Bundled Payments for Hip Fracture Surgery Are Associated With Improved Access, Quality, and Health Care Utilization, but Higher Costs for Complex Cases: An Interrupted Time Series Analysis.

OBJECTIVES: To study the impact of bundled payments for surgically managed hip fractures on care access, care quality, health care resource utilization, clinical impact, and acute care cost. DESIGN: An observational retrospective cohort study using a quasi-experimental design comparing prebundled and postbundled payments through an interrupted time series analysis. SETTING: A public acute care general hospital. PATIENTS: Patients 60 years and older, with surgery for an isolated, unilateral, nonpathological hip fracture during 2014-first quarter of 2019 [diagnosis-related group codes: I03A, I03B, I08A, and I08B] and transferred to specific rehabilitation institutions were studied. INTERVENTION: Bundled payments for funder-to-provider reimbursement. MAIN OUTCOMES MEASUREMENTS: Care access, care quality, health care resource utilization, clinical impact, and cost. RESULTS: Of 1477 patients, 811 were assigned to prebundled and 666 to postbundled payments. Although there was an improving trend of ward admission waiting times during postbundled payments [odds ratio (OR) = 1.14; 95% confidence interval (CI): 1.02-1.28], ward admission waiting times were longer when compared with prebundled payments (OR = 0.45; 95% CI: 0.23-0.85). Rates of 30-day all-cause readmissions were lower (OR = 0.08; 95% CI: 0.01-0.67), and trends of reducing inpatient rehabilitation and overall episode length of stay (OR = 1.26; 95% CI: 1.16-1.37 and OR = 1.17; 95% CI: 1.07-1.28, respectively) were demonstrated during postbundled payments. Acute care cost for complex cases were higher (OR = 0.49; 95% CI: 0.26-0.92) during bundled payments, compared with prebundled payments. CONCLUSIONS: Bundled payments for surgically managed hip fractures were associated with benefits for several outcomes pertinent to clinical improvement initiatives. More work, especially concerning cost-effective surgical implants and better care cost computations, are critically needed to contain the growth of acute medical care cost for these patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An evaluation of the Herscovici classification for fractures of the medial malleolus.

BACKGROUND: Despite its use in the literature, the application of the Herscovici classification system for medial malleolus fractures has not been evaluated. METHODS: We aimed to determine the reliability and accuracy of the Herscovici classification. The blinded radiographs of 130 patients were independently classified by four orthopaedic trauma surgeons. We held a consensus meeting where observers agreed on a final classification and this served as our reference standard. We used weighted kappa (κ) coefficients of agreement. RESULTS: Twenty-four fractures (18%) were deemed unclassifiable. The classification system demonstrated moderate inter-observer reliability (κ=0.54, 95% CI 0.40-0.68) but substantial reproducibility (κ=0.64, 95% CI 0.51-0.79). Accuracy, when compared with the reference standard, was κ=0.54 (95% CI 0.40-0.66). CONCLUSIONS: The obliquity of the fracture line, and fracture extension, created difficulty in classification in 26% of cases. 18% of our cases could not be classified by majority decision. Our results emphasise the challenges faced in classifying these fractures. Future work should focus on refining the Herscovici classification.