-effective. The quality of these studies, however, is fair, based on QHES grading. More attention should be paid to evaluating the cost-effectiveness of operative intervention in orthopedic trauma.

Financial aspects of arthroplasty options for intra-capsular neck of femur fractures: a cost analysis study to review the financial impacts of implementing NICE guidelines in the NHS organisations.

OBJECTIVES: To review the financial aspects of implementing the latest NICE guideline for neck of femur fracture (CG124), which recommends offering Total Hip Replacement (THR) as an alternative to hemiarthroplasty (HA) for patients, who are independently mobile before injury, not cognitively impaired and well enough to tolerate the operation. MATERIALS AND METHODS: Between April 2011 and April 2013 data collected from our Hip Fracture database (NHFD) showed that by following the latest NICE guideline (CG124), out of 840 patients, 176 patients (21%) should be considered for THR rather than HA. Individual procedure costs were calculated by considering cost of implants and consumables (extracted from providers' published catalogues) added to the cost of running operating theatre for each operation. We then used the national tariff for each procedure using relevant HRG codes to calculate the total cost and the income to the Trust. RESULTS: Our data indicated that by implementing the latest NICE guideline (CG124), 37.1% of patients with intra-capsular fracture neck of femur (IC-NOF fracture) would be eligible for THR rather than HA. Although performing cemented THR was the more expensive procedure, our calculation shows that despite increased cost of performing the operation, Trusts can increase their net income by £300-600 (depending on their market force factor) per patient using correct HRG coding and National Tariff. CONCLUSION: Utilising 2012-13 National Tariff, performing a cemented THR instead of a HA for patients with IC-NOF fracture, as recommended by the latest NICE guideline (CG124) can increase the Trust's revenue per patient in a predictable way. This practice not only results in potentially better patient outcomes but also can increase financial reward and potential for reinvestment in all hip fracture units in the UK.