Does Implant Selection Affect the Inpatient Cost of Care for Geriatric Intertrochanteric Femur Fractures?

Abstract

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.

Intramedullary Nailing vs Sliding Hip Screw in Trochanteric Fracture Management

“…To our knowledge, the INSITE trial is the first well-powered multicenter RCT comparing IMN with SHS fixation of trochanteric hip fractures in ambulatory patients, and our results lend support to this suggestion. Given that IMN implants cost up to 40% more than SHSs, and implants are the second highest driver of inpatient costs for these patients, there may be an economic benefit to choosing an SHS instead of the IMN …”

Trend and Economic Implications of Implant Selection in the Treatment of Intertrochanteric Hip Fractures: A Review of the American Board of Orthopaedic Surgery Database From 2007 to 2017

“…If the implant selection distributions reported by the ABOS data were extrapolated to the overall annual IT fracture incidence, this cost differential would surge to an estimated $280 million (Supplemental Digital Content 1, http://links.lww.com/ JAAOS/A637). The macroeconomic effect of implant stewardship is a clear area for cost savings in health care, 6,8,37 where implant selection is under the control of the orthopaedic surgeon. One study estimating internal cost reductions leading to a 51.2% increase in hospital savings by 2015 38 -of these, implant costs contributed to the largest amount of cost savings, with an average of $1,920.68 saved per case.…”

“…1 This incidence is increasing, creating a financial burden on the healthcare system, which has been estimated at $6 billion USD per year. [2][3][4][5][6][7][8] Surgical management continues to be the mainstay of treatment for IT fractures, with surgical implants and techniques evolving over the past 2 decades.…”

Variation of implant use in A1 and A2 trochanteric hip fractures

“…[9][10][11] This is important as SHS are considerably more cost-effective, and implant costs have a positive linear association with overall inpatient cost of care. 12 The National Institute for Health and Care Excellence (NICE) recommends that SHS should be used in preference to an IMN for A1 and A2 fractures. 8 It might therefore be expected that SHS would be used routinely and uniformly across England and Wales for the treatment of all A1 and A2 hip fractures.…”

“… 9 - 11 This is important as SHS are considerably more cost-effective, and implant costs have a positive linear association with overall inpatient cost of care. 12 …”