Abstract
Introduction:
The aim of this study was to assess the cost of hospital care related to fractures among the elderly patients.
Materials and Methods:
The aim was to conduct a study over a 12-month period involving patients aged 60 and older with at least 1 musculoskeletal fracture. The population under investigation included 314 patients, mainly female, with 319 fractures. Only 25.47% of the patients had access to government financial assistance. The cost of hospital treatment was assessed on the basis of 3 expense items; the standard currency used was the African Financial Community Franc (CFA franc) and 1 CFA franc equals 656 euros. Expense item No. 1: It related to the cost of diagnostic services that included surgical consultation and x-rays. Expense item No. 3: It is related to the duration of the stay at the hospital.
Results:
The cost of diagnostic services amounted to 5625 euros. The cost of the second item was put at 43 054 euros: conservative treatment: 43 118 euros; surgical treatment: 41 053 euros. Cost of the hospital stay amounted to 2607 euros. Proximal femur fractures accounted for 43.46% of the overall cost of the care provided.
Discussion:
Our patients’ medical history is similar to the data provided in developed countries: female predominance; predominance of proximal femoral fractures. The cost of the care provided was boosted by the surgical treatment and proximal femur fractures, whereas the cost of hospital stay was rather insignificant. Medical care is a problem among our patients, as few of them have access to government financial assistance.
Conclusion:
Among elderly people, fractures will soon become a public health issue in our context.
Introduction
Geriatrics relates to the medical treatment of elderly people. In developed countries, trauma emergencies, especially fractures, are major issues and represent a real challenge. 1 Patients with trauma are ever increasing, due to the aging of the population, leading inevitably to senile osteoporosis. It all results in an increase in the demand for care with considerable economic costs. 2 –6
In Africa, data relating to pathology in elderly people are scarce. Other emergencies seem to be more of a problem (malaria, malnutrition, AIDS, etc), whereas the aging of the population is becoming a worldwide issue. 7 This study aims to assess the direct cost of hospital treatment of fractures among elderly people.
Materials and Method
This was a long-term study, conducted over a 12-month period (January 01, 2011-December 31, 2012). All patients aged 60 or older with at least 1 musculoskeletal fracture (upper limb, pelvis, lower limb, and spine) were eligible. Pathological fractures and isolated face/skull/thorax fractures were ruled out. During the study period, 6760 patients having trauma were sent to the surgical emergency department. Among them, 546 (8.07%) were aged at least 60. Of the 546 patients aged 60 or older, 314 (57.50%) made up the study population, that is, they presented with upper limb, lower limb, spine, and pelvis fractures, including 182 females and 132 males. The mean age was 72, with extremes of 60 and 104 years. The older patients (between 60 and 75 years) accounted for 70% of the patients. All patients were living at home, surrounded by their family. Only 80 (25.4%) patients had access to government financial assistance, following a professional activity before retirement. History of pathology had been found among 30% of the patients (high blood pressure—isolated or combined with another disease: diabetes, cataract, Parkinson disease, etc). There were 310 (98.72%) patients with a simple fracture (Table 1) and 4 (1.27%) patients with multiple fractures (Table 2). In all, there were 319 fractures in 314 patients. The lower limb accounted for 62.73% of the fractures; the upper limb 34.03%; and the pelvis and the spine 1.17% and 1.49%, respectively. There were 127 (39.81%) proximal femoral fractures. Accidents in the home involving a fall were found among 210 (66.87%) patients. It was a surgical treatment in 147 patients with simple fracture and 3 (47.77%) patients with multifracture using osteosynthesis or arthroplasty. Conservative treatment was indicated in 109 patients and multifracture patients (35.03%). Functional treatment was used in 54 (17.19%) patients. It consisted of staying in bed, taking the strain off the limb involved, and using analgesic medications.
Distribution of Fracture Areas Among Patients With Simple Fracture.
Distribution of Fracture Areas Among Patients With Multifracture.
In all, 171 (54.45%) patients needed to stay in hospital; 73 patients for 1 week, 88 patients for 2 weeks, and 10 patients for 3 weeks. One hundred and forty-three (45.54%) patients were treated as outpatients. Hospital cost was assessed based on the financial implications of 3 expense items. The African Financial Community Franc (CFA franc) was used as a monetary unit. The expense items included the following: Diagnostic services
The cost of a consultation amounted to 08 euros while that of x-rays depended on the fracture area. Lower limb, spine, and pelvis x-rays cost 11 euros, whatever the implications, while lower limb x-rays cost 08 euros. Therapeutic services Conservative treatment
The cost of various processes is shown in Table 3. Control x-rays were taken into account while assessing the therapeutic cost. Surgical treatment
The assessment of surgical treatment included the following: The standard blood tests
It was systematically established for all patients operated on. Its cost was put at 37 euros. Echocardiograph
There was no systematic demand for it. It cost 34 euros. Costs relating to the operating room and implant used
The cost amounted to 305 euros for a hip arthroplasty surgery or a screw plate osteosynthesis (Dynamic Hip Screw). For all the other types of osteosynthesis, the cost amounted to 153 euros. Posttreatment control x-rays Hospital stay
Each week spent in hospital costs 153 euros.
Cost of Various Conservative Treatment.
Results
Cost of diagnostic services
The cost of the diagnostic services amounted to 5634 euros, including clinical checkup 2397 euros and x-rays 3237 euros.
Cost of treatment
The conservative treatment cost amounted to 2005 euros, including the various orthopedic process 1012 euros and control x-rays 993 euros.
The surgical treatment amounted to 41 113 euros including preoperative paraclinical checkup 5350 euros and expenses relating to surgery and implant 33 588 euros. Cost of hospital stay
Seventy-three patients spent 7 days at hospital; 88 patients 2 weeks; and 10 patients 3 weeks. The cost came to 1783 euros. Overall, the direct hospital cost among elderly people at Aristide Le Dantec Teaching Hospital (Dakar—Senegal) was put at 50 537 euros (Table 3).
Discussion
It is not easy to define an old person. Two different definitions have been put forward
8
: A French definition includes 2 subgroups. First, the retirement age when people are more than 60 years old and the age beyond 75. A North American definition considers people “old” when they are aged 50. It includes 2 subgroups: the old ones (less than 85) and the older ones (more than 85). As far as this study is concerned, the retirement age should not be the only criterion. In our context, few old people have had an occupation leading to a retirement pension. We chose 60 years as a benchmark, based on the categorization of old people by the World Health Organization. In clinical terms, our findings echo the current literature in many respects:
We noticed that most of our patients belong to the category of elderly people, whereas in richer countries, older people predominate, 20 life expectancy being longer in such countries. In therapeutic terms, surgery has been the most used method with our patients. Thanks to the improvement in operative techniques and the simplification of the setting of implants in addition to the progress made regarding anesthesia–resuscitation, currently the treatment of fractures among elderly people is still done primarily through surgery. This allows getting or restoring early motor autonomy in patients while avoiding such deleterious complications as compromising vital prognosis, especially concerning fractures of the lower limb. 21 However, it should be stressed that a significant number of patients (17%) received a functional treatment. This related mostly to patients with a proximal femoral fracture involving an anesthetically surgical contraindication. Such a treatment did not mean any therapeutic isolation but rather demands the full involvement of the family. This study shows that the expense item corresponding to the services leading to the surgical treatment is the most costly of them all (79.61%). This is due to the para clinical examination performed, expenses relating to the operating room and implant, and hospitalization. Proximal femur fractures boosted the cost; they dominate and account for 43.46% of the direct global cost of 22 443 euros. Such fractures are a real epidemic among elderly people. 19 The number will reach 6.26 million in 2050, more than 70% of which will occur in developing countries. 22 Many writers have pointed out the high cost relating to the treatment of such fractures, especially during the postoperative period. 23 –25 According to Norris, the total hospital expenses concerning all peripheral fractures amount to half of that relating to the higher end of the femur. 26 Contrary to observations made in poor countries, 2,3,23,24 hospital cost is very low in our study (5.02%). Our patients are reunited with their family at home as soon as they are discharged from the hospital. Postoperative follow-up (rehabilitation, home-based care, etc) occurred out of hospital. There is no center for rehabilitation, convalescing, or retirement. Such institutions boost the cost of treatment. It should be noted that we did not include in our assessment any additional medical treatment (analgesics, antibiotics, and anticoagulants) or rehabilitation. These 2 kinds of treatment could not be assessed in any precise way, given their specificity regarding each patient. Nowadays, fractures among elderly people are a major area of the study of trauma in musculoskeletal system, in developed countries. 27 They entail considerable expenses, in medical terms. There are social welfare schemes to meet the needs of elderly people. In Africa, few experts show any interest in pathology among elderly people, especially fractures, and there are almost no social welfare schemes. Zebaze study in Cameroon pointed out this problem and the lack of preventive and curative measures. 28
Other writers argue that such fractures were scarce. 29,30 Nevertheless, a study carried out in Senegal in 2005 relating to the proximal femoral fractures showed that 70% of these lesions occurred among people aged at least 60, with a low-energy predominant mechanism (accidents in the home involving a fall). 31 Among elderly people, medical cover is a problem. Of 650 000 people aged at least 60, in Senegal, only 15% have access to any social security scheme in case of disease. According to statistical forecasts, there will be a proportion of 11% among elderly people by 2011. 32
Conclusion
Fractures among elderly people will become a major issue in Senegal. Proximal femur will remain the main area affected, entailing high treatment costs. Solidarity and emergency funds should be created for old people, based on countries’ resources.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.