Hospital-related healthcare expenditure of impending versus completed pathological femur fractures: a propensity score matched study of 265 patients

Background and purpose — The prevalence of meta-static bone disease as well as the accompanying societal costs are expected to increase due to advances in cancer treatment. While the literature suggests that there is economic value in prophylactic stabilization compared with the fixation of completed pathological fractures in long bone metastases, studies are limited by their small sample sizes and insufficient correction for potential confound-ers. We aimed to evaluate whether prophylactic treatment of an impending femur fracture was associated with lower healthcare costs compared with completed pathologic frac-tures. We further aimed to compare prophylactic surgical treatment with completed pathological fractures in terms of postoperative complications, discharge disposition, and postoperative length of stay. 

Methods — This is a retrospective cohort study with propensity score matching (PSM). We included clinical and financial data for 265 patients who received surgery for impending (n = 161) or completed (n = 104) femoral fractures of metastatic lesions, from 2 affiliated urban tertiary care centers between 2016 and 2020 in the United States. After PSM on 13 variables, including demographics and clinical characteristics, 100 impending fractures were matched with 100 completed fractures. The primary outcome was health-care costs per episode of care, defined as the total cost from admission to 30 days after discharge. 

Results — We found no difference in total cost of care between patients undergoing prophylactic surgical treatment and patients who underwent surgical treatment for a completed pathological fracture (median difference 44 cost-units [CU], 95% confidence interval [CI] –294 to 262). No dif- ferences were seen when dividing total cost into cost during hospital admission (median difference –25 CUs, CI –152 to 159) and 30 days following discharge (median difference 31 CUs, CI –74 to 88). Patients with completed pathologic fractures were more often discharged to rehabilitation facilities (57/100, vs 30/100, P < 0.01). 

Conclusion — In contrast to earlier findings, we showed no difference in treatment costs between surgical management of impending and completed pathological fractures of femur metastases after adjusting for confounding factors. However, patients with completed pathological fractures were significantly more likely to require discharge to rehabilitation facilities, highlighting potential out-of-hospital costs related to extended rehabilitation, reduced mobility, and loss of independence.