Do We Understand the True Cost of Hip Fractures?

A disabling event can have an enormous impact on an older individual and his or her family, but it can also increase society's healthcare costs. Limitation of function, loss of independence, and need for human help greatly increases the cost of caring for disabled individuals. This cost may be borne informally by friends and family members, formally by the patient and his or her family, or by government and social agencies. Although the assistance in daily care provided to individuals in many countries is placed in the social services budget, it is classified as healthcare costs in the United States. The ability of society in the 21st century to care for its disabled older population concerns political leaders, economists, and social planners. As we attempt to adapt strategies to limit the costs of caring for older people, we must answer several questions: . What is the true impact of disabling events on the cost of care? . Do the events themselves alter the cost of care or do they simply mark a progressive decline in function? . What are the components of costs associated with these events? . What is the duration of these increased costs? A hip fracture is one of the most disabling events that affect older individuals. It is not always clear, however, whether the fracture itself is a cause of disability or is simply an event that marks the progressive decline of an older individual. The best method for determining the true impact of these fractures is to assess function and need for care, and the trajectory of this function, in a prospective fashion. This is done most effectively by following a cohort of individuals prospectively to assess function and changes in function before and after the fracture. Brainsky et al., in this month's issue of the Journal, have attempted to measure the economic costs of hip fractures. They are to be applauded for comparing the cost of care before and after the patient's hip fracture. The term “prospective study” in their title is, however, misleading. The patients were identified at the time of their hospital admission for a hip fracture and asked about the use of medical and non-medical services in the 6 months before the fracture. The authors were thus dependent on the memory of the patient and patient's family to identify the costs of caring for the individual. This review of care needs is retrospective. These authors found that the incremental costs in the 1 year after a hip fracture ranged from $16,322 to $18,727. The majority of these additional costs ($11,480) were in the costs for the index hospitalization for the hip fracture. Seven to 12 months after the fracture, the average monthly costs fell below their monthly costs before the fracture. These results are rather surprising. Two earlier papers from the same study pointed out that a majority of these hip fracture patients did not return to pre-fracture levels of performance in activities of daily living or instrumental activities of daily living.1, 2 Furthermore, there was no improvement noted in these activities from the 6-month to 12-month follow-up period. The impact of the cost of a nursing home on patients with hip fractures can be substantial. A number of studies3-7 have found that 10 to 39% of patients admitted from home are placed permanently in nursing homes 6 to 12 months after the hip fracture. In reviewing the authors' earlier papers on this study, I could not find the number of patients placed permanently in nursing homes. Nonetheless, it is difficult to explain the small amount of cost attributed to nursing home stays for this group of patients. See also p 281 One could anticipate the low cost of nursing and physical therapy visits at 12 months as the Medicare payment for these services would, in most cases, be exhausted by this time. It is more difficult to understand the minimal cost for informal assistance provided by the primary caregivers, household members, or their family and friends for these individuals. The significant deterioration in daily function of these patients reported by the authors in this cohort would seem to call for more assistance with daily living. The results in this study may be explained by a change in the way in which questions were asked about this support in the 12-month versus the initial, 2-month, and 6-month interviews. This study is limited in its ability to evaluate the costs of caring for patients with hip fractures in 1996. The authors report here on the costs of care for patients who fractured their hips between 1984 and 1986. Although they adjusted for present dollars, there have been major changes in the reimbursement for care, patterns of care, and sites of delivery of care for patients with hip fractures since 1986. In summary, the authors are to be applauded for trying to measure the true impact of a hip fracture on the cost of care. Their conclusions, however, that patients with hip fractures, who lose at least 50% of their daily living functions, have no increased cost of care 12 months after their fracture is quite surprising. In addition, the minimal nursing home costs reported by these authors is inconsistent with the substantial frequency of permanent nursing home placements reported in virtually all other studies of patients with hip fractures. It has been said that many a beautiful theory has been destroyed by ugly facts. This paper's finding that there is no increase in cost of caring for patients 1 year after they have had a hip fracture does not fit our belief that these fractures have a substantial impact on the care needs of older individuals. We cannot, however, ignore the contra-intuitive results of this study. This study should stimulate us to take a closer look at the true costs of the care that can be attributed to hip fractures.