costs of fragility hip fractures globally: a systematic ...10.1007/s00198-017-4153... · costs of...
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1
Costs of fragility hip fractures globally:
a systematic review and meta-regression analysis
Online Appendices
Appendix 1 – Search terms used in databases ....................................................................................... 2
Appendix 2 – Data extraction proforma ................................................................................................. 5
Appendix 3 – Quality checklist ................................................................................................................ 7
Appendix 4 – Table of included Studies .................................................................................................. 8
Appendix 5 – Supplementary Tables and Figures ................................................................................. 23
2
Appendix 1 – Search terms used in databases
Table A.1.1 – Search strategy for identifying relevant studies in Embase
Embase Searches
1 exp healthcare cost/
2 exp costs/
3 exp economics/
4 exp hip fracture/
5 exp femur neck fracture/
6 exp femur intertrochanteric fracture/
7 exp femur pertrochanteric fracture/
8 exp femur subtrochanteric fracture/
9 exp femur trochanteric fracture/
10 exp fragility fracture/
11 fracture/
12 osteoporo*.mp.
13 11 and 12
14 ("neck of femur" adj2 fracture*).mp.
15 ("femoral neck" adj2 fracture*).mp.
16 ((fracture* adj2 fragility) and (hip* or femur* or femor*)).mp.
17 1 or 2 or 3
18 4 or 5 or 6 or 7 or 8 or 9 or 10 or 13 or 14 or 15 or 16
19 17 and 18
20 limit 19 to yr="1990 -Current"
Table A.1.2 – Search strategy for identifying relevant studies in Medline
Medline Searches
1 exp economics/
2 cost*.mp.
3 osteoporo*.mp.
4 exp fracture bone/
5 3 and 4
6 exp osteoporotic fractures/
7 exp hip fracture/
8 ("neck of femur" adj2 fracture*).mp.
9 ("femoral neck" adj2 fracture*).mp.
10 (fracture* adj2 fragility).mp.
11 hip Fractures/ec [Economics]
12 1 or 2
13 5 or 6 or 7 or 8 or 9 or 10
14 12 and 13
15 11 or 14
16 exp animals/ not humans.sh.
17 15 not 16
18 limit 17 to yr="1990 -Current"
3
Table A.1.3 – Search strategy for identifying relevant studies in Global health
Global
health Searches
1 fracture* neck of femur.mp.
2 fracture/ or fracture*.mp.
3 osteoporo*.mp.
4 2 and 3
5 (bone fracture* and hips).sh.
6 hip fracture*.mp.
7 fragility fracture*.mp.
8 ("neck of femur" adj2 fracture*).mp.
9 ("femoral neck" adj2 fracture*).mp.
10 (fracture* adj2 fragility).mp.
11 exp costs/
12 exp economics/
13 cost*.mp.
14 1 or 4 or 5 or 6 or 7 or 8 or 9 or 10
15 11 or 12 or 13
16 14 and 15
17 limit 16 to yr="1990 -Current"
Table A.1.4 – Search strategy for identifying relevant studies in CAB abstracts
CAB
abstracts Searches
1 fracture* neck of femur.mp.
2 fracture/ or fracture*.mp.
3 (bone fracture* and hips).sh.
4 hip fracture*.mp.
5 fragility fracture*.mp.
6 osteoporo*.mp.
7 2 and 6
8 ("neck of femur" adj2 fracture*).mp.
9 ("femoral neck" adj2 fracture*).mp.
10 (fracture* adj2 fragility).mp.
11 exp costs/
12 exp economics/
13 cost*.mp.
14 1 or 3 or 4 or 5 or 7 or 8 or 9 or 10
15 11 or 12 or 13
16 14 and 15
17 limit 16 to yr="1990 -Current"
4
Table A.1.5 – Search strategy for identifying relevant studies in Econlit
Econlit Searches
1 ((fracture* neck of femur) OR (fracture* hip) OR (fragility fracture*) OR
(osteoporo* fracture*) OR (fracture* adj2 "neck of femur") OR ("femoral
neck" adj2 fracture*) OR (fracture* adj2 fragility))
2 (cost* OR (healthcare cost*) OR economic*)
3 1 and 2
Table A.1.6 – Search strategy for identifying relevant studies in NHS EED & HTA
NHS EED &
HTA Searches
1 (hip adj2 fracture*) IN NHSEED, HTA
2 (osteoporo* adj2 fracture*) IN NHSEED, HTA
3 (fragility adj2 fracture*) IN NHSEED, HTA
4 (fracture* adj2 neck of femur) IN NHSEED, HTA
5 #1 OR #2 OR #3 OR #4
Table A.1.7 – Search strategy for identifying relevant studies in Web of science
Web of science
(Databases=SCI-
EXPANDED,
SSCI, CPCI-S,
CPCI-SSH) Searches
1 Topic=(cost*)
2 Topic=(economic*)
3 Topic=((osteoporo* NEAR/2 fracture*))
4 Topic=((fracture* NEAR/2 hip))
5 Topic=(("fracture*" NEAR/2 "neck of femur"))
6 Topic=((fragility NEAR/2 fracture*))
7 #2 OR #1
8 #6 OR #5 OR #4 OR #3
9 #8 AND #7
10 Filter = years 1990 to current
5
Appendix 2 – Data extraction proforma
1. Authors and publication date: …………………………………………………………………………………………
2. Country and region: ………………………………………………………………………………………………………
3. Study design:
Randomised control trial Prospective observational study
Cross-sectional study Retrospective observational study
4. Costing methodology:
National Reference costs Own costs (finance department)
Combination of national reference and own costs
5. Economic perspective of analysis:
Societal Healthcare system
Healthcare provider Third party payer
6. Currency: ……………………………………………………………………………………………………………………
7. Exchange rate used if not local currency: …………………………………………………………………
8. Year of costing: ……………………………………………………………………………………………………………………
9. Discount rate used: …………………………………………… Not used N/A
10. Sample size: ……………………………………………………………………………………………………………………
11. Proportion of the sample that are female: …………………………………………………………………
12. Mean age of sample: ………………………………………………………………………………………………………
13. Follow-up period of analysis: …………………………………………………………………………………………
14. Length of stay of index hospitalisation episode: …………………………………………………………………
6
15. Categories of care included:
Healthcare
Inpatient Index hospitalisation
Other inpatient
Rehabilitation Index rehabilitation
Other rehabilitation
Index “Superspell“
Community healthcare
Medication
Outpatient
Total Healthcare
Social care
Social care in the patient’s home
Social care – residential/care home
Home modification/medical equipment
Total Social Care
Total Health and Social Care
Productivity loss and informal care
Out of Pocket Expense
Income foregone by patient
Income foregone by caregiver
Total Productivity loss and informal care
Other
Total
16. Results:
Reported Cost CI/SD/SE Category of care Subgroup
1.
2.
3.
4.
n.
7
Appendix 3 – Quality checklist
CHECKLIST Yes No N/A
Study Design
1. The research question is stated
2. Economic perspective of the study is clearly stated and
justified
Data collection
3. Details of the subjects is provided
4. Indirect costs reported separately
5. Methods for estimation of unit costs and quantities is
adequately described
6. Currency and price data are reported
7. Details of adjustments for inflation or currency conversion
are reported
Analysis and interpretation of results
8. Time horizon of the study is reported
9. Discount rate is stated
10. Details of statistical tests and confidence intervals reported
11. Sensitivity analysis is performed
12. The study question is answered
13. Conclusions follow on for the data
14. Conclusions are accompanied by caveats
Questions 4, 7 and 9 were not applicable to all studies, resulting in the maximum achievable score
ranging from 11 to 14. Quality score for each study was calculated by dividing the score by the
maximum score achievable, with equal weighting assigned to each point.
8
Appendix 4 – Table of included Studies
Authors Year Country Study design Economic perspective
Category of costs
included
Subgroup Sample size (hip
fractures)
Summary costs
(2014, US$)
Breakdown of costs by category
CI, SE or SD
provided
Quality Score
Alekna V, et al [1]
2015 LTU Cross-sectional
Societal Medical - 6 10,071 Yes Yes 75%
Althausen PL, et al [2]
2014 USA Retrospective Healthcare provider
Medical Control Intervention
81 88
9,054 6,913
Not Applicable
No 83%
Autier P, et al [3]
2000 BEL Prospective Healthcare system
Medical, Social
- 170 34,218 Yes Yes 73%
Azhar A, et al [4]
2008 IRL Retrospective Healthcare system
Medical - 143 11,124 Not Applicable
No 64%
Bass E, et al [5]
2008 USA Retrospective Societal Medical, Social
- 43,104 86,633 Yes Yes 75%
Beck TS, et al [6]
1996 USA Retrospective Healthcare provider
Medical - 41 23,588 Not Applicable
Yes 58%
Bessette L, et al [7]
2012 CAN Retrospective Healthcare provider
Medical - 4,536 42,624 No Yes 54%
Blouin J, et al [8]
2009 CAN Retrospective Healthcare system
Medical - 155 19,926 Not Applicable
Yes 77%
Blume SW, et al [9]
2011 USA Cross-sectional
Healthcare system
Medical, Social
- 166 50,453 No Yes 55%
Bonafede M, et al [10]
2013 USA Retrospective Societal Medical, productivity
- 11,585 46,542 Yes No 92%
Borgstrom F, et al [11]
2006 SWE Retrospective Societal Medical, social,
productivity
- 278 17,159 Yes Yes 92%
Bouee S, et al [12]
2006 EUR RCT Healthcare payer
Medical France Belgium Italy Spain UK
159 14,165 14,471 13,651 18,015 16,564
No No 100%
Brainsky A, et al [13]
1997 USA Prospective Societal Medical, social,
productivity
- 759 38,626 Yes No 100%
Brenneman SK, et al [14]
2013 USA Retrospective Healthcare payer
Medical Public Private
253 575
27,171 33,058
No Yes 83%
9
Authors Year Country Study design Economic perspective
Category of costs
included
Subgroup Sample size (hip
fractures)
Summary costs
(2014, US$)
Breakdown of costs by category
CI, SE or SD
provided
Quality Score
Brooks JM, et al [15]
2009 USA RCT Healthcare provider
Medical Control Intervention
720 658
9,195 7,481
Not Applicable
No 50%
Bubshait D, et al [16]
2007 SAU Retrospective Healthcare provider
Medical Female Men
20 23
51,823 44,932
Not Applicable
Yes 67%
Cameron ID, et al [17]
1994 AUS RCT Healthcare payer
Medical, social
Control Intervention
125 127
15,695 13,032
Yes Yes 92%
Carey D, et al [18]
2005 IRL Retrospective Healthcare provider
Medical, social
- 841 11,669 Not Applicable
No 50%
Centers for Disease Control Prevention [19]
1996 USA Retrospective Healthcare payer
Medical - 9,343 32,492 No No 50%
Chen L, et al [20]
2007 SGP Prospective Healthcare payer
Medical - 70 14,674 Not Applicable
Yes 75%
Christensen L, et al [21]
2010 USA Retrospective Healthcare payer
Medical Public Private
1,702 1,711
38,804 44,200
Yes Yes 83%
Clancy T, et al [22]
1998 USA Retrospective Healthcare provider
Medical - 153 13,836 Not Applicable
No 42%
Clark P, et al [23]
2008 MEX Cross-sectional
Healthcare provider
Medical, productivity
Public Public Private Private
61 118 20 19
1,991 4,841 7,662
17,009
Yes No 62%
Colla CH, et al [24]
2010 USA Retrospective Healthcare payer
Medical - 38,346 12,392 Yes Yes 67%
Cotter PE, et al [25]
2006 IRL Retrospective Healthcare system
Medical - 5 18,250 Yes No 50%
Cox MA, et al [26]
1993 NZL Retrospective Healthcare provider
Medical Female 65-74 Female 75+ Male
16 94 21
6,326 9,032 6,987
Yes No 50%
Cui Z, et al [27]
2015 USA Retrospective Healthcare payer
Medical Control Complication Complication
29,831 3,948 1,214
21,974 23,655 21,308
Not Applicable
Yes 92%
Dai KR, et al [28]
2007 CHN Retrospective Healthcare provider
Medical, productivity
- 101 6,820 Yes Yes 62%
De Laet CEDH, et al [29]
1999 NLD Prospective Healthcare system
Medical, social
- 44 38,489 Yes Yes 83%
10
Authors Year Country Study design Economic perspective
Category of costs
included
Subgroup Sample size (hip
fractures)
Summary costs
(2014, US$)
Breakdown of costs by category
CI, SE or SD
provided
Quality Score
Della Rocca GJ, et al [30]
2013 USA Prospective Healthcare payer
Medical Control Intervention
31 115
41,281 55,977
Not Applicable
Yes 42%
Duclos A, et al [31]
2010 FRA Retrospective Healthcare provider
Medical - 6,019 24,983 Yes Yes 100%
Edwards C, et al [32]
2008 GBR Retrospective Healthcare provider
Medical Control Complication
80 80
16,033 46,322
Not Applicable
No 67%
Eekman DA, et al [33]
2014 NLD Prospective Societal Medical, social,
productivity
- 4 16,674 Yes Yes 86%
Espino D, et al [34]
2008 USA Retrospective Healthcare payer
Medical Hispanic Black White
2,842 3,623
119,909
20,308 26,372 22,636
Not Applicable
Yes 58%
Farnworth MG, et al [35]
1994 AUS Prospective Healthcare provider
Medical Control Intervention
71 67
13,161 10,984
Yes No 58%
Findorff MJ, et al [36]
2007 USA RCT Healthcare payer
Medical, social
- 4 40,675 No No 33%
French FH, et al [37]
1995 GBR Prospective Healthcare system
Medical Control Complicated
50 10
7,095 8,395
Yes Yes 75%
Frihagen F, et al [38]
2010 NOR RCT Societal Medical, social
Hemiarthroplasty Internal fixation
110 112
47,857 58,479
Yes Yes 100%
Gabriel SE, et al [39]
2002 USA Retrospective Healthcare provider
Medical - 187 16,161 No No 67%
Galbraith JG, et al [40]
2011 IRL Prospective Healthcare provider
Medical - 4 22,541 Not Applicable
No 33%
Garcia AE, et al [41]
2012 USA Retrospective Healthcare provider
Medical - 660 34,279 Not Applicable
No 50%
Gill B, et al [42]
2007 USA Retrospective Healthcare provider
Medical Inter-medullary nail Internal fixation
44 51
33,933 33,001
Not Applicable
Yes 25%
Gutierrez L, et al [43]
2011 GBR Retrospective Healthcare system
Medical, productivity
- 2,427 8,773 Yes Yes 75%
Heinrich S, et al [44]
2011 DEU Retrospective Healthcare payer
Medical, social
- 1,525 10,770 Yes Yes 100%
Hirose J, et al [45]
2008 JPN Retrospective Healthcare provider
Medical Control Complication
650 163
14,049 20,638
Not Applicable
No 50%
11
Authors Year Country Study design Economic perspective
Category of costs
included
Subgroup Sample size (hip
fractures)
Summary costs
(2014, US$)
Breakdown of costs by category
CI, SE or SD
provided
Quality Score
Hollingworth W, et al [46]
1993 GBR Prospective Healthcare provider
Medical Control Intervention
301 779
13,023 11,346
Yes Yes 67%
Hopkins RB, et al [47]
2013 CAN Retrospective Healthcare payer
Medical, social
Female Male
507 244
39,427 38,779
Yes Yes 64%
Iglesias CP, et al [48]
2009 GBR Cross-sectional
Societal Medical, social,
productivity
- 10 27,809 No No 75%
Iorio R, et al [49]
2001 USA Retrospective Healthcare provider
Medical Total hip replacement Total hip replacement Hemiarthroplasty Hemiarthroplasty Internal fixation
5 10 16 31
123
28,928 27,809 29,657 30,270 33,789
Yes No 75%
Ishizaki T, et al [50]
2004 JPN Retrospective Healthcare payer
Medical - 778 14,413 Not Applicable
Yes 75%
Johansson T, et al [51]
2006 SWE RCT Healthcare provider
Medical - 146 16,416 Yes Yes 67%
Kates SL, et al[52] 2010 USA Retrospective Healthcare provider
Medical - 776 9,194 Not Applicable
Yes 67%
Kay HF, et al [53]
2014 USA Retrospective Healthcare provider
Medical Internal fixation Intramedullary nail Mixed
111 92 65
66,768 69,438 64,525
Not Applicable
Yes 58%
Kazi HA, et al [54]
2011 GBR Prospective Healthcare system
Medical - 11 8,780 Not Applicable
No 64%
Khasraghi FA, et al [55]
2003 USA Retrospective Healthcare provider
Medical Control Complication
293 217
13,600 21,427
Not Applicable
Yes 50%
Kilgore ML, et al [56]
2009 USA Retrospective Healthcare payer
Medical, social
- 60,354 34,833 No Yes 75%
Kondo A, et al [57]
2009 JPN Retrospective Healthcare payer
Medical, social,
productivity
- 148 20,689 Yes Yes 69%
Kramer AM, et al [58]
1997 USA Prospective Healthcare payer
Medical, social,
productivity
Control Intervention Intervention
163 101 172
25,246 12,234 17,199
Yes No 67%
Lambrelli D, et al [59]
2014 GBR Retrospective Healthcare system
Medical - 8,028 22,951 Yes Yes 75%
12
Authors Year Country Study design Economic perspective
Category of costs
included
Subgroup Sample size (hip
fractures)
Summary costs
(2014, US$)
Breakdown of costs by category
CI, SE or SD
provided
Quality Score
Lawrence TM, et al [60]
2005 GBR Retrospective Healthcare system
Medical - 100 22,351 Not Applicable
No 75%
Lee YHD, et al [61]
2008 SGP Prospective Healthcare provider
Medical - 62 13,728 Not Applicable
No 73%
Leslie WD, et al [62]
2013 CAN Retrospective Healthcare payer
Medical, social
Female Male
1,957 857
55,185 40,838
No No 100%
Leslie WD, et al [63]
2011 CAN Retrospective Healthcare system
Medical, social
Female Male
3,613 1,604
31,390 27,476
No No 75%
Liu JL, et al [64]
2014 CHN Retrospective Healthcare payer
Medical - 217 8,133 Not Applicable
Yes 58%
Loures FB, et al [65]
2015 BRA Retrospective Healthcare provider
Medical Control Intervention
83 27
3,784 2,440
Not Applicable
Yes 92%
Maravic M, et al [66]
2014 FRA Retrospective Healthcare payer
Medical Female, control Male, control Female, complication Male, complication
51,902 16,689
168 194
8,471 8,735
10,438 11,045
Not Applicable
Yes 73%
Max W, et al [67]
2002 USA Retrospective Societal Medical - 26,699 11,477 Not Applicable
No 58%
McGuire KJ, et al [68]
2011 USA Retrospective Healthcare payer
Medical - 18,908 21,335 No No 58%
Miura LN, et al [69]
2009 USA Prospective Healthcare provider
Medical Control Intervention
72 91
14,609 11,778
Not Applicable
Yes 75%
Nikitovic M, et al [70]
2013 CAN Retrospective Healthcare payer
Medical, social,
productivity
Female Male
22,418 7,611
31,708 33,898
Yes Yes 92%
Nikkel LE, et al [71]
2012 USA Retrospective Healthcare system
32,440 Not included as only presents results as coefficients of multivariate analysis.
67%
Nurmi I, et al [72]
2003 FIN Prospective Healthcare system
Medical, social,
productivity
- 106 18,626 Yes No 83%
Ohsfeldt RL, et al [73]
2006 USA Retrospective Healthcare payer
Medical, social
- 1,125 33,530 No No 67%
Olsson L-E, et al [74]
2009 SWE Prospective Healthcare provider
Medical Control Intervention
53 55
19,286 11,686
Not Applicable
Yes 85%
Orsini LS, et al [75]
2005 USA Retrospective Healthcare payer
Medical - 990 25,434 No No 67%
13
Authors Year Country Study design Economic perspective
Category of costs
included
Subgroup Sample size (hip
fractures)
Summary costs
(2014, US$)
Breakdown of costs by category
CI, SE or SD
provided
Quality Score
Oster G, et al [76]
2004 USA Retrospective Healthcare payer
Medical Control Complication Complication
198 40 59
43,147 76,417 54,210
Yes Yes 75%
Palmer SJ, et al [77]
2000 GBR Prospective Healthcare system
Medical Hemiarthroplasty, control Internal fixation, control Internal fixation, control Hemiarthroplasty, complication Internal fixation, complication Internal fixation, complication
864
634
1,246
44
54
146
10,612
7,559
12,030
24,755
24,809
15,543
No No 83%
Papakonstantinou VV, et al [78]
2008 GRC Prospective Healthcare provider
Medical Internal fixation Hemiarthroplasty
82 91
3,836 7,389
Not Applicable
No 75%
Pike C, et al [79]
2010 USA Retrospective Healthcare payer
Medical Public Private
7,997 255
40,702 21,259
No Yes 92%
Polder JJ, et al [80]
2003 NLD Prospective Societal Medical, social,
productivity
Control Intervention
102 106
25,077 23,349
Yes Yes 100%
Pollard TCB, et al [81]
2006 GBR Retrospective Healthcare system
Medical Control Complication
122 61
12,875 43,589
Not Applicable
No 83%
Qu B, et al [82]
2014 CHN Prospective Societal Medical, social,
productivity
- 437 10,160 Yes Yes 77%
Randell A, et al [83]
1995 AUS Retrospective Healthcare system
Medical, social
Female Male
17 9
22,138 15,018
No No 75%
Reginster JY, et al [84]
1999 BEL Retrospective Healthcare payer
Medical - 2,374 13,639 Not Applicable
Yes 91%
Rogmark C, et al [85]
2003 SWE RCT Healthcare system
Medical, social
Arthroplasty Internal fixation
32 36
20,689 28,896
No No 75%
Roy A, et al [86]
2006 USA Retrospective Healthcare provider
Medical Control Intervention
71 47
16,325 14,062
Not Applicable
Yes 42%
14
Authors Year Country Study design Economic perspective
Category of costs
included
Subgroup Sample size (hip
fractures)
Summary costs
(2014, US$)
Breakdown of costs by category
CI, SE or SD
provided
Quality Score
Saeb M, et al [87]
2014 IRN Prospective Healthcare provider
Medical - 103 3,026 Not Applicable
No 33%
Sahota O, et al [88]
2012 GBR Retrospective Healthcare system
Medical - 100 15,949 Not Applicable
No 80%
Schurch MA, et al [89]
1996 CHE Prospective Healthcare provider
Medical - 404 41,995 No No 67%
Shabat S, et al [90]
2003 ISR Retrospective Healthcare system
Medical - 191 4,417 Not Applicable
No 45%
Shi NW, et al [91]
2009 USA Retrospective Healthcare payer
Medical Public Private
2,423 21,504
44,159 28,933
Yes No 75%
Shields E, et al [92]
2014 USA Prospective Healthcare payer
Medical Internal fixation Hemiarthroplasty
120 491
8,546 10,431
Yes Yes 58%
Sloan FA, et al [93]
1999 USA Retrospective Healthcare payer
Medical, social
- 109 34,490 Yes No 58%
Song X, et al [94]
2011 USA Retrospective Healthcare payer
Medical, social
Public, control Public, complication Private, control Private, complication
29,369 2,837 4,377 375
16,690 37,254 22,726 77,767
No No 92%
Strom O, et al [95]
2008 SWE Prospective Societal Medical, social,
productivity
- 283 20,299 Yes Yes 92%
Stromberg L, et al [96]
1997 SWE Retrospective Healthcare system
medical Control Control Intervention
1,060 1,178
93
27,404 28,836 24,449
No No 75%
Sund R, et al [97]
2011 FIN Retrospective Healthcare system
Medical Hospital A Hospital B
527 731
23,223 24,414
No Yes 50%
Tamulaitiene M, et al [98]
2012 LTU Retrospective Healthcare system
Medical - 441 20,760 No No 78%
Taylor Jr DH, et al [99]
1999 USA Retrospective Healthcare payer
Medical, social
Hospital A Hospital B Hospital C Hospital D Hospital E
66 110 113 117 396
21,407 19,470 25,685 21,893 21,382
Yes No 75%
Thakar C, et al [100]
2010 GBR Prospective Healthcare system
Medical Control Complication
288 144
13,491 29,316
Yes No 83%
15
Authors Year Country Study design Economic perspective
Category of costs
included
Subgroup Sample size (hip
fractures)
Summary costs
(2014, US$)
Breakdown of costs by category
CI, SE or SD
provided
Quality Score
Thakore RV, et al [101]
2014 USA Retrospective Healthcare payer
Medical Complication Complication Complication
58 118 371
11,449 16,305 12,767
Not Applicable
Yes 67%
Tow BPB, et al [102]
2009 SGP Retrospective Healthcare provider
Medical Control Complication
33 33
8,326 8,690
Not Applicable
No 50%
van Balen R, et al [103]
2002 NLD Prospective Healthcare provider
Medical, social
Control Intervention
102 106
25,077 23,349
Yes Yes 75%
Viswanathan H, et al [104]
2012 USA Retrospective Healthcare payer
Medical, social
- 158 28,391 No Yes 92%
Waaler Bjornelv GM, et al [105]
2012 NOR RCT Societal Medical, social,
productivity
Hemiarthroplasty Internal fixation
80 86
53,337 70,886
No Yes 79%
Wiktorowicz ME, et al [106]
2001 CAN Retrospective Societal Medical, social,
productivity
Home dwelling Home to institution Institution to institution
338 61
105
24,402 50,386 38,488
Yes Yes 92%
Wong MK, et al [107]
2002 SGP Retrospective Healthcare system
Medical - 274 10,501 Not Applicable
No 42%
Woolcott JC, et al [108]
2012 CAN Prospective Healthcare provider
medical - 18 34,820 No Yes 75%
Woratanarat P, et al [109]
2005 THA Prospective Healthcare payer
Medical, productivity
- 37 13,429 No No 77%
Wyers CE, et al [110]
2013 NLD RCT Societal Medical, social,
productivity
Control Intervention
79 73
28,744 29,318
Yes Yes 92%
Zethraeus N, et al [111]
1997 SWE Retrospective Healthcare system
Medical, social
- 1,709 38,698 Yes No 82%
Zhao Y, et al [112]
2013 USA Retrospective Healthcare payer
Medical, social
Public, control Public, complication Public, complication Private, control Private, complication Private, complication
22,522 839
2,761 4,574 132 394
30,034 44,547 50,931 41,190 96,060 72,537
No Yes 83%
Zielinski SM, et al [113]
2014 NLD RCT Societal Medical, social
- 248 24,387 Yes Yes 92%
16
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Appendix 5 – Supplementary Tables and Figures
Table A5.1 – Number of included studies (left hand axis, bars) and mean quality of studies (right hand axis, circles with 95% confidence intervals) by year (n=113)
Table A5.2 - Follow-up period of included studies (n=113)
Time horizon Number of studies
Index hospitalisation or “superspell” 48
3 months 2
4 months 3
6 months 9
12 months 38
14 months 1
18 months 1
24 months 8
36 months 2
60 months 1
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
2
4
6
8
10
12
Me
an S
tud
y Q
ual
ity
Nu
mb
er
of
Stu
die
s
Year of Publication
Number of studies Mean study quality
24
Table A5.3 – Distribution of included studies by country and region (n=113)
Country Number of
Studies % a Region Regional total
United States of America 42 37.2% North America
50
Canada 8 7.1%
Great Britain 12 10.6% Western Europe
40
Sweden 7 6.2%
Netherlands 6 5.3%
Ireland 4 3.5%
Belgium 2 1.8%
Finland 2 1.8%
France 2 1.8%
Norway 2 1.8%
Germany 1 0.9%
Greece 1 0.9%
5 European countries (UK, France, Belgium, Italy, Spain)
1 0.9%
Singapore 4 3.5% Asia 11
China 3 2.7%
Japan 3 2.7%
Thailand 1 0.9%
Australia 3 2.7% Australasia 4
New Zealand 1 0.9%
Brazil 1 0.9% Latin America
3
Chile 1 0.9%
Mexico 1 0.9%
Iran 1 0.9% Middle East 3
Israel 1 0.9%
Saudi Arabia 1 0.9%
Lithuania 2 1.8% Eastern Europe
2
a – Values do not sum to 100% due to rounding
25
Figure A5.4 - Categories of care used for assigning costs.
Table A5.5 - Number of reported costs and costs with standard errors for index hospitalisation, index rehabilitation and index “Superspell”.
Category of care Observations Observations
with SD Pooled mean cost ($, 2014)
SE
Index Hospitalisation a 126 64 10,075 894
Index rehabilitation b 32 4 7,496 4,688
Index “Superspell” c 29 5 11,767 571
a – index hospitalisation relates to the initial inpatient episode immediately following hip fracture b – index rehabilitation related to rehabilitation care provided immediately following hip fracture (either in an acute hospital or in a rehabilitation ward) c – Index Superspell is a summary cost combining the cost of index hospitalisation and index rehabilitation.
Total costs
MedicalInpatient
• index hospitalisation
• other inpatient
Rehabilitation
• Index rehab
• other rehabOutpatient Primary care
Medications / Pharmacy
Social care
Social care in the home
Social care -residential /
nursing home
Medical equipment / Home modificationProductivity loss and
informal care
Out of pocket expenses
Income foregone by patient
Income foregone by relative / carer
Other
26
Table A5.6 - Number of reported costs with standard error extracted from studies with a follow up period beyond the index hospital discharge by category of care and follow-up period (n=170).
Category of Care Follow-up (months)
Total 1.5 3 4 6 12 14.3 18 24 36
Inpatient 3 4 13 1 1 5 27
Inpatient (excluding index hospitalisation)
4 1 3 2 10
Rehabilitation 3 3
Outpatient 1 7 1 3 12
Primary care and community health services
1 2 4 1 8
Pharmacy 1 2 7 1 1 12
Total medical care costs 2 11 13
Medical equipment and home modification
1 2 2 1 6
Social care in the patients' homes
1 2 2 4 3 12
Social care in an institutional setting
4 3 1 1 2 1 12
Total social care costs 2 2 4
Other direct costs 1 2 3
Total direct costs (health and social care)
1 4 4 11 1 4 1 26
Out of pocket expenses 1 1
Income foregone by caregiver
1 1 1 3
Income foregone by patient
2 1 3
Total productivity and informal care costs
0
Total costs 2 3 6 1 1 2 15
Total 2 8 21 18 81 4 9 25 2 170
27
Figure A5.7 - Scatter plot of cost of index hospitalisation against mean length of stay comparing
North American studies (black circles) to studies from other regions (grey circles). Solid horizontal
line = pooled mean cost of index hospitalisation ($10,075). Size of circle represents the weighting
of each observation. (n =64)
0
20
00
040
00
060
00
080
00
0
Inde
x h
osp
italis
ation
cost (U
S$, 2
01
4)
0 20 40 60 80Length of stay (days)
28
Table A5.8 - Univariate and multivariate analysis of index hospitalisation costs.
Univariate Multivariate (n=59)
Variable Marginal cost ($, 2014)
p-value Marginal cost ($, 2014)
p-value
Country and Healthcare system factors
GDP per capita -0.048 0.671 - -
Healthcare expenditure per capita -0.027 0.967 - -
% of healthcare expenditure, public -56.52 0.502 - -
Region North America (n=38)
Baseline - -
Western Europe (n=16)
-3,575 0.049 - -
Asia (n=4) -429 0.836 - -
Australasia (n=2) -910 0.556 - -
Latin America (n=2) -10,428 <0.001 - -
Middle East (n=2) 35,068 <0.001 - -
US vs. non-US studies US studies (n=35) Baseline Baseline
Non-US studies (n=29)
-4,248 0.157 10,701 0.001
Study design factors
Year of study a -389 <0.001 -292 <0.001
RCT vs. observational studies
Observational studies (N=59)
Baseline - -
RCT (n=5) 2,002 0.038 - -
Control vs. Intervention groups (n = 16) b
Control groups (n=8)
Baseline - -
Intervention group (n=8)
-1,738 <0.001 - -
Hip fracture with complications vs. hip fractures without complications (n=21) c
No complications (n=8)
Baseline - -
With complications (n=13)
1,352 <0.001 - -
Costs vs. Charges, US studies only (n=35)
Costs (n=23) Baseline - -
Charges (n=12) 6,779 0.099 - -
Demographic factors
Older age -103 0.031 - -
Gender Male Baseline Baseline
Female -332 <0.001 -134 0.001
Length of stay (n = 59) 205 <0.001 3,437 <0.001
Length of stay x non-US - - -3,304 <0.001
Intercept - - 2,481
Random effect (SD) - - 1,162
Intracluster correlation coefficient (ICC) - - 0.939
n=64 unless otherwise specified
a – centred to 1990
b – not including the cost of implementing the intervention
c – six studies reported index hospitalisation costs for both patients with no complications and
patients with complications. All costs for patients developing complications were included, as