Clin Orthop Relat Res (2016)

指導老師 : 陳志輝主任
報告 : PGY 古立承
Outline
◦ 提出問題 (Question formulation)
◦ 搜尋證據 (Evidence search)
◦ 嚴格判讀 (Critical appraisal)
◦ 恰當運用 (Evidence application)
◦ 評估結果 (Outcome evaluation)

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Question formulation
◦ Scenario( 臨床情境 )
◦ More than 300,000 hip fractures annually in the united states
population
◦ Total treatment costs estimated at more than USD 12 billion
◦ Elderly, with multiple comorbidities

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Question formulation

◦ Ask( 形成問題 )

◦ Cost effectiveness of a comanagement service for elderly hip

fracture patients

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Question formulation

◦ Ask( 形成問題 )
◦ Cost effectiveness of a comanagement service for elderly hip fracture patients

◦ 問題類型

◦ 介入型 (intervention)

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Question formulation
◦ PICO
P Hip fracture elderly patient
Patient/Problem
I Comanagment service
Intervention
C Traditional ward service
Comparison
O Cost
Outcome outcome

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Outline
◦ 提出問題 (Question formulation)
◦ 搜尋證據 (Evidence search)
◦ 嚴格判讀 (Critical appraisal)
◦ 恰當運用 (Evidence application)
◦ 評估結果 (Outcome evaluation)

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Evidence search
◦ Database source( 資料庫資源 )

◦ Pubmed(www.ncbi.nlm.nih.gov/pubmed)
◦ Cochrane Library(www.cochranelibrary.com)

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Evidence search
◦ Search key word( 搜尋關鍵字 )

◦ Economy cost
◦ Hip fracture
◦ otrhopedic

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Evidence search
◦ Search result( 搜尋結果 )

◦ Pubmed:73Systematic Reviews:6
◦ Cochrane(Systematic Reviews): 5

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Question formation

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Outline
◦ 提出問題 (Question formulation)
◦ 搜尋證據 (Evidence search)
◦ 嚴格判讀 (Critical appraisal)
◦ 恰當運用 (Evidence application)
◦ 評估結果 (Outcome evaluation)

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Critical appraisal
◦ 納入嚴格評讀的文獻：

此篇文章納入理由：
1. 最符合臨床問題 2. 最佳研究統計
3. 發表年份最新 4. 有全文可供評讀

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Critical appraisal
◦ 納入嚴格評讀的文獻：

文獻等級： LEVEL III ,case control study

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Critical appraisal
◦ 文章與我們的 PICO
本篇研究內容 我們的 PICO
P
I
C
O

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Critical appraisal
◦ 文章與我們的 PICO
本篇研究內容 我們的 PICO
P Hip fracture elderly patient YES
I Comanagment service YES

C Traditional ward service YES

O Cost YES
outcome
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Multidisciplinary care
◦ Geriatric patients with hip fractures are comanaged by an orthopaedic
surgeon along with a dedicated internal medicine physician
◦ Strategies
◦ Adding one hospitalist to an existing service
◦ Section of a hospital to specifically focus on hip fracture care

◦ Successful models:
◦ Both physicians act as a patient’s primary caregiver> single service + consult
◦ Medical and surgical complications anticipated rather than treated after occurrence
◦ Decreased complication rates
◦ Time from injury until the operating room
◦ Hospital length of stay
◦ Improved osteoporosis treatment
Multidisciplinary care
◦ Old studies
◦ Reducing time to the operating room
◦ Early initiation of osteoporosis treatment
◦ Identified important predictors of perioperative complications, costs, and mortality

◦ No formal economic analysis based on decision analysis

principles—which can be used to synthesize results over
multiple studies and create generalizable conclusions—has
been performed.
MATERIALS AND
METHODS
Model creation
◦ Economic decision analysis study conducted according to the published
guidelines(Cost-Effectiveness in Health and Medicine Marthe R. Gold 1996.)
◦ (1) admission to a traditional single service,
◦ (2) universal admission to a formally comanaged service with a specifically
dedicated geriatric healthcare team (with resources in place to expedite time
to the operating room)
◦ (3) a risk-stratified model where patients who were high risk and sicker are
assigned to a comanagement service, and patients who are healthier, with
less-complex conditions were admitted to a lower-cost traditional service
Primary goal
◦ Cost effectiveness of a comanagement service
◦ Minimum case volume required for a comanagement program to be either cost
effective or cost saving
◦ (1) cost effective: improved health outcomes but with increased costs (with cost
increase less than defined ICER cutoff of USD 100,000 per QALY)
◦ (2) cost saving: improved health outcomes but decreased costs(negative ICER)
◦ Assumed scenario:
◦ One full time hospitalist
◦ Full-time staff partially dedicated

Incremental cost-effectiveness ratio

Time to operating room and mortality
◦ Study showed addition of a hospitalist and technologist to
expedite preoperative workup cost effective
◦ Delay more than 48 hours estimated: traditional(30%) ,
comanaged (10%)
◦ Baseline 1-year mortality rate of 20%
◦ Delayed more than 48 hours: 30% increase in mortality ( 95%
CI(5-49%))

◦ Life expectancy after surgery: 8y

Costs
◦ Team would include:
◦ an orthopaedic surgeon and a dedicated hospitalist, along with therapists and social workers specifically
designated to a comanagement team
◦ Full time salary based on reported values

◦ Base-case: 100 cases per year

◦ Length of stay : 10 days
◦ Assumed major requirement of time and resources of the hospitalist staff was in
postoperative care
◦ Hospitalist salary: USD 268,000 (67 萬 NTD/M)
◦ Loading: 10 patients at a time,( 350 pt. /Year)(usd 899/case)

◦ Surgeon fees and operating room time and costs were not included
◦ Total per case costs of all staff were combined: USD 1406
Complication Rates and Length of Stay
 Complication rates and length of stay
• Major financial benefits result from reduce length of stay
• Systemic review
Include 8 study(1rct, 7 case control)
Average reduction in length of stay by 2.28 days (95% CI, 2.00–2.56 days)
Risk stratification
◦ (1) odds ratio (OR) of mortality as a function of risk
stratification(4 studies)
◦ Mean OR of 3.6
◦ Prevalence of high- risk patients: average of 74%(45-92%)

◦ (2) change in length of stay as a function of risk stratification(3

studies)
◦ Average increased length of stay of 28% (10-40%)

◦ Define High risk: Nottingham hip fracture

score 3,4
Sensitivity analysis
◦ Case volume set(high ,middle, low); Performed on all the
variables to evaluate their effect on the model’s results.
◦ parameters vary within 95% CI
◦ Monte carlo simulation generating a result known as an ‘‘acceptability curve’’

◦ Multiway sensitivity analysis was performed to evaluate the

combined effects
RESULTS
Universal comanagement was the most cost-
effective strategy(Base case)
◦ Traditional service
◦ Total cost of USD 7409 and a QALY gain of 4.38

◦ Risk-stratified comanagement
◦ USD 9467 and a QALY gain of 4.44

◦ Universal comanagement
◦ USD 10,286 per case and a QALY gain of 4.45
ICER as a function of total annual
patient volume
54 fractures per year to be cost effective
318 fractures per year to result in cost savings
Sensitivity analyses
◦ High-volume center (318case/y)
◦ Cost effective for all scenarios

◦ Middle-volume center (100 case/y)

◦ More likely to be cost effective for most scenarios when the willingness to pay
(ICER threshold) was greater than USD 40,000 per QALY
◦ Low-volume center (54 case/y)
◦ More likely to be cost effective when the ICER threshold was at or greater than
USD 100,000 per QALY
Acceptability curve results of
probabilistic sensitivity analysis
 one-way sensitivity analysis

• Low-cost programs (< USD 1200 per
case),universal comanagement is less
expensive and more effective (dominant,
ICER is negative).
• Remain cost effective until >usd 3600
• LOSr greater than 1.8 days, comanagement
strategies save money while improving
outcomes (ie, dominant)
• LOS (0days), universal comanagement and risk-
stratified comanagement show improved health
outcomes and are still cost effective
DISCUSSION
Discussion
◦ High-volume center (>300case/y) (23%)
◦ Cost effective for all scenarios
◦ May be cost-saving

◦ Moderate-volume center (54~300 case/y) (85%)

◦ More likely to be cost effective
Universal or high risk only?
◦ That both methods are reasonable, cost effective, and generally preferable to
traditional method
◦ Depends on risk-stratification system used, specific costs, and patient population
◦ Future study: how to more accurately triage patients? Which patients benefit most
from comanagement ?
Discussion
◦ Sensitivity analysis used whenever there was a high degree
of uncertainty regarding any given variable (eg, length of
stay, salary)
◦ Effectiveness underated: Decreased complications would
have other financial benefits not included
◦ Decrease cost: Decreasing length of stay>decrease per-case
costs
Discussion
◦ Only considered the effect of a hip fracture service on the
immediate perioperative period
◦ Excluding increased initiation of osteoporosis treatment

◦ Readmission rates: only improved in some studies

 CRITICAL
APPRAISAL
TOOL
◦ CASP checklist for case control study
Clinical significant result was reached
P<0.05
Limitation
◦ Low level of evidence
◦ Mostly retrospective data
◦ Prospective randomized studies for future study

◦ Mortality benefit of early surgery

◦ Controversial
◦ Interventions that shorten time to the operating room actually improve mortality?
◦ Excluding effect of “cost effective”

◦ Determination of costs is also a challenging(web based)(us based)

◦ Hospital stays generally are longer and inpatient rehabilitation and nursing homes are less
common (eg, europe, asia)
Conclusion
◦ Study support the formation of a formal osteoporotic fragility
fracture team that includes a dedicated hospitalist, physical
therapist, and social worker to comanage medically frail
patients alongside orthopaedic surgeons in centers that see
a moderate to high volume of patients with hip fractures.
◦ Universal or high risk ? Less clear
◦ Complication rates and length of stay improve
◦ Mortality may be reduced in a cost-effective manner