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.
Introduction
Metastatic bone disease is associated with substantial disability, pain, and expense. Current estimates suggest that there are more than 250,000 patients with metastatic bone disease in the United States (US), representing an annual cost of USD 12 billion [11, 13]. Advances in surgical and medical treatment have facilitated longer cancer survival rates after diagnosis and subsequent higher incidence of metastatic bone disease [1]. With increasing rates of metastatic bone disease, the economic burden of this group is expected to increase as well. Many lesions grow large enough to compromise the structural integrity of the bone and result in fracture unless addressed surgically. The goal of prophylactic surgical stabilization is to prevent fracture, limit disability, and decrease the duration of hospitalization. The determination of which patients would benefit from elective prophylactic intervention is subjective and difficult, as it is based on estimations of patients’ anticipated longevity, their postoperative convalescence, and the likelihood of fracture. The utility of prophylactic intervention increases with patients’ fracture risk and anticipated longevity.
The criteria of Mirels [19] and Harrington [12] are commonly used to determine which pathologic lesions are at the greatest risk for fracture and may benefit from prophylactic fixation. With the use of this risk-stratification tool, surgeons are able to determine accurately which pathologic lesions are prone to fracture and based on that, surgeons can decide which lesions to treat prophylactically with surgery. Prior retrospective studies have suggested many benefits of prophylactic surgical treatment of impending fractures compared with treatment of realized pathologic fractures, including less blood loss, less operative morbidity, and an improved likelihood of early mobilization [6, 20]. Although the clinical benefits of prophylactic stabilization have been well established, no studies to our knowledge, have provided a cost analysis comparing costs of this treatment option with the costs of providing care to patients after pathologic fractures have occurred. With the current healthcare focus on cost and value of treatments, physicians should be aware of relative costs of their treatment options [4, 5, 8, 9, 14, 15, 17].
We therefore 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?
Patients and Methods
We performed an institutional review board-approved, retrospective study of patients treated by our orthopaedic oncology division during a 3-year period. Forty-six patients were treated surgically for metastatic lesions of long bones. Of those, 40 were included in this study. Twenty-one (53%) presented with pathologic fractures; the other 19 patients (48%) underwent surgery for impending fractures, defined as a symptomatic lesion observed on plain radiographs or advanced imaging but no visible fracture. Surgical intervention included internal fixation or arthroplasty, as deemed appropriate by the treating surgeon (Fig. 1). A majority of all lesions treated by one surgeon (TBR), were considered to have a Mirels’ score greater than 8. Long bone lesions received intramedullary nail fixation and metaphyseal and epiphyseal lesions received a combination of wide resection and arthroplasty or curettage and locked plating fixation if the articular surface could be salvaged. Exclusion criteria were nonoperative treatment, diagnosis other than musculoskeletal tumor, and missing cost data. Each patient record was evaluated retrospectively by the lead author (ATB) and the medical center financial office, not the treating surgeon, for total cost per episode of care, our primary outcome. Secondary outcomes included hospital length of stay and discharge disposition. We also recorded the direct cost (total cost minus indirect costs of hospitalization), demographic information, pathology, comorbidities, surgical procedure, and implants used.
Fig. 1A–B.
AP radiographs of the humerus show (A) a pathologic humeral lesion secondary to lymphoma, and (B) a pathologic fracture, which occurred shortly after the initial radiograph. The patient subsequently was treated with surgical fixation after the fracture occurred.
Of the 40 patients reviewed, there were 28 women (70%) and 12 men (30%) with a mean age of 58 years. Twenty-eight of 40 patients (70%) were identified as white, seven (18%) as black, three (7%) as Latino, and two (5%) as Asian. Twenty-one patients (52%) were treated with operative fixation for a pathologic fracture, whereas 19(48%) were treated prophylactically for a pathologic lesion and did not sustain fracture. The mean age of the patients with pathologic fractures was 59 years (SD, 18 years). This group included five men and 16 women, and eight upper extremities and 13 lower extremities. The average age of patients with prophylactic fixation was 57 years (SD, 8 years). This included seven men and 12 women, and two upper extremities and 17 lower extremities. The most common underlying diagnosis of the pathologic lesions evaluated was metastatic carcinoma in 24 patients followed by multiple myeloma in six patients. There were no differences between the two study groups with respect to sex, age, race, or diagnosis (Table 1). When only lower extremity tumors were analyzed, there were 14 patients with a pathologic fracture and 19 without a fracture.
Table 1.
Comparison of demographic variables by presence of pathologic fracture
| Variable | Pathologic fracture | No fracture | p value |
|---|---|---|---|
| Sex | |||
| Male | 5 (24%) | 7 (37%) | 0.49 |
| Female | 16 (76%) | 12 (63%) | |
| Age (years) | 58.7 ± 18.3 | 56.7 ± 8.2 | 0.675 |
| Extremity | |||
| Upper | 8 (38%) | 2 (11%) | 0.069 |
| Lower | 13 (62%) | 17 (89%) | |
| Race | |||
| White | 15 (71%) | 13 (68%) | 0.23 |
| Black | 5 (24%) | 2 (11%) | |
| Latino | 0 (0%) | 3 (16%) | |
| Asian | 1 (5%) | 1 (5%) | |
| Diagnosis | |||
| Metastatic carcinoma | 11 (52%) | 13 (69%) | 0.35 |
| Multiple myeloma | 3 (14%) | 3 (16%) | |
| Lymphoma | 2 (9%) | 0 (0%) | |
| Nonossifying fibroma | 1 (5%) | 1 (5%) | |
| Enchondroma | 0 (0%) | 1 (5%) | |
| Fibrous dysplasia | 1 (5%) | 0 (0%) | |
| Metastatic melanoma | 1 (5%) | 0 (0%) | |
| Neurofibroma | 0 (0%) | 1 (5%) | |
| Chondrosarcoma | 1 (5%) | 0 (0%) | |
| Pleomorphic sarcoma | 1 (5%) | 0 (0%) | |
Evaluation of direct and indirect healthcare costs per episode of care has been used in some cost analyses [9, 24]. Direct costs per episode of care include costs of labor, medical supplies, and surgical implants. Indirect costs include secondary but necessary costs of a functional hospital such as administrative and social services and utility costs. Because of contractual restrictions between our institution and implant manufacturers, actual dollar values for each case could not be disclosed in this study. Only ratios and absolute cost differences can be presented. To provide meaningful data, all dollar values in the data set were divided by the same undisclosed number to create a new, representative value termed “cost units” (CU), which could be used for statistical testing (Fig. 2). Use of these units still allows one to accurately compare the ratio of cost savings between the study groups. This is a useful statistic, as absolute costs will vary among hospitals, but a ratio of costs is more likely to be consistent among institutions.
Fig. 2.
Our cost unit calculation method is shown. USD 2500 is not the actual number used to calculate values used in our data set; it is used here only as an example.
Variables of interest, as indicated previously, are total cost of care per episode, direct cost of care per episode, indirect cost of care per episode, length of admission, and discharge disposition.
Statistical Analysis
Demographic data were collected and differences were analyzed using standard descriptive statistics. All means are reported with SD (noted as “±”). Independent-samples t-tests were used to compare means. Proportions were compared using chi square or Fisher’s exact tests as appropriate. Statistical significance was defined as p less than 0.05, and 95% CI.
Results
Cost Comparisons
Total cost was lower in patients treated prophylactically for impending fracture than it was for patients who underwent surgery to treat pathologic fractures (Table 2). Mean total cost per episode of care was higher in patients with pathologic fractures (CU, 642 ± 519) compared with the group treated prophylactically without fractures (CU, 370 ± 171; mean difference, 272; 95% CI, 19–525; p = 0.036). This represents a 42% reduction in cost. This translates to an average of nearly USD 21,000 less for prophylactic surgery. The mean direct costs were 41% higher (nearly USD 12,000) when comparing both groups (CU, 382 ± 300 versus 227 ± 93; mean difference, 155; 95% CI, 9–300; p = 0.038). There was no difference in mean implant cost when comparing the patients with pathologic fractures with the patients treated prophylactically (CU, 47 ± 25 versus 54 ± 26; mean difference, −7; 95% CI, −23 to 9; p = 0.38).
Table 2.
Analysis of patients with lower extremity disorders
| Variable | Pathologic fracture | No fracture | p value |
|---|---|---|---|
| Implant cost | 55 ± 27 CU | 52 ± 24 CU | 0.72 |
| Direct cost | 374 ± 272 CU | 237 ± 92 CU | 0.06 |
| Total cost | 634 ± 477 CU | 390 ± 169 CU | 0.059 |
| Length of stay | 7 ± 6 days | 4 ± 3 days | 0.053 |
| Disposition | |||
| Home | 8 (62%) | 14 (82%) | 0.2 |
| Rehabilitation facility | 4 (31%) | 2 (12%) | |
| Hospice | 1 (8%) | 1 (6%) | |
CU = cost unit.
When analyzing lower extremity cases only, mean direct and total costs did not differ in patients with pathologic fractures compared with those treated prophylactically (Table 3). The mean total cost per episode of care in the group of patients with lower extremity pathologic fractures was 634 ± 477 CU compared with 390 ± 169 CU in those treated prophylactically (mean difference, 244; 95% CI, −10 to 499; p = 0.059). The mean direct costs were 374 ± 272 CU and 237 ± 92 CU in the pathologic fracture and prophylactic surgery groups, respectively (mean difference, 138; 95% CI, −6 to 282; p = 0.06). The mean implant cost was 55 ± 27 CU for patients with a fracture and 52 ± 24 CU for those treated prophylactically (mean difference, 3; 95% CI, −16 to 23; p = 0.72).
Table 3.
Comparison of variables by presence of pathologic fracture
| Variable | Pathologic fracture | No fracture | p value |
|---|---|---|---|
| Implant cost | 47 ± 25 CU | 54 ± 26 CU | 0.38 |
| Direct cost | 382 ± 300 CU | 227 ± 93 CU | 0.038 |
| Total cost | 642 ± 519 CU | 370 ± 171 CU | 0.036 |
| Length of stay | 7 ± 6 days | 4 ± 3 days | 0.053 |
| Disposition | |||
| Home | 12 (57%) | 16 (84%) | 0.063 |
| Rehabilitation facility | 8 (38%) | 2 (11%) | |
| Hospice | 1 (5%) | 1 (5%) | |
CU = cost unit.
Length of Stay and Disposition
Prophylactic surgery for impending pathologic fracture was predictive of shorter hospital stay (Table 2). The average hospital 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 days; 95% CI, 1–7 days; p = 0.01). Sixteen of 19 (84%) patients treated prophylactically were discharged home, as opposed to rehabilitation facilities, compared with 12 of 21 (57%) treated for fractures (odds ratio [OR], 4; 95% CI, 0.89–18.03; p = 0.063).
The mean duration of hospitalization was 7 ± 6 days in patients with lower extremity pathologic fractures and 4 ± 3 days in those with lower extremity lesions without a fracture (mean difference, 3 days; 95% CI, 0.9–7 days; p = 0.053) (Table 3). Fourteen of 17 (82%) patients with impending lower extremity fractures were discharged home compared with eight of 13 (62%) of those treated for pathologic lower extremity fracture (OR, 2.92; 95% CI, 0.55–15.56; p = 0.20).
Discussion
Metastatic bone disease effects more than a quarter of a million patients in the US. This diagnosis can be physically painful and emotionally stressful for the patient. Metastatic bone disease also represents a substantial economic burden to the healthcare system [13, 20]. The role of prophylactic stabilization for impending pathologic fractures has been well established to spare patients the pain, trauma, and stress of sustaining a long bone fracture (Fig. 3) [2, 10]. Prior retrospective studies have suggested additional benefits to prophylactic stabilization include decreased intraoperative blood loss, postoperative morbidity, and rapid postoperative mobilization [2, 10, 18]. Despite the substantial cost of care for patients with metastatic bone disease—USD 12 billion annually in the US—an economic analysis of potential treatment options is lacking in the current literature. We sought to address this deficiency and add to increasing knowledge by comparing prophylactic stabilization of impending pathologic lesions with the operative treatment of realized pathologic fractures.
Fig. 3A–D.
The (A) AP and (B) lateral proximal femoral radiographs show a pathologic femoral lesion secondary to multiple myeloma. The (C) AP and (D) lateral femur radiographs show prophylactic surgical stabilization for the impending pathologic fracture.
This study has several limitations. First, there was the heterogeneity of the disorders treated. Although the overall patient demographics appeared similar between the two groups, the sample size is too small to properly compare patients with the same diagnoses and number of metastatic lesions. However, in the setting of similar demographic data we believe that the groups are comparable for the purposes of our study. Another limitation is surgeon selection bias. All patients were treated by one surgeon (TBR) who generally believes that lytic, peritrochanteric lesions in symptomatic patients should be treated prophylactically. There always are extenuating circumstances in some patients, which can change operative decision making. Only having one surgeon creates a degree of operative selection bias. Another limitation is we did not evaluate data by specific fracture type. It is possible that some fracture types may create more or less expensive hospital admissions and implant costs which could have driven statistical findings. Another limitation is that we were unable to obtain imaging before fractures to accurately classify the pathologic lesions and properly match against similar prophylactic fixation cases. A matched assessment would provide the most accurate calculation of cost evaluation, however such a study is impractical (or impossible) to do for obvious reasons. It also is worth noting that Mirels’ [19] and Harrington’s [12] systems have not been validated formally, as far as we know; however, they are commonly used. Future studies should validate them. A final limitation of the study is the inability to disclose actual cost data for patient admissions. However, because all medical centers have very different reported costs for similar hospital admissions and procedures, we believe that providing a cost ratio is more useful for the interpretation of outside institutions.
Mean direct and total costs were higher in patients treated for pathologic fractures compared with those treated prophylactically for skeletal lesions (Table 2). We believe this is because patients sustaining the physical trauma of a fracture have more extensive hospital courses, possible concomitant injuries, and more difficult postoperative rehabilitation. Patients who sustain a fracture experience pain, anxiety, and the physiologic stress associated with long bone injury. We also believe that performing surgery semielectively for prophylactic purposes may provide less inherent risk for complications than operating on a fracture and performing unplanned surgery urgently, which was reported in one fracture study [3]. Steensma et al. [21, 22] reported that patients sustaining a pathologic fracture treated with arthroplasty had fewer treatment failures and revision surgeries than those treated with internal fixation. Because of improved outcomes with arthroplasty in pathologic fractures, trends are shifting toward treating more patients with pathologic fractures with joint replacements (Fig. 4) [22]. However, the nature of this more complex procedure may lead to more complications, worse outcomes, and increased cost.
Fig. 4A–D.
(A) AP and (B) lateral hip radiographs show a pathologic femoral neck fracture. (C) AP and (D) lateral radiographs show a press-fit hemiarthroplasty for treatment of the pathologic fracture.
We also noted that mean hospital length of stay was longer in patients with pathologic fractures compared with patients with prophylactic treatment. If the subsequent cost of rehabilitation facilities and nursing homes would have been available and factored into the cost analysis, this patient group would likely have an even-larger cost difference compared with the prophylactic fixation group. Deutsch et al. [7] found that Medicare payments for inpatient rehabilitation averaged USD 10,671 per admission for patients treated for hip fractures. Skilled nursing facilities can range from USD 200 to USD 600 per day [16]. In some cases, the cost of discharge to a care facility may nearly double the healthcare system total cost for a patient. As previously discussed, we believe that the traumatic event of a fracture in these patients has a negative effect on speed of recovery; therefore, more often patients with pathologic fractures require alternative care facilities postoperatively to regain functional independence.
Prophylactic fixation of long bones can provide many benefits to the patient with metastatic bone disease. McLaughlin [18] reported that intramedullary treatment of pathologic fractures could facilitate earlier ambulation, decreased pain, and possibly less cost to the hospital compared with nonoperative treatment of pathologic fractures. Gitelis et al. [10] reported that prophylactic surgery for impending fractures resulted in decreased mortality, less failure of fixation, and a greater percentage of early postoperative ambulators compared with surgical treatment for pathologic fractures. Arvinius et al. [2] documented that patients who had early prophylactic intramedullary nailing for femoral metastatic bone disease had lower rates of immediate postoperative death, higher postoperative ambulatory status, longer mean survival, shorter hospital stay, and lower transfusion rates compared with patients treated for pathologic fractures. We believe that patients with pathologic fractures are a population with limited physiologic reserve who may be able to tolerate prophylactic stabilization but may not tolerate the double stressor of sustaining fracture plus surgery with the same results. Sullivan et al. [23] found that patients with oncologic diseases who were treated with chemotherapy had higher postoperative rates of complications and mortality compared with a group not treated with chemotherapy.
Metastatic bone disease and pathologic fractures are physically and emotionally traumatic to patients. Metastatic disease also generates substantial costs. Our study is the first, of which we are aware, to show lower cost and shorter hospital length of stay in patients treated for impending fractures compared with those treated with pathologic fractures. Future studies may aim to determine which lesions and in which patients prophylactic fixation will provide the most cost-effective care.
Footnotes
All authors or any member of their immediate families, have no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
This work was performed at NYU Hospital for Joint Diseases, New York, NY, USA.
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