High Costs of Delayed Diagnosis of Septic Hip

Source: Nielsen E, Mortimer JA, Bompadre V, et al. The price for delayed diagnosis of pediatric septic hip: increased cost and poor outcomes. J Pediatr Orthop. 2024;44(10):614-618; doi: 10.1097/BPO.0000000000002791.Investigators from multiple institutions conducted a retrospective study to quantify the increase in interventions, length of hospital stay (LOS), and outpatient follow-up care associated with delayed vs non-delayed diagnosis of septic hip in children. For the study, they reviewed the medical records of patients treated for septic hip at a single children’s hospital between 2011 and 2016. Data abstracted from the records of study participants included duration of symptoms prior to diagnosis and laboratory values at presentation. Information on the inpatient hospital stay included number of irrigation and debridements (I&Ds) required, development of osteomyelitis, placement of a peripherally inserted central catheter (PICC) line, duration of antibiotic treatment, and LOS. The duration of outpatient follow-up care and occurrence of long-term complications was documented in study patients. The overall hospital charges for treatment of the septic hip also were recorded. Study patients were categorized as having a delayed diagnosis if symptoms were present for >4 days before diagnosis or a non-delayed diagnosis if symptoms were present for ≤4 days. Differences between the 2 groups (delayed and non-delayed diagnosis) were assessed using chi-square and t-tests.Data were analyzed on 43 children, with 12 (27.9%) having a delayed diagnosis. The mean duration of symptoms for patients in the delayed and non-delayed diagnosis groups were 11.3 and 2.1 days, respectively. At presentation, there were no significant differences between groups for most laboratory values except for erythrocyte sedimentation rate (ESR), which was significantly higher among those with a delayed diagnosis (mean 75.8 ±30.6 vs 43.3 ±27.3; P = 0.002). Children in the delayed diagnosis group had more I&Ds than those in the non-delayed group (median 2 and 1, respectively; P = 0.04), had longer mean duration of antibiotic treatment (7.8 ±4.3 and 5.5 ±2.3 weeks, respectively; P = 0.04), were more likely to require a PICC line (50% and 13%, respectively; P = 0.01), and had a longer mean LOS (17.4 ±13.4 and 9.1 ±4.5 days, respectively; P = 0.003). Among those in the delayed diagnosis group, 4 (33%) developed concomitant osteomyelitis compared to 0 patients in the non-delayed group (P = 0.004). Length of outpatient follow-up was significantly longer for children with a delayed diagnosis, and 5 of these patients had long-term complications, most commonly avascular necrosis, compared to 1 of those with a non-delayed diagnosis (P <0.001). Total charges for treatment of the septic hip for those in the delayed and non-delayed diagnosis groups were $243,411 and $102,775, respectively. (P = 0.01).The authors conclude that a delay in diagnosis of septic hip in children was associated with the need for more treatment and led to a higher rate of complications than when patients were diagnosed in a more timely manner.Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The diagnosis of a pediatric septic hip is based on clinical examination findings, laboratory values, imaging studies, and synovial fluid analysis, including culture.1 In the current study, synovial fluid aspiration was performed either before proceeding to the operating room (OR) or in the OR before I&D.The results of prior studies have demonstrated that early diagnosis and treatment of a pediatric septic hip within 4 days of symptom presentation can reduce the risk of osteomyelitis, avascular necrosis, and the need for future reconstructive surgery.2-4 However, to date, no prior investigator has evaluated the health care cost and value of this delay. Health care value is defined as outcomes relative to costs.5In the current study, delayed diagnosis of a pediatric septic hip led to more I&Ds, more antibiotics, longer hospitalizations, more PICC lines, longer follow-up, a higher rate of hip avascular necrosis, and double the hospital charges/costs compared to a non-delayed diagnosis. A delay in diagnosis of a pediatric septic hip results in worse outcomes, higher cost, and therefore, a significant decrease in health care value.The initial assumption of the authors in the current study was that a delayed diagnosis would be associated with significant abnormalities in WBC count and CRP as well as hemodynamic changes. Interestingly, with the exception of a higher ESR in patients with delayed diagnosis, laboratory tests and vital signs were similar in those with and without a delayed diagnosis of septic hip. This similarity in presentation may actually contribute to the delay in diagnosis in some patients.Delayed diagnosis of >4 days of a pediatric septic hip results in poor outcomes, increased costs, and a decrease in health care value. (See AAP Grand Rounds. 2021;46[5]:57.)6The results of the current study are almost intuitive. Absent, however, are total cost estimates for inpatient and outpatient, short- and long-term care. An analysis of causes for delayed diagnosis, which may be socioeconomic and or clinical in nature, is also lacking—fodder for future researchers.