The
Economic Impact of Treating Geriatric Hip Fracture -
A Study at Rustaq Referral Hospital , South Batinah Region,
Oman
Authors
Dr.
Dinesh Dhar (M.S. Orthopaedics)
Specialist
Department of Orthopaedics
Rustaq Hospital
South Batinah Region
Sultanate of OMAN
Correspondence:
Dr. Dinesh Dhar
Burj Al Raddha
P.O.Box 349
Al-Rustaq 329
Sultanate of Oman
| Telephone
number: |
(00)
(968) 92357505 |
| |
(00)
(968) 26878237 |
Fax
number: (00) (968) 26878237
|
Abstract:
Hip Fractures in the Geriatric
Population is on rise in Oman with need for increased
number of hip fracture beds and this has heavy impact
on the health service resources. To date there has been
no study detailing with the Economic Impact of such injuries
in Oman and the Middle East in general. In the present
study 150 patients who were admitted with a hip fracture
to Rustaq Hospital, which is a Referral Hospital in South
Batinah Region of Oman, from March1998 to March 2006 were
included in this study to determine the expenditure incurred
during hospitalization of patients, including the costs
associated with surgery (O.T., implants costs) and Radiological,
Laboratory investigations. The mean total hospital expenditure
per patient was found to be RO 1010.6 of which ward costs
contributed 60 percent, operative costs 21 percent and
investigations 19 percent. All of these results have shown
a growing Economic Impact arising from the inpatient treatment
of Acute hip fractures.
Key words: Hip fractures,
Economic Impact, Intracapsular, Extracapsular,
Abbreviations: GCC( Gulf
Cooperation Council),, RO (Rial Omani), MOH (Ministry
of Health), HDU (High Dependency).
|
Introduction
A hip fracture remains one of the commonest
reasons for an elderly person to be admitted to an acute Orthopaedic
Ward. The number of hip fractures is on the rise in the geriatric
population and with projected increases in population above
65 years the incidence of hip fractures will rise exponentially
(20). Hip fracture patients occupy more and more hospital beds
with a long hospital stay and a protracted rehabilitation period
9,22) which leads to a heavy economic impact on health service
resources (8,14). In addition, inflation in the health service
is greater than the general economy.
There is no study in the Middle East
detailing the costs of hospitalization and treatment of hip
fractures in geriatric populations. All literature available
is from the western world with data reports showing wide variation
in cost evaluation in different studies which may not be applicable
to this region (1). Most of the countries of GCC
have free treatment in Govt. Hospitals for their nationals.
The primary aim of the present study is to have detailed assessment
of medical costs incurred during acute hospitalization and treatment
of hip fracture as per the billing rates applicable to Non GCC
/ Non Omani Nationals which is an indicator of cost incurred
in treatment of Hip fracture in general in Oman.
Methods
The study was carried out at the MOH
Rustaq Hospital, which is the Referral Hospital for South Batinah
Region of Oman. A detailed retrospective study of hospital records
was undertaken for all patients. In all 150 patients were selected
for this study. Patients less than 60 years and those with peri-prosthetic
fractures, Metastatic disease or Polytrauma were excluded.
The cost of treatment was evaluated
by selecting the Major Components as : acute Ward Costs, Investigations
performed, Theatre expenses. (Table I)
Table I Demographic data
| |
Demographic |
Total
Number Patients 150 |
| 1. |
Mean
Age (Years) |
80 Years |
| 2. |
Sex
Distribution (%)
Female
Male |
95
55 |
| 3. |
Mean
Hospital Stay (days) |
16 days |
| 4. |
Fracture
TypesIntracapsular
Extracapsular
Sub Trochanteric |
68
74
8 |
| 5. |
Mean
Operating Time (min) |
70 |
Ward Costs: Included the length
of stay in Orthopaedic Ward, Intensive Care Unit, high dependency
beds. The help of the Finance Department of the hospital was
taken to determine the average cost per day as per the quoted
rates by MOH Oman Billing Rates. Any delay in surgery in days
was recorded for each patient and the total number of delayed
days with resultant costs was calculated. The average daily
cost of stay in Ward/HD was RO 10, ICU RO 40 respectively. This
included the cost of nursing care, meals provided by hospital
and other daily ward expenses.
The cost of Surgery was calculated
from the operation duration in minutes and cost of implant used.
(Table II) . Patients stay in recovery area, use of OT
Equipment, disposable items including those utilized by the
anaesthetic team. All costs including Pathology, Microbiology
and Radiological investigations performed were carefully
analysed for each patient. The sum total of all the expenses
(Table III) incurred in treatment of each patient was
calculated.
Table II Operations costs related
to duration
|
|
Operating Time |
Costs in Rial Omani |
| 1. |
180
minutes to 360 minutes |
848 |
| 2. |
91
minutes to 180 minutes |
424 |
| 3. |
46 minutes to 90 minutes |
212 |
| 4. |
01 minutes to 45 minutes |
106 |
Table III
Cost of inpatient investigations (as per rates of MOH)
| Test |
Cost (Rial Omani) |
|
Haematology
CBC
Sickling
Coagulation
Pupile
Blood
Grouping
ABG
|
3.000
3.000
15.000
3.000
3.000 |
|
Biochemistry
Glucose
LFT
RFT
|
3.000
3.000
3.000 |
|
Microbiology
Blood
Culture
Urine
Culture
Urine
Routine
Urine
Ketones
|
4.500
4.500
1.000
2.000 |
|
Radiology
X-Ray
(per film)
Ultrasound
MRI
C.T.
C
– Arm
|
8.000
25.000
150.000
100.000
25.000
|
|
Others
- ECG
|
5.000
|
Biopsy
|
10.000
|
Table IV
Breakdown of cost from inpatient
treatment of hip fractures in 150 patients
|
|
Items |
Costs (RO) |
% of Total Cost |
| 1. |
|
91000
|
60
|
| 2. |
Operative
|
31800
|
21
|
| 3. |
Laboratory
(including Transfusion)
|
20700
|
13.6
|
| 4. |
Radiology
/ ECG
|
8100
|
5.4
|
| 5. |
Total
Cost
|
151600
|
|
| 6. |
Average
Cost Per Patient (Rial Omani)
|
1010.6
|
|
Table V
Comparative data of acute care costs of treatment of hip fractures
| Study |
Year |
No. of Patients |
Average Hospital Stay (days) |
Average
Costs
£
/ R.O |
|
Present
Study
|
|
150
|
16
|
£1435
/ 744
|
|
Thomas
|
2003
|
100
|
23
|
£
12163/8687
|
|
French
|
1995
|
50
|
20
|
£
4018 /2870
|
|
Hollingworth(10)
|
1993
|
1080
|
42
|
£
5606 /4004
|
(Conversion Rate:
1 Rial Omani == Sterling £ 1.42)
Results
In our study of 150 patients there were
95 females and 55 males, the mean age was 80 years (range 60
- 90 years). The mean hospital stay was 16 days (range 10 -
21 days).
Seventy four patients had sustained
extra-capsular neck femur fractures, sixty eight had intra-capsular
fractures and the remaining eight had sub-trochanteric fractures.
Five patients were treated non-operatively. Surgical procedures
included: 62 Hemiarthroplasty (60 Austin Moore, 2 Thompsons),
69 Dynamic hip screw fixation, 6 cannulated cancellous screw
fixation. The mean operative time was 70 minutes (range 30 minutes
to 90 minutes). Thirty-two (21%) of patients had delay in surgery
due to lack of operating time. The mean delay was 3.3 days (1
- 5 days) which amounted to total of 105 bed days and total
cost of Rial Omani 1056.
The cost of routine investigations is
detailed in Table III. The mean total cost of hospital
expenditure per patient was found to be RO 1010.6. The details
of breakdown costs of Inpatient treatment of Hip Fractures is
outlined in Table IV.
Discussion
There are an increasing number of ageing
patients with Hip Fractures in Oman and therefore the cost of
falls incurred by the State health services is expected to escalate
(12,18). Hip Fractures accounted for approximately 30% of orthopaedic
bed occupancies in our hospital and based on the current population
trends the number of hip fractures will rise in the near future.
We calculated the mean hospital cost of treating hip fracture
to be RO 744. Since there are no figures from the Middle East,
to compare, we compared our costs with other studies from the
Western World. (Table V) Our cost estimates were lower
than the estimates in Table V. The observed differences may
be in part related to number of factors such as ethnic composition
of the population, diet, social factors and effects of inflation(16)
. Of the total costs ward stay contributed 60%, operative costs
21% only and the remainder were due to investigations carried
out such as Laboratory tests and Radiology.
These figures highlight the growing
expense incurred by the state health service in the acute treatment
of hip fractures most of which results from increased period
of hospital stay. One of the potential ways to minimize expenditure
following hip fractures is to reduce the duration of hospital
stay.(13,21,22) Delay in surgery due to inadequate operating
time on trauma list is common in many hospitals. In our study
32 patients (21%) had delay in Surgery and a total of 105 bed
days were used in this way costing RO 1056; this lead to inefficient
bed usage, increased nursing dependency, longer hospital stay
and more patient morbidity. This implies that provision of adequately
trained manpower and operation theatre resources would go a
long way in minimizing surgical delays and improve patient care
and reduce hospital expenditure.(16) The other aspect of introducing
shorter hospital inpatient stays after surgery and improving
rehabilitation programmes will prove to be very cost effective
and improve health outcomes(9,13)as the majority of inpatient
stay is spent after recovery from surgery (16) . Various strategies,
such as early mobilization of patients(4) joint orthopaedic
- geriatric rehabilitation(15) and "hospital at home"
teams(17) would reduce inpatient stay and also release hospital
beds with subsequent favourable effects on elective waiting
lists(19,20).
Our present study is unique. It is the
first study carried out in the Middle East where we have tried
to correlate in detail the clinical data from which costs were
derived for treating acute hip fractures in Referral MOH hospital
in Oman. We have retrospectively accounted for each patient's
day and all pre and post operative investigations, operative
data including the duration of surgery and type of implant used.
There are however several limitations in the interpretations
of these results. Firstly being a retrospective study, it is
possible that we may have failed to incorporate all costs related
to hip fracture. Secondly, the Ambulance Cost, Social care,
Travel and outpatient costs must be taken into account when
formulating the overall cost for hip fracture(13, 14). Finally
the accounting system of the MOH has had changes over a period
of time making precise billing evaluation difficult. However
the same limitations and inaccuracies in accounting are expected
to be present universally in other studies also (20,21). Nevertheless,
the present study is the most recent and only study projecting
the cost of treating hip fractures in Oman and Middle East in
general. Careful review of Table V has shown that reducing the
length of stay has not significantly reduced the overall costs,
possibly as inflation is going up. It is therefore more pertinent
to tackle the basic problem of reducing the occurrence of hip
fractures in geriatric population by targeting the osteoporosis
and prevention of falls(4,20) . In addition the use of External
hip protectors has proved to be valuable in decreasing rate
of hip fractures in Geriatric patients(3). The costs of inpatient
treatment of hip fractures in our study will be of use in the
long run in analyzing the cost benefit ratios of these preventive
measures.
The hip fractures in most parts of the
World are increasing by 1 - 3% annually(6,18). An estimated
1.3 million such fractures occurred globally in 1990, with numbers
expected to increase to 2.6 million by year 2025 and 4.5 million
by year 2050(11), indicating that hip fractures will place enormous
financial strain on the health service resources of any country
in future. Therefore it is required to determine the optimal
management for this fracture in order to cope with increasing
numbers of these patients and to reduce the cost of inpatient
treatment. Recent studies have suggested benefits, which could
be obtained from a designated hip fracture service being propagated
in certain countries.
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