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Liu Y, Meng XH, Wu C, Su KJ, Liu A, Tian Q, Zhao LJ, Qiu C, Luo Z, Gonzalez-Ramirez MI, Shen H, Xiao HM, Deng HW. Variability in performance of genetic-enhanced DXA-BMD prediction models across diverse ethnic and geographic populations: A risk prediction study. PLoS Med 2024; 21:e1004451. [PMID: 39213443 PMCID: PMC11404845 DOI: 10.1371/journal.pmed.1004451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 09/16/2024] [Accepted: 07/23/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Osteoporosis is a major global health issue, weakening bones and increasing fracture risk. Dual-energy X-ray absorptiometry (DXA) is the standard for measuring bone mineral density (BMD) and diagnosing osteoporosis, but its costliness and complexity impede widespread screening adoption. Predictive modeling using genetic and clinical data offers a cost-effective alternative for assessing osteoporosis and fracture risk. This study aims to develop BMD prediction models using data from the UK Biobank (UKBB) and test their performance across different ethnic and geographical populations. METHODS AND FINDINGS We developed BMD prediction models for the femoral neck (FNK) and lumbar spine (SPN) using both genetic variants and clinical factors (such as sex, age, height, and weight), within 17,964 British white individuals from UKBB. Models based on regression with least absolute shrinkage and selection operator (LASSO), selected based on the coefficient of determination (R2) from a model selection subset of 5,973 individuals from British white population. These models were tested on 5 UKBB test sets and 12 independent cohorts of diverse ancestries, totaling over 15,000 individuals. Furthermore, we assessed the correlation of predicted BMDs with fragility fractures risk in 10 years in a case-control set of 287,183 European white participants without DXA-BMDs in the UKBB. With single-nucleotide polymorphism (SNP) inclusion thresholds at 5×10-6 and 5×10-7, the prediction models for FNK-BMD and SPN-BMD achieved the highest R2 of 27.70% with a 95% confidence interval (CI) of [27.56%, 27.84%] and 48.28% (95% CI [48.23%, 48.34%]), respectively. Adding genetic factors improved predictions slightly, explaining an additional 2.3% variation for FNK-BMD and 3% for SPN-BMD over clinical factors alone. Survival analysis revealed that the predicted FNK-BMD and SPN-BMD were significantly associated with fragility fracture risk in the European white population (P < 0.001). The hazard ratios (HRs) of the predicted FNK-BMD and SPN-BMD were 0.83 (95% CI [0.79, 0.88], corresponding to a 1.44% difference in 10-year absolute risk) and 0.72 (95% CI [0.68, 0.76], corresponding to a 1.64% difference in 10-year absolute risk), respectively, indicating that for every increase of one standard deviation in BMD, the fracture risk will decrease by 17% and 28%, respectively. However, the model's performance declined in other ethnic groups and independent cohorts. The limitations of this study include differences in clinical factors distribution and the use of only SNPs as genetic factors. CONCLUSIONS In this study, we observed that combining genetic and clinical factors improves BMD prediction compared to clinical factors alone. Adjusting inclusion thresholds for genetic variants (e.g., 5×10-6 or 5×10-7) rather than solely considering genome-wide association study (GWAS)-significant variants can enhance the model's explanatory power. The study highlights the need for training models on diverse populations to improve predictive performance across various ethnic and geographical groups.
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Affiliation(s)
- Yong Liu
- Center for System Biology, Data Sciences, and Reproductive Health, School of Basic Medical Science, Central South University, Changsha, Hunan Province, China
| | - Xiang-He Meng
- Hunan Provincial Key Laboratory of Regional Hereditary Birth Defects Prevention and Control, Changsha Hospital for Maternal & Child Health Care Affiliated to Hunan Normal University, Changsha, Hunan Province, China
| | - Chong Wu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Kuan-Jui Su
- Tulane Center of Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Anqi Liu
- Tulane Center of Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Qing Tian
- Tulane Center of Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Lan-Juan Zhao
- Tulane Center of Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Chuan Qiu
- Tulane Center of Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Zhe Luo
- Tulane Center of Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Martha I Gonzalez-Ramirez
- Tulane Center of Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Hui Shen
- Tulane Center of Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Hong-Mei Xiao
- Center for System Biology, Data Sciences, and Reproductive Health, School of Basic Medical Science, Central South University, Changsha, Hunan Province, China
- Key Laboratory of Biological, Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Hong-Wen Deng
- Tulane Center of Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
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Welch JM, Gomez GI, Chatterjee M, Shapiro LM, Morris AM, Gardner MJ, Sox-Harris AHS, Baker L, Koltsov JCB, Castillo T, Giori N, Salyapongse A, Kamal RN. Contextual Determinants of Time to Surgery for Patients With Hip Fracture. JAMA Netw Open 2023; 6:e2347834. [PMID: 38100104 PMCID: PMC10724766 DOI: 10.1001/jamanetworkopen.2023.47834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023] Open
Abstract
Importance Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions. Objective To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals. Design, Setting, and Participants This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022. Main Outcomes and Measures Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds). Results A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work. Conclusions and Relevance In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.
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Affiliation(s)
- Jessica M. Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Duke University School of Medicine, Durham, North Carolina
| | - Giselle I. Gomez
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Stanford University School of Medicine, Stanford, California
| | - Maya Chatterjee
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Department of Human Development and Family Studies, Colorado State University, Fort Collins
| | - Lauren M. Shapiro
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Department of Orthopaedic Surgery, University of California, San Francisco
| | - Arden M. Morris
- Department of Surgery, Stanford University, Stanford, California
| | - Michael J. Gardner
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Alex H. S. Sox-Harris
- Department of Surgery, Stanford University, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Laurence Baker
- Department of Health Policy, Stanford University, Stanford, California
| | - Jayme C. B. Koltsov
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Tiffany Castillo
- Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, California
| | - Nicholas Giori
- Department of Orthopaedic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Aaron Salyapongse
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Robin N. Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
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Alnemer MS, Kotliar KE, Neuhaus V, Pape HC, Ciritsis BD. Cost-effectiveness analysis of surgical proximal femur fracture prevention in elderly: a Markov cohort simulation model. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:77. [PMID: 37880692 PMCID: PMC10601292 DOI: 10.1186/s12962-023-00482-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 09/20/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Hip fractures are a common and costly health problem, resulting in significant morbidity and mortality, as well as high costs for healthcare systems, especially for the elderly. Implementing surgical preventive strategies has the potential to improve the quality of life and reduce the burden on healthcare resources, particularly in the long term. However, there are currently limited guidelines for standardizing hip fracture prophylaxis practices. METHODS This study used a cost-effectiveness analysis with a finite-state Markov model and cohort simulation to evaluate the primary and secondary surgical prevention of hip fractures in the elderly. Patients aged 60 to 90 years were simulated in two different models (A and B) to assess prevention at different levels. Model A assumed prophylaxis was performed during the fracture operation on the contralateral side, while Model B included individuals with high fracture risk factors. Costs were obtained from the Centers for Medicare & Medicaid Services, and transition probabilities and health state utilities were derived from available literature. The baseline assumption was a 10% reduction in fracture risk after prophylaxis. A sensitivity analysis was also conducted to assess the reliability and variability of the results. RESULTS With a 10% fracture risk reduction, model A costs between $8,850 and $46,940 per quality-adjusted life-year ($/QALY). Additionally, it proved most cost-effective in the age range between 61 and 81 years. The sensitivity analysis established that a reduction of ≥ 2.8% is needed for prophylaxis to be definitely cost-effective. The cost-effectiveness at the secondary prevention level was most sensitive to the cost of the contralateral side's prophylaxis, the patient's age, and fracture treatment cost. For high-risk patients with no fracture history, the cost-effectiveness of a preventive strategy depends on their risk profile. In the baseline analysis, the incremental cost-effectiveness ratio at the primary prevention level varied between $11,000/QALY and $74,000/QALY, which is below the defined willingness to pay threshold. CONCLUSION Due to the high cost of hip fracture treatment and its increased morbidity, surgical prophylaxis strategies have demonstrated that they can significantly relieve the healthcare system. Various key assumptions facilitated the modeling, allowing for adequate room for uncertainty. Further research is needed to evaluate health-state-associated risks.
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Affiliation(s)
- Momin S. Alnemer
- Department of Medical Engineering and Technomathematics, Aachen University of Applied Sciences, Campus Juelich, Heinrich-Mussmann-Str. 1, 52428 Juelich, Germany
| | - Konstantin E. Kotliar
- Department of Medical Engineering and Technomathematics, Aachen University of Applied Sciences, Campus Juelich, Heinrich-Mussmann-Str. 1, 52428 Juelich, Germany
| | - Valentin Neuhaus
- Trauma Surgery Unit, Universitätsspital Zürich, Rämistrasse 100, Zürich, 8091 Switzerland
| | - Hans-Christoph Pape
- Trauma Surgery Unit, Universitätsspital Zürich, Rämistrasse 100, Zürich, 8091 Switzerland
| | - Bernhard D. Ciritsis
- Orthopaedic Surgery Unit, Centro Ortopedico di Quadrante, Lungolago Buozzi, 25, Omegna, VB 28887 Italy
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Loggers SAI, Geraerds AJLM, Joosse P, Willems HC, Gosens T, Van Balen R, Van de Ree CLP, Ponsen KJ, Steens J, Zuurmond RG, Verhofstad MHJ, Polinder S, Van Lieshout EMM. Nonoperative versus operative management of frail institutionalized older patients with a proximal femoral fracture: a cost-utility analysis alongside a multicenter prospective cohort study. Osteoporos Int 2023; 34:515-525. [PMID: 36609506 PMCID: PMC9908658 DOI: 10.1007/s00198-022-06638-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/05/2022] [Indexed: 01/09/2023]
Abstract
UNLABELLED Hip fractures are associated with significant healthcare costs. In frail institutionalized patients, the costs of nonoperative management are less than operative management with comparable short-term quality of life. Nonoperative management of hip fractures in patients at the end of life should be openly discussed with SDM. PURPOSE The aim was to describe healthcare use with associated costs and to determine cost-utility of nonoperative management (NOM) versus operative management (OM) of frail institutionalized older patients with a proximal femoral fracture. METHODS This study included institutionalized patients with a limited life expectancy aged ≥ 70 years who sustained a proximal femoral fracture in the Netherlands. Costs of hospital- and nursing home care were calculated. Quality adjusted life years (QALY) were calculated based on EuroQol-5D-5L utility scores at day 7, 14, and 30 and at 3 and 6 months. The incremental cost-effectiveness ratio (ICER) was calculated from a societal perspective. RESULTS Of the 172 enrolled patients, 88 (51%) patients opted for NOM and 84 (49%) for OM. NOM was associated with lower healthcare costs at 6 months (NOM; €2425 (SD 1.030), OM; €9325 (SD 4242), p < 0.001). The main cost driver was hospital stay (NOM; €738 (SD 841) and OM; €3140 (SD 2636)). The ICER per QALY gained in the OM versus NOM was €76,912 and exceeded the threshold of €20,000 per QALY. The gained QALY were minimal in the OM group in patients who died within 14- and 30-day post-injury, but OM resulted in more than triple the costs. CONCLUSION OM results in significant higher healthcare costs, mainly due to the length of hospital stay. For frail patients at the end of life, NOM of proximal femoral fractures should be openly discussed in SDM conversations due to the limited gain in QoL. TRIAL REGISTRATION Netherlands Trial Register (NTR7245; date 10-06-2018).
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Affiliation(s)
- S A I Loggers
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM, Alkmaar, the Netherlands
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - A J L M Geraerds
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - P Joosse
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM, Alkmaar, the Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, P.O. Box 1074, 1940 EB, Beverwijk, the Netherlands
| | - H C Willems
- Geriatrics Section, Department of Internal Medicine, Amsterdam UMC Location AMC, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - T Gosens
- Department of Orthopedic Surgery, Elisabeth-TweeSteden Ziekenhuis, P.O. Box 90151, 5000 LC, Tilburg, the Netherlands
| | - R Van Balen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - C L P Van de Ree
- Department Trauma TopCare, Elisabeth-TweeSteden Ziekenhuis, P.O. Box 90151, 5000 LC, Tilburg, the Netherlands
| | - K J Ponsen
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM, Alkmaar, the Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, P.O. Box 1074, 1940 EB, Beverwijk, the Netherlands
| | - J Steens
- Department of Orthopedic Surgery, Dijklander Ziekenhuis, P.O. Box 600, 1620 AR, Hoorn, the Netherlands
| | - R G Zuurmond
- Department of Orthopedic Surgery, Isala, P.O. Box 10400, 8000 GK, Zwolle, the Netherlands
| | - M H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - S Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
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Impact of the SARS-CoV-2 Outbreak on the Epidemiology and Treatment Outcomes of Fractures of the Proximal Femur in Kazakhstan. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2022-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Abstract
The study aimed to assess the impact of isolation and quarantine on the frequency of registration and the treatment of fractures of the proximal femur in Kazakhstan in the context of the COVID-19 pandemic in 2020 (compared to the pre-pandemic period). This retrospective observational comparative study included all primary patients with injuries (the code S72) in the period 2019-2020 according to the national register.
In 2020, the number of S72 fractures was 6.6 % higher compared to 2019. In comparison with 2019, in 2020 the number of beddays of patients was reduced to 7.1±3.8 days (p≤0.001). Both in 2019 and in 2020, the number of women predominated among all patients (p ≤ 0.05). The frequency of conservative treatment in 2020 compared to 2019 was increased from 26.6% to 35.6%, while the surgical procedure for internal fixation was reduced to 34.2% in 2020. In 2020, the highest number of cases among women with S72 fractures cases were recorded in the age groups 60-74 years and 75-90 years. In 2019 in female patients (42%) with S72 cases were registered in the age group 75-90 years.
The incidence of fractures of the proximal femur did not change significantly in 2020 compared to 2019. However, the number of conservative treatment methods has increased along with the decrease in the frequency of surgical interventions. We observed the growth of the frequency of non-surgical treatment methods in 2020 that might impose the possible risks of mortality of these patients in the long term after conservative treatment.
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Neilan AM, Landovitz RJ, Le MH, Grinsztejn B, Freedberg KA, McCauley M, Wattananimitgul N, Cohen MS, Ciaranello AL, Clement ME, Reddy KP, Hyle EP, Paltiel AD, Walensky RP. Cost-Effectiveness of Long-Acting Injectable HIV Preexposure Prophylaxis in the United States : A Cost-Effectiveness Analysis. Ann Intern Med 2022; 175:479-489. [PMID: 35099992 PMCID: PMC9087297 DOI: 10.7326/m21-1548] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The HIV Prevention Trials Network (HPTN) 083 trial demonstrated the superiority of long-acting injectable cabotegravir (CAB-LA) compared with oral emtricitabine-tenofovir disoproxil fumarate (F/TDF) for HIV preexposure prophylaxis (PrEP). OBJECTIVE To identify the maximum price premium (that is, greatest possible price differential) that society should be willing to accept for the additional benefits of CAB-LA over tenofovir-based PrEP among men who have sex with men and transgender women (MSM/TGW) in the United States. DESIGN Simulation, cost-effectiveness analysis. DATA SOURCES Trial and published data, including estimated HIV incidence (5.32, 1.33, and 0.26 per 100 person-years for off PrEP, generic F/TDF and branded emtricitabine-tenofovir alafenamide (F/TAF), and CAB-LA, respectively); 28% 6-year PrEP retention. Annual base-case drug costs: $360 and $16 800 for generic F/TDF and branded F/TAF. Fewer side effects with branded F/TAF versus generic F/TDF were assumed. TARGET POPULATION 476 700 MSM/TGW at very high risk for HIV (VHR). TIME HORIZON 10 years. PERSPECTIVE Health care system. INTERVENTION CAB-LA versus generic F/TDF or branded F/TAF for HIV PrEP. OUTCOME MEASURES Primary transmissions, quality-adjusted life-years (QALYs), costs (2020 U.S. dollars), incremental cost-effectiveness ratios (ICERs; U.S. dollars per QALY), maximum price premium for CAB-LA versus tenofovir-based PrEP. RESULTS OF BASE-CASE ANALYSIS Compared with generic F/TDF (or branded F/TAF), CAB-LA increased life expectancy by 28 000 QALYs (26 000 QALYs) among those at VHR. Branded F/TAF cost more per QALY gained than generic F/TDF compared with no PrEP. At 10 years, CAB-LA could achieve an ICER of at most $100 000 per QALY compared with generic F/TDF at a maximum price premium of $3700 per year over generic F/TDF (CAB-LA price <$4100 per year). RESULTS OF SENSITIVITY ANALYSIS In a PrEP-eligible population at high risk for HIV, rather than at VHR (n = 1 906 800; off PrEP incidence: 1.54 per 100 person-years), CAB-LA could achieve an ICER of at most $100 000 per QALY versus generic F/TDF at a maximum price premium of $1100 per year over generic F/TDF (CAB-LA price <$1500 per year). LIMITATION Uncertain clinical and economic benefits of averting future transmissions. CONCLUSION Effective oral PrEP limits the additional price society should be willing to pay for CAB-LA. PRIMARY FUNDING SOURCE FHI 360; Eunice Kennedy Shriver National Institute of Child Health and Human Development; National Institute of Allergy and Infectious Diseases; National Heart, Lung, and Blood Institute; National Institute on Drug Abuse; the Reich HIV Scholar Award; and the Steve and Deborah Gorlin MGH Research Scholars Award.
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Affiliation(s)
- Anne M Neilan
- Division of General Academic Pediatrics, Division of Infectious Diseases, and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts (A.M.N.)
| | - Raphael J Landovitz
- UCLA Center for Clinical AIDS Research and Education, Los Angeles, and Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California (R.J.L.)
| | - Mylinh H Le
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts (M.H.L., N.W.)
| | - Beatriz Grinsztejn
- Instituto de Pesquisa Clinica Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil (B.G.)
| | - Kenneth A Freedberg
- Division of Infectious Diseases, Medical Practice Evaluation Center, and Division of General Internal Medicine, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, and Harvard University Center for AIDS Research, Boston, Massachusetts (K.A.F.)
| | | | - Nattanicha Wattananimitgul
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts (M.H.L., N.W.)
| | - Myron S Cohen
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (M.S.C.)
| | - Andrea L Ciaranello
- Division of Infectious Diseases and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and Harvard University Center for AIDS Research, Boston, Massachusetts (A.L.C., E.P.H.)
| | - Meredith E Clement
- Division of Infectious Diseases, Louisiana State University Health Sciences Center, New Orleans, Louisiana (M.E.C.)
| | - Krishna P Reddy
- Medical Practice Evaluation Center and Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts (K.P.R.)
| | - Emily P Hyle
- Division of Infectious Diseases and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Harvard Medical School, Boston, and Harvard University Center for AIDS Research, Boston, Massachusetts (A.L.C., E.P.H.)
| | - A David Paltiel
- Yale School of Public Health, New Haven, Connecticut (A.D.P.)
| | - Rochelle P Walensky
- Division of Infectious Diseases, Medical Practice Evaluation Center, and Division of General Internal Medicine, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts, and Centers for Disease Control and Prevention, Atlanta, Georgia (R.P.W.)
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7
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Backman C, Harley A, Papp S, French-Merkley V, Beaulé PE, Poitras S, Dobransky J, Squires JE. Barriers and Enablers to Early Identification, Referral and Access to Geriatric Rehabilitation Post-Hip Fracture: A Theory-Based Descriptive Qualitative Study. Geriatr Orthop Surg Rehabil 2022; 13:21514593211047666. [PMID: 35340622 PMCID: PMC8943317 DOI: 10.1177/21514593211047666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 07/28/2021] [Accepted: 09/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background Geriatric hip fracture patients often experience gaps in care including
variability in the timing and the choice of an appropriate setting for
rehabilitation following hip fracture surgery. Many guidelines recommend
standardized processes, including timely access of no later than day 6 to
rehabilitation services. A pathway for early identification, referral and
access to geriatric rehabilitation post-hip fracture was created to
facilitate the implementation. The study aimed to describe the barriers and
enablers prior to the implementation of this pathway. Methods We conducted a qualitative descriptive study consisting of semi-structured
interviews with geriatric hip fracture patients (n = 8), caregivers (n = 1),
administrators (n = 12) and clinicians (n = 17) in 2 orthopaedics units and
a geriatric rehabilitation service. Responses were analysed using a
systematic approach, and overarching themes describing the barriers and
enablers were identified. Results The clinicians’ and administrators’ top barriers to implementation of the
pathway were competing demands (n = 24); lack of bed availability, community
resources and funding (n = 19); and the need for extended hours and
increased staff (n = 16). The top 3 enablers were clear communication with
patients (n = 27), awareness of the benefits of geriatric rehabilitation (n
= 24) and the need for education and resources to properly use the pathway
(n = 15). Common barriers among patients and caregivers included lack of
care coordination, overcoming some of their own specific challenges during
their transition, gaps in the information they received before discharge,
not knowing what questions to ask and lack of resources. Despite these
barriers, patients were generally pleased with their transition from the
hospital to geriatric rehabilitation. Conclusion We identified and described key barriers and enablers to early
identification, referral and access to geriatric rehabilitation post-hip
fracture. These influencing factors provide a basis for the development of a
standardized pathway aimed at improving access to rehabilitative care for
geriatric hip fracture patients.
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Affiliation(s)
- Chantal Backman
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada.,Ottawa Hospital Research Institute.,Bruyère Research Institute
| | - Anne Harley
- Attending Physician in Geriatric Rehabilitation at Bruyere Continuing Care, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Steve Papp
- Clinical Director and Trauma Surgeon at The Ottawa Hospital, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Veronique French-Merkley
- Department Chief in Care of the Elderly at Bruyere Continuing Care, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Paul E Beaulé
- Head of the Division of Orthopaedic Surgery at The Ottawa Hospital; Professor Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Stéphane Poitras
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa
| | - Johanna Dobransky
- Clinical Research Program Manager, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Canada
| | - Janet E Squires
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
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8
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Wodchis WP, Or Z, Blankart CR, Atsma F, Janlov N, Bai YQ, Penneau A, Arvin M, Knight H, Riley K, Figueroa JF, Papanicolas I. An international comparison of long-term care trajectories and spending following hip fracture. Health Serv Res 2021; 56 Suppl 3:1383-1393. [PMID: 34378190 PMCID: PMC8579202 DOI: 10.1111/1475-6773.13864] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/10/2021] [Accepted: 07/22/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The objectives of this study are to compare the relative use of different postacute care settings in different countries and to compare three important outcomes as follows: total expenditure, total days of care in different care settings, and overall longevity over a 1-year period following a hip fracture. DATA SOURCES We used administrative data from hospitals, institutional and home-based long-term care (LTC), physician visits, and medications compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) from five countries as follows: Canada, France, Germany, the Netherlands, and Sweden. DATA EXTRACTION METHODS Data were extracted from existing administrative data systems in each participating country. STUDY DESIGN This is a retrospective cohort study of all individuals admitted to acute care for hip fracture. Descriptive comparisons were used to examine aggregate institutional and home-based postacute care. Care trajectories were created to track sequential care settings after acute-care discharge through institutional and community-based care in three countries where detailed information allowed. Comparisons in patient characteristics, utilization, and costs were made across these trajectories and countries. PRINCIPAL FINDINGS Across five countries with complete LTC data, we found notable variations with Germany having the highest days of home-based services with relatively low costs, while Sweden incurred the highest overall expenditures. Comparisons of trajectories found that France had the highest use of inpatient rehabilitation. Germany was most likely to discharge hip fracture patients to home. Over 365 days, France averaged the highest number of days in institution with 104, Canada followed at 94, and Germany had just 87 days of institutional care on average. CONCLUSION In this comparison of LTC services following a hip fracture, we found international differences in total use of institutional and noninstitutional care, longevity, and total expenditures. There exist opportunities to organize postacute care differently to maximize independence and mitigate costs.
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Affiliation(s)
- Walter P. Wodchis
- Institute of Health Policy Management & EvaluationUniversity of TorontoTorontoOntarioCanada
- Institute for Better HealthTrillium Health PartnersMississaugaOntarioCanada
- ICESTorontoOntarioCanada
| | - Zeynep Or
- Institute for Research and Documentation in Health Economics (IRDES)ParisFrance
- Department of Economics (LEDa)University Dauphine PSLParisFrance
| | - Carl Rudolf Blankart
- KPM Center for Public ManagementUniversity of BernBernSwitzerland
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
- Hamburg Center for Health EconomicsUniversität HamburgHamburgGermany
| | - Femke Atsma
- Radboud University Medical CenterRadboud Institute for Health Sciences, Scientific Center for Quality of HealthcareNijmegenThe Netherlands
| | - Nils Janlov
- The Swedish Agency for Health and Care Services AnalysisStockholmSweden
| | - Yu Qing Bai
- Institute of Health Policy Management & EvaluationUniversity of TorontoTorontoOntarioCanada
- ICESTorontoOntarioCanada
| | - Anne Penneau
- Institute for Research and Documentation in Health Economics (IRDES)ParisFrance
- Department of Economics (LEDa)University Dauphine PSLParisFrance
| | - Mina Arvin
- Radboud University Medical CenterRadboud Institute for Health Sciences, Scientific Center for Quality of HealthcareNijmegenThe Netherlands
| | | | - Kristen Riley
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Jose F. Figueroa
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
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9
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Cost-effectiveness analysis of short versus long cephalomedullary nails for treatment of stable intertrochanteric femoral fractures: a theoretical cohort study. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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10
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Hollenberg AM, Huber A, Smith CO, Eliseev RA. Electromagnetic stimulation increases mitochondrial function in osteogenic cells and promotes bone fracture repair. Sci Rep 2021; 11:19114. [PMID: 34580378 PMCID: PMC8476611 DOI: 10.1038/s41598-021-98625-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Bone fracture is a growing public health burden and there is a clinical need for non-invasive therapies to aid in the fracture healing process. Previous studies have demonstrated the utility of electromagnetic (EM) fields in promoting bone repair; however, its underlying mechanism of action is unclear. Interestingly, there is a growing body of literature describing positive effects of an EM field on mitochondria. In our own work, we have previously demonstrated that differentiation of osteoprogenitors into osteoblasts involves activation of mitochondrial oxidative phosphorylation (OxPhos). Therefore, it was reasonable to propose that EM field therapy exerts bone anabolic effects via stimulation of mitochondrial OxPhos. In this study, we show that application of a low intensity constant EM field source on osteogenic cells in vitro resulted in increased mitochondrial membrane potential and respiratory complex I activity and induced osteogenic differentiation. In the presence of mitochondrial inhibitor antimycin A, the osteoinductive effect was reversed, confirming that this effect was mediated via increased OxPhos activity. Using a mouse tibial bone fracture model in vivo, we show that application of a low intensity constant EM field source enhanced fracture repair via improved biomechanical properties and increased callus bone mineralization. Overall, this study provides supporting evidence that EM field therapy promotes bone fracture repair through mitochondrial OxPhos activation.
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Affiliation(s)
- Alex M Hollenberg
- Center for Musculoskeletal Research, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Aric Huber
- Center for Musculoskeletal Research, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Charles O Smith
- Center for Musculoskeletal Research, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Roman A Eliseev
- Center for Musculoskeletal Research, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.
- University of Rochester Medical Center, 601 Elmwood Ave, Rm 1-8541, Rochester, NY, 14642, USA.
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11
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Wopat M, Breslow R, Chesney K, McCauley M, Van Gysel R, Gray A, Hilsenhoff J, Edwardson G, Nachreiner J, Hoff L, Gruber S, Shattuck P, Portillo E. Implementation of a pharmacist and student pharmacist-led primary care service to identify and treat rural veterans at risk for osteoporotic fracture. J Am Pharm Assoc (2003) 2021; 61:e105-e112. [PMID: 34393078 DOI: 10.1016/j.japh.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 06/03/2021] [Accepted: 07/15/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To develop and implement a pharmacist and student pharmacist-led osteoporosis service to increase dual-energy x-ray absorptiometry (DXA) screening rates among rural veterans and treat those at high risk of osteoporotic fractures. PRACTICE DESCRIPTION Pharmacists are uniquely positioned to provide direct patient care in the Department of Veterans Affairs ambulatory care setting owing to their broad scope of practice. Clinical Pharmacy Specialists (CPSs) have the authority to order laboratory tests and imaging, prescribe medications, refer patients to specialty services, and monitor patients along with the primary care team. PRACTICE INNOVATION The implementation of a pharmacist-led osteoporosis primary prevention service using student pharmacists to identify and treat patients has not been previously described in the literature to the authors' knowledge. EVALUATION METHODS Student pharmacists in their third year contacted veterans who met the inclusion criteria for osteoporosis screening. The veterans were offered DXA scans and provided education on the risk factors for osteoporosis. After the DXA scans were completed, the students and the CPS reviewed the results to determine treatment strategies. The primary objective was evaluated by comparing the pre- and post-implementation rates of DXA screening. The other process markers that were evaluated included (1) completed DXA scans, (2) new diagnoses of osteoporosis or osteopenia, (3) patients eligible for treatment on the basis of the DXA screening results, and (4) patients who started oral bisphosphonate therapy. RESULTS Of the 232 rural veterans evaluated, 36 had completed DXA scans before this service was implemented. After the service was implemented, 115 veterans completed DXA scans. A total of 57 patients received a new diagnosis, 33 were eligible for therapy, and 12 started oral bisphosphonate therapy after intervention by the CPS. CONCLUSION The implementation of a pharmacist-driven osteoporosis screening and treatment service demonstrated an increase in the rate of DXA screening among rural veterans.
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12
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Chen DQ, Quinlan ND, Browne JA, Werner BC. Increased Reimbursement for Surgical Fixation of Hip Fractures: The Difference Between the Hospital and the Surgeon. J Orthop Trauma 2021; 35:339-344. [PMID: 34131086 DOI: 10.1097/bot.0000000000002092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate trends and variations in hospital charges and payments relative to surgeon charges and payments for surgical treatment of hip fractures in the US Medicare population. METHODS Hospital and surgeon charges and payments after treatment of hip fractures by closed reduction and percutaneous pinning (CRPP), open reduction internal fixation (ORIF), or intramedullary nail (IMN), along with corresponding patient demographics, 90-day and 1-year mortality, Charlson Comorbidity Index (CCI), and length of stay (LOS) from 2005 to 2014 were captured from the 5% Medicare Standard Analytic Files. The ratio of hospital to surgeon charges (CM: Charge Multiplier) and the ratio of hospital to surgeon payments (PM: Payment Multiplier) were calculated for each year and region of the United States and trended over time. Correlations between the CM and PM and LOS were evaluated using a Pearson correlation coefficient (r). RESULTS Three thousand twenty-eight patients who underwent CRPP and 25,341 patients who underwent ORIF/IMN were included. The CM for CRPP increased from 10.1 to 15.6, P < 0.0001. The CM for ORIF/IMN increased from 11.9 to 17.2, P < 0.0001. The PM for CRPP increased from 15.1 to 19.2, P < 0.0001. The PM for ORIF/IMN increased from 11.5 to 17.4, P < 0.0001. CONCLUSIONS Hospital charges and payments have continually increased relative to surgeon charges and payments for treatment of hip fractures despite decreasing LOS.
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Affiliation(s)
- Dennis Q Chen
- Department of Orthopaedic Surgery, UVA Health System, Charlottesville, VA
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13
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Bae SJ, Lee SH. Computed tomographic measurements of the psoas muscle as a predictor of mortality in hip fracture patients: Muscle attenuation helps predict mortality in hip fracture patients. Injury 2021; 52:1456-1461. [PMID: 33279172 DOI: 10.1016/j.injury.2020.11.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/26/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION In recent years, sarcopenia has been identified as an important risk factor of patient prognosis. The aim of this study was to determine the association between prognosis of hip fracture and sarcopenia and to evaluate the prognostic performance of psoas muscle volume and attenuation measurements in hip computed tomography (CT). MATERIAL AND METHODS This was a retrospective cohort study of patients with hip fracture in our institution from 2014 to 2017. Baseline character data and hip CT scans were obtained. Two readers independently measured muscle size (cross-sectional area) and attenuation of the psoas muscle at the L4 vertebra on CT scans. Logistic regression analysis was used to identify the association between mortality and muscle index (the sum of the left and right muscle sizes divided by patient height) and muscle attenuation after adjusting for demographic variables. In addition, receiver operating characteristic (ROC) curves were obtained. RESULTS In the 462 patients included in the study, in-hospital mortality was 4%. Multivariate logistic regression analysis revealed that muscle attenuation was a risk factor for mortality. Among baseline characteristics, age, sex, diastolic blood pressure, and albumin were significant variables for mortality. The area under the ROC curve (AUC) of muscle attenuation for prediction of death was 0.839 (0.803-0.872) with 84.2% sensitivity and 69.5% specificity. Furthermore, when we combined all independent factors according to the results, the AUC was 0.929 (0.902-0.951) with 84.2% sensitivity and 93.6% specificity for prediction of mortality among hip fracture patients. CONCLUSION Among many variables, the most significant was muscle attenuation. CT is the most typical modality to determine treatment of hip fracture patients. Measuring muscle size and attenuation is simple using PACS software. Muscle attenuation has significant value for predicting the prognosis of hip patients.
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Affiliation(s)
- Sung Jin Bae
- Ewha Womans University Mokdong Hospital, Department of Emergency Medicine, College of Medicine, Ewha Womans University, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, South Korea; Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06973, South Korea
| | - Sun Hwa Lee
- Ewha Womans University Mokdong Hospital, Department of Emergency Medicine, College of Medicine, Ewha Womans University, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul, South Korea.
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14
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Gou RY, Hshieh TT, Marcantonio ER, Cooper Z, Jones RN, Travison TG, Fong TG, Abdeen A, Lange J, Earp B, Schmitt EM, Leslie DL, Inouye SK. One-Year Medicare Costs Associated With Delirium in Older Patients Undergoing Major Elective Surgery. JAMA Surg 2021; 156:430-442. [PMID: 33625501 DOI: 10.1001/jamasurg.2020.7260] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Delirium is a common, serious, and potentially preventable problem for older adults, associated with adverse outcomes. Coupled with its preventable nature, these adverse sequelae make delirium a significant public health concern; understanding its economic costs is important for policy makers and health care leaders to prioritize care. Objective To evaluate current 1-year health care costs attributable to postoperative delirium in older patients undergoing elective surgery. Design, Setting, and Participants This prospective cohort study included 497 patients from the Successful Aging after Elective Surgery (SAGES) study, an ongoing cohort study of older adults undergoing major elective surgery. Patients were enrolled from June 18, 2010, to August 8, 2013. Eligible patients were 70 years or older, English-speaking, able to communicate verbally, and scheduled to undergo major surgery at 1 of 2 Harvard-affiliated hospitals with an anticipated length of stay of at least 3 days. Eligible surgical procedures included total hip or knee replacement; lumbar, cervical, or sacral laminectomy; lower extremity arterial bypass surgery; open abdominal aortic aneurysm repair; and open or laparoscopic colectomy. Data were analyzed from October 15, 2019, to September 15, 2020. Exposures Major elective surgery and hospitalization. Main Outcomes and Measures Cumulative and period-specific costs (index hospitalization, 30-day, 90-day, and 1-year follow-up) were examined using Medicare claims and extensive clinical data. Total inflation-adjusted health care costs were determined using data from Medicare administrative claims files for the 2010 to 2014 period. Delirium was rated using the Confusion Assessment Method. We also examined whether increasing delirium severity was associated with higher cumulative and period-specific costs. Delirium severity was measured with the Confusion Assessment Method-Severity long form. Regression models were used to determine costs associated with delirium after adjusting for patient demographic and clinical characteristics. Results Of the 566 patients who were eligible for the study, a total of 497 patients (mean [SD] age, 76.8 [5.1] years; 281 women [57%]; 461 White participants [93%]) were enrolled after exclusion criteria were applied. During the index hospitalization, 122 patients (25%) developed postoperative delirium, whereas 375 (75%) did not. Patients with delirium had significantly higher unadjusted health care costs than patients without delirium (mean [SD] cost, $146 358 [$140 469] vs $94 609 [$80 648]). After adjusting for relevant confounders, the cumulative health care costs attributable to delirium were $44 291 (95% CI, $34 554-$56 673) per patient per year, with the majority of costs coming from the first 90 days: index hospitalization ($20 327), subsequent rehospitalizations ($27 797), and postacute rehabilitation stays ($2803). Health care costs increased directly and significantly with level of delirium severity (none-mild, $83 534; moderate, $99 756; severe, $140 008), suggesting an exposure-response relationship. The adjusted mean cumulative costs attributable to severe delirium were $56 474 (95% CI, $40 927-$77 440) per patient per year. Extrapolating nationally, the health care costs attributable to postoperative delirium were estimated at $32.9 billion (95% CI, $25.7 billion-$42.2 billion) per year. Conclusions and Relevance These findings suggest that the economic outcomes of delirium and severe delirium after elective surgery are substantial, rivaling costs associated with cardiovascular disease and diabetes. These results highlight the need for policy imperatives to address delirium as a large-scale public health issue.
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Affiliation(s)
- Ray Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Tammy T Hshieh
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Edward R Marcantonio
- Harvard Medical School, Boston, Massachusetts.,Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Zara Cooper
- Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island.,Department of Neurology, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Thomas G Travison
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Tamara G Fong
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ayesha Abdeen
- Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jeffrey Lange
- Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brandon Earp
- Harvard Medical School, Boston, Massachusetts.,Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, Massachusetts
| | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Douglas L Leslie
- Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, Massachusetts.,Center for Applied Studies in Health Economics, Department of Public Health Sciences, Pennsylvania State College of Medicine, Hershey, Pennsylvania
| | - Sharon K Inouye
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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15
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Lu T, Forgetta V, Keller-Baruch J, Nethander M, Bennett D, Forest M, Bhatnagar S, Walters RG, Lin K, Chen Z, Li L, Karlsson M, Mellström D, Orwoll E, McCloskey EV, Kanis JA, Leslie WD, Clarke RJ, Ohlsson C, Greenwood CMT, Richards JB. Improved prediction of fracture risk leveraging a genome-wide polygenic risk score. Genome Med 2021; 13:16. [PMID: 33536041 PMCID: PMC7860212 DOI: 10.1186/s13073-021-00838-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 01/22/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Accurately quantifying the risk of osteoporotic fracture is important for directing appropriate clinical interventions. While skeletal measures such as heel quantitative speed of sound (SOS) and dual-energy X-ray absorptiometry bone mineral density are able to predict the risk of osteoporotic fracture, the utility of such measurements is subject to the availability of equipment and human resources. Using data from 341,449 individuals of white British ancestry, we previously developed a genome-wide polygenic risk score (PRS), called gSOS, that captured 25.0% of the total variance in SOS. Here, we test whether gSOS can improve fracture risk prediction. METHODS We examined the predictive power of gSOS in five genome-wide genotyped cohorts, including 90,172 individuals of European ancestry and 25,034 individuals of Asian ancestry. We calculated gSOS for each individual and tested for the association between gSOS and incident major osteoporotic fracture and hip fracture. We tested whether adding gSOS to the risk prediction models had added value over models using other commonly used clinical risk factors. RESULTS A standard deviation decrease in gSOS was associated with an increased odds of incident major osteoporotic fracture in populations of European ancestry, with odds ratios ranging from 1.35 to 1.46 in four cohorts. It was also associated with a 1.26-fold (95% confidence interval (CI) 1.13-1.41) increased odds of incident major osteoporotic fracture in the Asian population. We demonstrated that gSOS was more predictive of incident major osteoporotic fracture (area under the receiver operating characteristic curve (AUROC) = 0.734; 95% CI 0.727-0.740) and incident hip fracture (AUROC = 0.798; 95% CI 0.791-0.805) than most traditional clinical risk factors, including prior fracture, use of corticosteroids, rheumatoid arthritis, and smoking. We also showed that adding gSOS to the Fracture Risk Assessment Tool (FRAX) could refine the risk prediction with a positive net reclassification index ranging from 0.024 to 0.072. CONCLUSIONS We generated and validated a PRS for SOS which was associated with the risk of fracture. This score was more strongly associated with the risk of fracture than many clinical risk factors and provided an improvement in risk prediction. gSOS should be explored as a tool to improve risk stratification to identify individuals at high risk of fracture.
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Affiliation(s)
- Tianyuan Lu
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Room H-413, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1E2, Canada
- Quantitative Life Sciences Program, McGill University, Montreal, Canada
| | - Vincenzo Forgetta
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Room H-413, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1E2, Canada
| | - Julyan Keller-Baruch
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Room H-413, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1E2, Canada
| | - Maria Nethander
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Bioinformatics Core Facility, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Derrick Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Marie Forest
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Room H-413, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1E2, Canada
| | - Sahir Bhatnagar
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Department of Diagnostic Radiology, McGill University, Montreal, Canada
| | - Robin G Walters
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- MRC Population Health Research Unit, University of Oxford, Oxford, UK
| | - Kuang Lin
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Zhengming Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- MRC Population Health Research Unit, University of Oxford, Oxford, UK
| | - Liming Li
- School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Magnus Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Orthopedics and Clinical Sciences, Lund University, Lund, Sweden
- Skåne University Hospital, Malmö, Sweden
| | - Dan Mellström
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eric Orwoll
- Bone & Mineral Unit, Oregon Health & Science University, Portland, USA
- Department of Medicine, Oregon Health & Science University, Portland, USA
| | - Eugene V McCloskey
- Mellanby Centre for Bone Research, Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Mary Mackillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Robert J Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Claes Ohlsson
- Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Drug Treatment, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Celia M T Greenwood
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Room H-413, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1E2, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Department of Human Genetics, McGill University, Montreal, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - J Brent Richards
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Room H-413, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1E2, Canada.
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.
- Department of Human Genetics, McGill University, Montreal, Canada.
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK.
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Tack P, Victor J, Gemmel P, Annemans L. Do custom 3D-printed revision acetabular implants provide enough value to justify the additional costs? The health-economic comparison of a new porous 3D-printed hip implant for revision arthroplasty of Paprosky type 3B acetabular defects and its closest alternative. Orthop Traumatol Surg Res 2021; 107:102600. [PMID: 32409268 DOI: 10.1016/j.otsr.2020.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 03/01/2020] [Accepted: 03/04/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE Total hip arthroplasty (THA) is a common operation for patients suffering from hip arthrosis. It has been proven effective in improving quality of life while being cost-effective. Meanwhile, the number of revision hip arthroplasty is growing and those may require bone reconstruction and are potential indications for 3D custom implants. In these specific indications, medical 3D-printing has grown over the years and the use of 3D-printed implants has become more frequent. To date, the cost-effectiveness of 3D-printed implants for acetabular revision THA has not been evaluated. Therefore we performed a health economic analysis to: (1) analyse the cost-effectiveness of the aMace implant compared to its closest alternative on the market, (2) have a better insight into Belgian costs of revision hip arthroplasties and (3) estimate the budget impact in Belgium. HYPOTHESIS 3D-printed acetabular implants provide good value-for-health in Paprosky type 3B defects in a Belgian setting. MATERIAL AND METHODS Custom Three-flanged Acetabular Components (CTAC) were compared to a 3D-printed implant (aMace) by means of a Markov model with four states (successful, re-revision, resection and dead). The cycle length was set at 6 months with a 10-year time horizon. Data was obtained through systematic literature search and provided by a large social security agency. The analysis was performed from a societal perspective. All amounts are displayed in 2019 euros. Discount rates were applied for future cost (3%) and QALY (1.5%) estimates. RESULTS Revision hip arthroplasty has an average societal cost of €9950 without implant. Based on the outcomes of our model, aMace provides an excellent value for money compared to CTAC. The Incremental Cost-Effectiveness Ratio (ICER) was negative for all age groups. The base case of a 65 year old person, showed a QALY gain of 0.05 with a cost reduction of €1265 compared to CTAC. The advantage of using aMace was found to be greater if a patient is younger. The re-revision rates of both CTAC and aMace and the utility of successful revision have the highest impact on costs and effects. A Monte Carlo simulation showed aMace to be a cost-effective strategy in 90% of simulations for younger patients and in 88% of simulations for patients above 85 years old. In Belgium it would imply a cost reduction of €20500 on an annual basis. CONCLUSIONS Based on the findings of this model, the new 3D-printed aMace implant has the potential to bring an excellent value for money when used in revision arthroplasty of Paprosky type 3B acetabular defects. For all patients, aMace resulted in a dominant, cost-saving strategy in Belgium compared to CTAC. LEVEL OF EVIDENCE III, comparative medico economical diagnostic tool.
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Affiliation(s)
- Philip Tack
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, 4K3, 9000 Ghent, Belgium; Department of Innovation, Entrepreneurship and Service Management, Ghent University, Tweekerkenstraat 2, 9000 Ghent, Belgium.
| | - Jan Victor
- Department of Department of Orthopedics and Traumatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Paul Gemmel
- Department of Innovation, Entrepreneurship and Service Management, Ghent University, Tweekerkenstraat 2, 9000 Ghent, Belgium
| | - Lieven Annemans
- Department of Public Health and Primary Care, Ghent University, Corneel Heymanslaan 10, 4K3, 9000 Ghent, Belgium
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Quinlan ND, Hogarth DA, Chen DQ, Werner BC, Browne JA. Hospital and Surgeon Reimbursement Trends for Femoral Neck Fractures Treated With Hip Hemiarthroplasty and Total Hip Arthroplasty. J Arthroplasty 2020; 35:3067-3075. [PMID: 32600815 DOI: 10.1016/j.arth.2020.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/09/2020] [Accepted: 05/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The economic impact of hip fractures on the health care system continues to rise with continued pressure to reduce unnecessary costs while maintaining quality patient care. This study aimed to analyze the trend in hospital charges and payments relative to surgeon charges and payments in a Medicare population for hip hemiarthroplasty and total hip arthroplasty (THA) for femoral neck fracture. METHODS The 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 32,340 patients who underwent hemiarthroplasty and 4323 patients who underwent THA for femoral neck fractures between 2005 and 2014. Two values were calculated: (1) charge multiplier (CM, ratio of hospital to surgeon charges), and (2) payment multiplier (PM, ratio of hospital to surgeon payments). Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index (CCI), length of stay (LOS), 90-day and 1-year mortality, CM, and PM were evaluated. RESULTS Hospital charges were significantly higher than surgeon charges and increased substantially for hemiarthroplasty (CM of 13.6 to 19.3, P < .0001) and THA (CM of 9.8 to 14.9, P = .0006). PM followed a similar trend for both hemiarthroplasty (14.9 to 20.2; P = .001) and THA (11.9 to 17.4; P < .0001). LOS decreased significantly for hemiarthroplasty (3.78 to 3.37d; P < .0001) despite increasing CCI (6.36 to 8.39; P = .018), whereas both LOS (3.71 to 3.79 days; P = .421) and CCI (5.34 to 7.08; P = .055) remained unchanged for THA. CONCLUSION Hospital charges and payments relative to surgeon charges and payments have increased substantially for hemiarthroplasty and THA performed for femoral neck fractures.
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Affiliation(s)
- Nicole D Quinlan
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Danielle A Hogarth
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Dennis Q Chen
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
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Ferry C, Kim V, Ostrander J, Gaughan J, Mashru RP, Graf KW. Surgical Fixation of Sacral Fractures in the Elderly Population: Are There Predictors of Outcome? An Analysis of Return to Ambulation and Residential Living Status. Geriatr Orthop Surg Rehabil 2020; 11:2151459320967198. [PMID: 35186416 PMCID: PMC8848078 DOI: 10.1177/2151459320967198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 02/05/2023] Open
Abstract
Introduction: Recent literature suggests that surgical fixation of elderly sacral fractures may reduce time to mobilization and ultimately self-sufficiency. However, it is unclear if predictors of success exist in this subpopulation. The objective of this study was to characterize relative change in ambulation and residential living statuses (pre-injury vs. post-surgery) of elderly patients who received surgical fixation of sacral fractures, as well as determine whether or not demographics and injury characteristics influence these findings. Methods: Fifty-four elderly patients (≥60 years old) receiving percutaneous screw fixation of sacral fractures were retrospectively reviewed. All fractures were traumatic in nature; insufficiency fractures were excluded. Patient and surgical demographic data, as well as 1-year mortality status, was reported. Primary study endpoints included relative change in patient ambulation and residential living statuses (pre-injury to post-surgery). Statistical analyses were performed to assess relative change in ambulation/living status from pre-injury to post-surgery and to determine if predictors of outcome existed. Results: Of the 54 patients who met inclusion criteria, 4 expired prior to discharge, 2 expired post-discharge, and 4 were lost to follow-up. Of those patients discharged, 95.7% regained some form of ambulation at last follow-up (mean: 22.4 ± 18.9 weeks). Of patients living independent pre-injury, 94.9% would eventually return to independent home living. Neither time-to-surgery, concomitant orthopaedic injury, Charlson Comorbidity Index, or injury mechanism were predictors of final ambulation or residential status (p ≥ 0.07). Mortality at 1-year was 11.1%. Discussion: Operative fixation supported a high rate of return to pre-injury ambulation and residential living status. However, there did not appear to be measures predictive of final functional status. Further efforts with larger, prospective cohorts are warranted.
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Affiliation(s)
- Chris Ferry
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Victoria Kim
- Temple University Hospital, Philadelphia, PA, USA
| | | | - John Gaughan
- Cooper Medical School of Rowan University, Camden, NJ, USA.,Cooper University Hospital, Camden, NJ, USA
| | - Rakesh P Mashru
- Cooper Medical School of Rowan University, Camden, NJ, USA.,Cooper University Hospital, Camden, NJ, USA
| | - Kenneth W Graf
- Cooper Medical School of Rowan University, Camden, NJ, USA.,Cooper University Hospital, Camden, NJ, USA
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19
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Casnovsky L, Blaschke BL, Parikh HR, Flagstad I, Wise K, McMilan LJ, Gorman T, Okelana AB, Horst P, Cunningham BP. Does Implant Selection Affect the Inpatient Cost of Care for Geriatric Intertrochanteric Femur Fractures? Geriatr Orthop Surg Rehabil 2020; 11:2151459320959005. [PMID: 32995066 PMCID: PMC7503001 DOI: 10.1177/2151459320959005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/30/2020] [Accepted: 08/25/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Geriatric intertrochanteric (IT) femur fractures are a common and costly injury, expected to increase in incidence as the population ages. Understanding cost drivers will be essential for risk adjustments, and the surgeon's choice of implant may be an opportunity to reduce the overall cost of care. This study was purposed to identify the relationship between implant type and inpatient cost of care for isolated geriatric IT fractures. METHODS A retrospective review of IT fractures from 2013-2017 was performed at an academic level I trauma center. Construct type and AO/OTA fracture classifications were obtained radiographically, and patient variables were collected via the electronic medical record (EMR). The total cost of care was obtained via time-driven activity-based costing (TDABC). Multivariable linear regression and goodness-of-fit analyses were used to determine correlation between implant costs, inpatient cost of care, construct type, patient characteristics, and injury characteristics. RESULTS Implant costs ranged from $765.17 to $5,045.62, averaging $2,699, and were highest among OTA 31-A3 fracture patterns (p < 0.01). Implant cost had a positive linear association with overall inpatient cost of care (p < 0.01), but remained highly variable (r2 = 0.16). Total cost of care ranged from $9,129.18 to $64,210.70, averaging $19,822, and patients receiving a sliding hip screw (SHS) had the lowest mean total cost of care at $17,077, followed by short and long intramedullary nails ($19,314 and $21,372, respectively). When construct type and fracture pattern were compared to total cost, 31-A1 fracture pattern treated with SHS had significantly lower cost than 31-A2 and 31-A3 and less variation in cost. CONCLUSION The cost of care for IT fractures is poorly understood and difficult to determine. With alternative payment models on the horizon, implant selection should be utilized as an opportunity to decrease costs and increase the value of care provided to patients. LEVEL OF EVIDENCE Diagnostic Level IV.
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Affiliation(s)
- Lauren Casnovsky
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA
| | - Breanna L Blaschke
- TRIA Orthopaedics Center, Bloomington, MN, USA
- Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, MN, USA
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA
| | - Ilexa Flagstad
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA
| | - Kelsey Wise
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA
| | - Logan J McMilan
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA
| | - Tiffany Gorman
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA
| | - A. Bandele Okelana
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, MN, USA
| | - Patrick Horst
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- TRIA Orthopaedics Center, Bloomington, MN, USA
| | - Brian P Cunningham
- TRIA Orthopaedics Center, Bloomington, MN, USA
- Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, MN, USA
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20
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Reyes BJ, Mendelson DA, Mujahid N, Mears SC, Gleason L, Mangione KK, Nana A, Mijares M, Ouslander JG. Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society. Geriatr Orthop Surg Rehabil 2020; 11:2151459320935100. [PMID: 32728485 PMCID: PMC7366407 DOI: 10.1177/2151459320935100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities. METHODOLOGY A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS. RESULTS/CONCLUSION A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.
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Affiliation(s)
- Bernardo J. Reyes
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | | | - Nadia Mujahid
- Warren Alpert School of Brown University, Rhode Island, USA
| | | | - Lauren Gleason
- The University of Chicago Medical and Biological Science, IL,
USA
| | | | - Arvind Nana
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | - Maria Mijares
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
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21
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Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in the Elderly: A Cost-Effectiveness Analysis. J Orthop Trauma 2020; 34:348-355. [PMID: 32398470 DOI: 10.1097/bot.0000000000001747] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of screw fixation versus hemiarthroplasty for nondisplaced femoral neck fractures in low-demand elderly patients. METHODS We constructed a Markov decision model using a low-demand, 80-year-old patient as the base case. Costs, health-state utilities, mortality rates, and transition probabilities were obtained from published literature. The simulation model was cycled until all patients were deceased to estimate lifetime costs and quality-adjusted life years (QALYs). The primary outcome was the incremental cost-effectiveness ratio with a willingness-to-pay threshold set at $100,000 per QALY. We performed sensitivity analyses to assess our parameter assumptions. RESULTS For the base case, hemiarthroplasty was associated with greater quality of life (2.96 QALYs) compared with screw fixation (2.73 QALYs) with lower cost ($23,467 vs. $25,356). Cost per QALY for hemiarthroplasty was $7925 compared with $9303 in screw fixation. Hemiarthroplasty provided better outcomes at lower cost, indicating dominance over screw fixation. CONCLUSIONS Hemiarthroplasty is a cost-effective option compared with screw fixation for the treatment of nondisplaced femoral neck fractures in the low-demand elderly. Medical comorbidities and other factors that impact perioperative mortality should also be considered in the treatment decision. LEVEL OF EVIDENCE Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
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22
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Padilla JA, Gabor JA, Ryan SP, Long WJ, Seyler TM, Schwarzkopf RM. Total Hip Arthroplasty for Femoral Neck Fracture: The Economic Implications of Orthopedic Subspecialty Training. J Arthroplasty 2020; 35:S101-S106. [PMID: 32067895 DOI: 10.1016/j.arth.2020.01.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Hip fractures have significant economic implications as a result of their associated direct and indirect medical costs. Under alternative payment models, it has become increasingly important for institutions to find avenues by which costs could be reduced while maintaining outcomes in these cases. METHODS A multi-institutional retrospective analysis of Medicare patients who underwent total hip arthroplasty (THA) for femoral neck fracture was conducted to assess the impact of fellowship training in adult reconstruction (AR) on the total costs of the 90-day episode of care. Patients were divided into 2 cohorts according to fellowship training status of the operating surgeon: (1) AR-trained and (2) other fellowship training (non-AR). The primary outcome was the total cost of the 90-day episode of care converted to a percentage of the bundled payment target price. RESULTS A total of 291 patients who underwent THA for the treatment of a femoral neck fracture were included. The average total cost percentage of the 90-day episode of care was significantly lower for the AR cohort 70.9% (±36.6%) than the non-AR cohort 82.6% (±36.1%) (P < .01). After controlling for baseline demographics in the multivariable logistic regression, the care episodes in which the operating surgeons were AR fellowship-trained were still found to be significantly lower, at a rate of 0.87 times the costs of the non-AR surgeons (95% confidence interval 0.78-0.97, P = .011). In addition, the non-AR cohort exceeded the bundle target price more frequently than the AR cohort, 49 (28.7%) vs 16 (13.3%) (P = .02). CONCLUSION In an era of bundled payments, ascertaining factors that may increase the value of care while decreasing the cost is paramount for institutions and policymakers alike. The results presented in this study suggest that in the femoral neck fracture population, surgeons trained in AR achieve lower total costs for the THA episode of care. Furthermore, non-AR fellowship-trained surgeons exceeded the bundled payment target more frequently than the AR surgeons.
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Affiliation(s)
- Jorge A Padilla
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York
| | - Jonathan A Gabor
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - William J Long
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ran M Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, New York, New York
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Walensky RP, Horn T, McCann NC, Freedberg KA, Paltiel AD. Comparative Pricing of Branded Tenofovir Alafenamide-Emtricitabine Relative to Generic Tenofovir Disoproxil Fumarate-Emtricitabine for HIV Preexposure Prophylaxis: A Cost-Effectiveness Analysis. Ann Intern Med 2020; 172:583-590. [PMID: 32150602 PMCID: PMC7217721 DOI: 10.7326/m19-3478] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Tenofovir alafenamide-emtricitabine (F/TAF) was recently approved as a noninferior and potentially safer option than tenofovir disoproxil fumarate-emtricitabine (F/TDF) for HIV preexposure prophylaxis (PrEP) in the United States. Objective To estimate the greatest possible clinical benefits and economic savings attributable to the improved safety profile of F/TAF and the maximum price payers should be willing to pay for F/TAF over generic F/TDF. Design Cost-effectiveness analysis. Data Sources Published literature on F/TDF safety (in persons with and those without HIV) and the cost and quality-of-life effects of fractures and end-stage renal disease (ESRD). Target Population Age-stratified U.S. men who have sex with men (MSM) using PrEP. Time Horizon Five years. Perspective Health care sector. Intervention Preexposure prophylaxis with F/TAF versus F/TDF. Outcome Measures Fractures averted, cases of ESRD averted, quality-adjusted life-years (QALYs) saved, costs, incremental cost-effectiveness ratios (ICERs), and maximum justifiable price for F/TAF compared with generic F/TDF. Results of Base-Case Analysis Over a 5-year horizon, compared with F/TDF, F/TAF averted 2101 fractures and 25 cases of ESRD for the 123 610 MSM receiving PrEP, with an ICER of more than $7 million per QALY. At a 50% discount for generic F/TDF ($8300 per year) and a societal willingness to pay up to $100 000 per QALY, the maximum fair price for F/TAF was $8670 per year. Results of Sensitivity Analysis Among persons older than 55 years, the ICER for F/TAF remained more than $3 million per QALY and the maximum permissible fair price for F/TAF was $8970 per year. Results were robust to alternative time horizons and PrEP-using population sizes. Limitation Intermittent use and on-demand PrEP were not considered. Conclusion In the presence of a generic F/TDF alternative, the improved safety of F/TAF is worth no more than an additional $370 per person per year. Primary Funding Source National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, National Institute of Mental Health, and Massachusetts General Hospital Executive Committee on Research.
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Affiliation(s)
- Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard University Center for AIDS Research, Harvard Medical School, Boston, Massachusetts (R.P.W.)
| | - Tim Horn
- National Alliance of State and Territorial AIDS Directors, Washington, DC (T.H.)
| | - Nicole C McCann
- Massachusetts General Hospital, Boston, Massachusetts (N.C.M.)
| | - Kenneth A Freedberg
- Massachusetts General Hospital and Harvard University Center for AIDS Research, Harvard Medical School, Boston, Massachusetts (K.A.F.)
| | - A David Paltiel
- Yale School of Public Health, New Haven, Connecticut (A.D.P.)
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Malik AT, Khan SN, Ly TV, Phieffer L, Quatman CE. The "Hip Fracture" Bundle-Experiences, Challenges, and Opportunities. Geriatr Orthop Surg Rehabil 2020; 11:2151459320910846. [PMID: 32181049 PMCID: PMC7059231 DOI: 10.1177/2151459320910846] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 02/10/2020] [Indexed: 12/19/2022] Open
Abstract
Introduction: With growing popularity and success of alternative-payment models (APMs) in elective
total joint arthroplasties, there has been recent discussion on the probability of
implementing APMs for geriatric hip fractures as well. Significance: Despite the growing interest, little is known about the drawbacks and challenges that
will be faced in a stipulated “hip fracture” bundle. Results: Given the varying intricacies and complexities of hip fractures, a “one-size-fits-all”
bundled payment may not be an amenable way of ensuring equitable reimbursement for
participating physicians and hospitals. Conclusions: Health-policy makers need to advocate for better risk-adjustment methods to prevent the
creation of financial disincentives for hospitals taking care of complex, sicker
patients. Hospitals participating in bundled care also need to voice concerns regarding
the grouping of hip fractures undergoing total hip arthroplasty to ensure that trauma
centers are not unfairly penalized due to higher readmission rates associated with hip
fractures skewing quality metrics. Physicians also need to consider the launch of better
risk-stratification protocols and promote geriatric comanagement of these patients to
prevent occurrences of costly adverse events.
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Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Safdar N Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thuan V Ly
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Laura Phieffer
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carmen E Quatman
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Geographic Variations in Intertrochanteric Femoral Fractures in China. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8396723. [PMID: 31772937 PMCID: PMC6854944 DOI: 10.1155/2019/8396723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 09/05/2019] [Indexed: 11/17/2022]
Abstract
Background Hip fracture is one of the major risk factors of global mortality and disability. The aim of this study was to map the pattern of intertrochanteric femoral fractures in China, providing a pilot national dataset and basis for medical policy proposals. Methods A multistage probability sampling strategy was applied in the national baseline survey. Thirty provinces in mainland China were included in this survey. A standardized questionnaire survey was conducted to collect information about basic characteristics such as age, working seniority, hospital level, and residence, with two other parts including perioperative and postoperative treatment parameters. Odds ratios and 95% confidence interval were used to determine essential statistical differences. The proportion of the options in each region was compared using the chi-square (χ 2) test. The histogram and choropleth map of the monthly number of admissions were created using Excel 2016 to show the distribution characteristics. Results In total, 1065 valid responses were included, representing a 96.7% survey capture rate. Perioperative treatment and postoperative care distinctly varied across regions and hospital levels. The monthly number of admissions was relatively lower in the Northern region, with higher proportion of hospitalizations to secondary hospitals compared with the Eastern region. The patients in the Eastern region or tertiary hospitals had shorter preoperative waiting time and hospitalization period. Conclusions We found apparent geographic variations in intertrochanteric femoral fractures in this study, and the data can be used for drafting national healthcare plans and medical policies.
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Mahmoudi E, Malay S, Maroukis BL, Sarsour T, Chung KC. The Application of Medicare Data for Musculoskeletal Research in the United States: A Systematic Review. J Am Acad Orthop Surg 2019; 27:e622-e632. [PMID: 31232800 PMCID: PMC6604860 DOI: 10.5435/jaaos-d-17-00297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Musculoskeletal conditions disproportionately affect the lives of aging adults. We aimed to examine the literature using Medicare claims data in the United States for musculoskeletal surgical procedures. METHODS Following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we searched the PubMed and Medline databases for peer-reviewed articles published between 1990 and 2015. We included the studies that (1) reported primary Medicare claims data use, (2) involved musculoskeletal surgery, and (3) were original peer-reviewed studies. We abstracted the types of surgical procedure and aims, and evaluated outcomes, and strengths and weaknesses of each included article. We assessed the quality of included articles with Newcastle Ottawa Assessment Scale. RESULTS The literature search returned 3,233 articles, of which 119 met our inclusion criteria. These studies focused on different outcomes: epidemiology and treatment variation (26), cost of care (15), hospital-level analyses (30), health outcomes (31), the validity and accuracy of Medicare claims data (4), disparities in health care (10), and policy evaluation (3). DISCUSSION Medicare claims data provide a unique way for researchers to study a nationally representative patient population longitudinally. A significant limitation of using claims data has been a lack of granularity on defining severity of a condition. LEVEL OF EVIDENCE Therapeutic level III.
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Affiliation(s)
- Elham Mahmoudi
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Sunitha Malay
- Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Brianna L. Maroukis
- Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Tiana Sarsour
- Michigan Health Science Undergraduate Research Academy, Office of Health Equity and Inclusion, University of Michigan, Ann Arbor, MI
- University of Toledo, College of Natural Sciences, Toledo, OH
| | - Kevin C. Chung
- Section of Plastic Surgery, Assistant Dean for Faculty Affairs, University of Michigan Medical School, Ann Arbor, MI
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Thong BKS, Ima-Nirwana S, Chin KY. Proton Pump Inhibitors and Fracture Risk: A Review of Current Evidence and Mechanisms Involved. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E1571. [PMID: 31060319 PMCID: PMC6540255 DOI: 10.3390/ijerph16091571] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 12/11/2022]
Abstract
The number of patients with gastroesophageal problems taking proton pump inhibitors (PPIs) is increasing. Several studies suggested a possible association between PPIs and fracture risk, especially hip fractures, but the relationship remains contentious. This review aimed to investigate the longitudinal studies published in the last five years on the relationship between PPIs and fracture risk. The mechanism underlying this relationship was also explored. Overall, PPIs were positively associated with elevated fracture risk in multiple studies (n = 14), although some studies reported no significant relationship (n = 4). Increased gastrin production and hypochlorhydria are the two main mechanisms that affect bone remodeling, mineral absorption, and muscle strength, contributing to increased fracture risk among PPI users. As a conclusion, there is a potential relationship between PPIs and fracture risks. Therefore, patients on long-term PPI treatment should pay attention to bone health status and consider prophylaxis to decrease fracture risk.
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Affiliation(s)
- Benjamin Ka Seng Thong
- Department of Pharmacology, Universiti Kebangsaan Malaysia Medical Centre, Cheras 56000, Malaysia.
| | - Soelaiman Ima-Nirwana
- Department of Pharmacology, Universiti Kebangsaan Malaysia Medical Centre, Cheras 56000, Malaysia.
| | - Kok-Yong Chin
- Department of Pharmacology, Universiti Kebangsaan Malaysia Medical Centre, Cheras 56000, Malaysia.
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Predictive Modeling for Geriatric Hip Fracture Patients: Early Surgery and Delirium Have the Largest Influence on Length of Stay. J Am Acad Orthop Surg 2019; 27:e293-e300. [PMID: 30358636 PMCID: PMC6411423 DOI: 10.5435/jaaos-d-17-00447] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Averaging length of stay (LOS) ignores patient complexity and is a poor metric for quality control in geriatric hip fracture programs. We developed a predictive model of LOS that compares patient complexity to the logistic effects of our institution's hip fracture care pathway. METHODS A retrospective analysis was performed on patients enrolled into a hip fracture co-management pathway at an academic level I trauma center from 2014 to 2015. Patient complexity was approximated using the Charlson Comorbidity Index and ASA score. A predictive model of LOS was developed from patient-specific and system-specific variables using a multivariate linear regression analysis; it was tested against a sample of patients from 2016. RESULTS LOS averaged 5.95 days. Avoidance of delirium and reduced time to surgery were found to be notable predictors of reduced LOS. The Charlson Comorbidity Index was not a strong predictor of LOS, but the ASA score was. Our predictive LOS model worked well for 63% of patients from the 2016 group; for those it did not work well for, 80% had postoperative complications. DISCUSSION Predictive LOS modeling accounting for patient complexity was effective for identifying (1) reasons for outliers to the expected LOS and (2) effective measures to target for improving our hip fracture program. LEVEL OF EVIDENCE III.
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Abstract
INTRODUCTION The National Surgical Quality Improvement Project (NSQIP) and the Trauma Quality Improvement Project (TQIP) collect data on geriatric hip fractures (GHFs) that could be used to generate risk-adjusted metrics for care of these patients. We examined differences between GHFs reported by our own trauma center to the NSQIP and TQIP and those vetted through an internal GHF list. METHODS We reviewed charts of GHFs treated between January 1 and December 31, 2015, and compared patients in an internal GHF database and/or reported to the NSQIP and/or TQIP and determined differences between databases. RESULTS We identified 89 "true" GHFs, of which 96% were identified by our institutional database, 70% by NSQIP, and 9% by the TQIP. No differences were found in outcomes and total costs. The net revenue/patient in the NSQIP database was $24,373 more than those in the institutional database. CONCLUSION Caution should be taken when using NSQIP/TQIP databases to evaluate the care of GHFs. LEVEL OF EVIDENCE Level III.
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Malik AT, Quatman CE, Phieffer LS, Ly TV, Khan SN. Timing of complications following surgery for geriatric hip fractures. J Clin Orthop Trauma 2019; 10:904-911. [PMID: 31528066 PMCID: PMC6739463 DOI: 10.1016/j.jcot.2018.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/27/2018] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Despite abundant literature present on complications following hip fracture surgery, few studies have focused on the timing of these complications. MATERIALS AND METHODS The 2015-2016 American College of Surgeons - National Surgical Quality Improvement Program database was queried for patients ≥65 years of age undergoing hip fracture surgery, due to trauma, using CPT-Codes for total hip arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). For each complication being studied, the median time to diagnosis was determined along with the interquartile range (IQR). Cox-regression analyses were used to assess complication timings between various surgeries. RESULTS A total of 31,738 were included in the final cohort. The median time of occurrence (days) for myocardial infarction was 2 [IQR 1-6], pneumonia 4 [IQR 2-12], stroke/CVA 3 [IQR 1-10], pulmonary embolism 5 [IQR 2-14], urinary tract infection (UTI) 8 [IQR 2-15], deep venous thrombosis (DVT) 9 [IQR 4-17], sepsis 11 [IQR 5-19], death 12 [IQR 6-20], superficial surgical site infection (SSI) 16 [IQR 12-22], deep SSI 23 [IQR 15-24] and organ/space SSI 19 [IQR 15-23]. Undergoing a THA vs. ORIF for hip fracture was associated a relatively early occurrence of pneumonia (day 3 [IQR 1-5.25]; p = 0.029) and urinary tract infection (day 4 [IQR 1-13]; p = 0.035) and a later occurrence of organ/space SSI (day 23.5 [IQR 19.5-26.75]; p = 0.002). CONCLUSION Orthopaedic trauma surgeons can utilize this data to optimize care strategies during the time-periods of highest risk to prevent complications from occurring early on in the course of post-operative care.
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Affiliation(s)
| | | | | | | | - Safdar N. Khan
- Corresponding author. Division of Spine Surgery, Department of Orthopaedic Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA. https://spine.osu.edu/about/our-team
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Wang M, Park S, Nam Y, Nielsen J, Low SA, Srinivasarao M, Low PS. Bone-Fracture-Targeted Dasatinib-Oligoaspartic Acid Conjugate Potently Accelerates Fracture Repair. Bioconjug Chem 2018; 29:3800-3809. [PMID: 30380292 DOI: 10.1021/acs.bioconjchem.8b00660] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Approximately 6.3 million bone fractures occur annually in the United States, resulting in considerable morbidity, deterioration in quality of life, loss of productivity and wages, and sometimes death (e.g., hip fractures). Although anabolic and antiresorptive agents have been introduced for treatment of osteoporosis, no systemically administered drug has been developed to accelerate the fracture-healing process. To address this need, we have undertaken to target a bone anabolic agent selectively to fracture surfaces in order to concentrate the drug's healing power directly on the fracture site. We report here that conjugation of dasatinib to a bone fracture-homing oligopeptide via a releasable linker reduces fractured femur healing times in mice by ∼60% without causing overt off-target toxicity or remodeling of nontraumatized bones. Thus, achievement of healthy bone density, normal bone volume, and healthy bone mechanical properties at the fracture site is realized after only 3-4 weeks in dasatinib-targeted mice, but it requires ∼8 weeks in PBS-treated controls. We conclude that targeting of dasatinib to bone fracture surfaces can significantly accelerate the healing process at dasatinib concentrations that are known to be safe in oncological applications.
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Affiliation(s)
- Mingding Wang
- Department of Chemistry , Purdue University , 560 Oval Drive , West Lafayette , Indiana 47907 , United States
| | - Soie Park
- Department of Chemistry , Purdue University , 560 Oval Drive , West Lafayette , Indiana 47907 , United States
| | - Yoonhee Nam
- Department of Chemistry , Purdue University , 560 Oval Drive , West Lafayette , Indiana 47907 , United States
| | - Jeffery Nielsen
- College of Pharmacy , Purdue University , 575 Stadium Mall Drive , West Lafayette , Indiana 47907 , United States
| | - Stewart A Low
- Department of Chemistry , Purdue University , 560 Oval Drive , West Lafayette , Indiana 47907 , United States
| | - Madduri Srinivasarao
- Department of Chemistry , Purdue University , 560 Oval Drive , West Lafayette , Indiana 47907 , United States
| | - Philip S Low
- Department of Chemistry , Purdue University , 560 Oval Drive , West Lafayette , Indiana 47907 , United States.,Institute for Drug Discovery , Purdue University , 720 Clinic Drive , West Lafayette , Indiana 47907 , United States
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Nherera LM, Trueman P, Horner A, Johnstone AJ, Watson TJ, Fatoye FA. Comparing the costs and outcomes of an integrated twin compression screw (ITCS) nail with standard of care using a single lag screw or a single helical blade cephalomedullary nail in patients with intertrochanteric hip fractures. J Orthop Surg Res 2018; 13:217. [PMID: 30165881 PMCID: PMC6117956 DOI: 10.1186/s13018-018-0923-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/20/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows for early rehabilitation and functional recovery. The purpose of the study was to assess the cost-effectiveness of commonly used cephalomedullary nails for the treatment of unstable intertrochanteric hip fractures. METHODS A decision analytic model was developed from a US payer's perspective using clinical data from a pairwise meta-analysis of randomised controlled trials (RCTs) and comparative observational studies comparing the integrated twin compression screw (ITCS) nail versus two single-screw or blade cephalomedullary nails [single lag screw (SLS) nail and single helical blade (SHB) nail]. The model considered a cohort of 1000 patients with a mean age of 76, as reported in the clinical studies over a 1-year time period. Cost data was obtained from the Center for Medicare and Medicaid Services website and published literature and adjusted for inflation. One-way and probabilistic sensitivity analyses were conducted to assess the effect of uncertainty in model parameters on model conclusions. RESULTS The model estimated 0.546 quality-adjusted life years (QALYs) and 0.78 complications avoided by using the ITCS nail and 0.455 QALYs and 0.67 complications avoided for the standard of care, using SLS or SHB nails. The cost per patient was $34,336 for patients treated with an ITCS nail and $37,036 for patients treated with the standard of care respectively, resulting in a cost saving of $2700 in favour of the ITCS nail. More savings were observed when the ITCS nail was compared to the SHB ($3280 per patient) and SLS ($1652 per patient). The findings were robust to a range of both one-way and the probabilistic sensitivity analyses. CONCLUSION In conclusion, the ITCS nail can be considered a cost saving intervention in patients undergoing intertrochanteric fracture fixation with an intramedullary device. Clinicians and policy makers should be encouraged to adopt healthcare technologies such as ITCS that will help them to provide quality healthcare despite falling budgets.
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Affiliation(s)
- Leo M Nherera
- Health Economics, Smith & Nephew Global Market Access, 101 Hessle Road, Hull, HU3 2BN, UK.
| | - Paul Trueman
- Health Economics, Smith & Nephew Global Market Access, 101 Hessle Road, Hull, HU3 2BN, UK
| | - Alan Horner
- Health Economics, Smith & Nephew Global Market Access, 101 Hessle Road, Hull, HU3 2BN, UK
| | - Alan J Johnstone
- University of Aberdeen and Aberdeen Royal Infirmary, Aberdeen, UK
| | - Tracy J Watson
- Orthopedic and Spine Institute at Banner University Medical Center, Phoenix, AZ, USA
| | - Francis A Fatoye
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
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Mather RC, Nho SJ, Federer A, Demiralp B, Nguyen J, Saavoss A, Salata MJ, Philippon MJ, Bedi A, Larson CM, Byrd JWT, Koenig L. Effects of Arthroscopy for Femoroacetabular Impingement Syndrome on Quality of Life and Economic Outcomes. Am J Sports Med 2018. [PMID: 29533689 DOI: 10.1177/0363546518757758] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The diagnosis and treatment of femoroacetabular impingement (FAI) have increased steadily within the past decade, and research indicates clinically significant improvements after treatment of FAI with hip arthroscopy. PURPOSE This study examined the societal and economic impact of hip arthroscopy by high-volume surgeons for patients with FAI syndrome aged <50 years with noncontroversial diagnosis and indications for surgery. STUDY DESIGN Economic and decision analysis; Level of evidence, 2. METHODS The cost-effectiveness of hip arthroscopy versus nonoperative treatment was evaluated by calculating direct and indirect treatment costs. Direct cost was calculated with Current Procedural Terminology medical codes associated with FAI treatment. Indirect cost was measured with the patient-reported data of 102 patients who underwent arthroscopy and from the reimbursement records of 32,143 individuals between the ages of 16 and 79 years who had information in a private insurance claims data set contained within the PearlDiver Patient Records Database. The indirect economic benefits of hip arthroscopy were inferred through regression analysis to estimate the statistical relationship between functional status and productivity. A simulation-based approach was then used to estimate the change in productivity associated with the change in functional status observed in the treatment cohort between baseline and follow-up. To analyze cost-effectiveness, 1-, 2-, and 3-way sensitivity analyses were performed on all variables in the model, and Monte Carlo analysis evaluated the impact of uncertainty in the model assumptions. RESULTS Analysis of indirect costs identified a statistically significant increase of mean aggregate productivity of $8968 after surgery. Cost-effectiveness analysis showed a mean cumulative total 10-year societal savings of $67,418 per patient from hip arthroscopy versus nonoperative treatment. Hip arthroscopy also conferred a gain of 2.03 quality-adjusted life years over this period. The mean cost for hip arthroscopy was estimated at $23,120 ± $10,279, and the mean cost of nonoperative treatment was estimated at $91,602 ± $14,675. In 99% of trials, hip arthroscopy was recognized as the preferred cost-effective strategy. CONCLUSION FAI syndrome produces a substantial economic burden on society that may be reduced through the indirect cost savings and economic benefits from hip arthroscopy.
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Affiliation(s)
- Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Shane J Nho
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Andrew Federer
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | - Asha Saavoss
- KNG Health Consulting, LLC, Rockville, Maryland, USA
| | - Michael J Salata
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Christopher M Larson
- Minnesota Orthopedic Sports Medicine Institute, Twin Cities Orthopedics, Edina, Minnesota, USA
| | - J W Thomas Byrd
- Nashville Sports Medicine Foundation, Nashville, Tennessee, USA
| | - Lane Koenig
- KNG Health Consulting, LLC, Rockville, Maryland, USA
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Lewiecki EM, Wright NC, Curtis JR, Siris E, Gagel RF, Saag KG, Singer AJ, Steven PM, Adler RA. Hip fracture trends in the United States, 2002 to 2015. Osteoporos Int 2018; 29:717-722. [PMID: 29282482 DOI: 10.1007/s00198-017-4345-0] [Citation(s) in RCA: 192] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/12/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED An analysis of United States (US) Medicare claims data from 2002 to 2015 for women aged ≥ 65 years found that age-adjusted hip fracture rates for 2013, 2014, and 2015 were higher than projected, resulting in an estimated increase of more than 11,000 hip fractures. INTRODUCTION Hip fractures are a major public health concern due to high morbidity, mortality, and healthcare expenses. Previous studies have reported a decrease in the annual incidence of hip fractures in the US beginning in 1995, coincident with the introduction of modern diagnostic tools and therapeutic agents for osteoporosis. In recent years, there has been less bone density testing and fewer prescriptions for osteoporosis treatments. The large osteoporosis treatment gap raises concern of possible adverse effects on hip fracture rates. METHODS We assessed hip fracture incidence in the US to determine if the previous decline in hip fracture incidence continued. Using 2002 to 2015 Medicare Part A and Part B claims for women ≥ 65 years old, we calculated age-adjusted hip fracture rates, weighting to the 2014 population. RESULTS We found that hip fracture rates declined each year from 2002 to 2012 and then plateaued at levels higher than projected for years 2013, 2014, and 2015. CONCLUSIONS The plateau in age-adjusted hip fracture incidence rate resulted in more than 11,000 additional estimated hip fractures over the time periods 2013, 2014, and 2015. We recommend further study to assess all factors contributing to this remarkable change in hip fracture rate and to develop strategies to reduce the osteoporosis treatment gap.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, 300 Oak St. NE, Albuquerque, NM, 87106, USA.
| | - N C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J R Curtis
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - E Siris
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - R F Gagel
- Department of Endocrine Neoplasia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K G Saag
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - A J Singer
- Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - P M Steven
- International Society for Clinical Densitometry, Hartford, CT, USA
| | - R A Adler
- Endocrinology Section, McGuire Veterans Affairs Medical Center, Richmond, VA, USA
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Azevedo PS, Gumieiro DN, Polegato BF, Pereira GJC, Silva IA, Pio SM, Junior CPC, Junior ELF, de Paiva SAR, Minicucci MF, Zornoff LAM. Goldman score, but not Detsky or Lee indices, predicts mortality 6 months after hip fracture. BMC Musculoskelet Disord 2017; 18:134. [PMID: 28372593 PMCID: PMC5379496 DOI: 10.1186/s12891-017-1480-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/08/2017] [Indexed: 12/21/2022] Open
Abstract
Background Over the past years, several cardiac risk indices were evaluated and modified, including Goldman, Detsky, and Lee scores. The predictive capacity of these scores in hip fracture patients is lacking. Thus, our objective was to compare the Goldman, Detsky, and Lee scores as predictors of mortality in 6 months after hip fracture. Methods We prospectively evaluated 80 consecutive patients with hip fractures, over the age of 65 admitted to an orthopedic ward at Botucatu Medical School. Patient demographic information, Goldman, Detsky and Lee scores were recorded. All patients were followed for 6 months after hip fracture, and mortality was recorded. Multiple logistic regression analyses were performed for mortality prediction. Results The mortality rate was 23% after a 6-month follow-up period. Patients who died had advanced age and the majority of them were male. They also had lower values of handgrip strength, and higher values of creatinine and urea. In the multiple logistic regression models when adjusted by age, gender, handgrip strength and creatinine, Goldman’s score (OR:3.025; 95%CI:1.022-8.953; p:0.046), but not Detsky (OR:2.328; 95%CI:0.422-12.835; p:0.332) and Lee (OR:1.262; 95%CI:0.649-2.454; p:0.494), was associated with mortality 6 months after hip fracture. Each 1 category increase in Goldman score increased the mortality to more than 3-fold. Conclusions In conclusion, our data suggest that Goldman score, but not Detsky or Lee indices, predicts mortality associated with hip fracture at up to 6 months post-injury.
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Affiliation(s)
- Paula Schmidt Azevedo
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Rubião Júnior s/n, ZipCode: 18618-970, Botucatu, SP, Brazil.
| | - David Nicoletti Gumieiro
- Surgery and Orthopedic Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil
| | - Bertha Furlan Polegato
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Rubião Júnior s/n, ZipCode: 18618-970, Botucatu, SP, Brazil
| | - Gilberto José Cação Pereira
- Surgery and Orthopedic Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil
| | - Igor Almonfrey Silva
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Rubião Júnior s/n, ZipCode: 18618-970, Botucatu, SP, Brazil
| | - Stephan Milhorini Pio
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Rubião Júnior s/n, ZipCode: 18618-970, Botucatu, SP, Brazil
| | - Cacionor Pereira Cunha Junior
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Rubião Júnior s/n, ZipCode: 18618-970, Botucatu, SP, Brazil
| | - Edson Luiz Favero Junior
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Rubião Júnior s/n, ZipCode: 18618-970, Botucatu, SP, Brazil
| | - Sergio Alberto Rupp de Paiva
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Rubião Júnior s/n, ZipCode: 18618-970, Botucatu, SP, Brazil
| | - Marcos Ferreira Minicucci
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Rubião Júnior s/n, ZipCode: 18618-970, Botucatu, SP, Brazil
| | - Leonardo Antonio Mamede Zornoff
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Rubião Júnior s/n, ZipCode: 18618-970, Botucatu, SP, Brazil
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Swart E, Roulette P, Leas D, Bozic KJ, Karunakar M. ORIF or Arthroplasty for Displaced Femoral Neck Fractures in Patients Younger Than 65 Years Old: An Economic Decision Analysis. J Bone Joint Surg Am 2017; 99:65-75. [PMID: 28060235 DOI: 10.2106/jbjs.16.00406] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The decision between open reduction and internal fixation (ORIF) and arthroplasty for a displaced femoral neck fracture in a patient ≤65 years old can be challenging. Both options have potential drawbacks; if a fracture treated with ORIF fails to heal it may require a revision operation, whereas a relatively young patient who undergoes arthroplasty may need revision within his/her lifetime. The purpose of this study was to employ decision analysis modeling techniques to generate evidence-based treatment recommendations in this clinical scenario. METHODS A Markov decision analytic model was created to simulate outcomes after ORIF, total hip arthroplasty (THA), or hemiarthroplasty in patients who had sustained a displaced femoral neck fracture between the ages of 40 and 65 years. The variables in the model were populated with values from studies with high-level evidence and from national registry data reported in the literature. The model was used to estimate the threshold age above which THA would be the superior strategy. Results were tested using sensitivity analysis and probabilistic statistical analysis. RESULTS THA was found to be a cost-effective option for a displaced femoral neck fracture in an otherwise healthy patient who is >54 years old, a patient with mild comorbidity who is >47 years old, and a patient with multiple comorbidities who is >44 years old. The average clinical outcomes of THA and ORIF were similar for patients 40 to 65 years old, although ORIF had a wider variability in outcomes based on the success or failure of the initial fixation. For all ages and cases, hemiarthroplasty was associated with worse outcomes and higher costs. CONCLUSIONS Compared with ORIF, primary THA can be a cost-effective treatment for displaced femoral neck fractures in patients 45 to 65 years of age, with the age cutoff favoring THA decreasing as the medical comorbidity and risk of ORIF fixation failure increase. Hemiarthroplasty has worse outcomes at higher costs and is not recommended in this age group. LEVEL OF EVIDENCE Economic and decision analysis Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eric Swart
- 1Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts 2Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina 3Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
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Yun BJ, Myriam Hunink MG, Prabhakar AM, Heng M, Liu SW, Qudsi R, Raja AS. Diagnostic Imaging Strategies for Occult Hip Fractures: A Decision and Cost-Effectiveness Analysis. Acad Emerg Med 2016; 23:1161-1169. [PMID: 27286291 DOI: 10.1111/acem.13026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/02/2016] [Accepted: 06/07/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Hip fractures cause significant morbidity and mortality. Determining the optimal diagnostic strategy for the subset of patients with potential occult hip fracture remains challenging. We determined the most cost-effective strategy for the diagnosis of occult hip fractures from the choices of performing only computed tomography (CT), performing only magnetic resonance imaging (MRI), performing CT and if negative performing MRI (MRI-selective strategy) or discharging the patient without advanced imaging. METHODS We developed a decision-analytic model to compare outcomes and costs of different diagnostic strategies for the diagnosis of an occult hip fracture from a societal perspective. Model inputs were derived from charge data, Medicare reimbursements, and the literature. Strategies with an incremental cost-effectiveness ratio (ICER) below $100,000 per quality-adjusted life-year (QALY) gained were considered cost-effective. We tested the robustness of our results using probabilistic sensitivity analysis. RESULTS Compared to a CT strategy, MRI provides an additional 0.05 QALY at an incremental cost of $1,227 and ICER of $25,438/QALY. For facilities without MRI capability, if the cost of transfer is below $1,228, transferring the patient to a MRI-capable facility is the most cost-effective strategy. Above this cost, employing a CT and if negative transfer to a MRI-capable facility strategy was more cost-effective. When the cost of a transfer reached more than $4,039, it became more cost-effective to only obtain a CT. CONCLUSION MRI is a cost-effective strategy for the diagnosis of an occult hip fracture. For facilities without MRI capability, the most cost-effective strategy depends on the cost of the interfacility transfer.
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Affiliation(s)
- Brian J. Yun
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
- Harvard Medical School Boston MA
| | - M. G. Myriam Hunink
- Departments of Radiology and Epidemiology Erasmus University Medical Center Rotterdam Netherlands
- Centre for Health Decision Science Harvard T.H. Chan School of Public Health Boston MA
| | - Anand M. Prabhakar
- Division of Cardiovascular Imaging Department of Radiology Boston MA
- Division of Emergency Imaging Department of Radiology Boston MA
- Harvard Medical School Boston MA
| | - Marilyn Heng
- Department of Orthopaedic Surgery Boston MA
- Harvard Orthopaedic Trauma Initiative Boston MA
- Harvard Medical School Boston MA
| | - Shan W. Liu
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
- Harvard Medical School Boston MA
| | - Rameez Qudsi
- Department of Orthopaedic Surgery Boston MA
- Harvard Medical School Boston MA
| | - Ali S. Raja
- Department of Emergency Medicine Massachusetts General Hospital Boston MA
- Department of Radiology Brigham and Women's Hospital Boston MA
- Harvard Medical School Boston MA
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38
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Abstract
The treatment of hip fractures in the elderly represents a major public health priority and a source of ongoing debate among orthopaedic surgeons and anesthesiologists. Most of these injuries are treated with surgery in an expedient fashion. From the surgical perspective, there are certain special considerations in this population including osteoporosis, pre-existing arthritis, age, activity level, and overall health that contribute to the type of surgical fixation performed. Open reduction and internal fixation versus arthroplasty remain the two major categories of treatment. While the indications and treatment algorithms still remain controversial, the overall goal for these patients is early mobilization and prevention of morbidity and mortality. The use of preoperative, regional anesthesia has aided in this effort. The purpose of this review article is to examine the various treatment modalities for hip fractures in the elderly and discuss the most recent evidence in the face of a rapidly aging population.
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Affiliation(s)
- Joshua C Rozell
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hasenauer
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Derek J Donegan
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
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Geriatric hip fracture management: keys to providing a successful program. Eur J Trauma Emerg Surg 2016; 42:565-569. [PMID: 27241865 DOI: 10.1007/s00068-016-0685-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hip fractures are a common event in older adults and are associated with significant morbidity, mortality and costs. This review examines the necessary elements required to implement a successful geriatric fracture program and identifies some of the barriers faced when implementing a successful program. INTERVENTION The Geriatric Fracture Center (GFC) is a treatment model that standardizes the approach to the geriatric fracture patient. It is based on five principles: surgical fracture management; early operative intervention; medical co-management with geriatricians; patient-centered, standard order sets to employ best practices; and early discharge planning with a focus on early functional rehabilitation. Implementing a geriatric fracture program begins with an assessment of the hospital's data on hip fractures and standard care metrics such as length of stay, complications, time to surgery, readmission rates and costs. Business planning is essential along with the medical planning process. CONCLUSION To successfully develop and implement such a program, strong physician leadership is necessary to articulate both a short- and long-term plan for implementation. Good communication is essential-those organizing a geriatric fracture program must be able to implement standardized plans of care working with all members of the healthcare team and must also be able to foster relationships both within the hospital and with other institutions in the community. Finally, a program of continual quality improvement must be undertaken to ensure that performance outcomes are improving patient care.
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40
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The Cemented Unipolar Prosthesis for the Management of Displaced Femoral Neck Fractures in the Dependent Osteopenic Elderly. J Arthroplasty 2016; 31:1040-6. [PMID: 26742902 DOI: 10.1016/j.arth.2015.11.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/14/2015] [Accepted: 11/24/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Significant variability exists across orthopedic surgeons in the management of the displaced femoral neck fracture in the elderly patient (>75 years old). These patients tend to be less healthy, have inferior bone quality, and gait instability leading to increased risk of periprosthetic fracture, compromised implant fixation, dislocation, and need for revision. The surgeon's goals should be to restore mobility while eliminating pain and need for reoperation. METHODS In this review article, we examine the best available evidence in the literature to determine which strategy achieves optimal outcomes. We examine outcome studies comparing use of hemiarthroplasty and total hip arthroplasty, unipolar and bipolar hemiarthroplasty, and cemented vs cementless fixation of femoral stems. RESULTS AND CONCLUSIONS For the active, healthy, and lucid patient, or one who has preexisting groin pain, who sustains a displaced femoral neck fracture, the literature supports a total hip arthroplasty. Patients sustaining a displaced femoral neck fracture and who are less active, have decreased bone mass, and are at increased risk of falls would benefit most from a device that optimally balances the need for revision surgery, restores ambulation, and eliminates pain. Thus, the current evidence favors cemented, unipolar hemiarthroplasty for the dependent osteopenic elderly patient with a displaced femoral neck fracture.
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Sheehan KJ, Sobolev B, Guy P, Bohm E, Hellsten E, Sutherland JM, Kuramoto L, Jaglal S. Constructing an episode of care from acute hospitalization records for studying effects of timing of hip fracture surgery. J Orthop Res 2016; 34:197-204. [PMID: 26228250 PMCID: PMC4995103 DOI: 10.1002/jor.22997] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 07/20/2015] [Indexed: 02/04/2023]
Abstract
Episodes of care defined by the event of hip fracture surgery are widely used for the assessment of surgical wait times and outcomes. However, this approach does not consider nonoperative deaths, implying that survival time begins at the time of procedure. This approach makes treatment effect implicitly conditional on surviving to treatment. The purpose of this article is to describe a novel conceptual framework for constructing an episode of hip fracture care to fully evaluate the incidence of adverse events related to time after admission for hip fracture. This admission-based approach enables the assessment of the full harm of delay by including deaths while waiting for surgery, not just deaths after surgery. Some patients wait until their conditions are optimized for surgery, whereas others have to wait until surgical service becomes available. We provide definitions, linkage rules, and algorithms to capture all hip fracture patients and events other than surgery. Finally, we discuss data elements for stratifying patients according to administrative factors for delay to allow researchers and policymakers to determine who will benefit most from expedited access to surgery.
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42
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Gumieiro DN, Murino Rafacho BP, Buzati Pereira BL, Cavallari KA, Tanni SE, Azevedo PS, Polegato BF, Mamede Zornoff LA, Dinhane DI, Innocenti Dinhane KG, Cação Pereira GJ, de Paiva SAR, Minicucci MF. Vitamin D serum levels are associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture. Nutrition 2014; 31:931-4. [PMID: 26015388 DOI: 10.1016/j.nut.2014.12.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/11/2014] [Accepted: 12/20/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the association between serum levels of 25(OH) vitamin D3 with midupper arm muscle circumference (MUAMC), handgrip strength and length of hospital stay (LOS) after hip fracture. METHODS In total, 102 consecutive patients with hip fracture over the age of 65 were admitted to the orthopedic unit and prospectively evaluated. All of the patients were treated according to specific protocols depending on the type of fracture. Anthropometric measurements and handgrip strength were performed, and blood samples were taken for serum biochemistry and 25(OH) vitamin D3 analysis within the first 72 h of admission. All of the patients were followed during their hospital stay, and the length of stay was recorded. RESULTS Of the patients, two were excluded because of pathologic fractures. In total, 100 patients with a mean age of 80 ± 7 y were included in the analysis. Among these patients, 73% were female, and 37% had vitamin D deficiency. The median LOS was 7 (5-11) d. Patients with vitamin D deficiency had lower handgrip strength in univariate analysis. In the multiple linear regression analysis with robust standard error, serum vitamin D levels adjusted by age and sex were associated with handgrip strength but not with MUAMC and LOS after hip fracture. CONCLUSIONS In conclusion, vitamin D serum levels were associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture.
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Affiliation(s)
- David Nicoletti Gumieiro
- Surgery and Orthopedic Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil
| | | | | | - Karelin Alvisi Cavallari
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil
| | - Suzana Erico Tanni
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil
| | - Paula Schmidt Azevedo
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil
| | - Bertha Furlan Polegato
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil
| | | | - Daniel Innocenti Dinhane
- Surgery and Orthopedic Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil
| | | | - Gilberto José Cação Pereira
- Surgery and Orthopedic Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil
| | | | - Marcos Ferreira Minicucci
- Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil.
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