8/12/2019 Pathways of care and direct costs associated with hip fracture in state-run health-care systems

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The Sheffield Health Economic Model for Osteoporosis(SHEMO) is individual-based state-transition model devel-oped at the University of Sheffield School of Health andRelated Research (ScHARR),1,2 and has been utilized in workfor both the National Institute for Clinical Excellence and theNational Co-ordinating Centre for Health TechnologyAssessment in the UK for the economic evaluation of osteo-porosis medications.3,4 Its major advantage over the memory-less Markov models is the ability to incorporate the patienthistory (prior fractures and current residential status) to deter-mine the likelihood of fractures in the subsequent 1-year mo-delling cycles, and provides more accuracy and flexibility thana cohort approach. SHEMO is thus scientifically as rigorous aspossible, and is ready to be utilized for evaluating osteoporo-sis drugs worldwide.

Hip fractures (HFx) make a substantial contribution to thedenominator of cost-effectiveness measures of osteoporosistherapies, regardless of the health-care system in question.Age-specific fracture rates, pathways of HFx care and theassociated direct cost items, however, show a large degree ofvariation internationally, which may cause SHEMO produceinvalid results unless modelling parameters are aligned locally.

1. Direct cost estimates for HFx in Hungary

Former estimates of direct costs of HFx in Hungary5-7

are notaddressing either the most relevant (i.e., postmenopausalosteoporotic [PMOP] female) population, or patients contribut-ing the most to HFx-related expenditures (those with comor-bidities or complications, and those immobile after primary hipsurgery).

An unknown proportion of the long-term care is not accountedfor as health-insurance expenditure because Hungarianpatients, depending on their social and health status, are pre-dominantly discharged to their own or their familys homesafter 10-15 acute hospital days, and only those largely immo-bile after this acute period (around 15.7%) are transferred tohospital wards for chronic care/rehabilitation (Table 1).10,11,14

3. HFx incidence and outcomes Hungary vs. UK

Compared to the Scottish fracture data18 used in economicevaluations for the UK setting,3,4 the incidence of hip (likewisewrist, and humerus data not shown) fractures in Hungary isestimated to be twice as high,19-22 (Table 4) while that of ver-tebral fractures is one of the highest among European coun-tries (similar to data from Sweden,23,24 which were used toapproximate the UK incidence rates in SHEMO3,4). Mortalityor immobility after the primary surgical treatment of hip frac-tures is more common compared to certain other EU memberstates.8-15,25

I am grateful to dr. Lszl Szekeres (St. Andrs State Hospital, Hvz), and Magdolna Szab (VI. Nursing Home of Zala County, Zalakomr-Ormndkastly)for their advice on additional direct costs of HFx management.

For further info on SHEMO, please visit: http://www.shef.ac.uk/scharr/sections/heds/modelling/osteoporosis.html

2. Adaptation of SHEMO health statesto the patient flow in Hungary

Up to 17% (risk increasing exponentially with age group) ofBritish HFx patients move to a nursing home, which is a majordeterminant of the total HFx cost covered by NHS. 3,4 In theHungarian setting, however, the important health state ofnursing home following a HFx in SHEMO should be replacedwith the much less costly (from the insurers perspective)health state of chronic care of immobile patients following aHFx [see Figure labelled as Hip fracture (patient immobileafter acute care)].

Except for the controversial hormone replacement therapy,none of the osteoporosis medications have been proven toalter the risk of coronary heart disease; related health stateshave been removed therefore for simplicity. (Figure)

A limited amount (mean 19 sessions/year) of professionaldomiciliary care is reimbursed by the National HealthInsurance Fund Administration (NHIFA), while the so-calledsocial homes (Hungarian counterparts of the NHS-sup-ported staffed residential homes), where some HFx patientsend up who cannot be cared for at home, are largely spon-sored from the social-care budget. Interestingly, therefore,the insurer (NHIFA) may spend around the same amountson the care of mobile patients (due to their travelallowance) than on the more severe, immobile patients(Table 2.).6-14

Further analyses are needed to show the improvementsin accuracy of costing if some other costs are also conside-red5,8-13,16,17 (Table 3).

BACKGROUND

An in-depth electronic literature search was undertaken, withspecial focus on the Hungarian Medical Bibliography, on allaspects of hip fracture related to the objective. Reference listsof papers obtained were searched for relevant articles.Estimation of adapted modelling parameters for SHEMO werebased on a synthesis of the published Hungarian evidence(with some assumptions and extrapolations not detailed here).In addition, senior management each of a health-care providerand a social-care provider institution was contacted for theexploration of hidden or ignored direct costs in Hungary.Costs, prices, and conversion rates of Hungarian Forints(HUF) to Euros ( ) reflect those of 2005.

METHODS

To compare the incidence rates, usual management path-ways, patient flows, and direct cost items associated with HFxin Hungary and the UK National Health Service (NHS), andaccordingly adapt the modelling parameters for SHEMO inorder to improve cost-effectiveness assessments of osteo-porosis medications in the setting of the Hungarian health-care system.

OBJECTIVES

RESULTS

CONCLUSIONSSHEMO is scientifically as rigorous as possible, still flexibleand convenient-to-use, economic model that can be recom-

mended worldwide to estimate cost-utility of osteoporosistherapies. The modelling parameters used in SHEMO for theUK,3,4 however, can produce invalid results in the Hungarian(and probably other international) setting because of themarked differences in...1. the direct costs associated with HFx;2. the pathways of care of HFx patients;3. the age-related patterns of fracture incidence.The current extensive literature review may enhance theaccuracy of economic evaluations by allowing for the abovediscrepancies by...1. calculating the available best estimate of direct HFx costs;2. determining the patterns of HFx patient flow in the path-

ways of care;3. calculating the available best estimate of age-specific frac-

ture indicence rates.

P85 (617)6th European

Conference onHealth Economics

July 69, 2006udapest, Hungary

Healthyosteoporosis

Death due toother causes

Death due tohip fracture

Death due tobreast cancer

Breastcancer

Noevent

or

or

Proximalhumerus fracture

Hip fracture(patient mobile

after acute care)

Hip fracture(patient immobileafter acute care)

Vertebralfracture

Wristfracture

Nonfatal fractures

Figure. Possible health state transitions in modelling cycles a modifiedSHEMO scheme (for details see text and publications1-4).

Table 1. Estimated average days of acute and chronic hospital careof PMOP HFx patients in Hungary

Acute care Chronic care

Typical cases 13 days 2 days

Severe casesa 13 days 19 days

a In Hungary: patients who cannot be mobilized after the acute hospital days (estimated

proportions: 3.9% to 21.4% for the age-groups 50-54 and 85+, respectively). 7-14 (Thesimilar category in the UK is that of patients entering nursery homes (age-specific pro-

portions: 0% to ~15%).4

Table 3. Direct HFx cost items for further research.

Costs covered by NHIFA

physiotherapy, balneotherapy, professional home care, ortheses and other devices,

specialist visits, patient travel, complications (e.g., infection, decubitus, VTE), se-

condary surgery (e.g., total hip replacement, implant removal)

Costs not covered by NHIFA

social homes, disability allowance, car purchase support, amortization-corrected

DRGs, out-of-pocket (informal and co-) payments, cost of healthy life-years

Table 2. Direct costa of HFx among PMOP women(insurers perspective)

Hungary (NHIFA)b UK (NHS)4

Typical cases H UF 45 9, 50 0-7 60, 60 0 G B 4 ,88 0-8 ,0 80

( 1,840-3,040) ( 7,000-11,600)

Severe casesc

1st year HUF 656,300-715,500 GB 29,620-32,795

( 2,260-2,860) ( 42,600-47,200)

Subsequent HUF 302,600-324,300 GB 22,298-23,897

years ( 1,210-1,300) ( 32,100-34,400)

a For the age-range of 50 (lower limit) to 80 (upper limit) yearsb Social-care costs are not covered by NHIFAc See definition at Table 1

* The Sheffield Health Economic Model for Osteoporosis (SHEMO) developed at the University of Sheffield - School of Health and Related Research (ScHARR)1,2

1. Stevenson MD, et al. J Oper Res Soc 2005;56:214-21. 2. Stevenson MD, et al.Med Decision Making 2004;24:89-100. 3. Kanis JA et al. Health Technol Assess2002;6(29). 4. Stevenson MD et al. Health Technol Assess2005;9(22). 5. KricsfalusyM, et al. Ca s Csont2000;3:118-23. 6. Sebestyn A, et al. Magyar Traumatolgia,Ortopdia, Kzsebszet, Plasztikai Sebszet 2000;43(1):57-62. 7. Sebestyn A, etal. Orv Hetil 2004;145:1115-21.8. Cserhti P, et al. Magy Traumat 1992;35(2):149-54. 9. Naumov I, et al. Magyar Traumatolgia, Ortopdia, Kzsebszet, PlasztikaiSebszet2002;45(1):38-48. 10. Cserhti P, et al. Magyar Traumatolgia, Ortopdia,Kzsebszet, Plasztikai Sebszet 1997;40(5):385-94. 11. Melly A, et al. MagyarTraumatolgia, Ortopdia, Kzsebszet, Plasztikai Sebszet 1998;41(1):15-27. 12.Kiss K. Nvr 2003;1:19-26. 13. Zahumenszky Z, Lukts M. Ca s Csont2000;3(3):125-8. 14. Rpolthy I, et al. Ca s Csont 2000;3(3):135-8. 15. Nacsai I, etal. Npegszsggy1991;72:139-41. 16. Hegeds L. Ca s Csont 2000;3(3):129-30. 17. Schreithofer L. Ca s Csont 2000;3(3):107-10. 18. Singer BR, et al. J BoneJoint Surg (UK) 1998;80:243-8. 19. Somogyi P, et al. Ca s Csont 2000;3(3):111-7.20. Somogyi P, et al. Ca s Csont 2003;6(1):22-9. 21. Por Gy. DSc thesis,Hungarian Academy of Sciences, 1999. 22. NHIFA data, 2003 http://www.osteofound.org/advocacy_policy/eu_policy_project/pdf/2003_pres_goenz.pdf(accessed Feb. 10, 2006) 23. O'Neill TW, et al. J Bone Miner Res. 1996;11(7):1010-8. 24. Por Gy, et al. Orv Hetil 1997;138(42):2647-52. 25. Kazr Gy, et al. Orv Hetil1997;138(50):3173-7.

REFERENCES

ACKNOWLEDGMENTS

PATHWAYS OF CARE AND DIRECT COSTSASSOCIATED WITH HIP FRACTURE

in state-run health-care systems (UK versus Hungary):Considerations for the adaptation of the ScHARR

osteoporosis model* to a Hungarian settingTams SORONCZ-SZAB, MD, MSc

MSD Hungary, Budapest (Subsidiary of Merck & Co., Inc., Whitehouse Station, NJ, USA). E-mail: tamas_szabo@merck.com

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Table 4. Estimates of age-specific annual incidence of osteoporotic [OP]HFx (estimated total of 10185 HFx/year) among postmenopausal women

Age group Annual incide rates of OP HFx Annual number(yr) of OP HFx in Hungary

Scottish cohort18 Hungary, calculated19-22 Hungary, calculated8-15

50-54 0.070% 0.106% 415

55-59 0.070% 0.106% 356

60-64 0.100% 0.152% 477

65-69 0.160% 0.243% 688

70-74 0.430% 0.654% 1739

75-79 0.560% 0.852% 1855

80-84 1.090% 1.658% 2400

85+ 1.900% 2.891% 2256