Home and Community Care Digest

Home and Community Care Digest March 2003 : 0-0

Cost-Effective Early Discharge Should Target Specific Patient Populations


A prospective study of post-hip fracture patients compared societal costs of conventional discharge with early discharge to nursing home rehabilitation. Early discharge did not result in significant savings due to a concentration of post-operative costs. However, several explanatory factors for post-operative costs (pre-fracture residence, existing co-morbidities, functioning before fracture, and dementia status) indicated that early discharge targeted at individuals living at home with good functional and cognitive status pre-hip fracture may prove cost-effective. The extent to which early discharge is cost effective is impacted by: (a) the economic evaluation employed, and (b) patients' physical functioning and cognitive status pre-fracture.
Background: The traditional hospital setting is associated with costly technological overhead. It is often assumed that health care costs are reduced when care is provided in appropriate settings outside of hospitals. This assumption was tested in a prospective study of patients after hip fracture repair in a university and general hospital in the Netherlands. Societal costs of conventional discharge were compared with costs of early discharge post hip fracture repair.

Method: Two groups of hip fracture patients were compared: (a) those who received conventional treatment (n=102), and (b) those who were discharged early (n=106). Patients in the conventional treatment group stayed in hospital for physiotherapy, twice daily. Those in the early discharge group were released from hospital five days post-operatively to a rehabilitation ward of a nursing home; rehabilitation providers included occupational, physiotherapists, and social workers. Patient groups were compared on functional and cognitive status. Clinical differences in these outcomes were not significant. The two treatments were then compared on costs. Costs were calculated from a societal perspective including: (a) real costs (where applicable) for a seven-month period (three months pre-operatively through to four months post-operatively) (b) all medical costs, and (c) indirect costs incurred by patients and families.

Findings: Cost savings associated with early discharge were not statistically significant. These findings were explained by two observations: (a) a high concentration of medical procedures during the early post-operative period for the early discharge group (i.e. increased medical expenditures), and (b) equal total time in health care institutions (e.g. hospital and/or nursing home) for both groups. Thus, costs were not decreased, but reallocated from hospitals to nursing homes. Further analyses demonstrated that the following patient subpopulations accrued significantly lower costs: (a) individuals living at home prior to fracture (b) individuals with better functional status and fewer comorbidities, and (c) those without dementia. Based on the significant cost savings for these patient populations, these individuals may be most eligible for early discharge.

Conclusions: Early discharge to nursing home rehabilitation may not be cost-effective due to concentration of costs post-operatively. However, explanatory factors for post-operative costs (pre-fracture residence, number of co-morbidities, functioning before fracture, and dementia status) indicate that early discharge targeted at individuals living at home with good functional and cognitive status pre-hip fracture may prove more cost-effective. The cost benefits of early discharge depend on: (a) the type of analysis employed, and (b) patient groups amenable to early discharge

Reference: Polder, J., van Balen, R., Steyerberg, E., Cools, H., & Habbema, J. A cost-minimization study of alternative discharge policies after hip fracture repair. Health Economics, in press, (2002).


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