The “Hip Fracture” Bundle—Experiences, Challenges, and Opportunities

Abstract

Introduction: With growing popularity and success of alternative-payment models (APMs) in elective total joint arthroplasties, there has been recent discussion on the probability of implementing APMs for geriatric hip fractures as well. Significance: Despite the growing interest, little is known about the drawbacks and challenges that will be faced in a stipulated “hip fracture” bundle. Results: Given the varying intricacies and complexities of hip fractures, a “one-size-fits-all” bundled payment may not be an amenable way of ensuring equitable reimbursement for participating physicians and hospitals. Conclusions: Health-policy makers need to advocate for better risk-adjustment methods to prevent the creation of financial disincentives for hospitals taking care of complex, sicker patients. Hospitals participating in bundled care also need to voice concerns regarding the grouping of hip fractures undergoing total hip arthroplasty to ensure that trauma centers are not unfairly penalized due to higher readmission rates associated with hip fractures skewing quality metrics. Physicians also need to consider the launch of better risk-stratification protocols and promote geriatric comanagement of these patients to prevent occurrences of costly adverse events.

Risk Factors Associated With Extended Length of Hospital Stay After Geriatric Hip Fracture

“…Of the total costs associated with geriatric hip fracture care, between 44% and 57% can be attributed to the inpatient stay alone, with LOS and inpatient complications being the strongest drivers of expenditures. 23 , 24 Care providers' efforts to address modifiable risk factors that lead to eLOS could diminish costs. However, geriatric hip fracture providers do not have ample time to preoperatively optimize this nonelective surgical patient population, and thus a thorough understanding of prehospital risk factors for eLOS is paramount in a bundled payment system.…”

Variations in hip fracture inpatient care in Japan, Korea, and Taiwan: an analysis of health administrative data

“…Facing rapidly aging populations with higher disease burdens, the sustainability of these countries' current inpatient-centered health care delivery is being challenged, and reforms to improve system efficiency have been implemented, including payment-system reforms [3,[5][6][7][8]. Inpatient care is also often the target of major health care reforms in most developed countries, as it is the most intense and expensive care [9][10][11][12][13]. International comparisons of health systems focusing on inpatient care have been widely conducted led by the OECD and WHO European Health Observatory [4,14], but little work has been done in Asia.…”

Prior Admissions as a Risk Factor for Readmission in Patients Surgically Treated for Femur Fractures: Implications for a Potential Hip Fracture Bundle

“…Therefore, a hip fracture bundled payment model that includes 90-day readmissions may unjustly penalize hospital systems. In a recent review article, Malik et al (2020) expressed their concern that the current structure of the BPCI model will create financial disincentives for providing care for the most medically complex patients. 5 This may result in some centers "cherry picking" healthier patients and transferring more medically complex patients to tertiary care centers.…”

“…The difference in these populations has led to the CJR bundle risk stratifying arthroplasty patients by including an arthroplasty for fracture modifier. 5 This was a result of multiple studies showing a higher rate of readmission, complication, non-home discharge and increased length of stay in arthroplasty for hip fracture patients compared to elective arthroplasty patients. [6][7][8] The same factors that led to this separation should be considered as attention is directed towards creating a separate hip fracture bundle.…”