Cost-effectiveness analysis of routine follow-up for hip fracture patients after dynamic hip screw and intramedullary nail fixation

Abstract

• Determining the appropriate outpatient management for patients following IM Nail or DHS for neck of femur fractures should be directed by clear objectives. • Routine post-operative surgical encounters with these patients rarely alter their clinical management. • We propose more selective follow-up protocols and adequately resourcing virtual alternatives. • The current outpatient hip fracture care pathway should be optimised to focus on comprehensive multidisciplinary treatment such as rehabilitation, fracture prevention and bone health optimisation. The rising number of hip fractures has incentivised several quality improvement initiatives aimed at improving outcomes. These include the national hip fracture audit and the best practice tariff. Whilst there is an established standard of care for inpatients, the optimal outpatient management of patients after hip fracture fixation remains undefined. We aim to evaluate the cost-effectiveness of routine surgical appointments and provide evidence to support an improved outpatient hip fracture care pathway that focuses on more comprehensive multidisciplinary treatment. This study retrospectively examined all patients who underwent either dynamic hip screw or intramedullary nail fixation for hip fragility fracture at our hospital over a 3-year period. Data was obtained from the Irish Hip Fracture Database (IHFD), the national integrated imaging system (NIMIS) and the medical charts. The number of outpatient appointments, postoperative radiographs and estimated cost of these patient encounters was examined. The rate of revision surgery as well as the type and timing of these interventions was also analysed. We included 272 patients. The mean number of inpatient and outpatient radiographs was 1.13 and 1.54 per patient respectively. There were 428 outpatient appointments scheduled, an average of 1.6 (SD 1.5) per patient. The median length of stay was 12 days (IQR 8-17). Only 16 (5.8%) patients had abnormal X-ray findings and only 8 (2.9%) patients underwent revision surgery. The majority (15/16, 94%) of patients with surgical complications presented with significant symptoms. There was a 13.1% DNA rate resulting in a cost to the health service of €1,400. The combined total cost of follow-up for all patients over the 3 year period was €92,252. Routine postoperative surgical encounters rarely alter a patient's management and contribute significantly to healthcare costs, resources and time loss for patients and their carers. We propose more selective follow-up protocols, adequately resourcing virtual alternatives and an improved outpatient hip fracture care pathway that focuses on comprehensive multidisciplinary treatment such as rehabilitation, fracture prevention and bone health optimisation.