The largest difference in LOS and costs after controlling for potential confounding variables was between HA/THA and CRPP ($7383.90). To our knowledge, only one study has performed a comparative analysis of LOS for CRPP and other surgical treatments for hip fractures. For femoral neck fractures treated between 1990 and 1994, Fekete and colleagues23 found that LOS was 14.9 days for ORIF cases and 12.1 days for CRPP cases—a difference of 2.8 days. In comparison, we found a 1-day difference in mean LOS between ORIF cases (6.59 days) and CRPP cases (5.59 days).
Other studies of LOS and associated costs over a 2-year period have found that ORIF is overall more costly than HA/THA. For example, Keating and colleagues13 compared total costs of care, including LOS, for healthy older patients with displaced intracapsular hip fractures treated with ORIF, bipolar HA, or THA. Although ORIF was initially less costly than HA/THA, overall ORIF costs over 2 years were significantly higher because of readmissions, which increased overall LOS. Similarly, in cases of displaced femoral fractures, Iorio and colleagues15 found that LOS was 6.4 days for ORIF, 4.9 days for unipolar HA, 6.2 days for bipolar HA, and 5.5 days for cemented and hybrid THA. However, when overall projected costs were estimated, including the costs of rehabilitation and of (probable) revision arthroplasty, ORIF was estimated to cost more over a 2-year period because of the need for additional care and in-patient stays. In contrast, we found that hospitalization costs were $3805.20 lower for ORIF than for HA/THA, even after adjusting for comorbidities, and that ORIF had a lower overall readmission rate. Early discharge of patients who are at risk for subsequent complications may have played a significant role in increasing readmission rates for arthroplasty patients. These findings indicate the complexities involved in a bundled payment system of reimbursement, in which a single payment for both initial stay and related readmissions will force orthopedists to consider long-term hospitalization costs when deciding on length of postoperative care and the most cost-effective surgical treatment.
One of the limitations of this study is its retrospective design. Although selection of our sample from a single level I trauma center reduced differences in cost and patient care protocols between institutions, it also reduced the generalizability of our actual costs. In addition, for some patients, LOS may have increased because of delays in surgery or discharge, lack of operating room availability, or need for further medical clearance for additional procedures. Day of admission could also have significantly affected LOS. However, the effects of these confounding factors were reduced because of the large sample analyzed. As stated earlier, overall LOS depends on both initial in-patient stays and readmissions. Therefore, long-term prospective studies that compare LOS and associated costs for patients with hip fractures treated with ORIF, CRPP, HA/THA, and CMN are needed.
Conclusion
It has been recently suggested that hip fracture repair be included in the National Pilot Program on Payment Bundling, which will potentially reimburse orthopedic surgeons a standardized amount for hip fracture surgery regardless of actual treatment costs.8 In this model, it will be essential to understand how type of fracture and surgical procedure can influence LOS and therefore hip fracture treatment costs. We found that, based on these factors, mean LOS ranged from 5.59 to 7.43 days, which translates to a cost range of $25,322.70 to $33,657.90. Before a standardized bundled payment system is implemented, further studies are needed to identify other factors that can significantly affect the cost of hip fracture repair.