The use of intramedullary nails for the treatment of intertrochanteric hip fractures has risen sharply over the past decade1,2 without substantive evidence to support this trend3-5. While a minority of extracapsular hip fractures (subtrochanteric, "reverse oblique," or other unstable fracture patterns) may benefit from the use of intramedullary nails6,7, the evidence is inconclusive at this time8,9. Moreover, the geographic variability and increasing use of these intramedullary devices are unlikely to be explained by any documented rise in the proportions of such fractures over the same period of time2. Thus, if changes in patterns of use of intramedullary nails for the treatment of intertrochanteric hip fractures are not explained by patient-related factors, the question remains: What surgeon and hospital-related factors explain the increasing use of this more expensive but not necessarily more efficacious treatment option for the management of intertrochanteric hip fractures?
In this edition of The Journal, Forte et al. provide a compelling answer to this question with use of a large Medicare database and sophisticated analytical methods to control for patient-related factors in order to assess the impact of surgeon and hospital factors on use of plate and screws compared with intramedullary nails. They evaluated 192,365 surgical procedures performed on Medicare beneficiaries by 15,091 surgeons at 3480 hospitals between March 2000 and December 2002. These investigators found that patients treated by younger surgeons (less than forty-five years old), surgeons with an osteopathic degree, and those who operated at more than one hospital were more likely to receive intramedullary nails. Patients treated at hospitals with higher hip fracture case volumes and academic resident training programs were also more likely to receive intramedullary nails. The surgeon-related factors that the authors identified explained more of the variability in device selection than the hospital-related factors did.
The authors postulate several reasons for their findings. One is that younger surgeons continue to perform procedures that they become familiar with in training (such as intramedullary nails) while older surgeons are less likely to change from using the plates and screws with which they are more familiar. Secondly, surgeons who operate at more than one facility may not be aware of the greater facility cost incurred by use of intramedullary nails or may assume that more efficient operating room turnover at these higher volume facilities may, in some way, offset the choice of a more expensive implant. These factors require further investigation. Finally, teaching hospitals are more likely to adopt newer technologies because of closer associations with the medical device industry and a desire to teach "state-of-the-art" techniques to trainees. This would seem to refute the notion that younger surgeons and academic surgeons practice evidence-based medicine more than others10.
Economic factors may also play a role in surgeons' selection of devices for the treatment of intertrochanteric hip fractures. While there were originally higher relative value units (RVUs) (and thus higher surgeon reimbursement) assigned to the intramedullary nail procedure over open reduction and internal fixation with plates and screws, this is less likely to be a persistent incentive for use of the intramedullary nail. It is important to note that the discrepant RVUs for these procedures have normalized almost completely since the period studied (2000 through 2002). Work RVUs completely normalized in 2010 (18.18) and total RVUs are nearly equal (32.27 compared with 32.76), the difference being the transitioning of practice expenses11. Thus, the surgeon payment incentive for one procedure over the other no longer persists in 2010. However, the financial incentives and consequences are different for hospitals, which are most often paid a fixed case rate under Medicare's Inpatient Prospective Payment system. Despite substantially higher costs associated with the intramedullary nail device as compared with a plate-and-screw construct, hospital reimbursement is the same or similar for both procedures, under Diagnosis-Related Group (DRG) 210. However, hospitals are unlikely to pressure surgeons over implant-related costs associated with these procedures, given the revenue generated by orthopaedic surgeons and the relatively low numbers of such cases in the most common settings where these surgical procedures are performed.
Hence, we agree with the authors that, in light of the preferential training in use of intramedullary nails and the lack of recourse in terms of differences in surgeon reimbursement based on device choice, the use of more expensive intramedullary nails is likely to continue to increase. This may occur despite a lack of evidence regarding their relative benefit compared with plate-and-screw constructs for the treatment of intertrochanteric hip fractures. However, as Medicare and other payers begin to experiment with bundled payments12, which combine hospital and physician payments for a single episode of care, physicians will need to become more aware of the costs associated with their treatment decisions, including their choice of implants. Under such payment systems, in the absence of evidence regarding the comparative safety and efficacy of a newer, more expensive device (such as the intramedullary nail), surgeons will have an incentive to choose less expensive, equally safe and efficacious treatment alternatives. Furthermore, the definitive, adequately powered, randomized controlled trial evaluating implant selection for the treatment of intertrochanteric hip fractures has yet to be completed13 and its results will need to be interpreted in the context of information regarding the cost of care in order to align surgeon decision-making with the best available evidence and facilitate high-quality cost-effective care.
*The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
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2. Forte ML, Virnig BA, Kane RL, Durham S, Bhandari M, Feldman R, Swiontkowski MF. Geographic variation in device use for intertrochanteric hip fractures. J Bone Joint Surg Am. 2008;90:691-9.
3. Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma. 2001;15:394-400.
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11. Centers for Medicare and Medicaid Services Physician Fee Schedule. http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp. Accessed January 16, 2010.
12. Pham HH, Ginsburg PB, Lake TK, Maxfield MM. Episode-based payments: charting a course for health care payment reform. 2010 Jan. http://www.nihcr.org/Policy%20Analysis%20No.%201.pdf. Accessed 2010 Jan 18.
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