SLR - August 2019 - Spenser Alan Soldano

Cost Comparison of Surgically Treated Ankle Fractures Managed in an Inpatient Versus Outpatient Setting

Reference: Bettin C, Nelson R, Rothberg D, Barg A, Lyman M, Saltzman C. Cost Comparison of Surgically Treated Ankle Fractures Managed in an Inpatient Versus Outpatient Setting J Am Acad Orthop Surg. 2019 Feb 1;27(3):e127-e134. Doi: 10.5435/JAAOS-D-16-00897

Scientific Literature Review

Reviewed By: Spenser Alan Soldano, DPM
Residency Program: University of Florida Health – Jacksonville, FL

Podiatric Relevance: As the United States continues to transition into a value-based health care system, costs become a major focus in all areas of medicine including foot and ankle surgery. While the percentage of podiatric-managed ankle fractures remains relatively small in comparison to orthopedic surgeons, this number continues to grow annually. It is imperative that podiatric surgeons not only focus on patient outcomes but also economic factors such as health care costs associated with treatment. This article seeks to compare costs between inpatient and outpatient surgical fixation of ankle fractures and to establish a record of cost information to allow foot and ankle surgeons to make better economic choices for their patients.

Methods: This is an IRB approved retrospective cohort study. All surgically treated isolated closed ankle fractures occurring between July 2013-July 2015 were recorded at a single hospital or hospital-owned outpatient surgical center using a CPT code search for fracture fixation. For example: 27792 ORIF of the lateral malleolus. Open fractures, bilateral fractures or polytrauma were excluded from the study.  Surgeries were grouped into inpatient or outpatient-based on the location of the patient at time of surgery. Hospital costs were recorded using the Value Driven Outcome tool, which accounts for all healthcare costs related to patient care. Costs were placed into various categories: facility and labor, imaging, implants and supplies, laboratory and pharmacy, with all fees from the ED visit being excluded. Univariate and multivariate regression analysis was then used to compare costs of surgical fracture repair in the outpatient and inpatient setting. Demographic data was also collected such as age, sex, and BMI among others.

Results: This study included 148 patients, with 61 inpatient surgeries and 87 outpatient surgeries. Outpatient surgery was associated with 50 percent lower costs than inpatient surgery overall. 46 percent lower facility and labor costs in the outpatient group was the primary reason for lower overall costs. When controlling for variables between groups, outpatient care was 31.6 percent lower than inpatient care of surgically treated fractures. Obesity was associated with 21.6 percent higher costs than non-obese patients regardless of where the surgery took place.

Conclusions: Based on the current study, total costs associated with ankle fracture surgery were significantly higher when performed as an inpatient. This is largely due to the higher facility and labor expenses associated with hospital inpatient care. Inpatients were typically unhealthier in comparison to outpatients, however, when controlling for these differences the overall costs of care were lower in the outpatient group. The author recommends that special consideration should be taken when deciding inpatient versus outpatient surgical management of ankle fractures. When appropriate, outpatient surgical management should be favored due to lower costs and overall economic burden to the health care system.

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