Cost-Effectiveness of Emergency Department Ultrasound-Guided Nerve Blocks for Older Adults With Hip Fracture: A Monte Carlo Cost-Utility Analysis

Hip fractures in older adults are a common Emergency Department (ED) presentation and are known to increase risk of delirium as well as inflate healthcare costs. Although ultrasound-guided nerve blocks (NB) in the ED reduce delirium and improve pain control, their overall economic utility is still unclear. We aimed to assess the cost-utility of NB in ED compared to usual care for older adults with hip fracture.

We used a probabilistic Monte Carlo cost-utility model with 10,000 simulations. Parameter estimates were derived from randomized trials, systematic reviews, and population studies. The analysis adopted a hospital perspective over 90 days and involved older adults aged 65 years and older presenting to United States EDs with hip fracture. The intervention was ultrasound-guided fascia iliaca block in the ED compared to usual care without NB. The primary outcomes were total hospital costs and quality-adjusted life-years (QALY) at 90 days. Secondary outcomes included delirium incidence, hospital length of stay, opioid use, and home discharge. We evaluated cost effectiveness with a willingness-to-pay threshold of $100,000 for each QALY.

The NB strategy resulted in lower mean total costs ($31,109 vs $39,119) and higher mean QALYs (0.1731 vs 0.1705), with mean cost savings per patient at $-8,009 (95% CI, $-39,353 - $20,587) and a QALY gain of 0.0031 (95% CI, -0.0108 - 0.0189). NBs were associated with less delirium (25% vs 35%), shorter length of stay (6 vs 7 days), and reduced opioid use (80 vs 140 MME). At a cost per QALY of $100,000, the likelihood of cost-effectiveness was 71.4%. NB strategy was dominant in 58% of simulations. A national implementation based on a 52.9% adoption would save approximately $800–850 million per year. These results were replicated across sensitivity analyses.

The application of NBs for older adults with hip fracture in ED appears to save healthcare costs while achieving modest quality-of-life benefits. This intervention reduces delirium incidence, shortens the hospital lengths of stay, and decreases opioid use. These results further justify the integration of NBs in hip fracture care pathways, especially in hospitals with high patient volumes. Future research should investigate skill barriers across EDs that limit fascia iliaca availability and potential system fixes, such as machine learning algorithms for procedural guidance.