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Title: The health and economic outcomes of managing complex proximal humerus fractures in the elderly
Author: Sabharwal, Sanjeeve
ISNI:       0000 0004 7228 9341
Awarding Body: Imperial College London
Current Institution: Imperial College London
Date of Award: 2017
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Proximal humerus fractures represent a significant burden to society in terms of disability to patients and healthcare costs. This thesis investigates the costs, health outcomes and cost-effectiveness of treatment strategies for the management of complex proximal humerus fractures in elderly patients. A meta-analysis of randomised trials comparing treatment strategies was performed. A qualitative clinical study was conducted exploring patient perceptions of their injury and recovery. A cost-analysis based on the principles of time-driven activity base costing was conducted to investigate the institutional burden of treatment costs relative to the national tariff. Finally, two separate health economic evaluations (HEEs) were performed which investigated the cost-effectiveness of existing treatment strategies over a 2-year and a 20-year time horizon. Sub-group and sensitivity meta-analysis demonstrated that clinical outcomes were improved for patients undergoing hemiarthroplasty for 4-part fractures. Qualitative analysis revealed that patients perceived the following themes as important in their recovery; pain, sleep, shoulder function, emotional state, support networks, relationship with health professionals and experience of healthcare institution. The cost analysis found that there were wide variations in treatment costs and large institutional losses were incurred if hemiarthroplasty was performed. The HEEs found that hemiarthroplasty was the most cost-effective treatment strategy, however the 20-year model was less prone to uncertainty based on sensitivity analysis. Despite a quantifiable benefit to health outcomes when hemiarthroplasty is performed in an elderly population with complex fractures, the national tariff in the English NHS may not adequately reimburse hospitals that perform this procedure. Furthermore, this inequity in financial reimbursement extends beyond the penalisation of clinically effective treatment; hemiarthroplasty also represents the most cost-effective treatment strategy for complex proximal humerus fractures in the English NHS. Finally, the measures of health outcomes within this field need further development so that they better represent the perceptions of the target population.
Supervisor: Reilly, Peter ; Gupte, Chinmay Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral