Kavin Sundaram1*, Steven Culler1, April Simon3, David S. Jevsevar1,2, I. Leah Gitajn1, Michael J Schlosser5
1The Geisel School of
Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center,1 Medical Center
Drive, Lebanon, NH, USA
2Emory School of
Public Health, Atlanta, GA, USA
3Cardiac Data
Solutions, GA, USA
4HealthTrust PCG, Brentwood, Tennessee, USA
*Corresponding author: Kavin Sundaram, Department of Orthopaedics, The Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center,1 Medical Center Drive, Lebanon, NH, USA. Tel: +16036536014; Fax: +16036533581; Email: Kavin.sundaram.med@dartmouth.edu
Received Date: 28 June, 2018; Accepted Date: 29
October, 2018; Published Date: 6
October, 2018
1. Abstract
1.1. Background: This paper reports trends in care and costs associated with hip fracture admissions among Medicare Beneficiaries (MB).
1.2. Methods: This retrospective study identified 1,558,428 primary hip fracture admissions using the Medicare Provider Analysis and Review Files from fiscal years 2010 through fiscal year 2015.
1.3. Results: The total number of admissions rose from 246,825 to 276,659; however, rate per 1000 MB was 4.96 in 2010 and 4.98 in 2015. In all years, the patients were mostly female, Caucasian, and over age 80. Patient complexity increased as evidenced by greater comorbidity reporting. Most patients received an Open Reduction and Internal Fixation (ORIF) or partial hip arthroplasty, although there was a slight decline in partial hip arthroplasty and concurrent rise in total hip replacement. The cost per patient rose from $12,363 to $14093 (p<0.0001) despite a fall in average LOS from 5.8 to 5.42 days (p<0.0001) and a fall in in-hospital mortality from 2.6% to 2.2%. Reimbursements fell $1,118 from $10,304 in 2010 to $9,186 in 2015.
1.4. Conclusions: Average hospital cost per beneficiary rose during our study period while inflation-adjusted reimbursements fell. We found lower average LOS and postop mortality. Rates of AKI on presentation and co-morbid infection have risen. The number of patients receiving THA has risen but the most common treatment is femur repair.
1. Background
On July 25, 2016, the
Department of Health & Human Services (HHS) proposed a new model that
expands bundled payments to include Surgical Hip and Femur Fracture Treatment
(SHFFT) [1-2]. This progression theoretically shifts Medicare payments from
quantity to quality by creating strong incentives for hospitals to deliver
better care at a lower cost [3-4]. An estimated 300,000 Medicare beneficiaries
suffer a hip fracture per year [5]. In 2014, an average of 5.8 beneficiaries
per 1,000 suffered a hip fracture [6]. The primary objective of this study is to
report on trends associated with MBs admitted to US hospitals with a primary
diagnosis of hip fracture from fiscal years 2010 through fiscal year 2015. We
report outcomes among patients receiving Total Hip Arthroplasty (THA), Partial
Hip Arthroplasty (PH), femur repair, and non-operative care. We predicted
higher prevalence of baseline comorbidities, higher costs, and lower
reimbursements due to national policies favoring cost settings in the setting
of an increasingly older US population.
2. Methods
2.1. Data Source
Center for Medicare and
Medicaid Services maintains a database called Med PAR that contains all
submitted claims for services provided to MBs. We obtained a data set from this
database that spanned from 2010 to 2015.
2.2. Study Population Selection
100% of Medicare Part A
and C claims were included. During the study period CMS required claims for
every hospitalization ensuring there were no missing claims from part C.
Individuals under age 65 may be eligible for Medicare due to disabilities.
After careful consideration, we decided to include this population based on
prior literature that demonstrated that most patients 40-50 years share a
common mechanism with patients over 65-osteoporotic fragility fractures with a
fall as an inciting event [7]. Furthermore, prior work from the Kaiser-Family
foundation found that a similar proportion of MBs under-65 versus over-65 have
5 or more medical conditions (31% versus 28% percent) suggesting a similar
burden of comorbid disease [8]. Patients under 65
eligible for Medicare due to end-stage renal disease were included due to
constraints of our data set but prior research suggests they constitute less
than 1% of the total Medicare Population [9-10].
The Med Par dataset
includes basic demographic information, up to 25 diagnostic ICD-9-CM codes with
Present on Admission (POA) flags, primary procedure code, up to 24 additional
ICD-9-CM procedures codes, LOS in days, discharge status (discharge disposition
or site), total charges, and total reimbursement from the Medicare program. We
identified patients using ICD-9 codes after careful consideration of prior
literature. Data support the use of “fracture of the neck of Femur” relative to
chart review (PPV=0.85-0.93) [11-14]. While “pathological fractures” most
commonly refer to osteoporotic fragility fractures some clinicians may use the
code for patients with metastatic disease. Prior studies have shown a very low
rate of metastasis related oncologic fracture in the Medicare population (0.3
patients per 1,000 MB) and the risk of false negatives when excluding
“pathologic fracture”, we elected to use ICD-9 code 733.14 for pathological
fracture of the neck of the femur [15-16]. Codes of for atypical femur
fractures had low sensitivity for extra-capsular fractures and rates of
mid-shaft and distal femur fractures are low in an elderly population, so we
included the ICD-9 code for pathological fracture of other specified part of
the femur. Ultimately we searched for patients who had any of the following 3
codes in any of the diagnostic positions in the database.
· Fracture
of the neck of Femur (ICD-9 Code 820)
· Pathologic
fracture of neck of femur (ICD-9 code 733.14)
· Pathologic
fracture of other specified part of femur (ICD-9 733.15)
A total of 1,558,428
Medicare beneficiaries were in the final study population. The observation
period for diagnoses for each patient began on admission and ended on
discharge.
2.3. Operational Definitions and
Analysis
2.3.1. Medicare
Reimbursement
Was defined strictly as
the Medicare payment for each hospitalization. This
does not include any out-of-pocket payments by MBs or secondary payers.
The cost of each hospitalization was estimated by multiplying total billed
charges by the hospital-level cost-to-charge ratio obtained from the
appropriate hospital’s Annual Medicare Cost Report (or the most recent settled
cost report of the hospital). Length-of-Stay (LOS) was defined as the whole
number of days from admission to discharge. Our treatment groups included
total-hip arthroplasty (THA), Partial Hip Arthroplasty (PHA), femur repair, and
non-operative treatment. Claims were evaluated using both Part A and Part C.
2.3.2. Statistical
Analysis
A two sided chi-square
test assessed the presence or absence statistically of significant univariate
trends over the study period. Subsequent one-sided analyses tested the presence
or absence of a trend with a positively skewed tail or a negatively skewed tail.
Trends were statistically different if the P value was less than or equal to
0.01. Organizational variables analyzed include estimated hospital costs,
Medicare reimbursements, length of stay, and discharge status. Clinical
variables included type of operative treatment, adverse events, and mortality.
All analyses were performed with SAS 9.3 (SAS Institute, Cary, North Carolina).
2.3.3. Approval
and Funding
Our study received
evaluation and approval from the Dartmouth-Hitchcock IRB as an exempt study.
Funding did not play a role in our study.
3. Results
The final study
population included a total of 1,558,428 Medicare beneficiaries over 6
years. (Figure 1) describes the number of beneficiaries treated by
year. The total number of MBs experiencing a primary hip fracture
has increased from 246,825 in FY-2010 to 276,659 in FY-2015. (Figure 1),
Compounded Annual Growth Rate=2.8%). The rate of fractures per 1000 MB was 4.96
in 2010 versus 4.98 in 2015. (Figure 2)
In 2015, women
constituted 70.5% of our population. 64.2% of patients had reached age 80 or
greater and Caucasians represented 91.4% of the population. Each of these
variables experienced a statistically significant fall (p≤0.001, Table 1);
however, none of the listed demographic changes declined by more
than 2%.
In contrast to
demographic characteristics-which remained largely-the prevalence of several
medical morbidities rose dramatically. (Table 2) There was a statistically
significant rise in several of the most common cardiovascular comorbidities
include hypertension (60.75% to 75.30%), chronic ischemic heart disease (18.73%
to 25.55%), atrial fibrillation (17.91% to 23.54%), congestive heart failure
(14.74% to 16.68%). (p≤0.001, Table 2) Type II diabetes and Osteoporosis were
common endocrine abnormalities with a statistically significant from 17.91% to
22.72% and 10.20% to 16.23% respectively. (p≤0.001, Table 2).
The number of smokers
doubled from 4.71% to 8.54%; history of smoking increased from 3.09% to 18.40%.
Prior myocardial infarction doubled from 3.48% to 7.19%, prior cva nearly
tripled from 4.04% to 11.12%. Long-term anticoagulation rose from 2.88% to
9.49%, long-term aspirin use rose from 2.34% to 14.50%. Patients with prior THA
doubled from 1.96% to 5.08%; prior TKA tripled from 1.67 to 5.08%. History of
prior pathological fractures tripled from 0.10% to 0.36% and prior traumatic
fractures rose from 0.19% to 0.76%. (Table 3) documents the procedural
treatment of these patients. The proportion of patients receiving primary femur
repair remain unchanged (50.8% to 50.9%, p=0.651). Fewer patients received
partial hip replacement (32.2% to 30.5%, p≤0.001); the number of total hip
replacements rose from 3.0% to
4.2% (p≤0.001).
Hospital LOS declined
slightly (5.8 to 5.42, p≤0.001). The reimbursements in 2010 was $10, 304
and in 2015 it was $9816 when adjusted for inflation. Hospitals
reported average cost per beneficiary of $12,363 and it was $14093 in 2015 when
adjusted for inflation and expressed in 2010 US Real dollars. (Table 4).
In 2015, renal failure
on presentation was more common than comorbid VTE, infection, and CHF combined.
Rates of renal failure on admission and all types of infection rose while
postop CHF and VTE fell. (Table 5). In-hospital mortality and 180-day
mortality fell, but only the fall in in-hospital mortality was statistically
significant (Table 6).
4. Discussion
Our analysis of over 1.5
million MBs who constitute 100% of the patients receiving coverage for a
hospital admission associated with hip fracture showed that 4.98 beneficiaries
per 1,000 suffered a hip fracture in 2015. During this period, the prevalence
of several comorbidities rose including AKI, infection, and anemia. These
findings are likely clinically significant because risk stratification models
predict worse outcomes with greater prevalence of co-morbidities17 or
example, the rise in comorbid infections is noteworthy because chest infections
stand as one of the leading causes of death at 180 days [18]. Future
research is needed to investigate this finding.
Our study shows rising
rates of treatment with hip arthroplasty. This is congruent with prior
literature that has favored THA, particularly for displaced fractures, though
specific indications for specific patients remain an area of continued research
[19]. During our study period, the average cost per patient rose.
Reimbursements fell after adjustment for inflation.
This study does have
some limitations that we have carefully considered. Our retrospective review
documented comorbidities documented on admission or during a patient’s length
of stay. As our data set did not include a look-back period, we could only
determine the timing of diagnoses “on admission.” Future research may provide
further clarity in this area that may be particularly important for patients
with infections and kidney injury.
We reviewed the
literature regarding the performance of ICD-10 and ICD-9 in administrative
databases compared to chart. Multiple studies have reported a PPV ranging from
0.85 to 0.93 when for using ICD-9 codes when searching for hip fractures
[12-14]. These studies supported the accuracy of PE recording
(sensitivity=0.91, PPV= 0.823, and NPV=0.999) [20-22]. Rates of DVT are
confounded by absence of imaging or proper documentation. These studies support
the validity of our finding that the rate of AKI rose on admission with
possible bias of under-reporting and no changes in the rate of coding diagnoses
[24-25]. Anemia data often have high NPV but suffer from under-reporting
(PPV=0.12-0.20); however, prior studies generally support the validity of our
findings with PPV and NPV values and caution against under-reporting of most
comorbidities and complications we reviewed [26-29].
Patients under 65, with
or without end-stage renal disease, may have different characteristics than
patients over 65 with osteoporotic fragility fractures. Future research may
investigate these populations specifically and compare their clinical outcomes
and hospital costs to patients over 65. Future research may also examine
factors affecting care of MBs with hip fractures due to metastatic disease.
Prior literature provides targets for reducing cost. Preventive osteoporosis
care remains underutilized based on prior studies and our data suggest a rising
prevalence [30-31]. Expedited care has improved outcomes and reduced costs
[32]. Optimization of pre-hospital fluid resuscitation may represent a
future area of [33]. Judicious selection of preoperative tests may represent
another area for improvement. Studies of pre-operative workup suggests clinical
laboratory testing may provide relevant information, particularly PT and PTT
[33]. On the other hand, as many as 34% of patients still get a TTE when they
do not meet ACA/AHA criteria which may significantly elevate costs [34-35]. Clinical
literature has supported use of Arthroplasty for treatment of displaced
fractures. The cost of associated implants has risen; however, several
hospitals have instituted policies that allow cost control while preserving
surgeon autonomy [36-38].
Preventing even common
complications may be both medically relevant and financially impactful.
In prior work in total knee arthroplasty patients, we demonstrated how common
complications such as AKI and bleeding requiring transfusion could add to costs
of hospitalization [39]. Studies have shown pneumonia and surgical site
infections can dramatically raise in-hospital costs and we found these
conditions rose during our study period [40]. Future research can define
outcomes at 1-2 year or gender differences. Ortho Care, a successful bundled
pay system in Sweden, does not cover rehabilitation but other models do include
bundles for rehabilitation [41]. Research on discharge status can provide more
information on ideal post-operative care and optimal delivery of such care. A
body of literature has accumulated to support the use of bundled payment
programs to promote efficient systems that provide evidence-based care [42-43].
5. Conclusions
Our study reports trends
in a data set that captures 100% Medicare Part A and C beneficiaries treated
from 2010 to 2015 with a hip fracture associated admission. The absolute number
of MBs admitted with a hip fracture diagnosis rose from 2010 to 2015, but the
rate per 1,000 MB was 4.96 in 2010 versus 4.98 in 2015. The prevalence of
comorbidities rose during our study period. MBs had lower in-hospital
mortality. Average cost rose and lower average LOS fell. Surgeons used THA at a
rising rate but femur repair is the most common treatment.
Figure 1: Absolute Annual Rate of Hip Fractures among Medicare
Beneficiaries.
Figure 2: Annual Rate of Hip Fractures per 1,000 Medicare
Beneficiaries.
Variable |
2010a |
2011a |
2012a |
2013a |
2014a |
2015a |
p-Valueb |
Age (years) |
|
|
|
||||
Less than 65 |
4.0% |
4.1% |
4.3% |
4.4% |
4.4% |
4.5% |
p≤0.001 |
65 to 69 |
6.9% |
7.2% |
7.4% |
7.5% |
8.1% |
8.3% |
p≤0.001 |
70 to 79 |
21.8% |
21.9% |
21.9% |
22.2% |
22.8% |
23.0% |
p≤0.001 |
80 or greater |
67.4% |
66.8% |
66.5% |
66.0% |
64.8% |
64.2% |
p≤0.001 |
Gender |
|
|
|
||||
Female |
72.1% |
71.6% |
72.0% |
71.4% |
70.7% |
70.5% |
p≤0.001 |
Race |
|
|
|
||||
White |
92.1% |
92.0% |
91.7% |
91.7% |
91.5% |
91.4% |
p≤0.001 |
Black |
4.0% |
3.9% |
4.1% |
4.0% |
4.1% |
4.1% |
p=0.007 |
Hispanic |
1.6% |
1.6% |
1.6% |
1.7% |
1.6% |
1.6% |
p=0.564 |
All others |
2.4% |
2.5% |
2.6% |
2.6% |
2.8% |
2.9% |
p≤0.001 |
aall rows expressed
as patients with variable divided by total beneficiaries diagnosed with hip
fracture in a given year. b p-value represent the result of a
chi-squared test comparing changes between 2010 and 2015. |
Table 1: Demographic
Characteristics.
Long-term
use of anticoagulation |
2.88% |
6.96% |
8.26% |
8.74% |
9.05% |
9.49% |
p≤0.001 |
6.61% |
Atrial fibrillation POA |
16.81% |
20.68% |
22.04% |
22.42% |
22.90% |
23.54% |
p≤0.001 |
6.73% |
Prior
PE |
0.00% |
0.00% |
1.07% |
1.49% |
1.66% |
1.80% |
p≤0.001 |
1.80% |
Prior VTE |
1.54% |
3.44% |
3.68% |
3.67% |
3.60% |
3.83% |
p≤0.001 |
2.29% |
Anemia
POA |
3.36% |
3.54% |
3.82% |
3.90% |
4.07% |
4.00% |
p≤0.001 |
0.64% |
Hypertension |
60.75% |
70.24% |
73.79% |
74.24% |
74.64% |
75.30% |
p≤0.001 |
14.55% |
Prior
coronary revascularization |
6.98% |
14.47% |
16.94% |
17.35% |
17.41% |
17.41% |
p≤0.001 |
10.43% |
Prior
CVA |
4.04% |
8.70% |
10.30% |
10.60% |
10.91% |
11.12% |
p≤0.001 |
7.08% |
Chronic
ischemic heart disease |
18.73% |
24.91% |
26.35% |
25.90% |
25.70% |
25.55% |
p≤0.001 |
6.82% |
Atrial fibrillation POA |
16.81% |
20.68% |
22.04% |
22.42% |
22.90% |
23.54% |
p≤0.001 |
6.73% |
Prior myocardial infarction |
3.48% |
6.25% |
6.95% |
6.97% |
7.06% |
7.19% |
p≤0.001 |
3.71% |
Congestive
heart failure |
14.74% |
16.30% |
16.66% |
16.38% |
16.33% |
16.68% |
p≤0.001 |
1.94% |
Peripheral vascular disease |
0.68% |
1.23% |
1.53% |
1.81% |
1.98% |
2.05% |
p≤0.001 |
1.37% |
Long-term use of Aspirin |
2.34% |
7.63% |
10.42% |
11.54% |
12.80% |
14.50% |
p≤0.001 |
12.16% |
Long-term use of antiplatelet |
0.47% |
1.82% |
2.46% |
2.47% |
2.55% |
2.68% |
p≤0.001 |
2.21% |
History of Smoking |
3.09% |
8.77% |
11.81% |
13.61% |
15.93% |
18.40% |
p≤0.001 |
|
Diabetes
Type II |
17.91% |
21.15% |
22.25% |
22.42% |
22.50% |
22.72% |
p≤0.001 |
4.81% |
Body
mass index greater than 30 |
0.53% |
1.13% |
1.61% |
2.02% |
2.44% |
2.92% |
p≤0.001 |
2.39% |
Obesity |
1.49% |
2.77% |
3.38% |
3.69% |
3.79% |
4.32% |
p≤0.001 |
2.83% |
Body
mass index less than 19 |
1.60% |
1.87% |
2.19% |
2.47% |
2.79% |
3.07% |
p≤0.001 |
1.47% |
Malnutrition |
4.49% |
5.37% |
5.66% |
5.69% |
5.60% |
5.88% |
p≤0.001 |
1.39% |
Chronic
kidney disease |
11.66% |
16.04% |
17.89% |
18.41% |
19.25% |
19.88% |
p≤0.001 |
8.22% |
Acute
renal failure POA |
4.34% |
4.68% |
5.31% |
5.73% |
6.30% |
6.84% |
p≤0.001 |
2.50% |
COPD |
2.74% |
3.14% |
3.11% |
3.13% |
3.07% |
3.19% |
p≤0.001 |
0.45% |
Smoker |
4.71% |
7.33% |
8.26% |
8.67% |
9.06% |
9.54% |
p≤0.001 |
4.83% |
Osteoporosis |
10.20% |
15.17% |
16.55% |
16.43% |
16.21% |
16.23% |
p≤0.001 |
6.03% |
Prior
TKA |
1.67% |
3.65% |
4.45% |
4.64% |
4.89% |
5.29% |
p≤0.001 |
3.62% |
Prior
THA |
1.96% |
3.57% |
4.27% |
4.45% |
4.70% |
5.08% |
p≤0.001 |
3.12% |
Table 2: Comorbidities Among Medicare Beneficiaries Who Experienced a Hip Fracture: 2010 To 2015.
Procedures |
2010 |
2011 |
2012 |
2013 |
2014 |
2015 |
Change |
p-Value, trend |
Hip Replacement |
3.0% |
3.3% |
3.5% |
3.8% |
4.1% |
4.2% |
1.20% |
p≤0.001 |
Partial Hip
Replacement |
32.2% |
31.7% |
31.3% |
31.2% |
30.8% |
30.5% |
-1.70% |
p≤0.001 |
Femur Repair |
50.8% |
50.8% |
50.8% |
50.9% |
50.7% |
50.9% |
0.10% |
p=0.651 |
Table 3: Operative Treatment Performed on MB during Primary
Hip Fracture Admission.
2010 |
2011 |
2012 |
2013 |
2014 |
2015 |
|
LOS |
5.80 [5.78 -5.82] |
5.72*** [5.70-5.74] |
5.61*** [5.59-5.63] |
5.54*** [5.52-5.56] |
5.43*** [5.41-5.45] |
5.42*** [5.40-5.44] |
Cost |
$12,363 [11,592-13,134] |
$13,306 [10255-13198] |
$15,149*** [10,346-14,064] |
$15,214*** [14,194-16,234] |
$16,010*** [14,944-17,077] |
$15,321*** [14,261-16,383] |
Medicare Reimbursement |
$10,304 [10,271-10,337] |
$10,255 [10,209-10,301] |
$10,346 [10,300-10,392] |
$10,365 [10,320-10,411] |
$10,226*** [10,181-10,271] |
9,987*** [9942-10,032] |
Note: ***The p-value ≤ 0.001 for each given year compared to
2010. Value estimated coefficient on the variable indicating specific year
had an estimated p-value. |
Table 4: Hospital Resources Consumed by MB during Hip
Fracture Admission Mean [95% Confidence Intervals],
*** p-value ≤ 0.001.
Table 5: All types of infection rose while postop CHF and
VTE fell.
In-Hospital |
|
|||||
|
All Groups |
Non- operative |
Femur Repair |
Partial Hip Arthroplasty |
Total Hip Arthroplasty |
|
|
2010 |
2.60% |
5.41% |
2.05% |
2.31% |
1.71% |
|
2015 |
2.2 |
4.23% |
1.82% |
1.88% |
1.11% |
|
Average |
|
4.75% |
1.91% |
2.09% |
1.32% |
|
Change |
-0.40% |
-1.05 |
-0.13 |
-0.43% |
-0.60% |
|
Ptrend |
p≤0.01 |
p≤0.01 |
p≤0.01 |
p≤0.001 |
p=0.001 |
30 days |
|
|||||
|
All Groups |
Non- operative |
Femur Repair |
Partial Hip Arthroplasty |
Total Hip Arthroplasty |
|
|
2010 |
6.10% |
9.96% |
5.47% |
5.72% |
3.13% |
|
2015 |
6.4 |
10.81% |
5.60% |
6.15% |
2.62% |
|
Average |
|
10.38% |
5.50% |
5.92% |
2.91% |
|
Change |
0.30% |
0.50% |
0.13% |
0.43 |
-0.41% |
|
Ptrend |
p≤0.001 |
p=0.006 |
p=0.009 |
p=0.006 |
p=0.040 |
90-Days |
|
|||||
|
All Groups |
Non- operative |
Femur Repair |
Partial Hip Arthroplasty |
Total Hip Arthroplasty |
|
|
2010 |
12.50% |
16.74% |
11.77% |
12.33% |
7.27% |
|
2015 |
12.8 |
17.63% |
11.84% |
13.01% |
5.67% |
|
Average |
|
17.16% |
11.72% |
12.65% |
6.46% |
|
Change |
0.30% |
-0.11% |
0.07% |
0.65% |
-1.60% |
|
Ptrend |
p=0.004 |
p=0.026 |
p≤0.001 |
p≤0.001 |
p≤0.001 |
180 Day mortality |
|
|
||||
|
All Groups |
Non- operative |
Femur Repair |
Partial Hip Arthroplasty |
Total Hip Arthroplasty |
|
|
2010 |
20.40% |
27.93% |
19.01% |
19.94% |
12.86% |
|
2015 |
20.1 |
27.55% |
18.70% |
20.73% |
9.67% |
|
Average |
|
27.68% |
18.73% |
20.02% |
11.02% |
|
Change |
0.30% |
-0.38 |
-0.31% |
0.79% |
-3.19 |
|
Ptrend |
p=0.063 |
p=0.028 |
p=0.006 |
p=0.003 |
p≤0.001 |
Table 6: In-hospital mortality and 180-day mortality fell, but
only the fall in in-hospital mortality was statistically significant.
1.
Medicare
Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care
Hospitals Furnishing Lower Extremity Joint Replacement Services; Corrections
and Correcting Amendments. Federal
Register (2016).
2.
Medicare
C, Baltimore MS, Usa SB (2016) Notice of proposed rulemaking for bundled
payment models for high-quality. coordinated cardiac and hip fracture care.
5.
HCUPnet. Healthcare Cost and
Utilization Project (HCUP) (2012) Agency for Healthcare Research and Quality.
Rockville MD.
6.
The
Dartmouth Atlas (2017) The Dartmouth Institute for Healthcare Policy.
9.
Arneson,
TJ, Am J Kidney D (2013) Trends in hip fracture rates in US hemodialysis
patients, 1993-2010.
41.
Porter ME (2014) OrthoChoice: Bundled Payments in the
County of Stockholm. Harvard Business School.
Citation: Sundaram K, Culler S, Simon A, Jevsevar DS, Gitajn IL, et
al. (2018) Hip Fracture Admissions among Medicare Beneficiaries 2010-2015-Rising
hospital costs and falling reimbursements. Int J Musculoskelet Disord: IJMD-107 DOI: 10.29011/IJMD-107.000007