The Journal of Hip Surgery 2017; 01(02): 080-086
DOI: 10.1055/s-0037-1603620
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Effect of Payer Type, Disposition, and Day of Surgery on Resource Consumption following Hip Fracture Care

Gonzalo Barinaga
1   Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
,
Zain Sayeed
2   Department of Surgery, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
,
Afshin A. Anoushiravani
3   Department of Orthopaedic Surgery, Hospital for Joint Diseases, New York University Langone Medical Center, New York, New York
,
Erik Wright
1   Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois
,
Mouhanad M. El-Othmani
4   Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, Michigan
,
Paul J. Cagle
5   Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
,
Khaled J. Saleh
4   Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, Michigan
› Author Affiliations
Further Information

Publication History

17 April 2017

24 April 2017

Publication Date:
24 May 2017 (online)

Abstract

As we shift from a fee-for-service to value-based reimbursement system, it is critical that orthopaedic surgeons assess all characteristics of the patient prior to surgical intervention. The purpose of this study was to evaluate the relationship of payer type and disposition on direct and indirect measures of resource consumption (length-of-stay [LOS], hospital cost, and 30-day readmission). Patients equal to or more than 55 years of age with radiographic evidence of hip fracture necessitating surgical intervention were included. Initially, baseline characteristics, including age, body mass index (BMI), American Society of Anesthesiologist (ASA) score, fracture type, and instrumentation, were reported by payer type (private versus Medicare) and disposition (skilled nursing facility [SNF], home, and home health). In the second phase, the independent effects of payer type and disposition on resource consumption were evaluated. Lastly, the impact of payer type and day of admission on disposition were assessed. A total of 478 patients met the inclusion criteria. Evaluation of baseline characteristics demonstrated that age and ASA scores were significantly higher within the Medicare and SNF cohorts, when compared with private payers and home/home health, respectively. Medicare as a payer type resulted in an increased LOS (5.6 versus 4.5 days) and greater hospital cost (12.1%) than private payers. Moreover, payer type was not predictive of 30-day readmission. Disposition following operative fixation resulted in an average LOS of 5.8, 4.4, and 4 days for patients discharged to SNF, home, and home health, respectively. No significant difference in hospital stay was noted between home and home health patients. Compared with patients discharged home, in-hospital cost was 33.9 and 12.3% greater for the SNF and home heath cohorts, respectively. Finally, 21.6% of patients discharged to a SNF were readmitted within 30 days. Our results indicate Medicare patients and those discharged to a SNF are more likely to have longer LOS and incur greater costs. Additionally, 30-day readmission is significantly higher in patients discharged to SNF. Thus, patients with hip fracture should be rigorously optimized within the preoperative setting to enhance clinical outcomes. Moreover, additional resources should be allocated to the higher risk patients.

 
  • References

  • 1 Schnell S, Friedman SM, Mendelson DA, Bingham KW, Kates SL. The 1-year mortality of patients treated in a hip fracture program for elders. Geriatr Orthop Surg Rehabil 2010; 1 (01) 6-14
  • 2 Iorio R, Robb WJ, Healy WL. , et al. Orthopaedic surgeon workforce and volume assessment for total hip and knee replacement in the United States: preparing for an epidemic. J Bone Joint Surg Am 2008; 90 (07) 1598-1605
  • 3 Iorio R, Schwartz B, Macaulay W, Teeney SM, Healy WL, York S. Surgical treatment of displaced femoral neck fractures in the elderly: a survey of the American Association of Hip and Knee Surgeons. J Arthroplasty 2006; 21 (08) 1124-1133
  • 4 Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 2007; 22 (03) 465-475
  • 5 FitzGerald JD, Boscardin WJ, Hahn BH, Ettner SL. Impact of the Medicare short stay transfer policy on patients undergoing major orthopedic surgery. Health Serv Res 2007; 42 (1, Pt 1): 25-44
  • 6 Observation status: new final rules from CMS do not help Medicare beneficiaries. (78 Fed. Reg. 50495-A; Weekly Alert, August 29, 2013). Available at: http://www.medicareadvocacy.org/observation-status-new-final-rules-from-cms-do-not-help-medicare-beneficiaries/
  • 7 Hernandez VH, Ong A, Post Z, Orozco F. Does the Medicare 3-day rule increase length of stay?. J Arthroplasty 2015; 30 (9 Suppl) 34-35
  • 8 Hussey PS, Eibner C, Ridgely MS, McGlynn EA. Controlling U.S. health care spending--separating promising from unpromising approaches. N Engl J Med 2009; 361 (22) 2109-2111
  • 9 The Lewin Group. CMS bundled payments for care improvement (BPCI) initiative models 2–4: year 1. Evaulation and Monitoring Annual Report. Falls Church, VA; 2015 . Available at: https://innovation.cms.gov/Files/reports/BPCI-EvalRpt1.pdf . Accessed October 15, 2015
  • 10 Turtle L, Vyakernam R, Menon-Johansson A, Nelson MR, Soni N. Intensive care usage by HIV-positive patients in the HAART era. Interdiscip Perspect Infect Dis 2011; 2011: 847835
  • 11 Ricci WM, Brandt A, McAndrew C, Gardner MJ. Factors affecting delay to surgery and length of stay for patients with hip fracture. J Orthop Trauma 2015; 29 (03) e109-e114
  • 12 Brown CA, Olson S, Zura R. Predictors of length of hospital stay in elderly hip fracture patients. J Surg Orthop Adv 2013; 22 (02) 160-163
  • 13 Garcia AE, Bonnaig JV, Yoneda ZT. , et al. Patient variables which may predict length of stay and hospital costs in elderly patients with hip fracture. J Orthop Trauma 2012; 26 (11) 620-623
  • 14 Schonberger RB, Dutton RP, Dai F. Is there evidence for systematic upcoding of ASA physical status coincident with payer incentives? A regression discontinuity analysis of the National Anesthesia Clinical Outcomes Registry. Anesth Analg 2016; 122 (01) 243-250
  • 15 Buntin MB, Colla CH, Deb P, Sood N, Escarce JJ. Medicare spending and outcomes after postacute care for stroke and hip fracture. Med Care 2010; 48 (09) 776-784
  • 16 Deakin DE, Wenn RT, Moran CG. Factors influencing discharge location following hip fracture. Injury 2008; 39 (02) 213-218
  • 17 Cullen DJ, Apolone G, Greenfield S, Guadagnoli E, Cleary P. ASA physical status and age predict morbidity after three surgical procedures. Ann Surg 1994; 220 (01) 3-9
  • 18 Jones JM, Skaga NO, Søvik S, Lossius HM, Eken T. Norwegian survival prediction model in trauma: modelling effects of anatomic injury, acute physiology, age, and co-morbidity. Acta Anaesthesiol Scand 2014; 58 (03) 303-315
  • 19 Bernatz JT, Tueting JL, Anderson PA. Thirty-day readmission rates in orthopedics: a systematic review and meta-analysis. PLoS One 2015; 10 (04) e0123593
  • 20 Nanjayan SK, John J, Swamy G, Mitsiou K, Tambe A, Abuzakuk T. Predictors of change in ‘discharge destination’ following treatment for fracture neck of femur. Injury 2014; 45 (07) 1080-1084
  • 21 Sathiyakumar V, Molina CS, Thakore RV, Obremskey WT, Sethi MK. ASA score as a predictor of 30-day perioperative readmission in patients with orthopaedic trauma injuries: an NSQIP analysis. J Orthop Trauma 2015; 29 (03) e127-e132
  • 22 Dailey EA, Cizik A, Kasten J, Chapman JR, Lee MJ. Risk factors for readmission of orthopaedic surgical patients. J Bone Joint Surg Am 2013; 95 (11) 1012-1019
  • 23 Basques BA, Bohl DD, Golinvaux NS, Leslie MP, Baumgaertner MR, Grauer JN. Postoperative length of stay and 30-day readmission after geriatric hip fracture: an analysis of 8434 patients. J Orthop Trauma 2015; 29 (03) e115-e120