Surgery for Hip Fracture Yields Societal Benefits That Exceed the Direct Medical Costs
A hip fracture is a debilitating condition that consumes significant resources in the United States. Surgical treatment of hip fractures can achieve better survival and functional outcomes than nonoperative treatment, but less is known about its economic benefits.
We asked: (1) Are the societal benefits of hip fracture surgery enough to offset the direct medical costs? (2) Nationally, what are the total lifetime benefits of hip fracture surgery for a cohort of patients and to whom do these benefits accrue?
We estimated the effects of surgical treatment for displaced hip fractures through a Markov cohort analysis of patients 65 years and older. Assumptions were obtained from a systematic literature review, analysis of Medicare claims data, and clinical experts. We conducted a series sensitivity analyses to assess the effect of uncertainty in model parameters on our estimates. We compared costs for medical care, home modification, and long-term nursing home use for surgical and nonoperative treatment of hip fractures to estimate total societal savings.
Estimated average lifetime societal benefits per patient exceeded the direct medical costs of hip fracture surgery by USD 65,000 to USD 68,000 for displaced hip fractures. With the exception of the assumption of nursing home use, the sensitivity analyses show that surgery produces positive net societal savings with significant deviations of 50% from the base model assumptions. For an 80-year-old patient, the breakeven point for the assumption on the percent of patients with hip fractures who would require long-term nursing home use with nonoperative treatment is 37% to 39%, compared with 24% for surgical patients. Nationally, we estimate that hip fracture surgery for the cohort of patients in 2009 yields lifetime societal savings of USD 16 billion in our base model, with benefits and direct costs of USD 21 billion and USD 5 billion, respectively. For an 80-year-old, societal benefits ranged from USD 2 billion to USD 32 billion, using our range of estimates for nursing home use among nonoperatively treated patients who are immobile after the fracture.
Surgical treatment of hip fractures produces societal savings. Although the magnitude of these savings depends on model assumptions, the finding of societal savings is robust to a range of parameter values.
Level of Evidence
Level III, economic and decision analyses. See the Instructions for Authors for a complete description of levels of evidence.
- Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma. 2001;15:394–400. CrossRef
- Agency for Healthcare Research and Quality. Calculating the U.S. population-based EQ-5D™ index score. Available at: http://www.ahrq.gov/rice/EQ5Dscore.htm. Accessed April 23, 2012.
- Agency for Healthcare Research and Quality. National and regional estimates on hospital use for all patients from the HCUP Nationwide Inpatient Sample (NIS). Available at: http://hcupnet.ahrq.gov/HCUPnet.jsp. Accessed July 26, 2012.
- Arias E. United States life tables, 2007. Natl Vital Stat Rep. 2011;59:1–60.
- Bentler S, Liu L, Obrizan M, Cook EA, Wright KB, Geweke JF, Chrischilles EA, Pavlik CE, Wallace RB, Ohsfeldt RL, Jones MP, Rosenthal GE, Wolinsky FD. The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol. 2009;170:1290–1299. CrossRef
- Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc. 2003;51:364–370. CrossRef
- Centers for Medicare and Medicaid Services. Market Basket Data. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/MarketBasketData.html. Accessed July 20, 2012.
- Chan L, Beaver S, MacLehose RF, Jha A, Maciejewski M, Doctor JN. Disability and health care costs in the Medicare population. Arch Phys Med Rehabil. 2002;83:1196–1201. CrossRef
- Chang RW, Pellissier JM, Hazen G. A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA. 1996;275:858–865. CrossRef
- Ekström W, Miedel R, Ponzer S, Hedström M, Samnegård E, Tidermark J. Quality of life after a stable trochanteric fracture: a prospective cohort study on 148 patients. J Orthop Trauma. 2009;23:39–44. CrossRef
- Giversen IM. Time trends of mortality after first hip fractures. Osteoporos Int. 2007;18:721–732. CrossRef
- Gregory JJ, Kostakopoulou K, Cool WP, Ford DJ. One-year outcome for elderly patients with displaced intracapsular fractures of the femoral neck managed non-operatively. Injury. 2010;41:1273–1276. CrossRef
- Haentjens P, Magaziner J, Colón-Emeric CS, Vanderschueren D, Milisen K, Velkeniers B, Boonen S. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152:380–390. CrossRef
- Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev. 2008;3:CD000337.
- Health and Retirement Study, 2010 Final Release public use dataset. Produced and distributed by the University of Michigan with funding from the National Institute on Aging (grant number NIA U01AG009740). Ann Arbor, MI. http://hrsonline.isr.umich.edu. Accessed July 20, 2012.
- Heetveld MJ, Rogmark C, Frihagen F, Keating J. Internal fixation versus arthroplasty for displaced femoral neck fractures: what is the evidence? J Orthop Trauma. 2009;23:395–402. CrossRef
- Holt G, Smith R, Duncan K, Hutchison JD, Gregori A. Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit. J Bone Joint Surg Br. 2008;90:480–483. CrossRef
- Hossain M, Neelapala V, Andrew JG. Results of non-operative treatment following hip fracture compared to surgical intervention. Injury. 2009;40:418–421. CrossRef
- Jain R, Basinski A, Kreder HJ. Nonoperative treatment of hip fractures. Int Orthop. 2003;27:11–17.
- Johnston AT, Barnsdale L, Smith R, Duncan K, Hutchison JD. Change in long-term mortality associated with fractures of the hip: evidence from the Scottish hip fracture audit. J Bone Joint Surg Br. 2010;92:989–993. CrossRef
- Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 Overview. Vital Health Statistics. National Center for Health Statistics, Hyattsville, MD. Available at: http://www.cdc.gov/nchs/data/series/sr_13/sr13_167.pdf. Accessed May 27, 2014.
- Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty: treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006;88:249–260. CrossRef
- Maestas N. Back to work: expectations and realizations of work after retirement. J Hum Resour. 2010;45:718–748. CrossRef
- Magaziner J, Hawkes W, Hebel JR, Zimmerman SI, Fox KM, Dolan M, Felsenthal G, Kenzora J. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci. 2000;55:M498–M507. CrossRef
- Marks R, Allegrante JP, Ronald MacKenzie C, Lane JM. Hip fractures among the elderly: causes, consequences and control. Ageing Res Rev. 2003;2:57–93. CrossRef
- MetLife Mature Market Institute. Market Survey of Long-Term Care Costs. The 2011 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs. New York, NY: MetLife Mature Market Institute; October 2011.
- Miedel R, Ponzer S, Törnkvist H, Söderqvist A, Tidermark J. The standard Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric fractures. A randomised, controlled trial. J Bone Joint Surg Br. 2005;87:68–75.
- Ooi LH, Wong TH, Toh CL, Wong HP. Hip fractures in nonagenarians: a study on operative and non-operative management. Injury. 2005;36:142–147. CrossRef
- Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010;9:CD000093.
- Raaymakers EL, Marti RK. Non-operative treatment of impacted femoral neck fractures: a prospective study of 170 cases. J Bone Joint Surg Br. 1991;73:950–954.
- Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fracture of femur: 13 year results of a prospective randomised study. Injury. 2000;31:793–797. CrossRef
- Schneider EL, Guralnik JM. The aging of America: impact on health care costs. JAMA. 1990;263:2335–2340. CrossRef
- Schrøder HM, Erlandsen M. Age and sex as determinants of mortality after hip fracture: 3,895 patients followed for 2.5–18.5 years. J Orthop Trauma. 1993;7:525–531. CrossRef
- Scott JC. Osteoporosis and hip fractures. Rheum Dis Clin North Am. 1990;16:717–740.
- Slover J, Hoffman MV, Malchau H, Tosteson AN, Koval KJ. A cost-effectiveness analysis of the arthroplasty options for displaced femoral neck fractures in active, healthy, elderly population. J Arthroplasty. 2009;24:854–860. CrossRef
- Stevens JA, Olson S. Reducing falls and resulting hip fractures among older women. MMWR Recomm Rep. 2000;49:3–12.
- Sugarman JR, Connell FA, Hansen A, Helgerson SD, Jessup MC, Lee H. Hip fracture incidence in nursing home residents and community-dwelling older people, Washington State, 1993–1995. J Am Geriatr Soc. 2002;50:1638–1643. CrossRef
- Tidermark J, Bergström G, Svensson O, Törnkvist H, Ponzer S. Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res. 2003;12:1069–1079.
- Tosteson A, Gottlieb D, Radley D, Fisher ES, Melton LJ 3rd. Excess mortality following hip fracture: the role of underlying health status. Osteoporos Int. 2007;18:1463–1472. CrossRef
- van den Bekerom MP, Hilverdink EF, Sierevelt IN, Reuling EM, Schnater JM, Bonke H, Goslings JC, van Dijk CN, Raaymakers EL. A comparison of hemiarthroplasty with total hip replacement for displaced intracapsular fracture of the femoral neck: a randomised controlled multicentre trial in patients aged 70 years and over. J Bone Joint Surg Br. 2010;92:1422–1428. CrossRef
- Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization, and functional status: a prospective study. Am J Public Health. 1997;87:398–403. CrossRef
- Surgery for Hip Fracture Yields Societal Benefits That Exceed the Direct Medical Costs
- Open Access
- Available under Open Access This content is freely available online to anyone, anywhere at any time.
Clinical Orthopaedics and Related Research®
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- Industry Sectors
- Author Affiliations
- 1. Econometrica, Inc, Bethesda, MD, USA
- 2. KNG Health Consulting LLC, 15245 Research Blvd, Suite 305, Rockville, MD, 20850, USA
- 3. Duke Orthopaedic Surgery, Durham, NC, USA
- 4. Oregon Health and Science University, Tualatin, OR, USA