2.1 Eligibility criteria

Studies were included if they: (1) were randomized controlled trials or comparative cohort studies (prospective or retrospective) evaluating hip fracture-related surgical treatments/interventions; (2) used real-world clinical data (simulation-only studies were excluded); and (3) reported a quantitative value comparison that incorporated both cost and quality measures.

Studies were excluded if they were not written in English, lacked full-text availability, did not compare two or more cohorts, relied on data not collected by the study institution, or did not report a clearly defined value equation incorporating both cost and quality components.

2.2 Search strategy and study selection

Search strategies were customized for each database to capture studies assessing healthcare “value,” recognizing that terminology and operational definitions varied across publications. Value-based care terms were combined using Boolean operators and wildcards to maximize sensitivity. Full search strategies were provided in the Supplemental File. After database export, duplicates were removed using Microsoft Excel through automated deduplication, followed by manual review as needed.

Title/abstract screening (and figures when necessary) was completed independently by at least two reviewers (Z.C., M.G., S.B., and T.H.) to determine eligibility. Disagreements were resolved through group discussion among all reviewers until consensus was achieved.

2.3 Data extraction and definitions

Data extraction was performed independently by four reviewers for all included studies. Extracted variables included publication year, geographic region, hip fracture pattern/pathology, intervention(s), economic evaluation perspective, costing methodology, quality outcome metric(s) with associated characteristics, and value equation(s). Key findings were summarized for each study, with emphasis placed on commonly evaluated hip fracture patterns. Operational definitions for extracted variables were provided in Tables 1 and 2.

2.4 Cost framework

Because reported costs varied by analytic perspective, cost inputs were recorded and then classified according to the perspective used (e.g., hospital/clinic, payer, or societal). Costs were organized into medical and non-medical categories to support cross-study comparisons. Medical costs included direct fixed, direct variable, indirect, and out-of-pocket components. Non-medical costs included non-medical direct and non-medical indirect costs. Definitions and examples for each category were provided in Table 2. This framework was used to harmonize costs derived from heterogeneous sources (e.g., claims data, patient-reported diaries, institutional financial records) and to support consistent comparison of costing methodologies across studies.

2.5 Quality metrics and value calculations

Quality outcomes were extracted only when explicitly incorporated into a study's quantitative value calculation; quality metrics reported without inclusion in a value equation were excluded from value input extraction. For each included quality metric, characteristics were recorded, including whether the measure was subjective vs objective and whether it was internally vs externally validated. The review focused on studies reporting explicit quantitative value estimates for hip fracture interventions, including cost-effectiveness analyses using clinical/functional outcomes and cost-utility analyses incorporating preference-based health measures (e.g., QALYs) to facilitate comparisons across conditions and subspecialties.^23,24

4.1 Summary of results

This systematic review examined 16 studies published over the past 20 years that compared value in orthopaedic hip fracture care using real-world clinical data and an explicit value framework incorporating both cost and quality. Most included studies were conducted in Europe, with only two originating from the United States.

Value-focused comparisons spanned multiple domains, including differences in surgical approach, perioperative care pathways, and postoperative rehabilitation strategies. Emerging delivery models, including integrated care pathways and home-based rehabilitation, demonstrated potential to improve outcomes while limiting costs. Across studies, cost-effectiveness in hip fracture care appeared to depend on multiple interacting factors, including patient demographics, clinical setting, and broader health system context, underscoring the complexity of value assessment in this population.

Most studies used cost-utility analyses and reported incremental cost-effectiveness ratios (ICERs). The societal perspective was most frequently used for cost identification, and the EQ-5D instrument, commonly converted to quality-adjusted life years (QALYs), was the most frequently reported quality metric.

The primary hypothesis, which anticipated that most studies would be conducted in Europe with a smaller contribution from the United States, was supported. The secondary hypothesis, which anticipated that cost-utility methods and ICERs would be the most common approach to value measurement, was also supported.

4.2 Summary of relevant existing literature

The push toward value-based care in hip fracture management has gained momentum in recent years, with an increasing focus on balancing cost and quality outcomes.^39,40 A key challenge in current value-based care models is the reliance on quality measures such as mortality and readmission rates, which are frequently used in programs like those initiated by the Centers for Medicare & Medicaid Services (CMS). While these metrics are important, they fail to capture the full spectrum of patient outcomes, particularly those related to functional recovery and quality of life.⁴⁰ This narrow focus risks alienating a large proportion of patients whose outcomes matter deeply but are not adequately reflected in these statistics. Expanding the scope of quality measures to include patient-centered outcomes is essential for a more comprehensive evaluation of value in hip trauma care.

The current state of cost-effectiveness analyses in hip fracture care demonstrates substantial progress, with many studies leveraging modeling techniques, such as Markov models.^41,42 These models are invaluable for simulating long-term outcomes and evaluating the value of specific interventions over time.^43,44 However, while these simulated approaches have enriched the value space, they cannot fully account for the real-world complexities of hip fracture care, which is influenced by patient-specific demographic factors in addition to the variations in case complexity.⁴⁵ Moving forward, real-world data can complement simulated models to provide an accurate and nuanced understanding of the true costs and outcomes associated with hip fracture interventions.^43,45

4.3 Comparison of our results to literature (our included study findings versus clinical recommendation standards

The included studies highlight several key findings on the cost-effectiveness of hip fracture interventions. While implant choice and surgical techniques matter, broader healthcare delivery models, rehabilitation strategies, and treatment settings are particularly relevant for clinical decision-making. From our included studies, nutritional and rehabilitation interventions showed variable cost-effectiveness, while home-based post-acute care and ortho-geriatric models were more cost-effective than hospital-based care. The cost-effectiveness of all interventions was influenced by contextual factors like patient age, willingness-to-pay thresholds, and care settings. In older institutionalized patients with limited life expectancy, non-operative management was cost-effective in the short term due to the high upfront cost of surgery.

These findings only partially align with current standards of care. Nutritional interventions have been linked to improved healing and reduced complications, but outcomes depend on factors like intervention type, adherence, comorbidities, and baseline nutritional status. Similarly, while rehabilitation is essential for functional recovery, studies differ on the most effective strategies, intensity, and settings—whether inpatient, outpatient, or home-based care.⁴⁶ Without clear evidence on which specific nutritional and rehabilitation approaches offer the most value, there remains a risk of implementing costly strategies that may not significantly improve outcomes, highlighting a need for analyses that determine which intervention yields the best balance of clinical benefit and economic sustainability. Future research should focus on identifying which subgroups benefit most from tailored interventions to optimize resource allocation.

In terms of operative versus non-operative management in geriatric patients, there are differences in our results compared to existing literature. In the geriatric population, operative management has been the standard of care compared to non-operative management, with non-operative management being associated with considerably larger mortality and morbidity.⁴⁷ While non-operative management may be appropriate for a small subset with severe comorbidities or limited functional capacity, this group is difficult to define precisely. For most patients, surgery remains the recommended approach.

These insights underscore the importance of personalized, context-dependent care in hip fracture management. The heterogeneity of cases presents both clinical and financial challenges for applying cost-effectiveness analyses.^18,19 Variability in study designs, differing willingness-to-pay thresholds, and a lack of consensus on specialty-specific value metrics underscore the need for a standardized value formula. Future work should develop a consistent framework integrating factors like cost, QALYs, and hip fracture-specific outcomes, enabling objective value assessments and supporting evidence-based, cost-effective decision-making.

4.4 Limitations of the current study

This systematic review has several limitations. Reliance on existing studies introduces bias from varying methodologies, such as most studies being conducted in European single-payer healthcare systems. This makes it challenging to generalize results based on the different ways healthcare is paid for by various countries. Excluding simulated data studies may have narrowed the scope of included evidence, though these aligned with our focus on real-world data. Finally, excluding non-English studies may have resulted in the omission of relevant literature pertinent to this review.

4.5 Take-home points and conclusions

Hip fracture care is complex, with diverse variables that demand comparative value analyses to improve delivery. Our review highlights a gap in the literature, with limited studies utilizing real-world data to assess cost-effectiveness in this high-impact population. Among available studies, substantial variability in the types of comparisons made and the specific pathologies analyzed has made it difficult to draw consistent conclusions. Moving forward, we recommend that future value studies incorporate the following elements. First, with costing, research must incorporate the hospital/clinic perspective. Understanding perioperative cost structures and identifying institutional opportunities through this perspective allows providers to directly engage in value optimization strategies. Second, studies should continue to use patient-reported outcome measures that can be transformed into Quality-Adjusted Life-Years (QALYs). This will allow for direct comparison between differing treatments and medical specialties. Third, value should be measured using cost-utility ratios and the ICER equation, which was used in the majority of studies analyzed.

Given the frequency of hip fractures and their relevance to orthopedic surgeons, hospitalists, and rehabilitation teams, future research should focus on optimizing the value of various delivery models, rehabilitation strategies, nutritional support, and treatment settings. These factors influence clinical decision-making and resource allocation, and the further integration of quantitative value formulas can continue to compare how each variable affects patient care.

Since hip fractures are treated in nearly every hospital, the need to enhance cost-effective care is particularly pressing. Future studies that integrate both cost and quality metrics can provide actionable insights that improve patient outcomes while ensuring economic sustainability in hip fracture management.^48,49