SLR - April 2021 - Sara Mateen
Costs of Care for Low-Energy Extremity Gunshot Injuries are Reduced with Standardized Treatment
Reference: Nguyen MP, Savakus JC, Reich MS, Golob Jr. JF, McDonald AA, Como JJ, Vallier HA. Costs of Care for Low-Energy Extremity Gunshot Injuries are Reduced with Standardized Treatment. J Orthop Trauma. 2021; 35(2): e61-e63.
Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Sara Mateen, DPM
Residency Program: Temple University Hospital – Philadelphia, PA
Podiatric Relevance: Lower extremity gun-shot wounds (GSWs) are commonly encountered among podiatric surgeons, especially those associated with a level one trauma center. The national economic impact of gunshot-related injuries and medical treatment exceeds $2.7 billion annually with the number of GSWs and healthcare costs rising. Previous publications have discussed single IV antibiotic dosing as a treatment in the emergency department without the need for formal debridement of extremity wounds, but did not specifically look at low-energy injuries and overall cost. The main objective of this publication was to determine the overall treatment cost associated with low-energy GSWs and determine potential cost savings with single-dose IV antibiotic treatment in the ER.
Methods: This was a level four retrospective chart review at an urban level one trauma center that evaluated 460 low energy GSWs in 380 patients with an average age of 30 years from 2010-2014. High energy GSWs or GSWs not involving the extremities were excluded from this study. Patients requiring vascular or nerve repair, fractures requiring fixation and patients with compartment syndrome requiring fasciotomies were also excluded. Eligible patients included were extremity only GSW with soft tissue injuries only, nonoperative fractures, and GSW tranversing a joint without intraarticular pathology or retained bullet fragments. Injury Severity Score (ISS), injury location, type and duration of antibiotic treatment, inpatient admission and surgical intervention were reviewed. Costs were also calculated including fixed and variable costs.
Results: Out of the 380 patients with 460 GSWs, there were 309 admissions, 273 operations performed, and 1010 days of antibiotics administered. The most common procedure performed was fracture stabilization (46.2 percent). Overall total facility cost was $1,701,154 with most of the cost coming from inpatient admission (73.2 percent) and operating room time (24.8 percent). Among 132 patients, there were 108 unnecessary admissions ($147,735), 26 unnecessary debridements ($40,144), and 322 days of unnecessary antibiotics ($11,828). The single IV antibiotic dose pathway would have saved approximately $1,436 per patient with low-energy GSWs in facility expenses.
Conclusions: Overall, the authors concluded that costs associated with patients with isolated low-energy extremity GSWs is high and with single IV antibiotic dosing in the emergency department, orthopedic expenses can be reduced substantially. Aside from cost saving, the single-dose care pathway can also eliminate unnecessary procedures and possibly bacterial resistance from prolonged antibiotic use. One major limitation of this study is that the authors did not factor in ER cost as well as the cost of professional services. In conclusion, the study provides compelling findings of treating low-energy GSWs with single-dose antibiotics and local wound care to minimize cost.