Impact of structural and economic factors on hospitalization costs, inpatient mortality, and treatment type of traumatic hip fractures in Switzerland

Unplanned hospital admissions due to secondary health conditions after spinal cord injury: a population-based description of determinants of length of stay

STUDY DESIGN

Population-based prospective study.

OBJECTIVES

To provide a population-based description of length of stay (LOS) and person-related risk factors following unplanned hospital admission due to a secondary health condition (SHC) in persons with spinal cord injury (SCI).

SETTING

Specialized SCI hospital and rehabilitation center in Switzerland.

METHODS

Descriptive analysis of LOS using routine clinical data of persons with SCI, who were acutely hospitalized between 01.01.2017-30.06.2018. Multivariable regression analysis was used to derive marginal predictions of LOS by acute SHCs and person characteristics.

RESULTS

The study included 183 persons, 83% were male, and the median age was 57 years (interquartile range, IQR, 49-67 years). SCI cause was traumatic in 160 (88.4%) cases, 92 (50.3%) were persons with tetraplegia, 147 (80.3%) were classified as motor complete lesions (American Spinal Injury Association Impairment Scale (AIS) A or B) and median time since injury (TSI) was 24 (IQR 13-34) years. Median LOS was 19 (IQR 9-39) days, varying from 74 (IQR 39-92) days for pressure ulcers, 13 (IQR 8-24) days for urinary tract infections (UTI), to 27 (IQR 18-47) days for fractures. LOS was prolonged in persons with multiple co-morbidities or those developing complications during hospitalization. Sex, SCI etiology and lesion level were not associated with LOS.

CONCLUSIONS

This population-based description identified substantial variation in LOS between acute SHCs and clinical complications as the main, potentially modifiable, person-related risk factors for extended hospital stay.

Comparison of Cardiovascular Procedure Rates in Patients With Supplementary vs Basic Insurance in Switzerland

Importance

Switzerland's mandatory health insurance provides universal coverage, but residents can opt for supplementary private insurance for nonessential, nonvital amenities. It is debated whether people with supplementary private insurance receive overtreatment due to financial incentives.

Objective

To assess whether incidence rates of cardiovascular procedures in people with supplementary private insurance are higher than in those with basic insurance only.

Design, Setting, and Participants

A population-based weighted cohort comparative effectiveness study, using administrative claims data from Switzerland assessing incidence rates (IRs), was conducted in adults undergoing a nonemergency cardiovascular inpatient procedure from January 1, 2012, to December 31, 2020. Analysis included primary or secondary discharge procedure codes for 1 of the following: percutaneous transluminal coronary angioplasty (PTCA), left atrial appendage (LAA) occlusion, patent foramen ovale (PFO) closure, transcatheter aortic valve replacement (TAVR), mitral valve clip implantation, cardiac pacemaker implantation, and atrial fibrillation/atrial flutter ablation.

Exposures

Supplementary private health insurance.

Main Outcomes and Measures

Incidence rates of cardiovascular procedures between insurance groups calculated by negative binomial regression adjusted by inverse probability weights.

Results

Of 590 919 admissions (median age, 68 years; IQR, 57-77 years), 55.5% male, 15.7% non-Swiss nationality), 70.1% had basic insurance only. Independent of insurance status, IR for all cardiovascular procedures steadily increased over the study years. In general, people with supplementary private insurance received cardiovascular procedures more frequently (IR ratio [IRR], 1.11; 99% CI, 1.10-1.11) than people with basic insurance only. There was also an increase for every procedure: PTCA (IRR, 1.12; 99% CI, 1.12-1.13), LAA closure (IRR, 1.15; 99% CI, 1.13-1.16), mitral valve clip implantation (IRR, 1.08; 99% CI, 1.07-1.09), TAVR (IRR, 1.04; 99% CI, 1.03-1.06), PFO closure (IRR, 1.01; 99% CI, 1.00-1.02), pacemaker implantation (IRR, 1.08; 99% CI, 1.07-1.09), and atrial fibrillation/atrial flutter ablation (IRR, 1.12; 99% CI, 1.11-1.12). Sensitivity analyses, including side procedures, stratification by length of stay, and propensity score matching, suggested robustness of the results.

Conclusions and Relevance

This study found an association between supplementary private insurance and a higher likelihood of receiving nonemergency cardiovascular procedures. Whether this higher rate of procedures in people with supplementary private insurance is based on clinical reasoning or due to financial incentives warrants further exploration.

The Effect of Additional Private Health Insurance on Mortality in the Context of Universal Public Health Insurance

(1) Background: Korea operates its national health insurance (NHI) system as a form of public health insurance, and is commonly regarded as having achieved universal health coverage (UHC). However, many Korean households register for additional private health insurance (PHI) programs. Typically, registration rates for PHI are higher for individuals with a higher socioeconomic status (SES). A difference in mortality between those with and without additional PHI would indicate that there are health inequalities within the Korean NHI system under UHC. Therefore, this study aimed to confirm whether additional PHI affects mortality under the Korean NHI system. (2) Methods: We conducted a longitudinal study using the Korean Longitudinal Study of Aging data from the first to the sixth wave. The analysis included 8743 participants, who were divided into two groups: those who only had NHI and those who had both NHI and PHI. Differences in mortality between the two groups were compared using the Cox proportional hazard regression. (3) Results: The group with both NHI and PHI had lower mortality than the group with only NHI (hazard ratio = 0.53, 95% confidence interval: 0.41, 0.9). (4) Conclusions: The results of this study reveal that there are health disparities according to SES and PHI within the Korean NHI system under UHC. Therefore, relevant government institutions and experts should further improve the NHI system to reduce health disparities.

Cognitive Impairment Level and Elderly Hip Fracture: Implications in Rehabilitation Nursing

PURPOSE

The aim of the study was to determine the cognitive impairment level influence in descriptive characteristics, comorbidities, complications, and pharmacological features of older adults with hip fracture.

DESIGN

Cross-sectional study.

METHOD

Five hundred fifty-seven older adults with hip fracture were recruited and divided into cognitive impairment levels (severe/moderate, mild, no impairment). Descriptive characteristics, comorbidities, complications, and pharmacological data were collected.

FINDINGS

Significant differences (p < .05, R = .012-.475) between cognitive impairment levels were shown. Shorter presurgery hospital length of stay and lower depression and Parkinson comorbidities; delirium complication; and antidepressants, antiparkinsonians, and neuroleptics use were shown for the no-impairment group. With regard to the cognitive impairment groups, lower presence of cardiopathy and hypertension; higher presence of dementia; antihypertensives, antiplatelets, and antidementia medication; infection/respiratory insufficiency complications; and lower constipation complications were shown.

CONCLUSION

Cognitive impairment levels may determine the characteristics, comorbidities, pharmacology, and complications of older adults with hip fracture.

CLINICAL RELEVANCE

Cognitive impairment level may impact rehabilitation nursing practice, education, and care coordination.

Trends in hip and distal femoral fracture rates in Italy from 2007 to 2017

Osteoporosis-related fractures are a growing public health concern worldwide due to high societal and economic burden. The study aims to assess trends in incidence rates of hip and distal femoral fractures and in the use of anti-osteoporosis drugs in Italy between 2007 and 2017. Patients with hip and distal femoral fractures (ICD-9-CM codes 820.x and 821.x) were identified in the Italian National Hospital Discharge Database while anti-osteoporosis medication data were retrieved from the National Observatory on the Use of Medicines Database. A joinpoint regression analysis was performed to identify the years where the trends in incidence rates of hip and distal femoral fractures changed significantly; the average annual percentage change for the period of observation was estimated. Hospitalizations for femoral fractures were 991,059, of which 91.4% were hip fractures and 76.5% occurred in women. Age-standardized hip fractures rate per 100,000 person-years decreased both in women (-8.7%; from 789.9 in 2007 to 721.5 in 2017) and in men (-4.3%; from 423.9 to 405.6), while the rate of distal femoral fractures increased by 23.9% in women (from 67.78 to 83.95) and 22.7% in men (from 27.76 to 34.06). These changes were associated with an increment in the use of anti-osteoporosis drugs from 2007 to 2011 (from 9.1 to 12.4 DDD/1000 inhabitants/day), followed by a plateau in the period 2012-2017. The use of bisphosphonates increased progressively from 2007 to 2010 (from 8.2 to 10.5 DDD/1000 inhabitants/day), followed by a plateau and then decreased from 2015 onwards. The decreasing trend of hip fractures could be related to a major intake of anti-osteoporosis medications while the increment of distal femoral fractures might be due to population aging and to the use of bisphosphonates and denosumab. Further research is needed to identify and implement interventions to prevent hip and distal femoral fractures.

Femoral fractures in the elderly in Brasil - incidence, lethality, and costs (2008-2018)

OBJECTIVES

To describe the incidence by gender and region, lethality, and costs associated with the treatment of femoral fractures in the elderly (≥ 60 years) hospitalized in the Unified Health System (SUS) of Brasil between 2008 and 2018.

METHODS

This is a cross-sectional, descriptive, retrospective study of hospitalizations of elderly people due to femoral fractures by analyzing secondary data obtained from the SUS Hospital Information System (SIH/SUS) between 2008 and 2018; for calculation of epidemiological coefficients, we used information from demographic censuses (2000 and 2010) of the Brazilian Geography and Statistics Institute (IBGE).

RESULTS

A total of 478,274 hospitalizations were recorded in the period; the incidence was 1.7 times higher in females (overall average of 274.91/100,000 for women and 161/100,000 for men). The Southeast region had the highest absolute number of hospitalizations and the South region presented the highest annual overall average incidence (224.02/100,000). The average annual cost for SUS for the treatment of femoral fractures in the elderly was R$ 99,718,574.30.

CONCLUSIONS

In the evaluated period (2008-2018), femoral fractures in the elderly had a high incidence (478,274 hospitalizations; 224.02 cases/100,000 elderly), a predominance of females (1.7F/1.0M), a higher absolute number of hospitalizations in the Southeast region and a higher incidence in the South region; the lethality was high (an increase of 17.46%; overall mean coefficient of 4.99%/year); and the costs for the SUS were huge (an increase of 126.24%; average annual expenditure of R$ 99,718,574.30).

Functionality, comorbidity, complication & surgery of hip fracture in older adults by age distribution

BACKGROUND

Hip fractures may be the greatest complication secondary to osteoporotic disorder. The objective of this study was to determine the influence of age distribution in the functionality, comorbidity, complications and surgical features of older adults with hip fractures.

METHODS

A prospective cohort study was carried out from 2013 to 2014. A sample of 557 adults over 75 years old with osteoporotic hip fractures was recruited from the Orthogeriatric Unit of the León University Hospital (Spain). Age distributions of 75-84, 85-90 and >90 years old were considered. Firstly, sociodemographic data, fracture type and hospital staying days were collected. Secondly, baseline functionality (Barthel index), ambulation, cognitive impairment and comorbidities were described. Thirdly, surgical intervention, urgency, type, American Association of Anesthesiologists (ASA) scores, non-surgical cause, and baseline pharmacologic treatments were determined. Finally, complications and features at hospital discharge were observed.

RESULTS

The age ranges did not show any statistically-significant differences (P<.05; R2=.000-.005) for gender, fracture type, or number of hospital staying days. Statistically-significant differences (P<.05; R2=.011-.247) between age groups were observed for Barthel index, cognitive impairment, dementia, osteoporosis, Parkinson's disease, aortic stenosis, surgery type, ASA-score, non-surgical cause, benzodiazepines, antidementia, anti-osteoporosis, insulin, pharmacologic treatments, renal function alteration, heart failure, destination and ambulation features. All other measurements did not show statistically-significant differences (P>.05; R2=.000-.010).

CONCLUSION

Age distributions greater than 75 years old may determine the functionality, comorbidities, surgical features, baseline pharmacologic treatments, complications and features at hospital discharge for older adults who suffer a hip fracture.

Comparison of functional outcome of bipolar hip arthroplasty and total hip replacement in displaced femoral neck fractures in elderly in a developing country: a 2-year prospective study

PURPOSE

To compare the short-term functional outcome between bipolar hip arthroplasty (BHA) and total hip replacement (THR) in displaced femoral neck fractures in elderly patients in a developing country.

MATERIALS AND METHODS

A prospective study was conducted which included a total of 42 patients of age more than 60 years with closed displaced femoral neck fractures, and the patients were randomized into two groups of 21 patients each and their outcomes were compared.

RESULTS

At 24-month follow-up, patients in BHA group had a mean modified Harris hip score of 83.85 ± 6.62 and patients in THR group had a mean modified Harris hip score of 88.00 ± 5.76 (p value = 0.067). Seven (35%) patients in BHA group and 11 (55%) patients in THR group had hip scores from 91 to 100 (excellent), 9 (45%) patients in BHA and seven patients (35%) in THR had hip scores 81-90 (fair) and 4 (20%) patients in BHA group and 2 (10%) patients in THR group were rated 71-80 (good) and none was found in poor category. Total amount of blood  loss while performing BHA was 238.15 ± 20.43 ml compared to 336.85 ± 23.56 ml in THR (p < 0.0001). Mean of total duration of surgery was found to be 51.80 ± 8.70 min in BHA group which was significantly lesser than 119.10 ± 16.75 min of THR group (p < 0.0001).

CONCLUSION

BHA being comparable to THR in terms of functional outcome by modified Harris hip scoring with significantly less blood loss during surgery, less duration of surgery, more cost-effective can be recommended as first line of surgical management in elderly patients with displaced femur neck fractures in developing countries.

LEVEL OF EVIDENCE

Level II, lesser-quality randomized controlled trial.

[Not Available]

Zusammenfassung. Diagnose-bezogene Fallgruppen, DRGs, sind eines der seit den 1960er in den USA entwickelten und erstmals 1983 zu Abrechnungszwecken eingeführten Patientenklassifikationssysteme, die den Anspruch erheben, klinisch ähnliche Fälle, die ähnlich teuer sind, zwecks einer erhöhten Vergleichbarkeit zusammenzufassen. Die Hauptziele, welche mit der Einführung von DRGs zu Abrechnungszwecken verfolgt werden, sind einerseits eine Erhöhung der Transparenz der erbrachten Leistungen, sowie andererseits eine Steigerung der Effizienz durch die pauschale Rückvergütung des durchschnittlichen Aufwands der Fälle der selben DRG. In der Schweiz werden seit 2012 sämtliche stationäre, akut-somatische Fälle über DRGs abgerechnet. Obwohl einige Befürchtungen nicht objektiviert werden konnten, haben sich andere bestätigt.