Total Hip Arthroplasty for Femoral Neck Fracture: The Economic Implications of Orthopedic Subspecialty Training

Abstract

Background: Hip fractures have significant economic implications as a result of their associated direct and indirect medical costs. Under alternative payment models, it has become increasingly important for institutions to find avenues by which costs could be reduced while maintaining outcomes in these cases. Methods: A multi-institutional retrospective analysis of Medicare patients who underwent total hip arthroplasty (THA) for femoral neck fracture was conducted to assess the impact of fellowship training in adult reconstruction (AR) on the total costs of the 90-day episode of care. Patients were divided into 2 cohorts according to fellowship training status of the operating surgeon: (1) AR-trained and (2) other fellowship training (non-AR). The primary outcome was the total cost of the 90-day episode of care converted to a percentage of the bundled payment target price. Results: A total of 291 patients who underwent THA for the treatment of a femoral neck fracture were included. The average total cost percentage of the 90-day episode of care was significantly lower for the AR cohort 70.9% (±36.6%) than the non-AR cohort 82.6% (±36.1%) (P < .01). After controlling for baseline demographics in the multivariable logistic regression, the care episodes in which the operating surgeons were AR fellowship-trained were still found to be significantly lower, at a rate of 0.87 times the costs of the non-AR surgeons (95% confidence interval 0.78-0.97, P ¼ .011). In addition, the non-AR cohort exceeded the bundle target price more frequently than the AR cohort, 49 (28.7%) vs 16 (13.3%) (P ¼ .02). Conclusion:In an era of bundled payments, ascertaining factors that may increase the value of care while decreasing the cost is paramount for institutions and policymakers alike. The results presented in this study suggest that in the femoral neck fracture population, surgeons trained in AR achieve lower total costs for the THA episode of care. Furthermore, non-AR fellowship-trained surgeons exceeded the bundled payment target more frequently than the AR surgeons.

Comparative Analysis of Total Knee Arthroplasty Outcomes Between Arthroplasty and Nonarthroplasty Fellowship Trained Surgeons

“…In the context of the present study, this suggests that the hospital would yield an average of $381 in savings when AR surgeons performed TKAs compared with that when NAR surgeons performed TKAs. Similar findings have been shown for hip fractures, with AR surgeons demonstrating a lower 90-day cost of care than NAR surgeons [6]. In an era of efficient staggered usage of 2-operating room for procedures, the added 10 minutes may translate to an added 10 minutes in both operating rooms as the second room is waiting idle.…”

“…An adult reconstruction (AR) fellowship is designed to provide advanced training for a broad range of primary reconstructive and complex knee and hip revision surgeries. Recent studies have demonstrated fewer complications and decreased cost [6] for hemiarthroplasties because of femoral neck fractures performed by AR fellowship-trained surgeons than those performed by general orthopedists [7], suggesting there may be a significant advantage to undergoing AR fellowship training. In addition, a recently published study that evaluated the impact of AR fellowship training in total joint arthroplasty (TJA) stated that for both total hip and knee arthroplasty, procedures were associated with significantly shorter surgical times and length of stay (LOS) and required fewer opioids when AR fellowship-trained surgeons than NAR fellowship-trained surgeons performed the joint replacement [8].…”

Surgeon Volume Impacts Outcomes Following Ankle Fracture Repair

“…It is long understood that hospital volume and surgeon case volume correlate with improved outcomes following various orthopaedic surgeries. 4 , 9 , 16 , 24 , 29 , 34 , 35 In orthopaedic residency programs, the average total number of cases logged per resident increased 17.4% from 2007 to 2013. 19 Even though trainees are gaining more experience overall, residents in the 90th percentile for case exposure consistently log more cases than those in the 10th percentile, showing that there remains a discrepancy in surgical experience among orthopaedic residents.…”

“… 35 From a financial standpoint, Padilla et al found that arthroplasty-trained surgeons achieved lower costs during total hip arthroplasty than non–arthroplasty-trained orthopaedic surgeons. 29 Beyond the scope of arthroplasty, one study found that reconstructive surgeons with higher case volumes had fewer complications and greater success following long bone nonunion repair. 16…”

Surgical Benchmarks for ACGME-accredited Adult Reconstructive Orthopaedic Fellowship Training

“…5 Lower volume total joint surgeons and hospital centers can have higher rates of inpatient mortality as evidenced by a study in the English National Health Service. 6 Fellowship-trained total joint surgeons have lower costs associated with total hip arthroplasty 7 and improved outcomes after total knee arthroplasty. 8 A large Swedish registry study found that if annual volume increases by 10 primary THAs, then the risk for adverse events decreases by 10%.…”