The issue of rising costs will likely dominate the healthcare debate in the forthcoming years. Limited resources may necessitate cost-cutting measures. Proximal humeral fractures account for 10% of all fractures in the elderly. We therefore assessed factors associated with lower hospital costs and variations in surgical treatment for proximal humeral fractures.
The limitations of our study include nonavailability of data for patients who did not undergo surgery because the NIS includes only inpatient admissions. The databases also do not provide information regarding degree of displacement or fracture classifications. Long-term functional outcomes such as pain and ROM also are not available in the NIS. We also do not have information for patients who were managed nonoperatively.
We found there was a linear association between reduced hospital costs and higher shoulder arthroplasty volume of the surgeon for treatment of proximal humeral fractures. We also found there was variation in practice patterns for surgical treatment of proximal humeral fractures. High-volume surgeons and hospitals were more likely to perform hemiarthroplasty as compared with ORIF, after adjusting for potential confounders. Contrary to expectation, the odds of a patient undergoing hemiarthroplasty were reduced during our study period from 2001 to 2008. The length of stay for patients operated on by high-volume surgeons was approximately 40% shorter than for patients operated on by low-volume surgeons.
As is evident from the current healthcare debate, issues relating to cost will be critical. This especially will be the case for costs associated with surgical procedures. Cost-cutting measures may not only aim at eliminating procedures and treatments that are not supported by outcome data but also at assessing factors that contribute to increased costs. Several studies have reported on the association of higher surgical volume with better outcomes [11, 17, 22, 24-28]. However, to our knowledge, no prior study has assessed the association between surgical volume and hospital costs for orthopaedic procedures. Auerbach et al.  reported lowest-volume hospitals had 19.8% higher costs and low surgeon volume was associated with 3.1% higher costs for coronary artery bypass grafting. Gourin et al.  also reported a negative correlation between hospital volume and hospital costs for laryngeal cancer surgery. However, for complex cancer surgery, Auerbach et al.  reported there were no consistent associations between higher hospital or surgeon volume and mortality, readmission, length of stay, or costs. Studies in the orthopaedic literature also have reported on the association of provider volume and hospital charges [17, 26, 28]. However, hospital charges are often an overestimation and offer little insight into the true costs or reimbursement associated with a procedure. Our results provide evidence that surgeons with high volumes of shoulder arthroplasties per year are associated with lower hospital costs. As an example, on average, adjusting for all other factors, a surgeon performing 20 shoulder arthroplasties per year saves a hospital approximately US $1800 in costs per surgery performed for proximal humeral fractures. This saving amounts to approximately 15% of the cost of an ORIF and 13% of the cost of a hemiarthroplasty. This is substantial from a hospital perspective given a flat rate of reimbursement provided for by Diagnostic Related Groups. Our finding is of critical importance to hospital leaderships and administrators as it may help to guide policies requiring a minimum procedure volume criterion during the hospital credentialing of surgeons.
The treatment of proximal humeral fractures has been debated by experts in several reports [18, 32, 36]. Studies in this area have provided little guidance owing to small sample sizes, lack of comparison groups, and bias in subject selection and study execution [15, 33, 37, 41, 46]. Petit et al.  provided evidence for poor agreement between shoulder and trauma surgeons regarding treatment of proximal humeral fractures. A Cochrane Review in 2010 concluded there was insufficient evidence to inform management of proximal humeral fractures, and it was unclear whether surgery provided better long-term outcomes . Moreover, in the future it is likely that patients with proximal humeral fractures will be older with more comorbidities. Thus, optimal treatment in such patients, including nonoperative management, needs further investigation. Many shoulder surgeons use Neer’s classification of two- versus three- versus four-part fractures for classifying proximal humeral fractures [30, 31]. However, there is no evidence that this classification informs surgical decision making. Moreover, several studies have reported poor agreement among surgeons for the Neer classification [10, 39, 40].
Our data show there is considerable variation in the surgical treatment of proximal humeral fractures by surgeon and hospital volume. Moreover, time trends show patients were more likely to undergo ORIF as compared with hemiarthroplasty in the later parts of our study. It is possible the increase in ORIF was attributable to the increased use of locking plates during the later years of the study . However, this information is not available from our data sets. Although, total shoulder arthroplasty is not performed routinely for proximal humeral fractures, 2.6% of patients in our study underwent total shoulder arthroplasties. These patients likely had a chronic fracture or had failure of the hemiarthroplasty. It also is possible that these patients underwent reverse shoulder arthroplasty. Bell et al.  reported substantial regional variation in surgical versus nonsurgical treatment of proximal humeral fractures. They did not report on the variation in use of hemiarthroplasty versus ORIF. We did not find regional variations in the use of hemiarthroplasty versus ORIF likely because we studied broad regions in the United States (Northeast, Midwest, South, and West).
To our knowledge, this is the first study to report on the association of higher surgeon volume and lower hospital costs in the area of musculoskeletal care. Because our findings can result in substantial savings, hospital leaderships and administrators should consider framing policies on minimum volume requirements for orthopaedic procedures if our findings are confirmed in future studies. Our study also provides evidence for provider-driven practice variations in the surgical treatment of proximal humeral fractures. This is likely because of the absence of evidence-based treatment guidelines. In the future, reimbursement for orthopaedic procedures will likely be driven by data on comparative effectiveness and will not be based on individual provider practices. Therefore, it is essential for clinicians providing musculoskeletal care to offer evidence for their practices in addition to focusing on improvisation of surgical and nonsurgical techniques.
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