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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. QUESTIONS/PURPOSES: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. LEVEL OF EVIDENCE:Level IV, economic and decision analysis.

journal_name

Clin Orthop Relat Res

journal_title

Clinical orthopaedics and related research

authors

Blank AT,Lerman DM,Patel NM,Rapp TB

doi

10.1007/s11999-016-4739-x

subject

Has Abstract

pub_date

2016-07-01 00:00:00

pages

1563-70

issue

eissn

0009-921X

issn

1528-1132

pii

10.1007/s11999-016-4739-x

journal_volume

474

pub_type

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Is Prophylactic Intervention More Cost-effective Than the Treatment of Pathologic Fractures in Metastatic Bone Disease?