Introduction: Geriatric hip fractures are a major, costly public health issue, expected to increase in incidence and expense with the aging population. As healthcare transitions towards value-based care, understanding cost drivers of hip fracture treatment will be necessary to perform adequate risk adjustment. Historically, cost has been variable and difficult to determine. This study was purposed to identify variables that can predict the overall cost of care for geriatric intertrochanteric (IT) hip fractures and provide a better cost prediction to ensure the success of future bundled payment models. Methods: A retrospective review of operatively-managed geriatric hip fractures was performed at single urban level I academic trauma center between 2013 and 2017. Patient variables were collected via the electronic medical record (EMR) including CCI, ACCI, ASA, overall length of stay (LOS), AO/OTA fracture classification and demographics. Direct and indirect costs were calculated by activity-based costing by the hospital’s accounting software. Multivariable linear regression models evaluated which parameters predicted total inpatient cost of care. Results: The mean cost of care was $19,822, ranging from $9,128 to $64,211. Critical care comprised 16.9% of total costs, followed by implant costs (13.6%), and nursing costs (12.6%). Regression analysis identified both ASA ( p < 0.01) and ACCI ( p = 0.01) as statistically significant associative parameters, but only LOS ( r 2 = 0.77) as a strong correlative measure for inpatient care cost. Conclusion: This study found no correlation between ACCI or ASA and the total inpatient cost of care in isolated intertrochanteric geriatric hip fractures, suggesting that the inpatient episode-of-care costs cannot be accurately predicted by the patient demographics/comorbidities alone. Future bundled care payment models would have to be adjusted to account for variables beyond just patient characteristics. Level of Evidence: Diagnostic Level IV.

Geriatric hip fractures are a common and costly injury. They are expected to surge in incidence and economic burden as the population ages. With an increasing financial strain on the healthcare system, payors and providers are looking toward alternative, value-based models to contain costs. Value in healthcare is the ratio of outcomes achieved over costs incurred, and can be improved by reducing cost while maintaining or improving outcomes, or by improving outcomes while maintaining or reducing costs. Therefore, an understanding of cost, the denominator of the value equation, is essential to value-based healthcare. Because traditional hospital accounting methods do not link costs to conditions, there has been little research to date on the costs of treating geriatric hip fractures over the entire cycle of care. The aim of this article is to summarize existing costing methodologies, and in particular, to review the strengths and limitations of Time-Driven Activity-Based Costing (TDABC) in orthopaedic trauma, especially as it pertains to the needs and challenges unique to hip fracture care. TDABC determines costs at the patient-level over the entire care cycle, allowing for population variability, while simultaneously identifying cost drivers that might inform risk-stratification for future alternative payment models. Through process mapping, TDABC also reveals areas of variation or inefficiency that can be targeted for optimization, and empowers physicians by focusing on costs in the control of the provider. Although barriers remain, TDABC is well-positioned to provide transparent costing and targets to improve the value of hip fracture care

Introduction: Geriatric intertrochanteric (IT) femur fractures are a common and costly injury, expected to increase in incidence as the population ages. Understanding cost drivers will be essential for risk adjustments, and the surgeon’s choice of implant may be an opportunity to reduce the overall cost of care. This study was purposed to identify the relationship between implant type and inpatient cost of care for isolated geriatric IT fractures. Methods: A retrospective review of IT fractures from 2013-2017 was performed at an academic level I trauma center. Construct type and AO/OTA fracture classifications were obtained radiographically, and patient variables were collected via the electronic medical record (EMR). The total cost of care was obtained via time-driven activity-based costing (TDABC). Multivariable linear regression and goodness-of-fit analyses were used to determine correlation between implant costs, inpatient cost of care, construct type, patient characteristics, and injury characteristics. Results: Implant costs ranged from $765.17 to $5,045.62, averaging $2,699, and were highest among OTA 31-A3 fracture patterns (p < 0.01). Implant cost had a positive linear association with overall inpatient cost of care (p < 0.01), but remained highly variable (r2 = 0.16). Total cost of care ranged from $9,129.18 to $64,210.70, averaging $19,822, and patients receiving a sliding hip screw (SHS) had the lowest mean total cost of care at $17,077, followed by short and long intramedullary nails ($19,314 and $21,372, respectively). When construct type and fracture pattern were compared to total cost, 31-A1 fracture pattern treated with SHS had significantly lower cost than 31-A2 and 31-A3 and less variation in cost. Conclusion: The cost of care for IT fractures is poorly understood and difficult to determine. With alternative payment models on the horizon, implant selection should be utilized as an opportunity to decrease costs and increase the value of care provided to patients. Level of Evidence: Diagnostic Level IV.