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An Economic Evaluation of a Systems-Based Strategy to Expedite Surgical Treatment of Hip Fractures
Christopher J. Dy, MD, MSPH1; Kathryn E. McCollister, PhD2; David A. Lubarsky, MD, MBA2; Joseph M. Lane, MD1
1 Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for C.J. Dy: dyc@hss.edu
2 Department of Epidemiology and Public Health (R-669) (K.E.McC.) and Department of Anesthesiology, Perioperative Medicine, and Pain Management (D.A.L.), Miller School of Medicine, University of Miami, P.O. Box 016069 (K.E.McC.) and 016370 (D.A.L.), Miami, FL 33101
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by the authors of this work are available with the online version of this article at jbjs.org.

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Investigation performed at the University of Miami School of Medicine, Miami, Florida, and the Hospital for Special Surgery, New York, NY
A commentary by Mininder S. Kocher, MD, MPH, is linked to the online version of this article at jbjs.org.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Jul 20;93(14):1326-1334. doi: 10.2106/JBJS.I.01132
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This article was updated on August 24, 2011, because of a previous error. In Figure 1, the labels that had previously read "Alive at 1 year" now read "Deceased at 1 year," and vice versa.


A recent systematic review has indicated that mortality within the first year after hip fracture repair increases significantly if the time from hospital admission to surgery exceeds forty-eight hours. Further investigation has shown that avoidable, systems-based factors contribute substantially to delay in surgery. In this study, an economic evaluation was conducted to determine the cost-effectiveness of a hypothetical scenario in which resources are allocated to expedite surgery so that it is performed within forty-eight hours after admission.


We created a decision tree to tabulate incremental cost and quality-adjusted life years in order to evaluate the cost-effectiveness of two potential strategies. Several factors, including personnel cost, patient volume, percentage of patients receiving surgical treatment within forty-eight hours, and mortality associated with delayed surgery, were considered. One strategy focused solely on expediting preoperative evaluation by employing personnel to conduct the necessary diagnostic tests and a hospitalist physician to conduct the medical evaluation outside of regular hours. The second strategy added an on-call team (nurse, surgical technologist, and anesthesiologist) to staff an operating room outside of regular hours.


The evaluation-focused strategy was cost-effective, with an incremental cost-effectiveness ratio of $2318 per quality-adjusted life year, and became cost-saving (a dominant therapeutic approach) if ≥93% of patients underwent expedited surgery, the hourly cost of retaining a diagnostic technologist on call was <$20.80, or <15% of the hospitalist's salary was funded by the strategy. The second strategy, which added an on-call surgical team, was also cost-effective, with an incremental cost-effectiveness ratio of $43,153 per quality-adjusted life year. Sensitivity analysis revealed that this strategy remained cost-effective if the odds ratio of one-year mortality associated with delayed surgery was >1.28, ≥88% of patients underwent early surgery, or ≥339.9 patients with a hip fracture were treated annually.


The results of our study suggest that systems-based solutions to minimize operative delay, such as a dedicated on-call support team, can be cost-effective. Additionally, an evaluation-focused intervention can be cost-saving, depending on its success rate and associated personnel cost.

Level of Evidence: 

Economic and decision analysis Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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