The socioeconomic impact of a femoral neck fracture on patients aged 18-50: A population-based study

Highlights

• By linking health and census data, the study estimates the effect of a hip fracture on household income in non-elderly Canadian patients.

• Over a quarter of non-elderly hip fracture patients in the study sustained a decline ≥2 deciles in their household income following their injury.

• Patients with a pre-injury household income in the top 4 income deciles were 38% more likely to experience ≥2 deciles of income decline.

Abstract

Background

By linking health and census data, the objective of this study was to determine the effect of a femoral neck fracture on the household income of non-elderly patients.

Methods

All individuals aged 18–50 who underwent internal fixation for a femoral neck fracture during the years 2006–2012 in the Canadian Province of British Columbia were included in the study. Patient-level hospital data was linked with patient’s after-tax household income decile, as estimated by Statistics Canada Postal Code Conversion Files. The primary endpoint was a decline of ≥2 income deciles following the index fracture. Kaplan-Meier analysis was performed to estimate the probability of income decline during the study period. A Cox regression model was used to study the association between a ≥2 income decline and patient age, sex, reoperation, and pre-injury income decile.

Results

Of the 391 femoral neck fracture patients included, the majority of patients were male (61.6%), with a median age of 43 years (IQR: 35–48), and a pre-injury median income in the fifth decile (IQR: decile 3–8). 27.0% of patients sustained a decline of ≥2 income deciles during the study period, with 16.3% declining ≥2 income deciles within 2-years of injury. A pre-injury household income in the top 4 deciles (mean of deciles: $57,000–170,500) was associated with an increased likelihood of a ≥2 drop in household income (HR: 1.38, 95% CI: 1.06–1.79, p = 0.02).

Discussion

Over a quarter of the femoral neck fracture patients in this study sustained a decline of ≥2 deciles in their household income following their injury. The income decline was disproportionately absorbed by patients with baseline incomes in the 6^th decile or higher. This suggests that the available incapacity programs are limited in providing income protection to patients with higher incomes.

Introduction

Sudden health events, such as myocardial infarction, a cancer diagnosis, or a femur fracture, bear substantial medical costs. A principal objective of healthcare insurance is to pool the risk of these health events among individuals, and therefore providing financial protection for the patient against a catastrophic health expenditure [1]. In Canada, and as in most countries of the Organisation for Economic Co-operation and Development (OECD), health systems and financial risk-pooling mechanisms have been developed to protect patients from catastrophic health expenditures [1]. However, less attention is directed towards the economic impact of these health conditions beyond direct healthcare expenditures.

Following recommendations by the National Academy of Sciences in 1966 that stated trauma should be recognized as an important public health issue [2], trauma systems in OECD countries have observed rapid advances in improving access and quality of care [3]. Financial protection against emergency medical costs is generally included in countries with universal health insurance coverage or supported through additional forms of protection such as the Emergency Medical Treatment and Active Labor Act in the United States [4]. The coverage of post-acute medical costs can vary substantially among countries. Protecting individuals from employment income loss following a medical condition may include private disability protection, workers compensation for work-related injuries, or incapacity protection by a government welfare system that may consist of employment insurance and disability coverage [5].

Resuming economic activities after an injury is important to patients and predictive of future health [6,7]. However, there is a paucity of data on the long-term economic impact of an orthopaedic injury or the effectiveness of post-acute financial protection in mitigating economic loss. A recent study in Italy estimated that patients with a pelvis or acetabular fracture lost over 17,000 euros in income due to lost productivity [8]. This estimate was calculated as the monetary value of one lost working day multiplied by the gross domestic product of the country per day. However, the study failed to account for any long-term impairment in productivity or modifications in occupation. Rotondi et al investigated the impact on fragility fractures on return to work and work productivity in a Canadian cohort and found 86% of the sample returned to work within 6-months with no work modifications [9].

Understanding the long-term economic impact of orthopaedic injuries is essential to developing effective health and welfare policies that provide long-term financial protection to patients and their families. Knowledge of the economic consequences of injury is also of value to the treating surgeon, to not only prepare fracture patients for the financial challenges they may face during recovery but also to refer their patients to other services or programs equipped to support the patient’s socioeconomic recovery.

Among orthopaedic injuries, femoral neck fractures in non-elderly adults are known to be associated with substantial healthcare costs [10]. These fractures often are the result of high-energy trauma, and successful treatment is challenging due to difficulty in preserving the native hip joint [[11], [12], [13], [14]]. Complications rates for femoral neck fractures in non-elderly adults likely exceed 20% and can substantially impact physical function [[14], [15], [16], [17]]. Given the challenges in treating femoral neck fractures and high rate of complications for this injury, it is a valuable benchmark for future post-injury financial protection policy.

By linking health and census data, this study aimed to describe the associated effect of a femoral neck fracture on the household income of non-elderly patients. The secondary objective was to determine the independent associations between post-fracture income decline and patient sex, age, pre-injury income, and reoperation for bone-healing complications. Furthermore, we investigated if income loss within the first two-years of injury was sustained.