title: Is Prophylactic Intervention More Cost-effective Than the Treatment of Pathologic Fractures in Metastatic Bone Disease?
abstract: BACKGROUND
  Metastatic bone disease is a substantial burden to patients and the healthcare system as a whole. Metastatic disease can be painful, is associated with decreased survival, and is emotionally traumatic to patients when they discover their disease has progressed. In the United States, more than 250,000 patients have metastatic bone disease, with an estimated annual cost of USD 12 billion. Prior studies suggest that patients who receive prophylactic fixation for impending pathologic fractures, compared with those treated for realized pathologic fractures, have decreased pain levels, faster postoperative rehabilitation, and less in-hospital morbidity. However, to our knowledge, the relative economic utility of these treatment options has not been examined.
  
  
  OBJECTIVE
  We asked: (1) Is there a cost difference between a cohort of patients treated surgically for pathologic fractures compared with a cohort of patients treated prophylactically for impending pathologic lesions? (2) Do these cohorts differ in other ways regarding their utilization of healthcare resources?
  
  
  METHODS
  We performed a retrospective study of 40 patients treated our institution. Between 2011 and 2014, we treated 46 patients surgically for metastatic lesions of long bones. Of those, 19 (48%) presented with pathologic fractures; the other 21 patients (53%) underwent surgery for impending fractures. Risk of impending fracture was determined by one surgeon based on appearance of the lesion, subjective symptoms of the patient, cortical involvement, and location of the lesion. At 1 year postoperative, four patients in each group had died. Six patients (13%) were treated for metastatic disease but were excluded from the retrospective data because of a change in medical record system and inability to obtain financial records. Variables of interest included total and direct costs per episode of care, days of hospitalization, discharge disposition, 1-year postoperative mortality, and descriptive demographic data. All costs were expressed as a cost ratio between the two cohorts, and total differences between the groups, as required per medical center regulations. All data were collected by one author and the medical center's financial office.
  
  
  RESULTS
  Mean total cost was higher in patients with pathologic fractures (cost unit [CU], 642 ± 519) than those treated prophylactically without fractures (CU, 370 ± 171; mean difference, 272; 95% CI, 19-525; p = 0.036). In USD, this translates to a mean of nearly USD 21,000 less for prophylactic surgery. Mean direct cost was 41% higher (nearly USD 12,000) in patients with a pathologic fracture (CU, 382 ± 300 versus 227 ± 93; mean difference, 155; 95% CI, 9-300; p = 0.038). Mean length of stay was longer in patients with pathologic fractures compared with the group treated prophylactically (8 ± 6 versus 4 ± 3 days; mean difference, 4; 95% CI, 1-7; p = 0.01).
  
  
  CONCLUSIONS
  These findings show economic and clinical value of prophylactic stabilization of metastatic lesions when performed for patients with painful lesions compromising the structural integrity of long bones. Patients sustaining a pathologic fracture may represent a more severe, sicker demographic than patients treated for impending pathologic lesions.
  
  
  METHODS
  Level IV, economic and decision analysis.
authors.affiliation: NYU Hospital for Joint Diseases, 301 E. 17th Street, New York, NY, 10003, USA. alan.blank@nyumc.org.
authors.forename: Alan T
authors.initials: AT
authors.lastname: Blank
authors.affiliation: Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Lerman
authors.affiliation: NYU Hospital for Joint Diseases, 301 E. 17th Street, New York, NY, 10003, USA.
authors.forename: Neeraj M
authors.initials: NM
authors.lastname: Patel
authors.affiliation: NYU Hospital for Joint Diseases, 301 E. 17th Street, New York, NY, 10003, USA.
authors.forename: Timothy B
authors.initials: TB
authors.lastname: Rapp
mesh_terms: D000328:Adult; D000368:Aged; D001859:Bone Neoplasms / Q000150:complications / Q000191:economics* / Q000556:secondary / Q000601:surgery*; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000191:economics* / Q000379:methods; D005598:Fractures, Spontaneous / Q000000981:diagnostic imaging / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay / Q000191:economics; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome