title: An economic evaluation of a systems-based strategy to expedite surgical treatment of hip fractures.
abstract: BACKGROUND
  A recent systematic review has indicated that mortality within the first year after hip fracture repair increases significantly if the time from hospital admission to surgery exceeds forty-eight hours. Further investigation has shown that avoidable, systems-based factors contribute substantially to delay in surgery. In this study, an economic evaluation was conducted to determine the cost-effectiveness of a hypothetical scenario in which resources are allocated to expedite surgery so that it is performed within forty-eight hours after admission.
  
  
  METHODS
  We created a decision tree to tabulate incremental cost and quality-adjusted life years in order to evaluate the cost-effectiveness of two potential strategies. Several factors, including personnel cost, patient volume, percentage of patients receiving surgical treatment within forty-eight hours, and mortality associated with delayed surgery, were considered. One strategy focused solely on expediting preoperative evaluation by employing personnel to conduct the necessary diagnostic tests and a hospitalist physician to conduct the medical evaluation outside of regular hours. The second strategy added an on-call team (nurse, surgical technologist, and anesthesiologist) to staff an operating room outside of regular hours.
  
  
  RESULTS
  The evaluation-focused strategy was cost-effective, with an incremental cost-effectiveness ratio of $2318 per quality-adjusted life year, and became cost-saving (a dominant therapeutic approach) if =93% of patients underwent expedited surgery, the hourly cost of retaining a diagnostic technologist on call was <$20.80, or <15% of the hospitalist's salary was funded by the strategy. The second strategy, which added an on-call surgical team, was also cost-effective, with an incremental cost-effectiveness ratio of $43,153 per quality-adjusted life year. Sensitivity analysis revealed that this strategy remained cost-effective if the odds ratio of one-year mortality associated with delayed surgery was >1.28, =88% of patients underwent early surgery, or =339.9 patients with a hip fracture were treated annually.
  
  
  CONCLUSIONS
  The results of our study suggest that systems-based solutions to minimize operative delay, such as a dedicated on-call support team, can be cost-effective. Additionally, an evaluation-focused intervention can be cost-saving, depending on its success rate and associated personnel cost.
authors.affiliation: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. dyc@hss.edu
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Dy
authors.forename: Kathryn E
authors.initials: KE
authors.lastname: McCollister
authors.forename: David A
authors.initials: DA
authors.lastname: Lubarsky
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Lane
mesh_terms: D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005592:Fracture Fixation / Q000191:economics*; D006620:Hip Fractures / Q000191:economics / Q000401:mortality* / Q000601:surgery*; D020445:Hospitalists / Q000191:economics; D006801:Humans; D018803:Models, Economic; D009871:Operating Room Nursing / Q000191:economics; D009872:Operating Room Technicians / Q000191:economics; D010561:Personnel Staffing and Scheduling / Q000191:economics; D011300:Preoperative Care / Q000191:economics; D019057:Quality-Adjusted Life Years; D040841:Resource Allocation; D013503:Surgery Department, Hospital / Q000458:organization & administration*; D013997:Time Factors; D014481:United States; D000078329:Workforce