PREDICTORS OF EPISODE-OF-CARE COSTS FOR ANKLE FRACTURES

The perioperative management of trauma patients in the context of a recent focus on value-based healthcare highlights the importance for hospitals to evaluate their episode-of-care costs (EOCC). Despite its large impact on hospital budgets, accurate episode-of-care costs calculation for trauma hospitalizations remains a challenge in Canada. Ankle fractures are one of the most resource-consuming traumatic injuries requiring orthopedic surgery care. Few studies have successfully evaluated the episode-of-care costs of common traumatic orthopedic injuries. The objective of this manuscript is to determine the episode-of-care costs for patients with surgically managed ankle fractures using an activity based costing (ABC) methodology and to assess the patient, injury and surgical factors that affect the episode of care cost of these fractures. A retrospective cohort study of 105 consecutive patients who underwent open reduction internal fixation of an isolated ankle fracture at a Level-1 trauma center in Quebec was conducted. Episode-of-care costs were generated using an activity based costing framework and itemized direct and indirect costs were obtained for every case. The median episode-of-care cost was compared based on patient demographics, injury characteristics and surgical data to identify predictors of episode-of-care costs for surgically treated ankle fractures. The median global episode-of-care cost for ankle fracture surgeries performed at the studied institution was $3,487. On average, 76% of the total costs were attributable to direct costs and 24% of the total costs were attributable to indirect expenditures. Patients aged between 60 and 90 years had a significantly higher median episode-of-care costs ($5051) compared to patients aged between 18 and 29 years ($3,411) and patients aged 30 to 59 years ($3,480) (p = 0.01). The type of ankle injury according to the Lauge-Hansen classification significantly impacted the episode-of-care costs. Supination-adduction (SAD) injuries had significantly higher median episode-of-care costs ($5332) than other types of injuries (p = 0.01). Patient gender, anesthesia type, ASA score and surgeon's fellowship training did not significantly increase the episode-of-care cost in our study. The median episode-of-care cost for patients who underwent surgery within 10 days of their injury was significantly lower than the cost for patients who had their surgery delayed more than 10 days after the injury ($3347 vs. $3634, p=0.03). Subgroup analysis demonstrated that the median direct and indirect costs were increased by $227 and $54 respectively in the group of patients that were delayed more than 10 days before their surgery. There was no difference in age, gender, ASA score or injury type between the two groups. This study provides valuable data on predictors of episode-of-care costs in the surgical management of ankle fractures. Delaying simple ankle fracture cases due to operating room time constraints can increase the total cost and burden of these fractures on the health care system. In addition, this study provides a framework for future episode-of-care cost analysis studies in orthopaedic surgery. Adequate episode-of-care cost analysis is crucial to ensure hospitals and departments receive appropriate funding.