w w w . r b o . o r g . b r
Original
article
Cost-effectiveness
of
surgical
treatment
for
hip
fractures
among
the
elderly
in
Brazil
夽
Fabiano
Bolpato
Loures
a,∗,
Alfredo
Chaoubah
b,
Vinícius
Silveira
Maciel
a,
Elenir
Pereira
Paiva
b,
Patrick
Pereira
Salgado
a,
Álvaro
Correa
Netto
aaSantaCasadeMisericórdiadeJuizdeFora,JuizdeFora,MG,Brazil
bUniversidadeFederaldeJuizdeFora,JuizdeFora,MG,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received3April2014 Accepted8April2014
Availableonline31January2015
Keywords:
HealthEconomicalAnalysis Hipfracture
Elderlyperson
a
b
s
t
r
a
c
t
Objectives:Toestimatethecostperquality-adjustedlife-year(QALY)focusingonthelength oftimebetweentraumaandsurgery.
Methods:Aretrospectivecohortwithsystematicsamplingwasconductedamongallthe patientswhowereadmittedtothestudyhospitalthroughtheBrazilianNationalHealth System(SUS)overathree-yearperiod.Twotreatmentstrategieswerecompared:early treat-ment,ifthepatientwasoperateduptothefourthday;andlatetreatment,ifthiswasdone afterthefourthday.ThecostwasthedirectmedicalcostfromthepointofviewofSUS,which wasgatheredfromthemanagementsystem,fromtheSUStableofprocedures,medications andimplantmaterialcosts(SIGTAP),toaccountforthecostsassociatedwiththehospital, medicalfeesandimplantsused.Theoutcomeofusefulnesswasmeasuredindirectlyby meansofEuroQOL-5D,whichisaninstrumentusedworldwide,andthesemeasurements weretransformedintousefulnessbymeansofthestandardrulesoftheRegionalPlanning andDevelopmentCenterofMinasGerais(CEDEPLAR)of2013.
Results:Thesampleincluded110patients:27intheearlygroupand83inthelategroup. Theconfoundingvariablesofage,gender,anestheticrisk(ASA),fracturetypeandsurgery typewerecontrolledfor.Thesampleswereshowntobehomogenouswithregardtothese variables.ThecostperQALYoftheearlystrategywasR$5,129.42andthecostofthelate strategywasR$8,444.50.
Conclusion:Theearlystrategywashighlyfavorableinrelationtothelatestrategyinthis study.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
夽
WorkdevelopedintheDepartmentofOrthopedicsandTraumatology,SantaCasadeJuizdeFora,JuizdeFora,MG,Brazil.
∗ Correspondingauthor.
E-mails:fabiano.loures@yahoo.com.br,elenirbolpato@yahoo.com.br(F.B.Loures).
http://dx.doi.org/10.1016/j.rboe.2015.01.007
Custo-efetividade
do
tratamento
cirúrgico
da
fratura
do
quadril
em
idosos
no
Brasil
Palavras-chave:
AnáliseEconômicaemSaúde Fraturadoquadril
Idoso
r
e
s
u
m
o
Objetivos:estimarocustoporanodevidaajustadoporqualidade(QALY)comfoconotempo entreotraumaeacirurgia.
Métodos:foifeitaumacoorteretrospectivacomamostrasistemáticacomtodosospacientes internadosnohospitaldoestudopeloSistemaÚnicodeSaúde(SUS)durantetrêsanos. Compararam-seduasestratégiasdetratamento,umaprecoce,seopacientefosse oper-adoatéoquartodia,eoutratardia,seapósoquartodia.Ocustofoiodiretomédicodo pontodevistadoSUS,colhidodiretamentedoSistemadeGerenciamentodaTabelade Procedimentos,MedicamentoseCustosdeMateriaisdeImplantes(OPM)doSUS(Sigtap), paracontagemdoscustosassociadosaohospital,aoshonoráriosmédicoseaosimplantes usados,eodesfechoutilidadefoimedidoindiretamentepormeiodoEuroQOL-5D, instru-mentomundialmenteusadoetransformadoemutilidadepelanormativadoCentrode DesenvolvimentoePlanejamentoRegionaldeMinasGerais(Cedeplar)de2013.
Resultados:aamostracontoucom110pacientes,27nogrupoprecocee83notardio.Variáveis confundidorasforamcontroladas,idade,gênero,riscoanestésico(ASA)etipodefraturae decirurgia.Asamostrasserevelaramhomogêneasquantoaessasvariáveis.Ocustopor QALYdaestratégiaprecocefoideR$5.129,42edaestratégiatardia,deR$8.444,50. Conclusão: aestratégiaprecocedemonstradominânciaemrelac¸ãoàtardianesteestudo.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Fractures of the proximal femur have extremely serious repercussions among elderly patients: high morbidity and mortality,high ratesofpostoperativeincapacityandhigher costsbothforthefamilyandforsociety,withpoorresultsfrom thetreatment.Theyareconsideredtobeoneofthebiggest publichealthproblemsworldwide.1,2
IntheUnitedKingdom,theguidelinesrecommendthatthe idealintervalbetweeninjury andsurgeryis24h, exceptin casesinwhichthepatient’sconditionnecessitatemoretime forclinicalimprovement.3Someauthorshavetakentheview thatadherencetothisidealtimeconstitutesaqualitycriterion fortheserviceinquestion.4
ThetimebetweeninjuryandsurgeryislengthyinBrazil, andthismaycauseworseningoftheclinicalresultsandof quality oflife,as well asincreasing the costs ina health-care system that is under development, like the Brazilian system.5–7
Thedirectmedicalcostsrelatingtotreatmentofhip frac-turesamongelderlypeoplehavebeenstudiedinBrazilsince 2001,andtheyvarysignificantly,particularlybecauseofthe differencesindata-gatheringorsurveymethodologies,from R$1,700.008toR$24,000.00.9
Effectivenesscanbemeasuredasqualityoflife,suchthat the result is named “usefulness”. This is a measurement methodinwhichacardinalnumberrangingfromzerotoone representsapossibleextractofthequalityoflife.Deathis rep-resentedas“zero”andperfectqualityoflifeisrepresentedas “one”.Thisoutcomecanbegathereddirectlyorindirectlyby meansofquestionnaires.
Indirectdata-gatheringmethodsareeasierandcheaper.10 Use of these instruments depends on the transformation normsthatideallyshouldbecreatedamongthelocaltarget population.11
Independentofwhethertheinvestmentisofpublicor pri-vatetype,healthcareexpenditurehasbeenincreasingaround the world, either through advances in hard technology or through the sumoftechnologies, whichis acharacteristic ofthehealthcaresector.Thismakesallocativeefficiencyand treatmentefficiencyevenmoreimportant.12Thisknowledge issomethingthatorthopedistsshouldhaveaninterestin.
Economic analysison “hipfractures amongtheelderly” constitutesanefforttocomprehendtheproblembetter,along withitsdetails,andenableadequateplanningtodealwithit. Itsmaincharacteristicisthecollectivepointofviewinstead ofthe individualpoint ofview,whichbettertranslates the dimensionofthequestioninoureyesandinthoseof health-caremanagers.
The aim of this study was to analyze the relationship betweencost,fromtheperspectiveoftheBrazilianNational HealthSystem(SUS),andtheeffectivenessofsurgical treat-mentforhipfracturesamongelderlypeopleinBrazil,focusing onthetimethatelapsesbetweeninjuryandsurgery.
Methods
intoconsiderationthedirectmedicalcostsassociatedwiththe variouspossibletechniquesfortreatinghipfracturesamong elderlypeople.Thetimespanconsideredwasoneyearand nocorrectionswereappliedtothetableofreimbursementsfor hospitalsworkingwithSUSpatientsduringthisperiod(which wasthesettingforthisstudy),sincenonewereapplicable.
From this cohort, data were gathered on the direct medical costs, time elapsed between the injury and the surgery,number ofdeathsatthehospital, lengthof hospi-talstayandusefulness,bymeansoftheEuroQOL-5D(EQ-5D) questionnaire,13 an instrument that had previously been usedinBrazil,withtransformationnormsavailableforthis country.14Thesewereconsideredtobethefinaloutcomesor dependentvariables.
Theindependentvariableswere takentobeage,gender, typeoffracture,typeoftreatmentandASAanestheticrisk.15 Thecostsassociatedwiththe treatmentswere surveyed directlythroughthemanagementsystemoftheSUStableof procedures,medicationsandorthoses,prosthesesandspecial materials(OPM)(SIGTAP), inaccordancewiththe following codesoftheInternationalClassificationofDiseases(ICD-10):16 S72-0,whichcorrespondstofracturesofthefemoralneck;and S72-1,whichcorrespondstotranstrochantericfractures.
These were divided into hospital costs, medical fees, implantmaterialcostsandtotalcosts.
Twogroupswerecreatedfocusingonthetimethatelapsed betweentheinjuryandthesurgery:“earlysurgery”(≤4days) and“latesurgery”(>4days).Thiscutoffpointwasbasedon theobservationsofFernandesetal.17inwhichtheearlygroup wouldhavedisappearedifthecutoffpointhadbeenlower,and Moronietal.18whoprovedthatmortalityincreasedafterthis cutoffpoint.
Thegroupswere comparedinrelationtoage bymeans ofStudent’sttestandwiththeotherindependentvariables dichotomouslybymeansofthechi-squaretest.
ThestatisticalanalysiswasperformedusingtheStatistical PackagefortheSocialSciences(SPSS)20.0andthedecision treewasgeneratedusingtheTreeageProsoftware2011.
ThestudywasapprovedbytheEthicsCommitteethrough ConsolidatedReportNo.126,931,datedOctober9,2012.
Results
FourtreatmentcodesandsixtypesofOPMandtheirvarious costswerefound,asshowninTables1–3.
TherealcostpaidbySUSwasappliedtothespreadsheet thuscreatedfromthe115patientsofthecohortstudied.From this,themeancostpertreatmentperpatient,ofR$1933.79 (standard deviation, SD, R$ 686.26), was found. The mean
Table1–Codesforprocedures.
Code Nameoftheprocedure
040805063-2 Surgicaltreatmentoftranstrochanteric fracture
040805048-9 Surgicaltreatmentoffemoralneck fracturewithfixation
040804005-0 Partialhiparthroplasty 040804008-4 Cementedtotalhiparthroplasty
Table2–Hospitalandmedicalcostsassociatedwiththe codes.
Code Hospitalcost Medicalcost
040805063-2 R$725.17 R$247.80
040805048-9 R$715.22 R$246.63
040804005-0 R$1292.50 R$278.16
040804008-4 R$1343.75 R$291.52
Table3–Costofimplants.
Implant Cost
Slidingscrew,135◦
R$764.34
Slidingscrew,95◦ R$678.73
Cannulatedscrew,each R$90.29(usually3) Proximalintramedullarynail R$936.58
Bipolarprosthesis R$1886.30
Cementedtotalprosthesis R$1867.37
hospitalcostamongthesamplewasR$813.92(SD,R$210.92), corresponding to42.09%ofthetotal,themean medicalfee costwasR$252.73(SD,R$12.13),correspondingto13.17%of thetotalcost,and meanOPMsofR$867.13(SD,R$473.52), correspondingto44.84%ofthetotalcost.
Thetwogroupswerecomparedaccordingtothe
indepen-dentvariables.TheresultsarepresentedinTable4.
Itwasconsideredthatthegroupswerehomogenousand thatthecostsforbothstrategies,fromtheperspectiveofSUS, werethesame.Thestrategiescouldthenbecompared.
Regardingdeathsatthehospital,theproportionofdeaths intheearlygroupwas7.41%versus16.86%inthelatesurgery group. Althoughthis result wasnot statisticallysignificant (oddsratio,OR:0.394;95%confidenceinterval,CI:0.084–1.859; p=0.226),itwasclinicallysignificant.
Withthe samecosts, consideringthetwostrategies,for everythousandpatientsundergoingtheearly-surgery strat-egy, in comparisonwith the late-surgerystrategy, 94 lives wouldbesaved.
Thelengthofhospitalstaywasstatisticallysignificantly differentbetweenthetwogroups,withameanof7.22days
Table4–Comparisonbetweengroups.
Variable Early Late pvalue
n 27patients 83patients
Age 78.78years(SD:11.38) 76.75years(SD:11.01) 0.411
Gender 77.8%♂×22.2%♀ 62.6%♂×37.4%♀ 0.148
ASAgrade 55.5%lowriskvs.44.5%highrisk 50.6%lowriskvs.49.4%highrisk 0.655
Table5–Analysisontheoutcomeofusefulness. Earlymeanvs.latemean pvalue
Usefulness 0.592vs.0.523 0.566
EVA 0.650vs.0.637 0.911
ofstay(SD,3.43days)forthepatientsundergoingthe early-surgerystrategy,versus15.90daysofstay(SD,6.81days)for thosewithlatesurgery(p<0.001).
Patientsundergoingtheearly-surgerystrategywouldeach generateadailycostforthehospitalofR$267.84,whilethose undergoingthelate-surgerystrategywouldgenerateadaily costofR$121.62.
Withregardtostudyingusefulness,bymeansofEQ-5D,the differencesfoundwerenotstatisticallysignificant,asshown
inTable5.
Decisionanalysisgeneratedbymeans ofadecisiontree showedanotableresultintermsofcostperquality-adjusted lifeyear(QALY).Fig.1showstheseresults.
Thestrategiesshownthroughthedecisionanalysismodel demonstratethepoornessoftheresults,combinedwithlow usefulnessforbothstrategies.Ontheotherhand,an advan-tageforallocationofresourcestotheearly-surgerystrategy wasdemonstrated:thiscostR$5129.42accordingtoQALY, ver-susR$8444.50accordingtoQALYforthelatesurgery.Thefirst strategywasthusshowntobesuperior.
Discussion
Thesampleofthepresentstudyresembledprevioussamples intheBrazilianandforeignliteratureregarding proportional-ity,predominanceoffemalesandapeakataroundtheageof 75years.19,20Thisinformationdemonstratesthecapacityfor extrapolationofthisstudy.
Transtrochanteric fractures predominated, as previously recognizedbyCastrodaRochaandRibeiro.21Thetreatments typicaloftranstrochantericfractures,withpredominanceof fixation inthe present study,had also been seen in other studies.21,22
Themeancostsperpatientpertreatment,ofR$1993.79 (SD,R$686.26),wereveryclosetothosefoundbyKraussSilva inapartialeconomicanalysis,inwhichonlythecostswere takenintoconsideration.8
Thetimethatelapsedbetweentheinjuryandthesurgery waslengthy,astoohavethetimesreportedinotherBrazilian studies.5–7Thisdiffersfromstudiesinothercountries,which haveshownearlyattendance.23,24
The time that elapses between injury and surgery has beencorrelatedwithdelayinpreparingthepatientandwith theavailabilityofapreoperativetheater,instudiesinother countries.24Inthepresentstudy,therewasastrong compo-nentassociatedwithdelayintransferringthepatientfromthe emergencyhospitaltooneequippedtodealwiththe complex-itylevelofthecase.Afterthisdelay,theprocedurescontinued moresmoothly.
Thepreoperativehospitalstaywaslongerthanthe post-operativestay.Thetransfertimealone,i.e.thelengthoftime betweenissuanceoftheauthorizationforhospitalizationand arrivalatthedestinationhospital,was3.57days(SD,4.57days) andthetransfertimehadadirectinfluenceonthetimethat elapseduntilsurgeryandontheentirestay.
Thepreoperativehospitalstaywasresponsiblefor64.3%of theentirestay,whichconfirmstheobservationthatdifficulties existinrelationtotransferringand/orpreparingthepatient fortheprocedure.
Inthissample,therewasahighdeathrateatthehospital, withameanof13.04%,thusdifferingfromthefindingsofthe meta-analysisbySakakietal.20 inwhichtheratewas5.5%. Theirlowervaluemayhaveresultedfromusingstudiesfrom othercountriesintheirmeta-analysis,anditresembledthe resultsfromtheearly-surgerygroup,whichhadadeathrate atthehospitalof7.14%.
Itcan beassumedthat the early treatmentprovidedin othercountriesisthegoldstandardandthatifthetreatment providedinBrazilwere similar,theresultswouldresemble thoseofothercountries.
Despitetheclinicalimportanceofthenumberofdeaths, therewasnostatisticallysignificantrelationshipwiththetime that elapseduntilsurgery,asseen inotherstudies already cited.
The mean hospital stay of our sample (13.4 days) was similar to that of other studies conducted in Brazil and elsewhere.20,25,26
Theoutcomeofusefulnessmeasuredbymeansofthe EQ-5Dconfirmedthepoorresultsrelatingtothistreatment,as previouslyshownthroughclinicalandquality-of-liferesults.27 Throughusingadecisiontreeasthemeansofanalyzing thedecision-making,thepresentstudybecomesnoteworthy
Femoral fracture
<4 Days
>4 Days
0.074
0.831
0.169
0.474 0.526 Alive
0.313
High High
0.926
0.687
Death in hospital Death in hospital
Dead
Dead
R$1.934\0.377
R$1.934\0; P=0.074 R$1.934\0.407
R$1.934\0.275
R$1.934\0.523; P=0.437
R$1.934\0; P=0.394
R$1.934\0; P=0.169 R$1.934\0.229
R$1.934\0; P=0.290 R$1.934\0 592; P=0.636
Alive
giventhatitsdesignclearlydemonstratesthecostand use-fulnessresultsrelatingtothestrategiesused.
The small number of comparable studies shows the scarcityofthistypeofstudyinthe literatureand thusthe presentstudy cannotbecomparedwithother studies con-ductedinBrazilorinothercountries.Therehavebeenmany clinical evaluations focusing on the time period between injuryandsurgery,butfewcost-effectivenessassessments.
Atthispoint,itshouldbeemphasizedthatthereisan ethi-callimitonthisandotherstudiesfocusingonthetimeelapsed betweeninjuryandsurgery,withregardtorandomallocation ofpatients.Insuchsituations,observationalstudieslikethe presentonearethetypethatbringsthebestevidence.
Cost-effectiveness analysis performed on a model produces QALY values. In the present study,early surgery generatedacostofR$5129.42accordingtoQALY,versusR$ 8444.50accordingtoQALYforlatesurgery.
Conclusion
Aftercontrollingfortheconfoundingvariablesofage,gender, typeoffracture,typeoftreatmentandASAanesthesiarisk, thecost-usefulnessratiooftheearly-surgerystrategy(<4days) wasshowntobesuperiortothelate-surgerystrategy(>4days). The economic analysis conducted here provides back-ing fordetermining that early surgeryshould be the ideal forguidelineswithinBrazilianrealitiesandforallocationof resourcestoseekthisobjective.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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