Abstract
Aims
This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma Evaluation (WHiTE)) in the UK.
Methods
A questionnaire containing health resource use was completed at baseline and four months post-injury by patients or their carer. Completion rate and mean cost of each health resource item were assessed and sensitivity analysis was performed to derive a conservative estimate of the informal care cost. All costs are presented in 2017/18 pound sterling.
Results
A total of 4,183 patients from the WHiTE cohort completed the baseline questionnaire between May 2017 and April 2018, of whom 3,524 (84.2%) completed the four-month health resource section. Estimated mean costs of formal and informal care, home adaptations, and physiotherapy during the four months following injury were £2,843 (SD 5,467), £6,613 (SD 15,146), £706 (SD 1,706) and £9 (SD 33), respectively. Mean cost of informal care decreased to £660 (SD £1,040) in the sensitivity analysis when informal care was capped at 17.2 hours per day.
Conclusion
Informal care is a significant source of costs after hip fracture and should therefore be included in future economical analyses of this patient group. Our results show that there is considerable variation in the interpretation of time-use of informal care among patients and further work is needed to improve how data regarding informal care are collected in order to obtain a more accurate cost estimate.
Cite this article: Bone Joint Res. 2020;9(5):250–257.
Article focus
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What is the utilization rate and cost of formal and informal care, home adaptations, and physiotherapy among hip fracture patients aged 60 years and above?
Key messages
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Formal and informal care are significant sources of cost following hip fracture in older patients.
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There is considerable variation in the interpretation of informal care requirements among patients.
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The design of health resource utilization section in the questionnaire needs to take these factors into account in order to obtain a more accurate cost estimate.
Strengths and limitations
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First study to estimate the cost of informal care as a result of a hip fracture in the UK.
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Patients had difficulty reporting their use of informal care and tended to report ‘care availability’, hence the cost of informal care could be overestimated.
Introduction
Each year approximately 1.6 million hip fractures occur worldwide,1 and the figure could reach between 4.5 million2 and 6.3 million3 by 2050 due to rising life expectancy. Fractures are associated with significant morbidity and premature mortality,4 loss of independence, development of chronic pain, diminished quality of life,5 and as a result increased financial burden.6 This is especially true in older adults where hip fractures are becoming more common and complex in an ageing and increasingly frail population.7-9
According to a recent systematic review conducted by Williamson et al10 regarding the cost of fragility hip fractures globally, the pooled estimate of health and social care costs in the first 12 months following a hip fracture was $43,669. In this evaluation, inpatient care was the main cost driver, responsible for 31% of total cost, with index hospitalization accounting for approximately 80% of the total inpatient cost in the first year.10 However, none of the studies included in the review investigated productivity loss or the cost of informal care for patients after a fragility hip fracture.
In the UK, over 65,000 hip fractures occur each year11 at an annual cost of £1 billion.11 Given the profound loss of function and independence following a hip fracture, manifested in around 50% of older patients unable to mobilize independently afterwards,12 patients need support once they leave the hospital. This support takes a different form for every patient, largely depending on their overall health and immediate environment, but it is usually a combination of formal (i.e. paid) care, informal care (unpaid, generally provided by family and/or relatives), and/or physical adaptations to their home. These are significant cost drivers, but are not routinely provided by the NHS. Furthermore, as elderly patients report being more concerned with potential loss of independence rather than the risk of mortality after a hip fracture, success in rehabilitation has been a key marker of quality of care used by the National Hip Fracture Database (NHFD).13 In this feasibility study, we therefore sought to estimate the level and costs associated with the utilization of formal and informal care, home adaptations, and physiotherapy, as a key component of rehabilitation among older patients with hip fractures in the UK.
Methods
Study population
The multicentre World Hip Trauma Evaluation (WHiTE) cohort was set up in 2014 to measure outcomes, including health-related quality of life, among UK patients with hip fracture.14 It uses the same eligibility criteria as the NHFD, so all patients with a hip fracture are included unless they are younger than 60 years or are treated nonoperatively. The data in WHiTE are broadly representative of the UK hip fracture population captures in the NHFD.15,16 The detailed study protocol has been described elsewhere.17 A number of randomized controlled trials are embedded within the WHiTE cohort (WHiTE 3,18 WHiTE4,19 WHiTE Five,20 WHiSH,21 and WHiTE 8 COPAL22). Patients included in this study were a subset of the full WHiTE cohort as the health economics component of the questionnaire was introduced to the cohort in April 2017. Hence, only patients who had completed their baseline questionnaire between May 2017 and April 2018 were included in this study.
Collection of health resource use data
Patients, or their main carer for those with cognitive impairment, completed a questionnaire at baseline, reflecting pre-injury status and four months post-injury. In the baseline resource use section of the questionnaire, patients were asked about their use of a formal full-time or part-time home care, informal care if they were not in a residential care home or nursing home, or in a hospital in the four months leading up to their hip fracture. In the four-month questionnaire, the same questions were asked in the resource use section, with participants reporting on their use based on their recall since the time of discharge from their acute hospital stay. Additional health resource items in the four-month health resource section included home adaptations as well as NHS-funded and privately funded physiotherapy sessions.
Cost of health resources
A descriptive cost analysis of formal and informal care, home adaptations, and physiotherapy, based on available cases, was performed. Available case analysis refers to analysis of all observed data at each timepoint from participants who completed baseline and/or four-month health resource section. The cost of formal care included cost of residential care facilities such as residential or nursing homes, as well as full- or part-time formal care at home.
The unit costs of health resources were obtained from the 2018 Personal Social Services Research Unit (PSSRU)23 publication (Table I).23-30 The estimated cost of each health resource item per patient was calculated by multiplying the frequency of resource use by the unit cost per resource (where applicable) and were expressed in 2017/2018 pound sterling (£). Unit costs were adjusted to 2017/2018 prices using the 2018 NHS Hospital & Community Health Services (HCHS) index23 for health service resources as necessary. No discounting of costs was applied since the time horizon was only four months.
Table I.
| Resource item | Unit type | Unit cost, £ | Source |
|---|---|---|---|
| Formal care | |||
| Residential care facilities | |||
| Residential home | Week | 847.00 | PSSRU 2018 p.2723 |
| Nursing home | Week | 698.80* | PSSRU 2010 p.4924 |
| Full-time home | Hour | 18.93 | UKHCA, 201925 |
| Part-time home | Hour | 26.36* | PSSRU 2017 p.12526 |
| Informal care | |||
| Median wage | week | 569.00 | Office for National Statistics, 201927 |
| Home adaptation | |||
| Bathroom | each | 4,563.00* | Garrett, 2016: Table 1128 |
| Bedroom | each | 118.00 | PSSRU 2018 p.9223 |
| Fixed hoist | each | 3,194.10* | Garrett, 2016: Table 1128 |
| Grab rail | each | 99.90 | PSSRU 2018 p.9223 |
| Level-access shower | each | 5,078.00 | PSSRU 2018 p.9223 |
| Outdoor rail | each | 95.80 | PSSRU 2018 p.9223 |
| Ramp | each | 906.00 | PSSRU 2018 p.9223 |
| Stair lift | each | 2,046.00 | PSSRU 2018 p.9123 |
| Steps | each | 879.00 | PSSRU 2018 p.9223 |
| Toilet | each | 2,535.00* | Garrett, 2016: Table 1128 |
| Physiotherapy | |||
| NHS | hour | 38.53* | PSSRU 2015 p.21729 |
| Private | hour | 75.00 | The Physio Centre, 201830 |
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*
Inflated to 2017/18 cost using hospital and community health services’ pay and price inflation.
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PSSRU, Personal Social Services Research Unit; UKHCA, United Kingdom Home Care Association.
In order to compute the estimated cost of health resource per patient, the following assumptions were made: 1) patients who reported living in residential care facilities at four months were assumed to have lived there since discharge from the acute hospital and hence not to have received any formal or informal care at their own home; 2) patients who reported staying in residential care facilities since discharge were assumed not to have any home adaptations; 3) patients who reported having formal full-time care were assumed not to have any informal care; 4) patients who reported staying in residential care facilities/hospitals or had formal full-time care were assumed not to have any physiotherapy; 5) among patients who indicated they received formal care, unless otherwise stated, they were assumed to have only one formal (full-time/part-time) carer; 6) if patients indicated receiving formal part-time care from more than one carer at a time, their reported use of formal part-time care was based on the carer who provided the longest duration of care; 7) no gender wage gap was applied during computation of the cost of informal care; 8) mean physiotherapy duration was one hour per session, and the number reported per week applied to each week within the four months; and 9) 37.5 working hours per week was assumed.
Statistical analysis
Descriptive statistics such as percentage, mean, and SD for normally distributed variables, as well as median and interquartile range (IQR) for non-normally distributed variables were used to describe the patients’ baseline characteristics. Costs were expressed in mean (SD) but the median and IQR were also presented in the tables since the cost was positively skewed. Statistical analysis was performed using R (version 3.5.2; R Foundation for Statistical Computing, Vienna, Austria).
Some patients reported that they received informal care 24 hours per day in the previous four months. This could be due to the difficulty in defining informal care in terms of the nature of the caring tasks and the care intensity, for example when a carer lived at the same address.31 Therefore, we performed a sensitivity analysis where we categorized patients who reported receiving informal care for more than 17.2 hours per day as outliers. After considering the mean UK sleep time of 6.8 hours,32 we capped their amount of informal care to waking hours at 17.2 hours per day.
Results
Study population
A total of 4,183 patients completed the baseline questionnaire, including the health economics component, between May 2017 and April 2018. Of these, 3,524 patients (84.2%) completed the four-month health economics component. At baseline, the majority of the patients were female (69.6%, n = 2,913), were non-smokers (79.1%, n = 3,310), were mobile outdoors with one or two aid(s) (60.9%, n = 2,546), and had severe systemic disease (53.5%, n = 2,238) based on the American Society of Anesthesiologists (ASA) physical status grade.33,34 Based on the Abbreviated Mental Test Score (AMTS)35 presented in Table I, the median postoperative AMTS was 9 (IQR 7 to 10) and the proportion of patients with AMTS of less than seven (which suggests cognitive impairment) was 22.3% (n = 934). The most common type of fracture was a displaced intracapsular fracture (46.1%, n = 1,928), treated with a hemiarthroplasty (38.3%, n = 1,602) (Table II).
Table II.
Baseline characteristics of patients from the World Hip Trauma Evaluation cohort between May 2017 and April 2018
| Characteristic | WHiTE cohort (n = 4,183)* |
|---|---|
| Mean age, yrs (SD) | 82.8 (8.6) |
| Sex, n (%) | |
| Female | 2,913 (69.6) |
| Male | 1,270 (30.4) |
| Diabetes, n (%) | |
| No | 3,108 (74.3) |
| Yes | 591 (14.1) |
| Unknown | 484 (11.6) |
| Smoker, n (%) | |
| No | 3,310 (79.1) |
| Yes | 374 (8.9) |
| Unknown | 499 (11.9) |
| Renal failure, n (%) | |
| No | 3,389 (81.0) |
| Yes | 295 (7.1) |
| Unknown | 499 (11.9) |
| Median preoperative AMTS (IQR) | 9 (7 to 10) |
| Median postoperative AMTS (IQR) | 9 (7 to 10) |
| Pre-injury mobility, n (%) | |
| Freely mobile without aids | 36 (0.9) |
| Mobile outdoors with one aid | 1,602 (38.3) |
| Mobile outdoors with two aids or frame | 944 (22.6) |
| Some indoor mobility | 665 (15.9) |
| No functional mobility | 785 (18.8) |
| Unknown | 151 (3.6) |
| ASA physical status grade, n (%) | |
| I | 84 (2.0) |
| II | 907 (21.7) |
| III | 2,238 (53.5) |
| IV | 592 (14.2) |
| V | 15 (0.4) |
| Unknown | 347 (8.3) |
| Fracture classification, n (%) | |
| Intertrochanteric | 1,748 (41.8) |
| Intracapsular (undisplaced) | 238 (5.7) |
| Intracapsular (displaced) | 1,928 (46.1) |
| Subtrochanteric | 141 (3.4) |
| Unknown | 128 (3.1) |
| Operation type, n (%) | |
| Hemiarthroplasty | 1,602 (38.3) |
| Total hip arthroplasty | 378 (9.0) |
| Screw fixation | 85 (2.0) |
| Intramedullary nail fixation | 537 (12.8) |
| Sliding hip screw fixation | 1,429 (34.2) |
| Other | 26 (0.6) |
| Unknown | 126 (3.0) |
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*
Due to rounding off errors, the percentages may not always add up to 100%.
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AMTS, abbreviated mental test score; ASA, American Society of Anesthesiologists; IQR, interquartile range; WHiTE, World Hip Trauma Evaluation.
Completion rate
Completion rates per question varied between 75% and 89% for the pre-injury health resource section, and between 96% and nearly 100% at four months (Table III). Completion rate at four months is higher than at baseline because the completion of the baseline health resource section was not mandatory, unlike baseline clinical information. The high completion rate suggests that enough useful information could be extracted from the patients’ responses in order to estimate the utilization rate and mean cost of health resources per patient during pre- and post-injury periods.
Table III.
Completion rate (%) of health resource items during pre- and post-injury
| Resource item | Pre-injury (n = 4,183) | Post-injury (n = 3,524) |
|---|---|---|
| Formal care | ||
| Residential care facilities | 3,705 (88.6) | 3,516 (99.8) |
| Full-time home | 3,543 (84.7) | 3,461 (98.2) |
| Part-time home | 3,497 (83.6) | 3,451 (97.9) |
| Informal care | 3,149 (75.3) | 3,420 (97.0) |
| Home adaptation | N/A | 3,490 (99.0) |
| Physiotherapy | ||
| NHS | N/A | 3,375 (95.8) |
| Private | N/A | 3,381 (95.9) |
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N/A, not applicable.
Utilization rate of health resource
Table IV reports the noticeable increase in utilization of part-time home care (from 12.0% (n = 501) pre-injury to 23.6% (n = 832) post-injury) and informal care (17.7% (n = 739) pre-injury and 35.2% (n = 1,242) post-injury) after a hip fracture. Among 2,288 patients who returned to their own home by four months post-injury, 1,630 (71.2%) had formal or informal care while 1,142 (49.9%) had at least one form of home adaptation. The utilization rate of NHS or private physiotherapy between discharge from their index hospital and four months post-injury among patients who returned to their own home was 54.9% (n = 1,256).
Table IV.
Utilization rate of health resources and estimated cost per patient over four months for pre- and post-injury periods (in 2017/18 £)
| Resource item | Pre-injury (n = 4,183) | Post-injury (n = 3,524) | ||||
|---|---|---|---|---|---|---|
| No. of patients (%) | Mean cost, £ (SD) | Median cost, £ (IQR) | No. of patients (%) | Mean cost, £ (SD) | Median cost, £ (IQR) | |
| Formal care | ||||||
| Residential care facilities | ||||||
| Residential home | 292 (7.0) | 1,135 (3,880) | 0 (0 to 0) | 265 (7.5) | 1,085 (3,802) | 0 (0 to 0) |
| Nursing home | 188 (4.5) | 603 (2,608) | 0 (0 to 0) | 326 (9.3) | 1,101 (3,446) | 0 (0 to 0) |
| Full-time home | 107 (2.6) | 21 (122) | 0 (0 to 0) | 39 (1.1) | 8 (75) | 0 (0 to 0) |
| Part-time home | 501 (12.0) | 435 (1,774) | 0 (0 to 0) | 832 (23.6) | 669 (3,016) | 0 (0 to 0) |
| Informal care | 739 (17.7) | 1,761 (7,297) | 0 (0 to 0) | 1,242 (35.2) | 6,613 (15,146) | 0 (0 to 0) |
| Home adaptation | ||||||
| Bathroom | N/A | N/A | N/A | 407 (11.5) | 532 (1,465) | 0 (0 to 0) |
| Bedroom | N/A | N/A | N/A | 13 (0.4) | 0.44 (7.19) | 0 (0 to 0) |
| Fixed hoist | N/A | N/A | N/A | 11 (0.3) | 10 (179) | 0 (0 to 0) |
| Grab rail | N/A | N/A | N/A | 584 (16.6) | 17 (37) | 0 (0 to 0) |
| Level-access shower | N/A | N/A | N/A | 34 (1.0) | 49 (499) | 0 (0 to 0) |
| Outdoor rail | N/A | N/A | N/A | 92 (2.6) | 2.53 (15) | 0 (0 to 0) |
| Ramp | N/A | N/A | N/A | 27 (0.8) | 7.01 (79) | 0 (0 to 0) |
| Stair lift | N/A | N/A | N/A | 135 (3.8) | 79 (395) | 0 (0 to 0) |
| Steps | N/A | N/A | N/A | 15 (0.4) | 3.78 (58) | 0 (0 to 0) |
| Toilet | N/A | N/A | N/A | 7 (0.2) | 5.08 (113) | 0 (0 to 0) |
| Physiotherapy | ||||||
| NHS | N/A | N/A | N/A | 1,206 (34.2) | 8.22 (33) | 0 (0 to 6.94) |
| Private | N/A | N/A | N/A | 87 (2.5) | 0.74 (6.76) | 0 (0 to 0) |
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IQR, interquartile range; N/A, not applicable.
Mean cost per patient
In the base case analysis, the main cost driver pre-injury was formal care; this changed to informal care in the post-injury phase (Figure 1). However, in the sensitivity analysis, where informal care was capped, the main cost driver was formal care, both before and after the injury.
Fig. 1
Mean cost of each cost component during pre- and post-injury for base case and sensitivity analysis.
Only 75 (8.2%) patients reported that informal carers were providing over 155 hours of care per week (or approximately 22 to 24 hours per day) before their injury. This rose to 511 (34.8%) in the four months post-injury (Figure 2). Applying the limit of 17.2 hours per day (or 120.4 hours per week) for informal care would drastically decrease the mean cost of informal care from £1,761 (SD 7,297) to £361 (SD 819) in the four months prior to the injury and from £6,613 (SD 15,146) to £660 (SD 1,040) in the four months after the injury (Table V). This in turn resulted in a decrease in the total mean cost in the sensitivity analysis, where the overall cost decreased from £3,659 (SD 7,992) to £2,470 (SD 4,669) during the pre-injury time frame and was almost halved from £9,969 (SD 15,173) to £4,189 (SD 5,426) during the post-injury time frame. However, if median cost and its IQR were considered, median cost of informal care pre-injury remained unchanged due to its positive skewness while the IQR became narrower (from £0 to £2,064, to £0 to £1,827) when the number of hours of informal care was capped. Estimated mean costs for home adaptations and physiotherapy were £706 (SD 1,706; median £0, IQR 0 to 100) and £9 (SD 33; median 0, IQR 0 to 8), respectively.
Fig. 2
Frequency of the mean number of hours of informal care received per week during pre- and post-injury.
Table V.
Estimated cost of the main cost components per patient over four months in base case and sensitivity analyses (in 2017/18 £)
| Analysis | Pre-injury (n = 4,183) | Post-injury (n = 3,524) | ||
|---|---|---|---|---|
| Mean cost, £ (SD) | Median cost, £ (IQR) | Mean cost, £ (SD) | Median cost, £ (IQR) | |
| Base case | ||||
| Formal care | 2,164 (4,684) | 0 (0 to 710) | 2,843 (5,467) | 0 (0 to 2,241) |
| Informal care | 1,761 (7,297) | 0 (0 to 0) | 6,613 (15,146) | 0 (0 to 2,064) |
| Home adaptation | N/A | N/A | 706 (1,706) | 0 (0 to 100) |
| Physiotherapy | N/A | N/A | 9 (33) | 0 (0 to 8) |
| Total | 3,659 (7,992) | 0 (0 to 3,137) | 9,969 (15,173) | 3,620 (0 to 11,880) |
| Sensitivity | ||||
| Informal care | 361 (819) | 0 (0 to 0) | 660 (1,040) | 0 (0 to 1,827) |
| Total | 2,470 (4,669) | 0 (0 to 1,827) | 4,189 (5,426) | 1,846 (0 to 6,499) |
-
IQR, interquartile range; N/A, not applicable.
Discussion
This feasibility study found that there is considerable variation in the interpretation of informal care, which might explain informal care being the main cost driver for patients over the age of 60 years following a hip fracture but formal care being the main cost driver after the informal care hours were capped at 17.2 hours per day. The high levels of informal care reported could be due to some patients signalling the care availability instead of the time-use of care as patients in this study had found it difficult to assess the time and intensity of informal care, particularly when carers live at the same address as the patient. However, since the mode of administration and content of the resource use section was the same before and after the injury, any measurement error can be assumed to be the same for both. Therefore, while the magnitude of the use of informal care may be subject to interpretation, there is a clear increase in the need for informal care following a hip fracture.
Based on a study conducted by Leal et al,36 the mean cost of hospital treatment in the 12 months following a hip fracture in the UK was approximately £8,613 (in 2012/2013 prices). This would amount to around £8,813 in 2017/2018 prices after adjusting for inflation using the HCHS index. If the amount of formal and informal care recorded in this study were assumed to remain constant between four and 12 months, the mean cost of formal care after a hip fracture would be similar at around £8,529, and mean cost of informal care would be about £1,980 over 12 months, using the conservative estimate of informal care from our sensitivity analysis. Given that the majority of the patients reported a need for formal or informal care following their injury, these costs clearly need to be included when examining the ‘true’ economical burden of hip fractures in older patients. We found that informal care plays a significant role in the care of older patients in the UK. Around 85% of the 2.3 million elderly with functional disabilities living in private households in England received informal care37 and, according to the National Audit Office, the value of informal care provided in 2015/16 is comparable to the national spending on healthcare and significantly outweighs that of formal care provided by local government and the NHS.38
There is a desire of the majority of older people to live independently in their own homes for as long as possible and home adaptations have been shown to improve older and disabled people's quality of life by enabling such independence.39,40 This is reflected in our preliminary results where 981 (85.9%) patients who lived in their homes and made at least one home adaptation were patients with limited mobility (i.e. needed at least one aid or help to move around). Although almost half of the patients who live in their homes reported not having physiotherapy within 120 days since discharge, it remains unknown if this was due to patient’s choice or the logistics of receiving rehabilitation after leaving the hospital. According to the Physiotherapy Hip Fracture Sprint Audit, the wait for physiotherapy after a hip fracture was 15 days on average but could be as high as 80 days.41
To our knowledge, this is the first study that estimates the cost of informal care as a result of a hip fracture in the UK. However, it is not without its limitations. In order to keep the length of the questionnaire short to reduce respondent fatigue and increase completion rate of health resource use in a frail elderly cohort, assumptions that could underestimate/overestimate the cost of the examined health resources were made. Patients who had died before the completion of the four-month questionnaire were treated as non-response (n = 38, or 0.9% of the baseline population) instead of assuming that they had not incurred any cost. These patients were likely to require more care before they died and hence the actual cost of care may be underestimated in this study. Patients who reported to be living in residential care facilities at four months were assumed to have stayed there since discharge from the acute hospital, although patients could potentially have been discharged home and then moved to a care facility. Hence, the cost of residential care could be overestimated and the cost of formal home care, informal care, home adaptation, or physiotherapy could in turn be underestimated. Likewise, we assumed that patients living in residential care facilities/hospitals or those who had formal full-time care would not have any physiotherapy. While it seems unlikely that patients received much physiotherapy in these contexts, this could lead to an underestimate of the physiotherapy costs. We did not collect detailed information on the home care companies which patients used or how much the patient paid out-of-pocket versus how much was subsidized by the local government agency in order to reduce the length of the questionnaire to prevent respondent fatigue. We used the UK Home Care Association’s estimation of the minimum price that homecare providers need to receive from councils as a conservative estimate of the cost of full-time home care.
Another key limitation is the difficulty patients had in reporting their use of informal care. Although we sought to account for this in our sensitivity analysis, those results may still overestimate informal care as the carer was assumed to be providing care except when he/she was sleeping. The challenges when measuring the amount of informal care using surveys are not unique to this study; similar concerns were reported in the English Longitudinal Study of Ageing.31 These challenges, nonetheless, must be borne in mind when designing, conducting, and interpreting results from these types of studies.
Based on findings from this feasibility study, the health resource section used in the WHiTE cohort and embedded randomized trials will be refined, with emphasis on capturing the time-use of informal care by patients in order to obtain more accurate cost estimates. We will include a definition of informal care with an emphasis on stating the time taken to perform specific tasks. This is consistent with the practice used in validated questionnaires on productivity loss and informal care.42
In conclusion, formal and informal care are the major drivers of costs for patients after they leave hospital following a hip fracture and should be included in economical analyses where an accurate measure of overall costs is necessary. Informal costs in particular can be challenging to collect but understanding the complexities of these data can help design questionnaires that produce reliable estimates. Once more reliable estimates can be obtained, future work could include subgroup analysis of formal and informal care by, for example, patients with cognitive impairment versus those without.
Acknowledgements
The authors would like to thank Melina Dritsaki for the design of the health economics component in the questionnaire. We would like to thank all those involved in the World Hip Trauma Evaluation (WHiTE) cohort study, including patients and their carers, the research associates at the recruitment centres and the central WHiTE team including Stephanie Wallis, Robin Lerner, Katy Mironov, Charlie Vicary, Svetlana Milca, and all the data clerks who performed over 10,000 phone calls to collect the data. We further acknowledge the contributions of the WHiTE Oversight Committee members (Tim Chesser, John Keating, Iain Moppett, Antony Johansen, Alwin McGibbon, Karen May, and Richard Grant); WHiTE Scientific Committee members (Stu White, Tim Chesser, Jenny Gould, Josephine Rowling, Mark Baxter, Philip Bell, Sarah E Lamb, Andrew Judge, and Chris Boulton); as well as the WHiTE Principal Investigators (Peter Hull, Graham Smith, William Eardley, Robert Handley, John Davison, Iain McNamara, Mike Reed, Mark Farrar, Ad Gandhe, Ansar Mahmood, Ben Ollivere, Andrew McAndrew, Damian McClelland, Benedict Rogers, R John Barr, Paul Fearon, Kanthan Theivendran, Mehool Acharya, Paul Dixon, Jonathan Young, Khitish Mohanty, and Callum Clark).
Open access
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credted. See https://creativecommons.org/licenses/by-nc-nd/4.0/.
Funding statement
This study was supported by the NIHR Oxford Biomedical Research Centre.
Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but will be directed solely to a research fund, foundation, educational institution, or other non- profit organization with which one or more of the authors are associated.
Conflict of interest statement
X. L. Griffin reports consultancy fees from Synthes and Stryker, an institutional payment from Stryker for the development of educational presentations, employment payment from the University of Oxford, multiple institutional grants from NIHR Industry, multiple institutional payments for speaking engagements, and multiple travel/accommodation/meeting expenses, unrelated to this study.
J. Acthen reports employment payment from the University of Oxford, unrelated to this study.
M. Costa reports employment payment from the University of Oxford, and an institutional research grant from NIHR, the EU, RCS England and Industry, unrelated to this study. M. Costa is a NIHR Senior Investigator. The views expressed in this article are those of the author(s) and not necessarily those of the NIHR, or the Department of Health and Social Care.
Ethical review statement
The World Hip Trauma Evaluation (WHiTE) cohort study has NHS Research Ethics Committee (REC) Approval (on 18 August 2011 by London-Camberwell St Giles REC; ref. 11/LO/0927) and approval from the Research and Development Department at each recruiting hospital. The study is registered with the National Institute for Health Research Portfolio (UKCRN ID 12351) and the ISRCTN registry (ISRCTN63982700).
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References
1. No authors listed. Facts and Statistics. International Osteoporosis Foundation. 2017. https://www.iofbonehealth.org/facts-statistics (date last accessed 5 March 2019). Google Scholar
2. Gullberg B , Johnell O , Kanis JA . World-wide projections for hip fracture. Osteoporos Int. 1997;7(5):407-413.CrossrefPubMed Google Scholar
3. Cooper C , Campion G , Melton LJ III . Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992;2(6):285-289.CrossrefPubMed Google Scholar
4. Keene GS , Parker MJ , Pryor GA . Mortality and morbidity after hip fractures. BMJ. 1993;307(6914):1248-1250.CrossrefPubMed Google Scholar
5. Parsons N , Griffin XL , Achten J , Chesser TJ , Lamb SE , Costa ML . Modelling and estimation of health-related quality of life after hip fracture: A re-analysis of data from a prospective cohort study. Bone Joint Res. 2018;7(1):1-5.CrossrefPubMed Google Scholar
6. Dhanwal DK , Dennison EM , Harvey NC , Cooper C . Epidemiology of hip fracture: worldwide geographic variation. Indian J Orthop. 2011;45(1):15-22.CrossrefPubMed Google Scholar
7. Herron J , Hutchinson R , Lecky F et al. . The impact of age on major orthopaedic trauma: an analysis of the United Kingdom Trauma Audit Research Network database. Bone Joint J. 2017;99-B(12):1677-1680.CrossrefPubMed Google Scholar
8. Tucker A , Donnelly KJ , McDonald S , Craig J , Foster AP , Acton JD . The changing face of fractures of the hip in Northern Ireland: a 15-year review. Bone Joint J. 2017;99-B(9):1223-1231.CrossrefPubMed Google Scholar
9. Shafafy R , Valsamis EM , Luck J et al. . Predictors of mortality in the elderly patient with a fracture of the odontoid process. Bone Joint J. 2019;101-B(3):253-259.CrossrefPubMed Google Scholar
10. Williamson S , Landeiro F , McConnell T et al. . Costs of fragility hip fractures globally: a systematic review and meta-regression analysis. Osteoporos Int. 2017;28(10):2791-2800.CrossrefPubMed Google Scholar
11. No authors listed. National Hip Fracture Database (NHFD) Annual Report 2018. Royal College of Physicians. 2018. https://www.rcplondon.ac.uk/projects/outputs/national-hip-fracture-database-nhfd-annual-report-2018 (date last accessed 6 March 2019). Google Scholar
12. Gray A , Chesser T . Measuring and changing practice: making a difference in hip fractures. J Trauma Orthop. 2014;2(2):60-64. Google Scholar
13. Johansen A , Wakeman R , Boulton C , Plant F , Roberts J , Williams A . The National Hip Fracture Database: National Report2013. 2013. https://www.nhfd.co.uk/20/hipfractureR.nsf/0/CA920122A244F2ED802579C900553993/$file/NHFDReport2013.pdf (date last accessed 6 March 2019). Google Scholar
14. Costa ML , Griffin XL , Achten J et al. . World Hip Trauma Evaluation (WHiTE): framework for embedded comprehensive cohort studies. BMJ Open. 2016;6(10):e011679.CrossrefPubMed Google Scholar
15. Metcalfe D , Costa ML , Parsons NR et al. . Validation of a prospective cohort study of older adults with hip fractures. Bone Joint J. 2019;101-B(6):708-714.CrossrefPubMed Google Scholar
16. Masters J , Metcalfe D , Parsons NR , Achten J , Griffin XL , Costa ML ; WHiTE Collaborative Investigators. Interpreting and reporting fracture classification and operation type in hip fracture: implications for research studies and routine national audits. Bone Joint J. 2019;101-B(10):1292-1299.CrossrefPubMed Google Scholar
17. Metcalfe D , Gabbe BJ , Perry DC et al. . Quality of care for patients with a fracture of the hip in major trauma centres: a national observational study. Bone Joint J. 2016;98-B(3):414-419.CrossrefPubMed Google Scholar
18. Sims AL , Parsons N , Achten J , Griffin XL , Costa ML , Reed MR . The World Hip Trauma Evaluation Study 3: Hemiarthroplasty Evaluation by Multicentre Investigation - WHITE 3: HEMI - An Abridged Protocol. Bone Joint Res. 2016;5(1):18-25.CrossrefPubMed Google Scholar
19. Griffin XL , Achten J , Sones W , Cook J , Costa ML . Randomised controlled trial of the sliding hip screw versus X-Bolt Dynamic Hip Plating System for the fixation of trochanteric fractures of the hip in adults: a protocol study for WHiTE 4 (WHiTE4). BMJ Open. 2018;8(1):e019944.CrossrefPubMed Google Scholar
20. Lerner R , Costa M . World hip trauma evaluation five: a randomised controlled trial comparing cemented and uncemented implants for the treatment of displaced intracapsular hip fractures. ISRCTN. 2020. http://www.isrctn.com/ISRCTN18393176 (date last accessed 4 March 2020). Google Scholar
21. Masters JPM , Achten J , Cook J , Dritsaki M , Sansom L , Costa ML . Randomised controlled feasibility trial of standard wound management versus negative-pressure wound therapy in the treatment of adult patients having surgical incisions for hip fractures. BMJ Open. 2018;8(4):e020632.CrossrefPubMed Google Scholar
22. Wallis S , Reed M . A randomised controlled trial of single antibiotic cement versus dual antibiotic cement in patients receiving a partial hip joint replacement after fracture. ISRCTN. 2019. https://www.isrctn.com/ISRCTN15606075 (date last accessed 4 March 2020). Google Scholar
23. Curtis L , Burns A . Unit Costs of Health and Social Care 2018. Personal Social Services Research Unit (PSSRU). 2018. https://www.pssru.ac.uk/project-pages/unit-costs/unit-costs-2018/ (date last accessed 28 February 2020). Google Scholar
24. Curtis L . Unit Costs of Health and Social Care 2010. Personal Social Services Research Unit (PSSRU). 2010. https://www.pssru.ac.uk/project-pages/unit-costs/unit-costs-2010/ (date last accessed 9 March 2020). Google Scholar
25. No authors listed. Getting the price right: Calculating the cost of homecare in 2019. United Kingdom Homecare Association. 2019. https://www.ukhca.co.uk/CostOfHomecare2019.aspx (date last accessed 19 November 2019). Google Scholar
26. Curtis L , Burns A . Unit Costs of Health and Social Care 2017. Personal Social Services Research Unit (PSSRU). 2017. https://www.pssru.ac.uk/project-pages/unit-costs/unit-costs-2017/ (date last accessed 9 March 2020). Google Scholar
27. Smith R . Employee earnings in the UK: 2018. Office for National Statistics. 2018. https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/earningsandworkinghours/bulletins/annualsurveyofhoursandearnings/2018 (date last assessed 9 March 2020). Google Scholar
28. Garrett H , Roys M , Burris S , Nicol S . The cost-benefit to the NHS arising from preventative housing interventions. Bracknell: IHS BRE Press. 2016. Google Scholar
29. Curtis L , Burns A . Unit Costs of Health and Social Care 2015. Personal Social Services Research Unit (PSSRU). 2015. https://www.pssru.ac.uk/project-pages/unit-costs/unit-costs-2015/ (date last assessed 9 March 2020). Google Scholar
30. No authors listed. How much?The Physiotherapy Centre. 2018. https://www.thephysiocentre.co.uk/consultation-fees/ (last assessed 9 March 2020). Google Scholar
31. Rutherford AC , Bu F . Issues with the measurement of informal care in social surveys: Evidence from the English Longitudinal Study of Ageing. Ageing Soc. 2018;38(12):2541-2559. Google Scholar
32. No authors listed. Public missing out on a night’s worth of sleep every week. Royal Society for Public Health. 2016. https://www.rsph.org.uk/about-us/news/public-missing-out-on-a-night-s-worth-of-sleep-every-week.html (date last accessed 15 March 2019). Google Scholar
33. Dripps RD . New classification of physical status. Anesthesiology. 1963;24:111. Google Scholar
34. Saklad M . Grading of patients for surgical procedures. Anesthesiol. 1941;2(5):281-284. Google Scholar
35. Hodkinson HM . Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972;1(4):233–238.CrossrefPubMed Google Scholar
36. Leal J , Gray AM , Prieto-Alhambra D et al. . REFReSH study group. Impact of hip fracture on hospital care costs: a population-based study. Osteoporos Int. 2016;27(2):549-558. Google Scholar
37. Pickard L , Wittenberg R , Comas-Herrera A , King D , Malley J . Care by Spouses, Care by Children: Projections of Informal Care for Older People in England to 2031. Soc Policy Soc. 2007;6(3):353-366. Google Scholar
38. No authors listed. A short guide to local authorities. National Audit Office. 2017. www.nao.org.uk/report/short-guide-to-local-authorities (date last accessed 6 March 2019). Google Scholar
39. Adams S , Ellison H . Time to Adapt. Home adaptations for older people: the increase in need and future of state provision. Nottingham Care & Repair England. 2009. http://careandrepair-england.org.uk/wp-content/uploads/2014/12/time_to_adapt_report.pdf (date last accessed 1 July 2019). Google Scholar
40. Heywood F , Turner L . Better outcomes, lower costs: implications for health and social care budgets of investments in housing adaptations, improvements and equipment: a review of the evidence. Office for Disability Issues, Department of Work and Pensions. 2007. http://www.wohnenimalter.ch/img/pdf/better_outcomes_report.pdf (date last accessed 1 July 2019). Google Scholar
41. No authors listed. Recovering after a hip fracture: helping people understand physiotherapy in the NHS. Physiotherapy ‘Hip Sprint’ audit report. Royal College of Physicians. 2017. https://www.rcplondon.ac.uk/projects/outputs/recovering-after-hip-fracture-helping-people-understand-physiotherapy-nhs (date last accessed 4 March 2020). Google Scholar
42. Zhang W , Bansback N , Kopec J , Anis AH . Measuring time input loss among patients with rheumatoid arthritis: validity and reliability of the Valuation of Lost Productivity questionnaire. J Occup Environ Med. 2011;53(5):530-536.CrossrefPubMed Google Scholar
