title: Impact of structural and economic factors on hospitalization costs, inpatient mortality, and treatment type of traumatic hip fractures in Switzerland.
abstract: The assessment of structural and potentially economic factors determining cost, treatment type, and inpatient mortality of traumatic hip fractures are important health policy issues. We showed that insurance status and treatment in university hospitals were significantly associated with treatment type (i.e., primary hip replacement), cost, and lower inpatient mortality respectively.
  
  
  BACKGROUND
  The purpose of this study was to determine the influence of the structural level of hospital care and patient insurance type on treatment, hospitalization cost, and inpatient mortality in cases with traumatic hip fractures in Switzerland.
  
  
  METHODS
  The Swiss national medical statistic 2011-2012 was screened for adults with hip fracture as primary diagnosis. Gender, age, insurance type, year of discharge, hospital infrastructure level, length-of-stay, case weight, reason for discharge, and all coded diagnoses and procedures were extracted. Descriptive statistics and multivariate logistic regression with treatment by primary hip replacement as well as inpatient mortality as dependent variables were performed.
  
  
  RESULTS
  We obtained 24,678 inpatient case records from the medical statistic. Hospitalization costs were calculated from a second dataset, the Swiss national cost statistic (7528 cases with hip fractures, discharged in 2012). Average inpatient costs per case were the highest for discharges from university hospitals (US$21,471, SD US$17,015) and the lowest in basic coverage hospitals (US$18,291, SD US$12,635). Controlling for other variables, higher costs for hip fracture treatment at university hospitals were significant in multivariate regression (p < 0.001). University hospitals had a lower inpatient mortality rate than full and basic care providers (2.8% vs. both 4.0%); results confirmed in our multivariate logistic regression analysis (odds ratio (OR) 1.434, 95% CI 1.127-1.824 and OR 1.459, 95% confidence interval (CI) 1.139-1.870 for full and basic coverage hospitals vs. university hospitals respectively). The proportion of privately insured varied between 16.0% in university hospitals and 38.9% in specialized hospitals. Private insurance had an OR of 1.419 (95% CI 1.306-1.542) in predicting treatment of a hip fracture with primary hip replacement.
  
  
  CONCLUSIONS
  The seeming importance of insurance type on hip fracture treatment and the large inequity in the distribution of privately insured between provider types would be worth a closer look by the regulatory authorities. Better outcomes, i.e., lower mortality rates for hip fracture treatment in hospitals with a higher structural care level advocate centralization of care.
authors.affiliation: Medical Directorate, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland. tarun.mehra@usz.ch.
authors.forename: Tarun
authors.initials: T
authors.lastname: Mehra
authors.affiliation: Medical Directorate, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland.
authors.forename: Rudolf M
authors.initials: RM
authors.lastname: Moos
authors.affiliation: Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland.
authors.forename: Burkhardt
authors.initials: B
authors.lastname: Seifert
authors.affiliation: Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland.
authors.forename: Matthias
authors.initials: M
authors.lastname: Bopp
authors.affiliation: Institute for General Practice, University Hospital of Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.
authors.forename: Oliver
authors.initials: O
authors.lastname: Senn
authors.affiliation: Division of Trauma Surgery, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland.
authors.forename: Hans-Peter
authors.initials: HP
authors.lastname: Simmen
authors.affiliation: Division of Trauma Surgery, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland.
authors.forename: Valentin
authors.initials: V
authors.lastname: Neuhaus
authors.affiliation: Division of Trauma Surgery, University Hospital Zurich, Rämistr. 100, 8091, Zurich, Switzerland.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Ciritsis
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D017048:Health Care Costs; D006269:Health Facilities, Proprietary; D006620:Hip Fractures / Q000191:economics / Q000401:mortality / Q000628:therapy; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement; D013557:Switzerland / Q000453:epidemiology
keywords: Femoral neck fracture, costs; Hip fracture; Osteoporosis