Hip Arthroplasty for Fracture vs Elective Care: One Bundle Does Not Fit All

Abstract

Background: To quantify how baseline differences in patients undergoing hip arthroplasty for fracture vs elective care potentially lead to significant differences in immediate health care outcomes and whether these differences affect feasibility of current bundled payment models.

Methods: New York Statewide Planning and Research Cooperative System database for the years 2000-2014.

Results: A total of 76,654 patients underwent total hip arthroplasty or hemiarthroplasty between 2010 and 2014; 82.8% of the sample was for elective care and 17.2% for fracture-related etiology. Fracture patients were significantly older, more likely to be female, Caucasian, reimbursed by Medicare, and receive general anesthesia. Comorbidity burden and postoperative complications were significantly higher in the fracture group, and hospital charges were significantly greater for fracture patients as compared with those of the elective cohort.

Conclusion: Patients undergoing hip arthroplasty for fracture care are significantly older and have more medical comorbidities than patients treated on an elective basis, leading to more in-hospital complications, greater length of stay, increased hospital costs, and significantly more hospital readmissions. The present bundled payment system, even with the recent modification, still unfairly penalizes hospitals that manage fracture patients and has the potential to incentivize hospitals to defer providing definitive surgical management for these patients. Future amendments to the bundled payment system should consider further separating hip arthroplasty patients based on etiology and comorbidities, allowing for a more accurate reflection of these distinct patient groups.

Keywords: Medicare; bundled payments; fracture care; nonmodifiable risk factors; optimization; orthopedic trauma.