SLR - October 2015 - Hannah Johnk

Cost Consequence Analysis of Implementing the Low Risk Ankle Rule in Emergency Departments

Reference: Boutis K, von Keyserlingk C, Willan A, Narayanan UG, Brison R, Grootendorst P, Plint AC, Parker M, Goeree R. Cost Consequence Analysis of Implementing the Low Risk Ankle Rule in Emergency Departments. Ann Emerg Med. 2015 Jul 10

Scientific Literature Review

Reviewed By: Hannah Johnk, DPM
Residency Program: Unity Point Health - Trinity Regional Medical Center

Podiatric Relevance: According to the author, pediatric ankle injuries result in more than two million emergency department visits in Canada and the US each year. Radiographs are ordered for 85-95 percent of these children, although only 12 percent of these reveal a fracture. Ankle fractures are one of the most common injuries treated by podiatric physicians. The Ottawa Ankle Rules are often used to determine whether radiographs are appropriate; however, they only reduce ankle radiographs by 10-15 percent due to their low specificity. The Low Risk Ankle Rule has been shown to have higher specificity, reducing imaging by 50-60 percent. The goal of this study was to compare the costs and clinical consequences of managing pediatric ankle injuries using the Low Risk Ankle Rule versus control sites.

Methods: In this prospective, pair-matched controlled study, six Canadian emergency departments were evaluated for their treatment of pediatric ankle injuries, specifically including radiograph use. There were no changes made to usual practice at the three control sites. At the three intervention sites, there were three consecutive 26-week phases. No changes to treatment practices were made during phase one. In phase two, staff was educated about the Low Risk Ankle Rule and its practical implications, but the ultimate treatment decision was left to each provider. In phase three, a computer support system was responsible for radiology decisions.

Children between ages 3 and 16 years who presented with an acute ankle injury with no previous radiographs were eligible. Exclusion criteria included developmentally delayed children, children at risk for pathologic fractures, or children who had recent injury to the same ankle. Extensive data collection was performed for each visit, including whether a radiograph was performed, lengths of ED stay, follow-up visits to determine missed diagnoses, and total cost analysis. An economic evaluation team separate from the clinical evaluation team to minimize bias performed the cost analysis.

Results: Cost data from 2,151 children with acute ankle injuries was used. There was a statistically significant decrease in costs of $36.93 per patient at the intervention sites from phase one to phases two and three compared to control sites. Reduced radiography costs were the largest contributor, accounting for -$18.58 per patient; this was the only statistically significant change in costs. Out-of-pocket costs to patient were $2.09 higher at intervention sites, which was not statistically significant.

There was a 22.9 percent decrease in ankle radiographs at the intervention sites from phase one to phases two and three. There was no statistically significant difference in missed clinically important fractures between the intervention and control groups when Low Risk Ankle Rule was implemented. During implementation, sensitivity of the rule was 100 percent.

Conclusions: This study revealed that implementation of the Low Risk Ankle Rule safely reduced total number of radiographs by 23 percent, resulting in a significant decrease in healthcare costs, while producing no difference in missed clinically important fractures. While some may argue that radiographs are a good source of income in their practice, the rising costs of healthcare cannot be ignored. With the increase in patients with government-funded health insurance, as well as an increase in capitation payment systems and value-based reimbursement, we as physicians must do our part to decrease healthcare costs.

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