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How does deprivation influence secondary care costs after hip fracture?

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Abstract

Summary

We studied the association between deprivation and healthcare costs after hip fracture. Hospital costs in the year following hip fracture were £1120 higher for those living in more deprived areas. Most of this difference was explained by pre-existing health inequalities which should be targeted to reduce this disparity.

Introduction

To quantify differences in hospital costs following hip fracture between those living in higher and lower deprivation areas of England, we investigate pre- and post-fracture variables that explain the association.

Methods

We used English Hospital Episodes Statistics linked to the National Hip Fracture Database (April 2011–March 2015) and national mortality data to identify patients admitted with hip fracture aged 60+ years. Hospital care was costed using 2017/2018 national reference costs, by index of multiple deprivation quintile. Three generalised linear model regressions estimated associations between deprivation and costs and the pre- and post-fracture variables that mediate this relationship.

Results

Patients from the most deprived areas had higher hospital costs in the year post-fracture (£1,120; 95% CI £993 to £1,247) than those from the least deprived areas. If all patients could have incurred similar costs to those in the least deprived quintile, this would equate to an annual reduction in expenditure of £28.8 million. Pre-fracture characteristics, particularly comorbidities and anaesthetic risk grade, accounted for approximately 50% of the association between deprivation and costs. No evidence was found that post-fracture variables, such as transfer to a residential or nursing home, contributed to the association between deprivation and costs.

Conclusions

Socioeconomic inequalities are associated with substantial costs for the NHS after hip fracture. We did not identify post-fracture targets for intervention to reduce the impact of inequalities on post-fracture costs. The case for interventions to reduce comorbid conditions, improve health-related behaviours and prevent falls in deprived areas is clear but challenging to implement.

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References

  1. Bunning T, Dickinson R, Fagan E, Inman D, Johansen A, Judge A, Hannaford J, Liddicoat M, Wakeman R (2018) National Hip Fracture Database (NHFD) annual report September 2018. Healthcare quality improvement partnership 2018. https://nhfd.co.uk/. Accessed 2 December 2019

  2. Leal J, Gray AM, Prieto-Alhambra D, Arden NK, Cooper C, Javaid MK, Judge A (2016) Impact of hip fracture on hospital care costs: a population-based study. Osteoporos Int 27:549–558

    Article  CAS  Google Scholar 

  3. Lambrelli D, Burge R, Raluy-Callado M, Chen SY, Wu N, Schoenfeld MJ (2014) Retrospective database study to assess the economic impact of hip fracture in the United Kingdom. J Med Econ 17:817–825

    Article  Google Scholar 

  4. Asaria M, Doran T, Cookson R (2016) The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighborhood deprivation. J Epidemiol Community Health 70:990–996

    Article  Google Scholar 

  5. Jayatunga W, Asaria M, Belloni A, George A, Bourne T, Sadique Z (2019) Social gradients in health and social care costs: analysis of linked electronic health records in Kent, UK. Public Health 169:188–194

    Article  CAS  Google Scholar 

  6. Bhimjiyani A (2019) Social and regional inequalities in the incidence of and outcomes after hip fracture in England. Dept Translational Health Sciences. University of Bristol, Bristol Medical School Thesis Repositoty

  7. World Health Orginisation (2016) International statistical classification of diseases and related health problems.5th. World Health Organization

  8. Smith T, Noble M, Noble S, Wright G, McLennan D, Plunkett E (2015) The English indices of deprivation 2015. Crown, Department for Communities and Local Government

  9. NHS Digital (2018) HES Data dictionary admitted patient care. Health and Social Care Information Centre

  10. NHS Digital (2017/18) HRG4+ 2017/18 Refrence Cost Grouper

  11. NHS Improvement (2017/18) National schedule of reference costs

  12. Armitage JN, van der Meulen JH (2010) Identifying co-morbidity in surgical patients using administrative data with the Royal College of Surgeons Charlson Score. Br J Surg 97:772–781

    Article  CAS  Google Scholar 

  13. Mayhew D, Mendonca V, Murthy BVS (2019) A review of ASA physical status - historical perspectives and modern developments. Anaesthesia 74:373–379

    Article  CAS  Google Scholar 

  14. Partha D, Norton EC, Manning WG (2017) Health econometrics using Stata. Stata Press, College Station

    Google Scholar 

  15. Spiess AN, Neumeyer N (2010) An evaluation of R2 as an inadequate measure for nonlinear models in pharmacological and biochemical research: a Monte Carlo approach. BMC Pharmacol 10:6

    Article  Google Scholar 

  16. Wang Z (2007) Two postestimation commands for assessing confounding effects in epidemiological studies. Stata J 7:183–196

    Article  Google Scholar 

  17. Castelli A, Daidone S, Jacobs R, Kasteridis P, Street AD (2015) The determinants of costs and length of stay for hip fracture patients. PLoS One 10:e0133545

    Article  Google Scholar 

  18. Greenland S (2001) Ecologic versus individual-level sources of bias in ecologic estimates of contextual health effects. Int J Epidemiol 30:1343–1350

    Article  CAS  Google Scholar 

  19. HES Data Quality Team (2016) Data Quality checks performed on SUS and HES Data. Information and Analytics. NHS Digital

  20. Leslie WD, Lix LM, Finlayson GS, Metge CJ, Morin SN, Majumdar SR (2013) Direct healthcare costs for 5 years post-fracture in Canada: a long-term population-based assessment. Osteoporos Int 24:1697–1705

    Article  CAS  Google Scholar 

  21. Kates SL, Shields E, Behrend C, Noyes KK (2015) Financial implications of hospital readmission after hip fracture. Geriatr Orthop Surg Rehabil 6:140–146

    Article  Google Scholar 

  22. Schousboe JT, Paudel ML, Taylor BC, Kats AM, Virnig BA, Dowd BE, Langsetmo L, Ensrud KE (2017) Pre-fracture individual characteristics associated with high total health care costs after hip fracture. Osteoporos Int 28:889–899

    Article  CAS  Google Scholar 

  23. Kroll LE, Lampert T (2013) Direct costs of inequalities in health care utilization in Germany 1994 to 2009: a top-down projection. BMC Health Serv Res 13:271

    Article  Google Scholar 

  24. de Boer WIJ, Buskens E, Koning RH, Mierau JO (2019) Neighborhood socioeconomic status and health care costs: a population-wide study in the Netherlands. Am J Public Health 109:927–933

    Article  Google Scholar 

  25. Bhimjiyani A, Neuburger J, Jones T, Ben-Shlomo Y, Gregson CL (2018) The effect of social deprivation on hip fracture incidence in England has not changed over 14 years: an analysis of the English hospital episodes statistics (2001-2015). Osteoporos Int 29:115–124

    Article  CAS  Google Scholar 

  26. Selbie D (2019) Turning the tide on tobacco: smoking in England hits a new low. Public Health Matters. GOV.UK, Public Health England

  27. Public Health England (2018) Local alcohol profiles for England. https://fingertips.phe.org.uk/profile/local-alcohol-profiles. Accessed 2 December 2019

  28. Marmot M, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M, Geddes I (2010) Fair Society, Healthy Lives. Strategic Review of Health Inequalities in England post-2010. Institute of Health Equity

  29. Edwards BJ, Bunta AD, Simonelli C, Bolander M, Fitzpatrick LA (2007) Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res 461:226–230

    PubMed  Google Scholar 

  30. Port L, Center J, Briffa NK, Nguyen T, Cumming R, Eisman J (2003) Osteoporotic fracture: missed opportunity for intervention. Osteoporos Int 14:780–784

    Article  Google Scholar 

  31. Compston J, Cooper A, Cooper C et al (2017) UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 12:43

    Article  CAS  Google Scholar 

  32. Neil Gittoes AM, Cooper A, Dockery F, Davenport G, Goodwin V, Hui A, Long Z, Mitchell P, Jha P, Poulton S, Stephenson S, Thurston A (2015) Effective secondary prevention of fragility fractures: clinical standards for fracture liaison services clinical standards. National Osteoporosis Society.

  33. Bhimjiyani A, Neuburger J, Jones T, Ben-Shlomo Y, Gregson CL (2018) Inequalities in hip fracture incidence are greatest in the North of England: regional analysis of the effects of social deprivation on hip fracture incidence across England. Public Health 162:25–31

    Article  CAS  Google Scholar 

  34. Royal College of Physicians (2019) Fracture liaison service database Commissioner’s report 2019. RCP, London

    Google Scholar 

  35. Davies SC (2019) Annual Report of the Chief Medical Officer, 2019: Health, our global assest- partnering for progress Department for Health and Social Care

  36. Severgnini C (2014) Life with osteoporosis: the untold story. National Osteoporosis Society

  37. Holt-Lunstad J, Smith TB, Layton JB (2010) Social relationships and mortality risk: a meta-analytic review. PLoS Med 7:e1000316

    Article  Google Scholar 

  38. Jopling K (2015) Promising approaches to reducing loneliness and isolation in later life. Age UK Campaign to End Loneliness. https://www.campaigntoendloneliness.org. Accessed 2 December 2019

  39. National Institute for Health and Care Excellence (NICE) (2017) Hip fracture: management: clinical guideline [CG124]. NICE, Manchester

    Google Scholar 

  40. Perry DC, Metcalfe D, Griffin XL, Costa ML (2016) Inequalities in use of total hip arthroplasty for hip fracture: population based study. BMJ 353:i2021

    Article  Google Scholar 

  41. Auais M, Al-Zoubi F, Matheson A, Brown K, Magaziner J, French SD (2019) Understanding the role of social factors in recovery after hip fractures: a structured scoping review. Health Soc Care Community 27:1375–1387

    Article  Google Scholar 

  42. Freburger JK, Holmes GM, Ku LJ (2012) Postacute rehabilitation care for hip fracture: who gets the most care? J Am Geriatr So 60:1929–1935

    Article  Google Scholar 

  43. Seitz DP, Gill SS, Austin PC, Bell CM, Anderson GM, Gruneir A, Rochon PA (2016) Rehabilitation of older adults with dementia after hip fracture. J Am Geriatr Soc 64:47–54

    Article  Google Scholar 

  44. Neuburger J, Harding KA, Bradley RJ, Cromwell DA, Gregson CL (2014) Variation in access to community rehabilitation services and length of stay in hospital following a hip fracture: a cross-sectional study. BMJ Open 4:e005469

    Article  Google Scholar 

  45. Sheehan KJ, Fitzgerald L, Hatherley S, Potter C, Ayis S, Martin FC, Gregson CL, Cameron ID, Beaupre LA, Wyatt D, Milton-Cole R, DiGiorgio S, Sackley C (2019) Inequity in rehabilitation interventions after hip fracture: a systematic review. Age Ageing 48:489–497

    Article  CAS  Google Scholar 

  46. Ben-Shlomo Y, Cooper R, Kuh D (2016) The last two decades of life course epidemiology, and its relevance for research on ageing. Int J Epidemiol 45:973–988

    Article  Google Scholar 

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Acknowledgements

We are grateful to NHS Digital, the Royal Collage of Physician’s Falls and Fragility Fracture Audit Programme and the Office of National Statistics for providing the data used in this study and to Crown for extracting and supplying the data. The views expressed in this publication are those of the authors and do not necessarily reflect those of the NHS or the Department of Health and Social Care. This publication is based on data collected by or on behalf of the Healthcare Quality Improvement Partnership, who have no responsibility or liability for the accuracy, currency, reliability and/or correctness of this publication.

Funding

This study was funded by the Royal Osteoporosis Society (formerly the National Osteoporosis Society). The funders had no role in the study design, analysis or reporting.

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Authors and Affiliations

  1. Health Economics at Bristol, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK

    J. Glynn & W. Hollingworth

  2. Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK

    A. Bhimjiyani & C.L. Gregson

  3. Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

    Y. Ben-Shlomo

Authors
  1. J. Glynn
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  2. W. Hollingworth
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  3. A. Bhimjiyani
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  4. Y. Ben-Shlomo
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  5. C.L. Gregson
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Correspondence to J. Glynn.

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Glynn, J., Hollingworth, W., Bhimjiyani, A. et al. How does deprivation influence secondary care costs after hip fracture?. Osteoporos Int 31, 1573–1585 (2020). https://doi.org/10.1007/s00198-020-05404-1

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