Sources of Postacute Care Episode Payment Variation After Traumatic Hip Fracture Repair Among Medicare Beneficiaries: Cross-Sectional Retrospective Study

John R Montgomery; Pooja U Neiman; Craig S Brown; Anne H Cain-Nielsen; John W Scott; Naveen F Sangji; Bryant W Oliphant; Mark R Hemmila

doi:10.1097/AS9.0000000000000218

Sources of Postacute Care Episode Payment Variation After Traumatic Hip Fracture Repair Among Medicare Beneficiaries: Cross-Sectional Retrospective Study

Ann Surg Open. 2022 Nov 7;3(4):e218. doi: 10.1097/AS9.0000000000000218. eCollection 2022 Dec.

Authors

John R Montgomery¹, Pooja U Neiman^{1

2

3}, Craig S Brown¹, Anne H Cain-Nielsen¹, John W Scott¹, Naveen F Sangji¹, Bryant W Oliphant^{1

4}, Mark R Hemmila¹

Affiliations

¹ From the Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
² National Clinician Scholars Program, University of Michigan, Ann Arbor, MI.
³ Department of Surgery, Brigham and Women's Hospital, Boston, MA.
⁴ Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI.

Abstract

The objective of this study was to evaluate how much variation in postacute care (PAC) spending after traumatic hip fracture exists between hospitals, and to what degree this variation is explained by patient factors, hospital factors, PAC setting, and PAC intensity.

Background: Traumatic hip fracture is a common and costly event. This is particularly relevant given our aging population and that a substantial proportion of these patients are discharged to PAC settings.

Methods: It is a cross-sectional retrospective study. In a retrospective review using Medicare claims data between 2014 and 2019, we identified PAC payments within 90 days of hospitalization discharges and grouped hospitals into quintiles of PAC spending. The degree of variation present in PAC spending across hospital quintiles was evaluated after accounting for patient case-mix factors and hospital characteristics using multivariable regression models, adjusting for PAC setting choice by fixing the proportion of PAC discharge disposition across hospital quintiles, and adjusting for PAC intensity by fixing the amount of PAC spending across hospital quintiles. The study pool included 125,745 Medicare beneficiaries who underwent operative management for traumatic hip fracture in 2078 hospitals. The primary outcome was PAC spending within 90 days of discharge following hospitalization for traumatic hip fracture.

Results: Mean PAC spending varied widely between top versus bottom spending hospital quintiles ($31,831 vs $17,681). After price standardization, the difference between top versus bottom spending hospital quintiles was $8,964. Variation between hospitals decreased substantially after adjustment for PAC setting ($25,392 vs $21,274) or for PAC intensity ($25,082 vs $21,292) with little variation explained by patient or hospital factors.

Conclusions: There was significant variation in PAC payments after a traumatic hip fracture between the highest- and lowest-spending hospital quintiles. Most of this variation was explained by choice of PAC discharge setting and intensity of PAC spending, not patient or hospital characteristics. These findings suggest potential systems-level inefficiencies that can be targeted for intervention to improve the appropriateness and value of healthcare spending.

Keywords: geriatric trauma; hip fracture repair; payment variation.