The paper "An Economic Evaluation of a Systems-Based Strategy to Expedite Surgical Treatment of Hip Fractures" by Dy et al. is a cost-effectiveness analysis of two systems-based strategies to expedite surgical repair of hip fractures.
Reading a cost-effectiveness analysis may seem foreign to many JBJS readers. These analyses are based on models that include probabilities of outcomes derived from systematic literature reviews, utilities based on qualitative surveys of the value that patients place on various health states, and cost estimates based on economic data. These studies involve a whole new vocabulary: QALYs (quality-adjusted life years), Monte Carlo simulation, sensitivity analysis, ICER (incremental cost-effectiveness ratio), utilities, and time trade-off.
It is easy for an orthopaedic surgeon to skip over this article, saying, "I don't understand the methodology," "It's an abstract model," or "I'm not a health care economist."
However, economic analyses in orthopaedic surgery have never been more important. Contemporary forces in medicine have driven economic analyses to the foreground. The federal government, state governments, and insurers are analyzing cost-effectiveness data to determine how to "ration" limited resources. Hospitals and medical groups are trying to limit costs yet still provide effective care. Quality and safety initiatives are being implemented from all directions. Accountable Care Organizations (ACOs) are looming on the horizon.
There can be an inherent mistrust of decision analysis and cost-effectiveness analysis among clinicians who mistrust the modeling process and also among those who view these techniques as a means to reduce costs, impinge on physician autonomy, corrupt the doctor-patient relationship, and compromise individualized patient care. In fact, the goal of decision analysis and cost-effectiveness analysis is to optimize patient care. These techniques can be applied either at the level of individual decisions involving patient evaluation and treatment or at the level of population-wide policy decisions. In a framework of clinical uncertainty and limited resources, the benefits of any intervention should justify its costs and its opportunity costs. By allocating resources on the basis of cost-efficiency, the care of a population of patients and the care of an individual patient can be optimized.
Economic evaluation is the comparative analysis of alternative courses of action in terms of their costs and consequences. Medical studies whose design involves economic evaluation include cost-identification studies, cost-effectiveness analyses, cost-benefit analyses, and cost-utility analyses1. There is substantial overlap between these types of cost-evaluation studies. The term cost-effectiveness is often used as a generic term for economic analysis, but it also connotes a specific type of economic analysis. Cost-effectiveness analysis is a method for evaluating the outcomes and costs of interventions designed to improve health care; therefore, the term is most appropriately used only in situations in which data on costs and effectiveness are known and analyzed. The objective of cost-effectiveness analysis is to maximize the health care benefits for a given population when resources are assumed to be limited. In cost-identification studies, only the costs associated with providing the intervention are identified. In cost-benefit analysis, both the costs and the economic benefits associated with the intervention are assessed, and both are reported in monetary units. In cost-effectiveness analysis, the costs and the clinical outcome are assessed, and the result is reported as the cost per improvement in clinical outcome. In cost-utility analysis, costs and utility values (value to the patient) are measured, and the result is reported as the cost per quality-adjusted life year gained.
In their study, Dy et al. address an important clinical problem that results in high costs and high mortality and morbidity: hip fractures. The annual health care cost associated with hip fractures in the U.S. is estimated to exceed $10 billion, and the one-year mortality rate associated with a hip fracture has been estimated to be between 12% and 37%2. Early surgery for hip fracture offers an improved mortality rate: the results of a recent systematic review of over 21,000 patients indicated that the one-year mortality rate increased by 32% if surgical repair was delayed forty-eight hours after hospital admission3. Systems-related factors, such as the need for medical clearance or a shortage of available operative facilities, are frequently barriers to early surgery for hip fracture.
The authors studied the cost-effectiveness of two strategies to expedite surgical repair: (1) a strategy to address the need for preoperative medical evaluation by funding an on-call hospitalist and an on-call diagnostic technician, and (2) a strategy to address limited operating room availability as well, by also adding an on-call operating room team. Mortality estimates and health state utilities were obtained from systematic reviews, and costs were obtained from economic data. A decision-tree model was utilized, cost-effectiveness analysis was performed, and sensitivity analysis was then performed to assess the effect of varying key parameters.
The authors found that both strategies were cost-effective. The first strategy, which focused on expediting patient evaluation, had an incremental cost-effectiveness ratio of $2318 per QALY (far better than the generally accepted cost-effectiveness threshold of $50,000 per QALY) and became cost-saving if at least 93% of patients underwent expedited surgery. The second strategy, which added an on-call operating room team, had an incremental cost-effectiveness ratio of $43,153 per QALY and remained cost-effective if the odds ratio of one-year mortality associated with delayed repair was greater than 1.28.
All economic analyses have limitations, particularly with respect to the quality of the literature used to obtain the probability estimates and the cost estimates. Some costs were not included in this study, including indirect costs and facility costs. Wages may vary by geographic location. Costs may be shifted from the inpatient setting to the outpatient setting by implementation of the strategy. Sensitivity analysis allows the probabilities associated with key parameters to be varied in order to determine how this changes the estimated cost-effectiveness, and such analyses were performed in this study.
Cost-effectiveness analysis is usually performed from the perspective of the society as a whole. In this study, the perspective of a single hospital administration was used. Although this perspective is not the standard one, it is nevertheless an important perspective since the decision to implement these strategies would be made by the hospital administration. However, the use of this perspective does mean that additional costs relevant to a societal perspective (such as outpatient costs, costs to the family, and costs related to the patient's loss of productivity) are not taken into account. It would be interesting to perform this economic analysis from the societal perspective as well in order to determine whether the cost-effectiveness of these strategies is maintained.
Validation of this hypothetical model is also important. It is unlikely that a randomized clinical trial of early versus delayed fixation of hip fractures will ever be performed; indeed, such a trial might be unethical. However, a prospective study performed at a hospital that institutes either of these strategies would be valuable, particularly if the study includes not only outcome data such as one-year mortality but also cost data.
In summary, I believe this paper to be an excellent example of the application of cost-effectiveness analysis to a common and important clinical problem. The paper provides an impetus for orthopaedic surgeons and their hospitals to consider the implementation of such strategies to expedite the surgical management of hip fractures and to examine the results of the change, in terms of both outcome and cost, in a prospective fashion.