Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis

Abstract

Background: Osteoporotic hip fractures are common injuries typically occurring in patients who are older and medically frail. Studies have suggested that creation of a multidisciplinary team including orthopaedic surgeons, internal medicine physicians, social workers, and specialized physical therapists, to comanage these patients can decrease complication rates, improve time to surgery, and reduce hospital length of stay; however, they have yet to achieve widespread implementation, partly owing to concerns regarding resource requirements necessary for a comanagement program.

Questions/purposes: We performed an economic analysis to determine whether implementation of a comanagement model of care for geriatric patients with osteoporotic hip fractures would be a cost-effective intervention at hospitals with moderate volume. We also calculated what annual volume of cases would be needed for a comanagement program to "break even", and finally we evaluated whether universal or risk-stratified comanagement was more cost effective.

Methods: Decision analysis techniques were used to model the effect of implementing a systems-based strategy to improve inpatient perioperative care. Costs were obtained from best-available literature and included salary to support personnel and resources to expedite time to the operating room. The major economic benefit was decreased initial hospital length of stay, which was determined via literature review and meta-analysis, and a health benefit was improvement in perioperative mortality owing to expedited preoperative evaluation based on previously conducted meta-analyses. A break-even analysis was conducted to determine the annual case volume necessary for comanagement to be either (1) cost effective (improve health-related quality of life enough to be worth additional expenses) or (2) result in cost savings (actually result in decreased total expenses). This calculation assumed the scenario in which a hospital could hire only one hospitalist (and therapist and social worker) on a full-time basis. Additionally, we evaluated the scenario where the necessary staff was already employed at the hospital and could be dedicated to a comanagement service on a part-time basis, and explored the effect of triaging only patients considered high risk to a comanagement service versus comanaging all geriatric patients. Finally, probabilistic sensitivity analysis was conducted on all critical variables, with broad ranges used for values around which there was higher uncertainty.

Results: For the base case, universal comanagement was more cost effective than traditional care and risk-stratified comanagement (incremental cost effectiveness ratios of USD 41,100 per quality-adjusted life-year and USD 81,900 per quality-adjusted life-year, respectively). Comanagement was more cost effective than traditional management as long as the case volume was more than 54 patients annually (range, 41-68 patients based on sensitivity analysis) and resulted in cost savings when there were more than 318 patients annually (range, 238-397 patients). In a scenario where staff could be partially dedicated to a comanagement service, universal comanagement was more cost effective than risk-stratified comanagement (incremental cost effectiveness of USD 2300 per quality-adjusted life-year), and both comanagement programs had lower costs and better outcomes compared with traditional management. Sensitivity analysis was conducted and showed that the level of uncertainty in key variables was not high enough to change the core conclusions of the model.

Conclusions: Implementation of a systems-based comanagement strategy using a dedicated team to improve perioperative medical care and expedite preoperative evaluation is cost effective in hospitals with moderate volume and can result in cost savings at higher-volume centers. The optimum patient population for a comanagement strategy is still being defined.

Level of evidence: Level 1, Economic and Decision Analysis.

Fig. 1

A forest plot and meta-analysis of the literature shows the reduction in length of stay after implementation of a comanagement protocol, with an average reduction in length of stay of 2.28 days (95% CI, 1.96–2.32). IV = interval value.

Fig. 2

The incremental cost-effectiveness ratio (ICER) is shown as a function of total annual patient volume. At more than 54 patients annually, the program becomes cost effective (ie, the ICER decreases below the threshold of USD 100,000 per QALY). For more than 318 cases annually, it becomes cost saving. QALY = quality-adjusted life-years.

Fig. 3

Acceptability curve results of probabilistic sensitivity analysis show that at high volume centers, comanagement is the preferred option for all levels of willingness to pay. For middle-volume centers, comanagement is more likely preferred when the willingness to pay is greater than USD 40,000 per QALY, whereas for low-volume centers, comanagement is preferred only when willingness to pay is greater than USD 100,000 per QALY. QALY = quality-adjusted life-years.

Fig. 4

The estimated cost (per case) to implement a comanagement program and its effect on incremental cost-effectiveness ratio (ICER) are shown. For low-cost programs (less than USD 1200 per case), universal comanagement is less expensive and more effective (dominant, ICER is negative). Universal comanagement remains cost effective (less than USD 100,000 per QALY) at more than USD 1200 until the cost increases to greater than USD 3600 per case, at which point a risk-stratified comanagement system is cost-effective as long as the cost of comanagement is less than USD 10,000 per case. QALY = quality-adjusted life-years.

Fig. 5

The projected improvement in length of stay (LOS) for implementation of a comanagement system and its effect on incremental cost-effectiveness ratio (ICER) are shown. For an improvement in LOS greater than 1.8 days, comanagement strategies save money while improving outcomes (ie, dominant), therefore the ICER becomes negative. Even without any improvement in LOS (0 days), universal comanagement and risk-stratified comanagement show improved health outcomes and are still cost effective, with ICERs well below the cost-effectiveness threshold of USD 100,000 per QALY. QALY = quality-adjusted life-years.