Economic Burden of Inpatient Admission of Ankle Fractures

Abstract

Category: Trauma Introduction/Purpose: Ankle fractures are one of the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency room prior to surgical management. In our experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. This study aims to characterize the economic impact of routine inpatient admission of ankle fractures. Methods: A retrospective review of all closed ankle fracture surgery performed by a single foot and ankle fellowship trained surgeon at a tertiary level academic center in 2012 was conducted to identify patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 to evaluate national estimates and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements and Medicare outpatient facility reimbursements were obtained from the Medicare Acute Inpatient Prospective Pricer and a Medicare Outpatient Pricer Code respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision tree model was derived from probabilities and associated costs and evaluated with modified Monte Carlo simulation. Results: Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture ORIF performed in 2012 by the senior author, 7 required admission due to polytrauma, medical comorbiditites or age. Of the 67 outpatient cases, all were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. Median length of stay was three days, and associated with facility reimbursement ranging from $12,920 for Medicare lateral malleolus fractures to $18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were $4,125 for Medicare patients and $11,459 for private insurance patients. The national cohort’s inpatient admission accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with $419,327,612 for treatment of these ankle fractures. Conclusion: Closed lateral malleolus, bimalleolar, and trimalleolar fractures may be safely and effectively treated as outpatient procedures. Routine perioperative admission for ankle fractures results in over $367 million of excess facility reimbursements annually in the US. Even if a conservative 25% necessary admission rate was assumed, routine inpatient admission of ankle fractures results in a $282 million dollar excess economic burden annually. While certain cases necessitate inpatient admission, with value based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding cost implications of inpatient ankle fracture management may result in savings to the US healthcare system and patients individually.