Does Fracture Care Make Money for the Hospital? An Analysis of Hospital Revenues and Costs for Treatment of Common Fractures

Ankle fractures: High implant cost is not associated with better patient reported outcomes

INTRODUCTION

Ankle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries. Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture.

METHODS

All ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost.

RESULTS

There was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [-411.8, -54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [-74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48).

CONCLUSIONS

The utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.

The economics of patients undergoing periacetabular osteotomy for hip dysplasia: the financial relationship between physicians and hospitals

Periacetabular osteotomy (PAO) is the gold standard for treating hip dysplasia in patients with preserved articular cartilage. The aim of this study is to evaluate the financial relationship between facility and professional revenue for patients undergoing PAO for hip dysplasia and acetabular version abnormalities. All patients who underwent PAO for hip dysplasia by a single surgeon at a tertiary academic medical center between December 2016 and November 2020 were identified. Financial records for facility and professional services were reviewed and analyzed. The orthopedic charge multiplier, the dollars of facility charge created by a single dollar of orthopedic professional charge, and orthopedic net revenue multiplier, the dollars collected by the hospital for facility services generated for each dollar collected by the orthopedic surgeon, were calculated. A total of 36 patients were included in the study. The mean total charge for all patients was $144 939.35 ± $23 726.48 (range $109 002.71 to $227 290.20), and the average total revenue for all patients was $44 218.79 ± $12 352.97 (range $29 397.39 to $90,830.62). The mean orthopedic charge multiplier was 2.47 ± 1.32 (range 0.78-6.53), and the net revenue collection multiplier was 8.62 ± 10.69 (range, 1.20-57.80). The majority of charges and revenue related to care of patients undergoing PAO return to the hospital. The significant mean orthopedic charge multiplier for this procedure increases the value of the service and the surgeon to hospital profitability. This information can help shape the relationship between the hospital and the surgeon and create a firm platform to advocate for program advancement.

The Hip and Femur Fracture Bundle: Preliminary Findings From a Tertiary Hospital

BACKGROUND

The voluntary hip and femur fracture Bundled Payments for Care Improvement Advanced (BCPI-A) includes Diagnosis Related Groups (DRG) 480, 481, and 482, which include diverse and medically complex patients undergoing urgent inpatient surgery without optimization. Concern exists that this bundle is financially unfavorable for hospitals, and this study aimed to identify the costliest services.

METHODS

We retrospectively reviewed a 12-month cohort of 32 consecutive patients in the DRG 480-482 bundle at our academic tertiary referral center. Cost of discharge disposition, readmission, and other variables were analyzed for all patients in the 90-day bundle.

RESULTS

Overall, a net financial gain averaging $2,028 per patient (range -$52,128 to +$30,199) was seen. Discharge to facilities (n = 19) resulted in higher costs than discharge to home (n = 11, P < .0001). Use of inpatient rehabilitation (n = 6) averaged a loss of $11,028 per patient and use of skilled nursing facilities (n = 15) averaged a loss of $7,250 per patient, compared to a gain of $15,011 for patients discharged home (n = 11). Episodes with readmission (n = 6) averaged a loss of only $1,390. Total index admission costs averaged $12,489 ± $2,235 per patient (range $9,329-$18,884) while post-inpatient cost averaged $30,150 per patient (range $4,803 - $77,768).

CONCLUSION

The BPCI-A hip and femur fracture bundle has a wide variability in costs, with the largest component in the post-acute care phase. Discharge home is favorable in the bundle while discharge to post-acute facilities leads to net losses. Institutions in this bundle need to develop multi-disciplinary teams to promote safe discharge home.

Cracking the Hip: Does Protocol Matter? A Retrospective Cohort Study Investigating the Effect of Protocol Implementation

Introduction

Approximately 300 000 hip fractures occur annually in the USA in patients >65 years old. Early intervention is key in reducing morbidity and mortality. Our institution implemented a collaborative hip fracture protocol, streamlining existing processes to reduce time to OR (TTO) and hospital length of stay (LOS). Our aim was to determine if this protocol improved these outcomes.

Study Design

We conducted a retrospective cohort study using our level-1 trauma center’s trauma registry, comparing outcomes for patients >60 years old with isolated hip fractures pre-and post-hip protocol implementation in May 2018. Our primary outcomes were TTO and in-hospital mortality. Secondary outcomes included LOS and postoperative complications. Univariate analysis was done using chi-square and T-test.

Results

We identified 176 patients with isolated hip fractures: 69 post- and 107 pre-protocol. Comparing post- to pre-protocol, TTO decreased by 18hrs (39 vs 57h; P = .013) and patients had fewer postoperative complications (9 vs 23%; P = .016) despite post-protocol patients being more likely to have diabetes (42 vs 27%, P < .05), elevated BMI (22 vs 25; P < .001), and to be current smokers (9 vs 2%; P < .05). LOS and in-hospital mortality also decreased (11 vs 20d; P = .312, 4.3 vs 7.5%; P = .402). Post-protocol patients were more likely to go to the OR within 24hrs of presentation (39 vs 16%; P < .001) and to go straight from ED to OR (32 vs 4%; P < .001).

Conclusion

TTO, LOS, and postoperative complications for isolated hip fracture patients were lower post-protocol. Though not all statistically significant, this trend indicates that the protocol was helpful in improving hip fracture outcomes but may require further improvement and institution-wide education.

Iranian public hospitals' challenges regarding revenue deficits: A mixed-method study

Background: The main part of hospitals' funding comes from insurance organizations. In some cases, for different reasons such as not filed services or unpaid health insurance bills, a part of these funding cannot be derived from health insurance companies. This study aims to describe different aspects of the hospitals' revenue deficits in Iranian public hospitals. Methods: This was a mixed-method study consisting of qualitative and quantitative studies. Qualitative data were collected through 17 semi-structured interviews and were analyzed using the analytical framework by MAXQDA.10. Quantitative data were analyzed by the TOPSIS method and Smart TOPSIS Solver.3.2.0. Results: Based on the framework analysis, five sets of the underlying causes of hospital revenue deficits were identified and categorized in 5 themes: bottlenecks, direct causes of revenue deficits, root causes of revenue deficits, revenue deficits management strategies, and challenges and barriers to managing revenue deficits. Through inadequate clinical documentation and failed to provide the insurance organization's requirements, the surgical units, operating rooms, and inpatient units were found as the main sources of revenue deficit. Lack of senior management commitment and inconsistency of insurance organizations for evaluating claims are often listed as the major barriers to effective implementation of corrective interventions. Conclusion: Revenue deficits occurs in most hospital departments and in all stages of converting services into revenue, and a variety of human and organizational factors contribute to them. Therefore, focusing on the main causes of deductions and the participation of all individuals and departments involved in it is critical to reducing deductions.

Significant Improvement in the Value of Surgical Treatment of Tibial Plateau Fractures Through Surgeon Practice Standardization

INTRODUCTION

It is unclear whether cost-based decisions to improve the value of surgical care (quality:cost ratio) affect patient outcomes. Our hypothesis was that surgeon-directed reductions in surgical costs for tibial plateau fracture fixation would result in similar patient outcomes, thus improving treatment value.

METHODS

This was a prospective observational study with retrospective control data. Surgically treated tibial plateau fractures from 2013 to October 2014 served as a control (group 1). Material costs for each case were calculated. Practices were modified to remove allegedly unnecessary costs. Next, cost data were collected on similar patients from November 2014 through 2015 (group 2). Costs were compared between groups, analyzing partial articular and complete articular fractures separately. Minimum follow-up (f/u) was 1-year. Outcomes data collected include Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference domains, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog pain scale, infection, nonunion, unplanned return to surgery, demographics, injury characteristics, and comorbidities.

RESULTS

Group 1 included 57 partial articular fractures and 57 complete articular fractures. Group 2 included 37 partial articular fractures and 32 complete articular fractures. Median cost of partial articular fractures decreased from $1,706 to $1,447 (P = 0.025), and median cost of complete articular fractures decreased from $2,681 to $2,220 (P = 0.003). Group 1 had 55 patients who consented to clinical f/u, and group 2 had 39. Median PROMIS PF score was 40 for group 1 and was 43 for group 2 (P = 0.23). There were no significant differences between the groups for any clinical outcomes, demographics, injury characteristics, or comorbidities. Median f/u in group 1 was 31 months compared with 15 months in group 2 (P < 0.0001).

DISCUSSION

We have demonstrated that surgeons can improve value of surgical care by reducing surgical costs while maintaining clinical outcomes.

Variation in Implant Selection for Ankle Fractures: Identifying Cost Drivers

BACKGROUND

Implant selection is the first opportunity for surgeons to control costs of fracture fixation. The current literature has demonstrated surgeons' poor understanding of implant costs. Our study evaluated implant cost variability for surgically treated ankle fractures and distal tibia fractures. Our hypothesis was that significant cost variation exists among providers. The goal was to identify cost drivers and determine whether specialty training is linked to implant selection.

METHODS

A retrospective 2010-2017 chart review was performed for 1281 patients at a Level I trauma center. Patients were excluded for skeletal immaturity, open fractures, polytrauma, and concurrent surgeries. Variables were assessed included age, sex, body mass index, OTA/AO classification, Weber classification, 1-year reoperation status, surgeon specialty, and use of syndesmotic screws, locking plates, and cannulated screws. Construct cost was determined by using electronic medical record implant model numbers cross-referenced with the chargemaster database. Statistical analysis involved intergroup comparative tests, regression analysis, and goodness-of-fit analyses.

RESULTS

Implant cost was different among OTA patterns (P < 0.01), highest among 43C ($3771) and lowest with 44A ($819). Construct costs of OTA 43 fractures varied from $2568 to 3771, whereas OTA 44 ranged from $819 to $1474. Costs were comparable across Weber patterns (P = 0.15), with Weber B having the highest ($1494). Costs were highest among reconstructive, podiatry, and spine surgeons, with mean costs of $1804, $1404, and $1396, respectively. Traumatologist constructs had the lowest overall price ($987). A total of 433 (33.8%) procedures used locking plates with 512 (40.0%) using at least one cannulated screw. Locking plates averaged a larger total implant cost ($1947) than nonlocking plates ($1313) but had a comparable reoperation rate (18.5% vs. 17.7%, P = 0.81). Use of a cannulated screw presented a higher total cost ($2008 vs. $1435) with comparable reoperation rates (17.4% vs. 18.8%, P = 0.72). A total of 401 (31.5%) patients received syndesmotic fixation and a significantly higher reoperation rate (17.0% vs. 11.0%, P < 0.01). Overall, 199 patients underwent elective hardware removal, 23 were infected, 7 required revision, and 3 were identified with a nonunion.

CONCLUSIONS

Our study demonstrated significant variability in implant costs for ankle fracture fixation and identified the key cost drivers as locking plates and cannulated screws. Surgical management of ankle fractures could be an ideal setting to pilot economic alignment between physicians and hospitals to drive value.

LEVEL OF EVIDENCE

Level III. Retrospective Cohort.

Value Denominator: The Fundamentals of Costing for Orthopaedic Surgeons

In any discipline, improving quality and efficiency of services acts as a unifying goal. In health care, the goal of achieving high-value care is the new doctrine for all individual entities: payors, providers, and patients. Value is defined as the ratio of outcomes to costs incurred. Therefore, a strong understanding and interpretation of cost measures is crucial to accurately deriving health care value. Health care costing is not simply limited to the costs of implants or the procedure but the costs required to deliver treatment throughout the episode of care. Consequently, physicians serve a keystone role toward driving change in health care costs and initiate high-value care practices. However, physicians require a better understanding of health care costs and institutional accounting practices. To this effort, it is critical that health care providers begin to close the knowledge gap around health care costing and provide leadership when advocating for high-value patient care. This review is purposed to provide a basic review of fundamental components for health care economics, deciphering health care costing, and preview current strategies that prioritize high-value patient care.

The national burden of periprosthetic hip fractures in the US: costs and risk factors for hospital readmission

INTRODUCTION

Periprosthetic hip fractures (PPFX) are serious complications that result in increased morbidity, mortality and healthcare costs. Decreasing hospital readmissions has been a recent healthcare focus, but little is known about the overall costs associated with PPFX or the risk factors associated with readmissions. We investigated patient demographics, treatment types, 30- and 90-day readmission rates, direct costs, and patient risk factors associated with PPFX readmission.

METHODS

We used the 2013 Nationwide Readmissions Database to select patients who underwent total hip arthroplasty (THA), revision THA, and PPFX treated with open reduction internal fixation (ORIF) or revision THA. Survival analysis was used to evaluate the 90-day all-cause hospital readmission rate, and risk factors were identified using a Cox proportional hazards model, adjusting for patient and hospital characteristics.

RESULTS

We identified 1269 patients with PPFX treated with ORIF and 3254 treated with revision THA. 90-day readmissions were 20.9% and 27.3%, respectively. Patients with PPFX were older, female, and had multiple medical comorbidities. Patient factors associated with increased risk of readmission include: age; comorbidities; and discharge to skilled nursing facility; Medicare or Medicaid insurance. Hospital factors associated with increased risk of readmission include: large hospitals; nonprofits; metropolitan and teaching hospitals. The cost of readmission for PPFX treated with ORIF was $17,206 and revision THA was $16,504.

DISCUSSION

Periprosthetic hip fractures have high rates of hospital readmission, implying a significant burden to the healthcare system. Identifying risk factors is an important step towards identifying treatment pathways that can improve outcomes.

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 1: Overview and critical appraisal

BACKGROUND

Ankle and foot sprains and fractures are common injuries affecting many individuals, often requiring considerable and costly medical interventions. The objectives of this systematic review are to collect, assess, and critically appraise the published literature on the health economics of ankle and foot injury (sprain and fracture) treatment.

METHODS

A systematic literature review of Ovid MEDLINE, EMBASE, Cochrane DSR, ACP Journal Club, AMED, Ovid Healthstar, and CINAHL was conducted for English-language studies on the costs of treating ankle and foot sprains and fractures published from January 1980 to December 2014. Two reviewers assessed the articles for study quality and abstracted data.

RESULTS

The literature search identified 2047 studies of which 32 were analyzed. A majority of the studies were published in the last decade. A number of the studies did not report full economic information, including the sources of the direct and indirect costs, as suggested in the guidelines. The perspective used in the analysis was missing in numerous studies, as was the follow-up time period of participants. Only five of the studies undertook a sensitivity analysis which is required whenever there are uncertainties regarding cost data.

CONCLUSION

This systematic review found that publications do not consistently report on the components of health economics methodology, which in turn limits the quality of information. Future studies undertaking economic evaluations should ensure that their methods are transparent and understandable so as to yield accurate interpretation for assistance in forthcoming economic evaluations and policy decision-making.

The health economics of ankle and foot sprains and fractures: A systematic review of English-language published papers. Part 2: The direct and indirect costs of injury

BACKGROUND

Ankle and foot sprains and fractures are prevalent injuries, which may result in substantial physical and economic consequences for the patient and place a financial burden on the health care system. Therefore, the objectives of this paper are to examine the direct and indirect costs of treating ankle and foot injuries (sprains, dislocations, fractures), as well as to provide an overview of the outcomes of full economic analyses of different treatment strategies.

METHODS

A systematic review was carried out among seven databases to identify English language publications on the health economics of ankle and foot injury treatment published between 1980 and 2014. The direct and indirect costs were abstracted by two independent reviewers. All costs were adjusted for inflation and reported in 2016 US dollars (USD).

RESULTS

Among 2047 identified studies, 32 were selected for analysis. The direct costs of ankle sprain management ranged from $292 to $2268 per patient (2016 USD), depending on the injury severity and treatment strategy. The direct costs of managing ankle fractures were higher ($1908-$19,555). Foot fracture treatment had similar direct costs ranging from $998 to $21,801. The economic evaluations were conducted from the societal or payer's perspectives.

CONCLUSION

The costs of treating ankle and foot sprains and fractures varied among the studies, mostly due to differences in injury type and study characteristics, which impacted the ability of directly comparing the financial burden of treatment. Nonetheless, the review showed that the costs experienced by the patient and the health care system increased with injury complexity.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Operative Ankle Fractures

OBJECTIVES

To investigate the ability of a validated geriatric trauma risk prediction tool to stratify hospital quality metrics and inpatient cost for middle-aged and geriatric patients admitted from the emergency department for operative treatment of an ankle fracture.

DESIGN

Prospective cohort study.

SETTING

Single Academic Medical Center.

PATIENTS

Patients 55 years of age and older who sustained a rotational ankle fracture and who were treated operatively during their index hospitalization.

INTERVENTION

Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), using patient demographics, injury severity, and functional status. Patients were stratified into groups based on scores to create a minimal-, low-, moderate-, and high-risk cohort.

MAIN OUTCOME MEASUREMENTS

Length of stay, complications, need for intensive care unit-/step-down unit-level care, discharge location, and index admission costs.

RESULTS

Fifty ankle fracture patients met inclusion criteria. The mean length of stay was 7.8 ± 5.2 days with a significant difference among the 4 risk groups (4.6-day difference between low and high risk). 73.1% of minimal-risk patients were discharged home compared with 0% of high-risk patients. There was no difference in complication rate or in need for intensive care unit-level care between groups. However, high-risk patients had a mean total inpatient cost 2 times greater than that of minimal-risk patients.

CONCLUSION

The Score for Trauma Triage in Geriatric and Middle-Aged tool is able to meaningfully stratify older patients with ankle fracture who require operative fixation regarding hospital quality metrics and cost. This information may allow for efficient targeted reductions in costs while optimizing outcomes.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost Comparison of Surgically Treated Ankle Fractures Managed in an Inpatient Versus Outpatient Setting

INTRODUCTION

Although choices physicians make profoundly affect the cost of health care, few surgeons know relative costs associated with the setting in which care is provided. Without valid cost information, surgeons cannot understand how their choices affect the total cost of care.

METHODS

Actual costs for all isolated, surgically treated ankle fractures at a level I trauma hospital and affiliated outpatient surgery center were determined using a validated episode of care costing system and analyzed using multivariate regression analysis in this retrospective cohort study.

RESULTS

One hundred forty-eight patients (ie, 61 inpatients and 87 outpatients) with isolated, surgically treated ankle fractures were included. After controlling for confounding variables, outpatient care was associated with 31.6% lower costs compared with inpatient care. Obese patients had 21.6% higher costs compared with patients who were not obese. No difference was noted in revision surgery, readmission, or return visits to the emergency department for patients treated on an inpatient or outpatient basis.

CONCLUSION

Where medically/socially appropriate, this analysis suggests that ankle fracture surgery should be provided in an outpatient surgical facility to provide the greatest value to the patient and society.

LEVEL OF EVIDENCE

Level III.

The Coming Hip and Femur Fracture Bundle: A New Inpatient Risk Stratification Tool for Care Providers

INTRODUCTION

In response to increasing health-care costs, Centers for Medicare & Medicaid Services has initiated several programs to transition from a fee-for-service model to a value-based care model. One such voluntary program is Bundled Payments for Care Improvement Advanced (BPCI Advanced) which includes all hip and femur fractures that undergo operative fixation. The purpose of this study was to analyze the current cost and resource utilization of operatively fixed (nonarthroplasty) hip and femur fracture procedure bundle patients at a single level 1 trauma center within the framework of a risk stratification tool (Score for Trauma Triage in the Geriatric and Middle-Aged [STTGMA]) to identify areas of high utilization before our hospitals transition to bundle period.

MATERIALS AND METHODS

A cohort of Medicare-eligible patients discharged with the Diagnosis-Related Group (DRG) codes 480 to 482 (hip and femur fractures requiring surgical fixation) from a level 1 trauma center between October 2014 and September 2016 was evaluated and assigned a trauma triage risk score (STTGMA score). Patients were stratified into groups based on these scores to create a minimal-, low-, moderate-, and high-risk cohort. Length of stay (LOS), discharge location, need for Intensive Care Unit (ICU)/Step Down Unit (SDU) care, inpatient complications, readmission within 90 days, and inpatient admission costs were recorded.

RESULTS

One hundred seventy-three patients with a mean age of 81.5 (10.1) years met inclusion criteria. The mean LOS was 8.0 (4.2) days, with high-risk patients having 4 days greater LOS than lower risk patients. The mean number of total complications was 0.9 (0.8) with a significant difference between risk groups (P = .029). The mean total cost of admission for the entire cohort of patients was US$25,446 (US$9725), with a nearly US$9000 greater cost for high-risk patients compared to the low-risk patients. High-cost areas of care included room/board, procedure, and radiology.

DISCUSSION

High-risk patients were more likely to have longer and more costly admissions with average index admission costs nearly US$9000 more than the lower risk patient cohorts. These high-risk patients were also more likely to develop inpatient complications and require higher levels of care.

CONCLUSION

This analysis of a 2-year cohort of patients who would qualify for the BPCI Advanced hip and femur procedure bundle demonstrates that the STTGMA tool can be used to identify high-risk patients who fall outside the bundle.

Locking Plate Fixation in a Series of Bicondylar Tibial Plateau Fractures Raises Treatment Costs Without Clinical Benefit

OBJECTIVES

To compare outcomes and costs between locking and nonlocking (NL) constructs in the treatment of bicondylar tibial plateau (BTP) fractures.

DESIGN

Retrospective cohort study.

SETTING

Level 1 academic trauma center.

PATIENTS

All patients who presented with complete articular, BTP fractures OTA/AO 41-C and Schatzker VI between 2013 and 2015 were screened (n = 112). Patients treated with a mode of fixation other than plate-and-screw were excluded. Fifty-six patients with a minimum follow-up of 12 months were included in the analysis.

INTERVENTION

Operative fixation of BTP fractures with locking (n = 29) or NL (n = 27) implants.

MAIN OUTCOME MEASUREMENTS

Implant cost, patient-reported outcomes (PROMIS physical function and pain interference), clinical, and radiographic outcomes.

RESULTS

There were no differences between the 2 groups with respect to demographics, injury characteristics, radiographic outcomes (change in alignment), or clinical outcomes (PROMIS, reoperation, nonunion, and infection). Implant costs were significantly greater in the locking group compared with the NL group (mean L, $4453; mean NL, $2569; P < 0.01).

CONCLUSIONS

This study demonstrated improved value of treatment (less cost with no difference in clinical outcome) with NL implants for BTP fractures when dual-plate fixation strategies are performed.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Use of Oral Anticoagulants at the Time of Admission Affect Outcomes Following Hip Fracture

PURPOSE

The purpose of this study was to compare hospital quality outcomes in patients over the age of 60 undergoing fixation of hip fracture based on their anticoagulation status.

MATERIALS AND METHODS

Patients aged 60 and older with isolated hip fracture injuries treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patients on the following medications were included in the anticoagulation cohort: warfarin, clopidogrel, aspirin 325 mg, rivaroxaban, apixaban, dabigatran, and dipyridamole/aspirin. We compared outcome measures including time to surgery, length of stay (LOS), transfusion rate, blood loss, procedure time, complication rate, need for intensive care unit (ICU)/step-down unit (SDU) care, discharge disposition, and cost of admission. Outcomes were controlled for age, Charlson comorbidity index (CCI), and anesthesia type.

RESULTS

A total of 479 hip fracture patients met the inclusion criteria, with 367 (76.6%) patients in the nonanticoagulated cohort and 112 (23.4%) patients in the anticoagulated cohort. The mean LOS and time to surgery were longer in the anticoagulated cohort (8.3 vs 7.3 days, P = .033 and 1.9 vs 1.6 days, P = .010); however, after controlling for age, CCI, and anesthesia type, these differences were no longer significant. Surgical outcomes were equivalent with similar procedure times, blood loss, and need for transfusion. The mean number of complications developed and inpatient mortality rate in the 2 cohorts were similar; however, more patients in the anticoagulated cohort required ICU/SDU-level care (odds ratio = 2.364, P = .001, controlled for age, CCI, and anesthesia). There was increased utilization of post-acute care in the anticoagulated cohort, with only 10.7% of patients discharged home compared to 19.9% of the nonanticoagulated group (P = .026). Lastly, there was no difference in cost of care.

CONCLUSION

This study highlights that anticoagulation status alone does not independently put patients at increased risk with respect to LOS, surgical outcomes, and cost of hospitalization.

Costs and Risk Factors for Hospital Readmission After Periprosthetic Knee Fractures in the United States

BACKGROUND

Periprosthetic fractures (PPFX) around total knee arthroplasty (TKA) are devastating complications with significant morbidity. With growing healthcare costs, hospital readmissions have become a marker for quality healthcare delivery. However, little is known about the risk factors or costs associated with readmission after treatment of PPFX. We sought to identify the patient demographics, prevalence of treatment types (open reduction internal fixation [ORIF] vs revision TKA), 30 and 90-day readmission rates, costs of initial treatment and readmission, and risk factors for readmission.

METHODS

We used the 2013 Nationwide Readmissions Database to select patients who underwent TKA, revision TKA, and treatment of PPFX with either ORIF or revision TKA. The 90-day readmission rate was determined through a survival analysis, and risk factors were identified using a cox proportional hazards model that adjusted for patient and hospital characteristics.

RESULTS

We identified 1526 patients with PPFX treated with ORIF and 1458 treated with revision TKA. Ninety-day readmissions were 20.5% and 21.8%, respectively. Patients with ORIF were more often female and had multiple medical comorbidities. Patient factors associated with readmission included advanced age, male gender, comorbidities, discharge to a skilled nursing facility or home with health aide, and Medicare or Medicaid insurance. Treatment at a teaching hospital was the only hospital-associated risk factor identified. ORIF cost USD 25,539 and revision THA cost USD 37,680, with associated readmissions costing 15,269 and 16,806, respectively.

CONCLUSION

PPFX results in greater costs compared to primary and revision TKA. This study highlights risk factors for readmission after PPFX treatment.

Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue

OBJECTIVES

We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay.

DESIGN

Prospective consecutive series.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0.

INTERVENTION

Femur, pelvis, or spine fractures treated surgically.

MAIN OUTCOME MEASUREMENTS

Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded.

RESULTS

Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days).

CONCLUSIONS

Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.