We estimated the cost-effectiveness of hemiarthroplasty compared to internal fixation for elderly patients with displaced femoral neck fractures. Over 2 years, patients treated with hemiarthroplasty gained more quality-adjusted life years than patients treated with internal fixation. In addition, costs for hemiarthroplasty were lower. Hemiarthroplasty was thus cost effective.
Estimating the cost utility of hemiarthroplasty compared to internal fixation in the treatment of displaced femoral neck fractures in the elderly.
A cost-utility analysis (CUA) was conducted alongside a clinical randomized controlled trial at a university hospital in Norway; 166 patients, 124 (75%) women with a mean age of 82 years were randomized to either internal fixation (n = 86) or hemiarthroplasty (n = 80). Patients were followed up at 4, 12, and 24 months. Health-related quality of life was assessed with the EQ-5D, and in combination with time used to calculate patients’ quality-adjusted life years (QALYs). Resource use was identified, quantified, and valued for direct and indirect hospital costs and for societal costs. Results were expressed in incremental cost-effectiveness ratios.
Over the 2-year period, patients treated with hemiarthroplasty gained 0.15–0.20 more QALYs than patients treated with internal fixation. For the hemiarthroplasty group, the direct hospital costs, total hospital costs, and total costs were non-significantly less costly compared with the internal fixation group, with an incremental cost of €2,731 (p = 0.81), €2,474 (p = 0.80), and €14,160 (p = 0.07), respectively. Thus, hemiarthroplasty was the dominant treatment. Sensitivity analyses by bootstrapping supported these findings.
Hemiarthroplasty was a cost-effective treatment. Trial registration, NCT00464230.
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Health-related quality of life
Incremental cost-effectiveness ratio
Quality-adjusted life year
Parker M, Johansen A (2006) Hip fracture. BMJ 333:27–30
Johnell O, Kanis JA (2004) An estimate of the worldwide prevalence, mortality and disability associated with hip fracture. Osteoporos Int 15:897–902
Ismail AA, Pye SR, Cockerill WC, Lunt M, Silman AJ, Reeve J et al (2002) Incidence of limb fracture across Europe: results from the European Prospective Osteoporosis Study (EPOS). Osteoporos Int 13:565–571
Kanis JA, Johnell O, De Laet C, Jonsson B, Oden A, Ogelsby AK (2002) International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res 17:1237–1244
Lofthus CM, Osnes EK, Falch JA, Kaastad TS, Kristiansen IS, Nordsletten L et al (2001) Epidemiology of hip fractures in Oslo, Norway. Bone 29:413–418
Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7:407–413
Gjertsen JE, Engesaeter LB, Furnes O, Havelin LI, Steindal K, Vinje T et al (2008) The Norwegian Hip Fracture Register: experiences after the first 2 years and 15,576 reported operations. Acta Orthop 79:583–593
Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P III, Obremskey W, Koval KJ et al (2003) Internal fixation compared with arthoplasty for displaced fractures in the femoral neck. A meta-analysis. J Bone Joint Surg 85:1673–1681
Parker MJ, Gurusamy K (2006) Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev 18:CD001708
Rogmark C, Johnell O (2006) Primary arthroplasty is better than internal fixation of displaced femoral neck fractures: a meta-analysis of 14 randomized studies with 2,289 patients. Acta Orthop 77:359–367
Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE (1994) Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg Am 76:15–25
Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J (2005) Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am 87:1680–1688
Keating JF, Grant A, Masson M, Scott NW, Forbes JF (2006) 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 88:249–260
Rogmark C, Carlsson A, Johnell O, Sernbo I (2002) A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at 2 years. J Bone Joint Surg Br 84:183–188
Tidermark J, Ponzer S, Svensson O, Soderqvist A, Tornkvist H (2003) Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Joint Surg Br 85:380–388
Frihagen F, Nordsletten L, Madsen JE (2007) Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial. BMJ 335:1251–1254
Parker MJ, Myles JW, Anand JK, Drewett R (1992) Cost-benefit analysis of hip fracture treatment. J Bone Joint Surg Br 74:261–264
Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ (2001) Displaced femoral neck fractures in the elderly: outcomes and cost effectiveness. Clin Orthop Relat Res 383:229–242
Johansson T, Bachrach-Lindstrom M, Aspenberg P, Jonsson D, Wahlstrom O (2006) The total costs of a displaced femoral neck fracture: comparison of internal fixation and total hip replacement. A randomised study of 146 hips. Int Orthop Feb 30:1–6
Rogmark C, Carlsson A, Johnell O, Sembo I (2003) Costs of internal fixation and arthroplasty for displaced femoral neck fractures: a randomized study of 68 patients. Acta Orthop Scand 74:293–298
Frihagen F, Waaler GM, Madsen JE, Nordsletten L, Aspaas S, Aas E (2010) The cost of hemiarthroplasty compared to that of internal fixation for femoral neck fractures. Acta Orthop 81:446–452
EuroQol-group (2009) EQ-5D—a standardised instrument for use as a measure of health outcome. [Online]. Available from: www.euroqol.org. Accessed 11 March 2009
Dolan P, Gudex C, Kind P, Williams A (1996) The time trade-off method: results from a general population study. Health Econ 5:141–154
Tidermark J, Zethraeus N, Svensson O, Thörnkvist H, Ponzer S (2002) Femoral neck fractures in the elderly: functional outcome and quality of life according to EuroQol. Qual Life Res 11:473–481
Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GL (2005) Methods for the economic evaluation of health care programmes. Oxford University Press, New York
National Institute of Health and Clinical Excellence (2008) Guide to the methods of technology appraisal. Available from: http://www.nice.org.uk
Ministry of finance (2010) Veileder isamfunnsøkonomiske analyser (Guidelines in socioeconomic analyses). [Online]. Available from: Oslo: www.regjeringen.no/opload/FIN/Vedlegg/okstyring/Veileder_i_samfunnsokonomiske_analyser.pdf. Accessed June 2010
Champbell MK, Torgerson DJ (1999) Bootstrapping: estimating confidence intervals for cost-effectiveness ratios. Q J Med 92:177–182
Hawthorne G, Richardson J, Day NA (2001) A comparison of the Assessment of Quality of Life (AQoL) with four other generic utility instruments. Ann Med 33:358–370
Frihagen F, Grotle M, Madsen JE, Wyller TB, Mowinckel P, Nordsletten L (2008) Outcome after femoral neck fractures: a comparison of Harris Hip Score, EQ-5D and Barthel Index. Injury 39:1147–1156
Iorio R, Healy WL, Appleby D, Milligan J, Dube M (2004) Displaced femoral neck fractures in the elderly: disposition and outcome after 3- to 6-year follow-up evaluation. J Arthroplasty 19:175–179
Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev. 2010;16:CD001706.
Johansson T, Jacobsson SA, Ivarsson I, Knutsson A, Wahlström O. Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips. Acta Orthop Scand. 2000;71:597–602.
Hopley C, Stengel D, Ekkernkamp A, Wich M (2010) Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: systematic review. BMJ 340:c2332
Kenneth Nilsen, Wender Figved, Silje Aspaas, Eivind Kaare Osnes, Bjørn Robstad, Wendy Hornum, and Kirsti Hildur Nielsen who participated considerably in the collection of data.
Conflicts of interest
All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) none of the authors have support from any company for the submitted work; (2) FF and LN have received consulting and lecturing fees from OrtoMedic who markets the orthopedic implants used in this trial and that might have an interest in the submitted work in the previous 3 years; (3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and (4) GW, EA, LN, FF, and JEM have no non-financial interests that may be relevant to the submitted work.
Funding for this work was from the Norwegian Foundation for Health and Rehabilitation through the Norwegian Osteoporosis Society, South-Eastern Norway Regional Health Authority, the Norwegian Research Council, Nycomed, Smith and Nephew, and OrtoMedic. The researchers have worked independently and have not been influenced by the funders.
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Waaler Bjørnelv, G.M., Frihagen, F., Madsen, J.E. et al. Hemiarthroplasty compared to internal fixation with percutaneous cannulated screws as treatment of displaced femoral neck fractures in the elderly: cost-utility analysis performed alongside a randomized, controlled trial. Osteoporos Int 23, 1711–1719 (2012). https://doi.org/10.1007/s00198-011-1772-1