Demographic issues in Medicare reform

Risk factors and clinical outcomes of delirium in osteoporotic hip fractures

PURPOSE

This study is performed to identify risk factors for delirium in osteoporotic hip fractures and to evaluate the hospitalization cost and clinical outcomes of delirium in osteoporotic hip.

METHODS

A total of 221 patients with osteoporotic hip fractures were assessed for eligibility between 2010 and 2014. Among them, 37 patients with delirium were allocated into the delirium group (group D) and 37 patients without delirium were allocated into the non-delirium group (group ND) by matching demographic factors. Risk factors such as time between admission and operation, body mass index, American Society of Anesthesiologists status, cognitive impairment, preoperative urinary catheter, electrolyte imbalance, preoperative hemoglobin, polymedication (medications > 5), pneumonia, anesthesia time, operation time, estimated blood loss, and total amount of transfusion were evaluated for correlation with incidence of delirium. The hospitalization cost was evaluated, and clinical outcomes such as readmission, mortality, and activity level at 1-year follow-up were evaluated.

RESULTS

In multivariate analysis, polymedication ( p = 0.028) and preoperative indwelling urinary catheter insertion status ( p = 0.007) were related to the incidence of delirium in patients with osteoporotic hip fractures. Group D showed a significantly higher hospitalization cost compared to group ND. However, delirium did not have a significant effect on length of hospital stay, readmission rate, postoperative 1-year mortality, and activity level.

CONCLUSIONS

Polymedication and preoperative urinary catheter were related to perioperative delirium. In addition, delirium in osteoporotic hip fractures may not have a detrimental effect on clinical outcomes; however, hospitalization cost seemed to be increased due to delirium.

The value of an organized fracture program for the elderly: early results

OBJECTIVES

To describe the early financial results of an organized hip fracture program for older adults.

DESIGN

Retrospective evaluation of financial data for a 1-year period on a hip fracture program for older adults.

SETTING

University medical center.

PATIENTS

All 193 adults older than age 60 with a native, nonpathologic hip fracture admitted to the hospital and surgically treated from May 2005 to April 2006 were included as subjects in this study.

INTERVENTION

The comanaged, protocol-driven fracture management program was used as the specific intervention for treating all patients with hip fractures.

MAIN OUTCOME MEASURE

The primary outcome was profit or loss resulting from treatment of patients. Key quality measures studied included length of hospital stay, mortality rates, complication rates, and hospital readmission rates.

RESULTS

With use of an organized program, substantial savings in nearly all areas of expenditure is demonstrated. Adjusting for patient characteristics, costs are demonstrated to be 66.7% of the expected costs nationally. The length of stay, mortality, complication rates, and readmission rates were all noted to be below national averages.

CONCLUSIONS

The improved quality measures suggest that better quality of patient care is associated with reduced costs.

Early infection after hip fracture surgery: risk factors, costs and outcome

Prospective data on hip fracture from 3686 patients at a United Kingdom teaching hospital were analysed to investigate the risk factors, financial costs and outcomes associated with deep or superficial wound infections after hip fracture surgery. In 1.2% (41) of patients a deep wound infection developed, and 1.1% (39) had a superficial wound infection. A total of 57 of 80 infections (71.3%) were due to Staphylococcus aureus and 39 (48.8%) were due to MRSA. No statistically significant pre-operative risk factors were detected. Length of stay, cost of treatment and pre-discharge mortality all significantly increased with deep wound infection. The one-year mortality was 30%, and this increased to 50% in those who developed an infection (p < 0.001). A deep infection resulted in doubled operative costs, tripled investigation costs and quadrupled ward costs. MRSA infection increased costs, length of stay, and pre-discharge mortality compared with non-MRSA infection.

Estimating hip fracture morbidity, mortality and costs

OBJECTIVES

To estimate lifetime morbidity, mortality, and costs from hip fracture incorporating the effect of deficits in activities of daily living.

DESIGN

Markov computer cohort simulation considering short- and long-term outcomes attributable to hip fractures. Data estimates were based on published literature, and costs were based primarily on Medicare reimbursement rates.

SETTING

Postacute hospital facility.

PARTICIPANTS

Eighty-year-old community dwellers with hip fractures.

MEASUREMENTS

Life expectancy, nursing facility days, and costs.

RESULTS

Hip fracture reduced life expectancy by 1.8 years or 25% compared with an age- and sex-matched general population. About 17% of remaining life was spent in a nursing facility. The lifetime attributable cost of hip fracture was $81,300, of which nearly half (44%) related to nursing facility expenses. The development of deficits in ADLs after hip fracture resulted in substantial morbidity, mortality, and costs.

CONCLUSION

Hip fractures result in significant mortality, morbidity, and costs. The estimated lifetime cost for all hip fractures in the United States in 1997 likely exceeded $20 billion. These results emphasize the importance of current and future interventions to decrease the incidence of hip fracture.

Adding aging and gender to the women's health agenda

The complex interaction of medical, social, and economic factors that affect women's wellness as they age requires a new paradigm that bridges the gap between those who are concerned about aging issues and those concerned about women's health. In this article, we begin this endeavor by advancing three interrelated themes: (1) there is a gendered relationship between socioeconomic structures and health over time; (2) there are gender-specific implications of health care financing and policy; and (3) there are health consequences to the gendered nature of caregiving.

Medicare: what's right? What's wrong? What's next?

Although future Medicare costs are highly uncertain, reasonable projections of those costs suggest a major financing problem. The Balanced Budget Act of 1997 will provide temporary relief, although it introduced some new problems, including its geographic adjustment of Medicare+Choice rates. For the future we propose a premium-support system and an expanded benefits package. Such a system would provide a more flexible means to adjust the division of the financing burden between the elderly and the nonelderly, potentially gain some efficiencies from greater price competition and less reliance on administered pricing, and partly address the issue of uninsured early retirees.