SLR - April 2021 - Clair Cadena Miranda

Estimates of Direct and Indirect Costs of Ankle Fractures: A Prospective Analysis

Reference: Noback PC, Freibott CE, Dougherty T, Swart EF, Rosenwasser MP, Vosseller JT. Estimates of Direct and Indirect Costs of Ankle Fractures: A Prospective Analysis. J Bone Joint Surg Am. 2020 Dec 16;102(24):2166-2173. doi: 10.2106/JBJS.20.00539. PMID: 33079902

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Clair Cadena Miranda, DPM
Residency Program: Carl T. Hayden VA Medical Center – Phoenix, AZ

Podiatric Relevance: Overall, cost-effectiveness analysis is important to assess in all realms of healthcare so that we can hopefully grow toward better health care efficiency.  

Methods: This is a prospective, observational study of patients treated operatively and non-operatively for ankle fractures. The direct and indirect costs were reported. Patients were included if they were at least 18 years old and could read and write in either English or Spanish. Patients were excluded if they were unwilling to provide consent, unable to complete surveys, had multiple concomitant injuries or the date of injury was greater than six weeks prior to initial consult. All fractures were classified using the Weber classification. Patients were followed over a four-year period until recurring indirect costs amounted to zero. Direct costs were calculated using patient billing records. Indirect costs were self-reported by patient completed cost assessments at every visit and included lost work as well as cost associated with transportation, household chores and self-care.

Results: Sixty patients were ultimately included in the study. Thirty-seven were treated operatively. Thirty-seven patients reported working full time prior to their injury, two were working part-time and 21 were either retired or unemployed. Total cost was found to be significantly different between operative and non-operative patients. Total direct costs were significantly higher ($23,938) in operative group compared to the non-operative group ($3,611). However, total indirect costs were not significantly different between groups. Missed work accounted for the largest total cost and indirect cost associated with ankle fracture treatment for both groups. 

Conclusions: Overall, the authors found that direct costs were higher in operative patient than the non-operative patient, which is not surprising given associated surgical costs in the operative group. However, indirect costs were relatively equal across groups. Indirect costs were the largest cost component amongst both operative and non-operative ankle fracture patients accounting for 41.3 percent of overall cost. The majority of direct costs were accrued in the immediate period following injury, however indirect costs were incurred for five months or longer. It is important to consider the indirect cost following injury with a focus on reducing indirect costs, specifically missed work. In the future, it is important to develop treatments that can reduce indirect costs following ankle fractures. 

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