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Cost Savings Opportunities in Perioperative Management of the Patients With Orthopaedic Trauma

Moody, Alastair E. BS; Moody, Catriona E. BS; Althausen, Peter L. MD, MBA

Journal of Orthopaedic Trauma: December 2016 - Volume 30 - Issue - p S7–S14
doi: 10.1097/BOT.0000000000000716
Supplement Article

Summary: Considerable opportunities for cost savings exist surrounding the perioperative management of patients with orthopaedic fracture and trauma. Scientific evidence is available to support each potential cost savings measure. Much of these data had been documented for years but has never been adhered to, resulting in millions of dollars in unnecessary testing and treatment. Careful attention to preoperative laboratory testing can save huge amounts of money and expedite medical clearance for injured patients. The use of a dedicated orthopaedic trauma operating room has been shown to improve resource utilization, decrease costs, and surgical complications. A variety of anesthetic techniques and agents can reduce operative time, recovery room time, and hospital lengths of stay. Strict adherence to blood utilization protocols, appropriate deep venous thrombosis prophylaxis, and multimodal postoperative pain control with oversight from dedicated hip fracture hospitalists is critical to cost containment. Careful attention to postoperative disposition to acute care and management of postoperative testing and radiographs can also be another area of cost containment. Institutional protocols must be created and followed by a team of orthopaedic surgeons, hospitalists, and anesthesiologists to significantly impact the costs associated with care of patient with orthopaedic trauma and fracture.

*University of Nevada School of Medicine, Reno, NV; and

Reno Orthopaedic Clinic, Reno, NV.

Reprints: Peter L. Althausen, MD, MBA, Reno Orthopaedic Clinic, 555 North Arlington Avenue, Reno, NV 89503-4724 (e-mail: peteralthausen@outlook.com).

Supported by research grant from Smith & Nephew.

P. L. Althausen has stock ownership in the Orthopaedic Implant Company. The remaining authors report no conflict of interest.

Accepted September 15, 2016

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INTRODUCTION

Significant opportunities for cost savings exist surrounding the perioperative management of patients with orthopaedic fracture and trauma. These include preoperative evaluation, intraoperative management, postoperative hospital management, and postacute care treatment issues. Appropriate utilization of institutional protocols, orthopaedic trauma surgeons, geriatric hospitalists, and anesthesiologists can have a significant impact on the costs associated with trauma care. This article summarizes the contributions to cost savings that can be made in the perioperative period by coordinating a team approach with other providers based on existing scientific evidence.

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PREOPERATIVE

Preoperative evaluation represents an opportunity to save money by allocation of appropriate laboratory testing. Savings can result from elimination of both unnecessary and avoidance of delays incurred from incomplete evaluations. A number of recommendations for preoperative testing have been put forth to guide care based on the severity of the patient's condition and the complexity of the surgical procedure. Many times, well-known recommendations are not followed. One reason is that complex protocols may be difficult to implement. In addition, many centers have noted institutional resistance to reducing testing, as it is a well-known revenue stream for the hospital. The driving force should always be cost-effective care. Not only this is beneficial to our health care system as a whole but also it will allow the institution to flourish as competition for low-cost high-quality care increases. Specific investigations of the value of preoperative testing in the trauma setting are sparse, but there is information from other surgical areas that can be extended to trauma services.

Many orthopaedic fracture cases are nonemergent and can be fixed either acutely or on a delayed basis at outpatient or ambulatory surgery centers. One study evaluated the need for preoperative testing in ambulatory patients with isolated injuries.1 After evaluation of 1061 patients randomized to either no preoperative testing or indicated testing, they found no difference in adverse events within 30 days. They concluded that preoperative testing was not indicated in the ambulatory surgery patient with isolated orthopaedic injuries. Just over 4 million outpatient orthopedic surgeries were performed in 2015.2 The savings from eliminating preoperative testing in these individuals would be astronomical.

Many emergency departments and physicians automatically order chest x-rays for preoperative clearance. Multiple articles and anesthesia guidelines have shown for years that most of these tests are unnecessary. Chest x-rays may be a useful study in patients with active pulmonary disease and those undergoing cardiothoracic surgery, but are of limited utility in other settings. Some patients with trauma need chest x-rays because of the nature of their injury (ie, blunt chest injury) but screening studies on others would be very unlikely to provide useful information. A meta-analysis of 21 studies examined the value of preoperative chest x-rays in the perioperative setting.3 It concluded that these x-rays were very unlikely to provide clinical useful information, only altering management in 0.1% of cases, and should not be performed. This study from 1993 provides the basis for current testing recommendations, but nonetheless is not universally followed. A multicenter prospective trial produced similar results.4 Silvestri et al demonstrated that preoperative chest x-rays provided useful information in only 0.2%–3.5% of low-risk patients. In older patients with coexisting disease and increasing American Society of Anesthesiologists status, the probability of finding useful information was higher. A further extensive meta-analysis of preoperative chest x-rays determined that there was no association with morbidity and mortality in patients aged below 70 without risk factors.5 Given that the average chest x-ray costs $201, millions of dollars could be saved by adherence to these well-known studies.

Another commonly overused test is the electrocardiogram (EKG). There is significant evidence that EKGs should be selectively ordered based on patient's condition and the seriousness of the surgery. Liu et al6 demonstrated in 2002 that age alone is not a reason to order this preoperative test. EKG abnormalities are common and nonspecific in elderly patients and do not significantly impact a clinician's ability to predict complications in the postoperative period. Current American Society of Anesthesiologists guidelines recommend an EKG in patients with cardiovascular risk factors, and agree with the guidelines of the American College of Cardiology that states that EKGs are not recommended for patients who are asymptomatic and are undergoing low-risk surgery.7 There is a cost for every EKG test and cost to interpret them. The national average of these combined costs is $225. The money that could be saved with appropriate ordering is astronomical.

It has been clear for years that routine laboratory testing is not cost-effective and does not add substantively to patient care. Routine testing results in overwhelmingly normal values in healthy individuals. It is estimated that abnormal laboratory values are found in only about 0.2% of cases, and the majority of these do not impact patient care.8 Thus, preoperative laboratory testing should be individualized to the patient's condition. Otherwise healthy patient need no studies.1 Patients with coexisting disease may need laboratory studies focused on their specific medical problems. For example, patients with renal insufficiency or dialysis need potassium levels drawn while patients on anticoagulants will need evaluation of their clotting status. The severity of the injury and proposed surgery also impacts the need for testing, specifically the potential for blood loss. Although simple fractures are very unlikely to result in a transfusion regardless of starting hemoglobin levels, surgeries such as pelvic fracture have the potential for significant blood loss and would require preoperative hemoglobin values. Be conscious of the tests you order as a Complete Blood Count costs $35, Basic Metabolic Panel costs $44, Comprehensive Metabolic Panel costs $150, and Prothrombin Time/International Normalized Ratio costs $21.

Preoperative evaluation centers have been started by many institutions as a means to provide comprehensive yet cost-effective workups of patients undergoing surgery.9 Experience has shown that these centers save more than enough in reduced testing to off set their costs.1 This strategy may not apply well to emergent orthopaedic trauma; however, it is certainly applicable to nonemergent fracture care. Subsequent elective follow-up surgeries in patients with trauma may benefit from the preoperative evaluation center model, saving significant costs.

One of the most debated cost centers in orthopedic fracture care involves evaluation of the left ventricular function in elderly patients undergoing high-risk surgeries. This is often determined by echocardiography, which has an average cost of $1357. This procedure should only be performed in risk-stratified patients who will benefit from them as echocardiography is not only expensive but also time consuming and many hip fracture surgeries are delayed while waiting for these tests. Stitgen et al10 studied preoperative cardiac consultations in patients with hip fracture at their institution and found that 71% received unnecessary consults that did not meet ACC/AHA guidelines. These consultations delayed surgery (43.9 vs. 23.1 hours) and increased hospital length of stay (7.9 vs. 5.3 days). No differences in outcome, other than cost of care, were observed. Preoperative echocardiography should be considered in patients with heart valvular disease or known depressed left ventricular function. Studies demonstrate that echocardiography is only necessary for patients with ventricular dysfunction undergoing orthopedic operations with potential for high blood loss such as pelvic fractures, but would not be indicated for hip nailing, percutaneous pinning, or distal extremity operations.11,12 Testing for ischemic heart disease with dobutamine stress echocardiogram should only be considered in a patient with more than 3 clinical risk factors.11 These examples should make it clear that orthopedic surgeons must be vocal to prevent unnecessary cardiac evaluation in patients because cost savings opportunities are massive. Current recommendations for preoperative testing are summarized in Table 1.

TABLE 1

TABLE 1

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INTRAOPERATIVE

Perhaps the greatest contributor to operating room costs is operating room time. These costs are problematic to estimate as they may include various overhead costs not directly related to operating room care. Operating room charges are easier to obtain and are sometimes used as a surrogate for actual costs. These are even more variable and do not actually reflect what the hospital may receive. A sophisticated understanding of fixed and variable costs is needed to fully evaluate the potential impact of cost savings efforts. Charges for operating room time in the United States vary from $22 to 133 per minute not including charges for surgeons and anesthesiologists.13 Professional charges for anesthesia services average about $4 per minute but will vary by region.14 It is important to note that any factor that influences operating room time will have a very significant effect on cost as the average charge will be $66 per minute. Thus, techniques or drugs that may be less costly but increase operating room time may have a net increase in costs. These factors must be weighed as we discuss intraoperative cost saving opportunities.

Effective pain control is necessary in patients with orthopaedic trauma because of the nature of the injury and surgery. Acetaminophen is an effective component in pain control and results in significant decreases in narcotic use. The introduction of intravenous acetaminophen provides a convenient mode of administration in many surgical patients, but is an expensive way to administer the drug as each dose (1 g) costs about $50, whereas the oral dose is less than $0.50. Numerous studies have demonstrated that oral administration results in effective analgesia that is comparable to that achieved by intravenous dosing.15 Thus, oral dosing of acetaminophen is a cost-effective way to supplement analgesia, and the intravenous form should be reserved only for patients without a functioning gastrointestinal tract. At our hospital, 1 g or 15 mg/kg of oral acetaminophen is given to patients preoperatively as part of a multimodal analgesia protocol.

The choice of anesthetics used to maintain general anesthesia has a major effect on the total drug cost for a case. There are 3 commonly used volatile general anesthetics used at present. Desflurane and sevoflurane are modern agents with desirable pharmacokinetics. Their onset and recovery are rapid. In contrast, isoflurane is a drug with slower recovery characteristics, but it is much less expensive. The minimum price for maintaining general anesthesia under ideal conditions with volatile agents is approximately $9.67/h with desflurane and $2.20/h with sevoflurane, but only about $0.70/h for isoflurane. Given the comparable recovery times between sevoflurane and desflurane, significant savings can be obtained using sevoflurane. It is fashionable to use sevoflurane and desflurane because of fast recovery times; however, there are large institutions that continue to use isoflurane for many cases without apparent increases in recovery room times. The cost for maintaining anesthesia with a propofol infusion for an adult costs $7.50/h; because this drug is traditionally dosed by weight, this would be significantly cheaper in patients who weigh less such as children. These drug costs clearly indicate that analysis of anesthetic drug choice can lead to significant cost savings.

Controversy has existed in the anesthesiology literature for decades about the relative advantages and costs of general anesthesia versus regional anesthetic techniques. As discussed above, there are complicated factors to consider in the analysis. For example, drug costs may be significantly lower with a spinal anesthetic versus a general anesthetic, but those savings may be overshadowed by even a small increase in operating room time or length of stay at the hospital. In addition, some data indicate that outcomes may be superior in regional anesthetic techniques (see below) in certain subsets of patients with trauma. However, there are significant obstacles to the use of spinal blocks in patients with trauma including difficulty in positioning, coexisting injuries, time constraints, and patient acceptance.

Several studies have evaluated the use of general versus spinal anesthesia in patients with hip fracture. A recent retrospective cohort study published in the Journal of the American Medical Association found that there was no significant difference in the 30-day mortality of patients with hip fracture who received general anesthesia versus spinal anesthesia.16 This is in contrast with an earlier study published by the same group that found a significant 29% reduction in 30-day mortality in patients who received spinal anesthesia versus those who received general.17 The authors noted that this may have been due to some confounding variables in their original research but demonstrates the difficulty in examining this issue retrospectively. A significant finding in the most recent article was that there was a 0.6-day reduction in the hospital length of stay for patients who received spinal anesthesia versus those who received general anesthesia during their procedures. This most recent evidence suggests that with current anesthesia techniques there is no difference in the 30-day mortality, whereas the length of stay and operating room time differences were modest. A separate propensity matched multivariate analysis by Basques et al18 conversely found a shorter length of stay associated with general anesthesia. Basques et al found there to be “no clear overall advantage of one type of anaesthesia over the other.” Given these modest differences, it may be appropriate to follow institutional surgical or patients preferences.

Although no difference in anesthesia technique has been demonstrated in patients with hip fracture, good evidence supports its use in arthroplasty.19,20 A meta-analysis of 14,052 total knee arthroplasties found lower postoperative complications for patients with multiple preoperative comorbidities when using spinal anesthesia (11.63% vs. 15.28%; P = 0.0152).21 In addition, the rate of superficial wound infections decreased from 0.92% to 0.68% (P = 0.0003). Moreover, this study also found that the average operating room time (96 vs. 100 minutes) and average hospital stays (3.45 vs. 3.77) (both at a level of P < 0.0001) were lower in the spinal anesthesia group. This suggests that comparable effects could be obtained in patients with trauma with lower-extremity fractures.

Further studies such as a retrospective propensity matched cohort of 12,929 total hip arthroplasties found lower infection rates (odds ratio = 0.38; 95% confidence interval, 0.20–0.72; P < 0.01) in surgical sites and lower cardiovascular and pulmonary problems.22 Importantly, this study also found that the use of spinal anesthesia decreased the average hospital stay by 0.17 days or approximately 5% (95% confidence interval, 3%–7%; P < 0.001), which represents significant savings. The cost-effectiveness would be higher in hospitals that have dedicated teams as they will make efficient use of operating room time.20 Potentially this could be applicable to femoral neck fractures requiring total hip or hemiarthroplasty.

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POSTOPERATIVE PAIN MANAGEMENT

The area of postoperative pain management is a vital component to determining not only long-term outcomes of surgery but also the cost-effectiveness of care. Steps can be taken during intraoperative care to increase rehabilitation and obtain better outcomes thus contributing to cost savings. There is conflicting evidence on whether regional anesthesia can help with postoperative pain control.23,24 In one study, Chelly et al23 found that using a lumbar plexus block for acetabular injuries lead to decreased length of stay in the hospital from an average of 4 to 3 days. Another study by Strauss et al24 found that the addition of epidurals was not helpful in decreasing the length of hospital stay (6.2 days vs. 5.9; P = 0.62), pain scores (2.5 vs. 3.3; P = 0.13), or improving time to rehabilitation in acetabular fractures, but did lead to an increase in the anesthesia time from 66 minutes with general anesthesia alone to 85 minutes with the combination of general and epidural anesthesia (P < 0.01).

The technique of multimodal pain management that targets pain in different ways has been broadly shown to increase pain control.25–27 More specifically in orthopaedics, this multimodal approach has been shown to improve pain control with minimal side effects in total knee arthroplasties.28 Another study by Peters et al29 found that a multimodal approach was effective in decreasing the length of stay while improving pain control and decreasing the amount of narcotics used in both total hip and total knee arthroplasties. Although this multimodal approach has not been studied extensively in patients with orthopaedic trauma, the same general principles are applicable, and coadministration of acetaminophen, COX inhibitor, and gabapentin would likely result in better pain control with lower narcotic usage.

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DEDICATED ORTHOPAEDIC TRAUMA/FRACTURE OPERATING ROOM

Implementation of a dedicated orthopaedic trauma operating room (OTOR) for fracture care has been an extremely successful strategy over the past 10 years for both clinical outcomes and cost containment. Several studies have demonstrated its utility. Von Meibom et al30 performed a prospective 2-center study looking at operative delay in the treatment of proximal femur fractures. They noted that 22%–55% suffered an avoidable delay and that 76%–78% of this was due to of lack of operating room capacity. With implementation of an OTOR, Wixted et al31 demonstrated a 16% decline in cases performed after 7 PM, and a 44% decrease in cases performed between midnight and 7 AM This change also allowed for a 9.5% increase in trauma cases with less nighttime surgery. In addition, because of increased efficiency, the total number of elective orthopaedic cases increased 14%, providing the hospital with increased revenue. Furthermore, with the presence of a trauma room, cases were 4.5 times more likely to be transferred to a traumatologist for care. They demonstrated less activation of after hours operating room resources, fewer disruptions to the operating room schedule and office hours, and more frequent care by orthopaedic traumatologists. This is important given data from Althausen et al32 who showed that fracture care by traumatologists at our institution for 16 of 18 most common fracture patterns was accomplished in significantly less time and reduced cost. Bhattacharyya et al33 examined the effect of an OTOR on hip fractures. They found a 72% reduction in hip fracture surgery performed after 5 PM and a 6% decrease in daytime overutilization. Most importantly, they noted that nighttime surgery resulted in significantly more operative time and an increased complication rate. Similar findings were published by Chacko et al34 who discovered a significant increase in surgical time and blood loss in nighttime surgery and a 22% decrease in 2-year mortality in patients with hip fracture after implementation of an OTOR. For all the reasons above, an OTOR is a vital component of cost-effective fracture care and should be present at all trauma centers and hospitals with high-volume emergency department.

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BLOOD TRANSFUSION PROTOCOLS

Recent transfusion guidelines have shown the potential to save a modest amount of money on each patient leading to cost savings. Frank et al35 introduced the concept of maximum surgical blood order schedule, which allows team members to predict the probability of a patient needing a blood transfusion based on historical data. Thus, type and screen orders are unnecessary for procedures with exceeding low transfusion rates, which would include most orthopaedic trauma cases. They used this concept along with an electronic blood release system, which is a system that allows blood to be readily available through an automated vending machine. This reduced unnecessary preoperative blood orders and reduced costs. The analysis of over 30,000 hospitalized patients, over a 34-month period, found a 27% decrease in preoperative blood orders, leading to a cost savings of $137,322 for surgical patients and $298,966 for all hospitalized patients, with an estimated cost of $55.24 per type and screen. This was accomplished without a significant increase in emergency blood release.

There are significant costs and complications associated with blood transfusions, therefore it is important to avoid unnecessary transfusions. Current blood transfusion protocols dictate much lower hemoglobins than in the past. In 2016, the recommendations are to consider transfusion only when hemoglobin decreases to 8 in patients with significant coronary disease and 7 in all other patients.36 Following these protocols results in significantly fewer transfusions. This represents a significant cost savings because the transfusion includes not only the direct acquisition costs but also the associated expenses. One study put this cost at $656 per unit of packed red blood cells transfused.37 However, another more recent study investigating costs from 4 area hospitals found the cost to be as high as $1329 per unit of packed red blood cells transfused.38 In addition, transfusions can have other significant medical side effects and should be minimized if possible.

The use of blood-salvaging devices, such as Cell Saver, and its disposables has become common practice in pelvis and acetabular surgery despite several studies showing no difference in outcomes.39,40 Interestingly, Scannell et al39 showed that not only was there no difference in the outcome but also blood-related charges increased $1264 (2.8 times) per patient. The only time that Firoozabadi et al40 found blood-salvaging devices to be reasonable was with anterior approaches to the acetabulum when high blood loss was expected. The only study supporting the use of blood-salvaging devices in orthopaedic trauma surgery failed to include the device capital cost and the operating personnel, and as a result, does not give a complete economic picture.41 Thus, Cell Saver should be used rarely, if at all.

Tranexamic acid (TXA) is an antifibrinolytic that results in decreased blood loss in a variety of surgical settings; however, there is currently a paucity of articles exploring the use of TXA in orthopaedic trauma. Recent data have demonstrated the benefits of TXA in the treatment of hip fractures.42,43 Sarzaeem et al42 found 14% of patients with total knee arthroplasty without TXA required transfusion, whereas no patients with TXA were transfused. Wang performed a meta-analysis of TXA use in total hip arthroplasty and found significant decreases in intraoperative blood loss, postoperative hemoglobin decline, and drain output. They found a 12% decrease in transfusion requirement.43 The cost of 1 preoperative dose is $26.89 at our institution. Cost analysis studies have estimated $1500 savings per patient with the use of TXA.44 Data from arthroplasty studies are clear and trauma utilization of TXA in high-risk blood loss cases is sure to follow when clinical and economic benefits become clear. A recent meta-analysis of TXA in hip fractures also demonstrated a significant decrease in blood loss.45 This is definitely a drug to consider.

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HIP FRACTURE PROTOCOLS/GERIATRIC FRACTURE TEAMS

Many studies have shown massive cost savings associated with dedicated hip fracture protocols and services. In addition to the potential of these protocols to increase cost savings, they have also been shown to enhance outcomes such as reducing the length of stay in hospitals and reduced complications.46 A study by Swart et al47 further examined the number of patients needed to make these protocols cost-effective. They found that these protocols become cost-effective when at least 54 patients participate each year and further result in cost savings when there are 318 patients annually. The landmark study by Kates et al48 found that using a dedicated hip fracture protocol led to a 33.3% reduction from the expected national cost along with decreasing length of stays, complication rates, and readmission rates to below the national average. In light of these data, Kates et al estimated that if these protocols were applied to the care of the 350,000 annual hip fractures in the United States, the savings would exceed one billion dollars.

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POST OPERATIVE DVT PROPHYLAXIS

Prevention of deep venous thrombosis (DVT) and pulmonary embolism are an essential component of good clinical and cost-effective postoperative care. Guidelines recommend both mechanical and chemical prophylaxis. Unfortunately, there is insufficient evidence in the literature to make strong recommendations on the type or duration of prophylaxis in regard to patients with orthopaedic trauma.49 Traditionally, the use of coumadin and aspirin has been effective in decreasing these postoperative complications. The introduction of enoxaparin, a low-molecular-weight heparin, has shown the potential to decrease DVTs more effectively than traditional methods. However, low-molecular-weight heparin has not been shown to decrease the incidence of pulmonary emboli. There is currently no consensus, and most physicians adhere to a community standard. Fortunately, the patent on Lovenox recently expired, so costs have reduced enormously. At our institution, the dose cost of enoxaparin is $3.69, Xarelto is $3.78, Pradaxa is $2.75, Heparin 5000U SQ is $0.90, warfarin is $0.38, and aspirin is $0.03. The more expensive issue is the cost of lack of prophylaxis. Baser et al50 demonstrated that the incidence of venous thromboembolism (VTE) increased cost by $13,638 in patients with postoperative total knee arthroplasty. Edelsberg et al51 estimated the cost of VTE after major orthopaedic surgery, including initial therapy, follow-up care, and the expected costs of major hemorrhage due to anticoagulation, recurrent VTE, and postthrombotic syndrome to be approximately $11,600. Clearly, avoidance of VTE and pulmonary embolism is the most cost-effective strategy.

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POST ACUTE CARE

The highest cost for hip fracture and arthroplasty patients in the United States currently is embodied by postacute care. Chandra et al52 found that spending on postacute care was the fastest growing major Medicare spending category and accounted for a significant portion of spending growth from 1994 to 2009. During that period, average spending for postacute care doubled for patients with hip fractures. Braithwaite et al53 studied the economics of hip fractures and found that the lifetime attributable cost of hip fracture was $81,300, of which nearly half (44%) related to nursing facility expenses. For those involved in the care of these patients, this is no surprise. Most postacute care facilities automatically keep patients until their insurance-allowed days expire. In addition, discharge planning at many centers only occurs on a certain day each week. Our experience with the Bundled Payments for Care Improvement (BPCI) has demonstrated that hiring staff to expedite discharge for hip fracture and arthroplasty patients from postacute care facilities has been a huge cost savings measure. Ideally, patients should go home if they are able with Home Health care (HHC) if needed. Studies have addressed this issue in patients with lower-extremity joint replacement54,55 and hip fractures.56 For patients with lower-extremity joint replacement who were healthy, Mallinson et al54 found that HHC lead to the best outcomes of mobility and self-care. However, for more at-risk patients, they found that skilled nursing facilities (SNF) had better outcomes in self-care than those who participated in inpatient rehabilitation facilities (IRF). These results were supported by another study that showed that the 30-day readmission rates were lower for patients who participated in HHC rather than IRF.55 The authors also noted that this may have been due to HHC patients having fewer comorbidities, supporting the notion that low-risk patients are better served by HHC. Readmission rates are vitality important in minimizing cost with one study finding that readmission costs were almost equal to original treatment costs.57 Considering that patients with hip fractures are at the highest risk in orthopaedics for readmission,57 it is critical to use the type of postoperative care best suited to help these patients stay healthy. A further study by Mallinson et al56 investigating hip fractures found that SNF patients had higher level of self-care at discharge than patients who participated in HHC and IRF. If a patient must go to a postacute care facility, the difference between SNF and IRF has large cost implications. IRF are much more expensive per day but some claim that the length of stay is shorter and can be more cost-effective. Herbold et al addressed this issue for patients with hip fracture, total hip, and total knee replacement. This study found that although inpatient rehabilitation lead to better outcomes, such as, ambulating independently and requiring less home care, it had a significantly greater cost ($11,984 vs. $10,001, P = 0.008).58 Physicians must stay involved in the disposition of patients and closely manage their postacute care not only to improve clinical outcomes but also to mitigate the massive costs of these overused services.

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POSTOPERATIVE RADIOGRAPHS

Significant cost savings are associated with better management of postoperative radiographic protocols. Some surgeons still take plain x-rays in the operating room or postanesthesia care unit after surgery. Many studies have shown the limited utility of this practice, demonstrating that these do not influence course of care, and are therefore not required. There are many barriers to completing correct and high-quality postoperative x-rays, including immobilization and time constraints. This was elucidated in a 2015 study of ankle fractures, which found that only 10.3% of patients had high-quality immediate postoperative radiographs of all 3 views of the ankle (anterior–posterior, lateral, and mortise).59 Furthermore, immediate postoperative x-rays of ankle fractures did not lead to any reoperations. Harish et al60 performed a similar study, which also demonstrated the limited utility of this practice. Immediate postoperative films inflate patient charges for the cost of the x-ray ($175) and the charge for the radiologist to read it ($250).

Several recent studies have also shown the limited utility of postoperative x-rays taken at the first postoperative 10–14 days visit. A study by McDonlad et al61 found no statistical difference in complication rate when comparing patients who were put into groups based on early postoperative radiographs (7–21 days) and late postoperative radiographs (22–120 days). A study retrospectively examining 2-week postoperative radiographs in distal radius fractures found that of 268 patients, only 3, or approximately 1.1%, had a loss of fixation at the 2-week point that required a reoperation.62 Another smaller study of 38 radial shaft fractures found that upon retrospective review by blinded orthopedists, x-rays taken between 0 and 4 weeks postoperatively did not influence care; however, x-rays between 4 and 8 weeks influenced care in 33% of cases.63 These studies have estimated the cost per patient for a series of x-rays between $85 and 18159,62 with charges to the patient of up to $335,64 showing a significant opportunity for cost savings. In light of these studies, our physicians have abandoned this practice unless patients report a significant fall, increase in pain, or change in alignment.

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CONCLUSIONS

This review clearly demonstrates that significant opportunities for cost savings exist surrounding perioperative management of patients with orthopaedic fracture and trauma. Careful attention to preoperative laboratory testing can save massive amounts of money and expedite medical clearance for injured patients. A variety of anesthetic techniques and agents can reduce operative time, recovery room time, and hospital lengths of stay. Careful attention to postoperative disposition to acute care and management of postoperative testing and radiographs can also be another area of huge cost savings. Institutional protocols must be created and followed by a team of orthopaedic surgeons, hospitalists, and anesthesiologists to significantly impact the costs associated with care of patients with orthopaedic trauma and fracture.

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ACKNOWLEDGMENTS

The authors acknowledge Eric J. Moody, MD. for his technical assistance in the field of anesthesia.

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Keywords:

cost containment; orthopedic trauma; perioperative care; economics

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