SLR - November 2020 - Jacob M. Perkins

Reduction of Routine Use of Radiography in Patients with Ankle Fractures Leads to Lower Costs and Has No Impact on Clinical Outcome: An Economic Evaluation

Reference: van Gerven, P., van Dongen, J.M., Rubinstein, S.M. et al. Reduction of Routine Use of Radiography in Patients with Ankle Fractures Leads to Lower Costs and Has No Impact on Clinical Outcome: An Economic Evaluation. BMC Health Serv Res 20, 893 (2020). https://doi.org/10.1186/s12913-020-05725-1

Scientific Literature Review

Reviewed By: Jacob M. Perkins, DPM 
Residency Program: UF Health Jacksonville – Jacksonville, FL

Podiatric Relevance: Ankle fractures are a routine podiatric pathology seen in a typical clinic and each patient is treated objectively on what would best address their medical needs; however sometimes socioeconomic factors can play a significant role in compliance and follow up care. Being able to not only treat patients effectively from a surgical and medical standpoint, but also in the most cost-effective way possible, can potentially lead to better outcomes if patients and insurances are better able to afford the treatment. There is little research on cost effectiveness of omitting routine extremity radiographs, and if similar outcomes can be reached with reduced routine radiographs, it may be easier for patients to facilitate appropriate follow ups and potentially ensure better compliance. 

Methods: This multicenter, randomized controlled trial of 246 participants compared a control group “usual care” (128 patients) with a “reduced imaging” intervention group (118 patients). Of note, 60 percent of patients in usual care and 65 percent in intervention group had surgery. The control care had outpatient follow up radiographs at one, two, six, and twelve weeks follow up. The intervention group had follow up radiographs at one and two weeks, and later radiographs were only obtained if there was an indication to do so. These indications were new onset trauma, pain score of six or higher on the Numerical Rating Scale, an interval decrease ankle ROM, or neurovascular defects. Other than the imaging protocol, both groups were treated similarly. Cost was compared using resource use questionnaires amongst categories of intervention, primary care, secondary care, medication, informal care, absenteeism, presenteeism, unpaid productivity loss. 

Results: Functional status of the ankle was evaluated using Olerud and Molander Ankle Score, which assessed both pain and disability. There was no statistical significant difference in the groups. There was a significant reduction in costs in radiographs as to be expected, and the other cost categories were not statistically different. 

Conclusions: The outcomes demonstrate a significant decrease in associated costs compared to control group. Although when grouped with all other associated costs the impact seems to decrease, there is still an overall reduction of what the patient has to pay for OMAS scores that are not statistically different. This brings into question about what, if any, other treatment protocols can possibly be re-evaluated for overall economic efficiency in treatment plans. 

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