Reduction of Treatment Duration in Periprosthetic Infection with a Fast-Track Concept Is Economically Not Feasible

Abstract

In the two stage revision of periprosthetic joint infection (PJI), the prosthesis-free interval may be reduced to 2-3 weeks (fast-track). This is an innovative approach with clear advantages for both the patient and health insurance stakeholders. The prosthesis-free interval with conventional two-stage PJI slow-track procedures lasts 6-12 weeks. In Germany, the patient spends this time either at home or in a geriatric hospital. This period is mainly used to manage infections. The patient is then readmitted for implantation of the revision prosthesis. This readmission then leads to additional reimbursement, as this is formally a new insurance case. Despite this double payment, the costs for the treatment of such complex diseases are not covered by the German DRG system. If hospitals are to implement the proven fast-track concept, they need to invest in a multidisciplinary medical team. This would be responsible for defining infections, selecting patients, and improving diagnosis and antimicrobial therapy and should thus improve the rates of cure of infections. However, the G-DRG reimbursement system treats the two surgeries as a single case, providing that less than 30 days lies between the two interventions; as a result, the reimbursement is inadequate for patients with the fast-track interval. We analysed the theoretical financial deficit for a hospital and describe the cost-saving potential for payers applying the fast-track interval rather than the slow-track approach in selected PJI patients, using a comprehensive and individualised treatment concept. Our analysis covered thirty-two consecutive patients with infected joint prosthesis (17 hips, 15 knee) admitted to our hospital from January 2011 to December 2012 undergoing a two-stage exchange (ICD-10-GM: T84.5). We excluded patients who underwent only one hospital admission during the analysed time frame or who were admitted to another hospital. Patients treated with joint fusion and patients who died were also excluded. A retrospective simulation of the DRG reimbursement was then performed according to the German Hospital Fees Act (§ 21 KHEntgG) for the two-stage fast-track interval concept. Due to the retrospective character, we could not analyse detailed financial differences specifically related to the fast-track treatment, such as the cost for biofilm active antimicrobial drugs and savings for outpatient care during the long interval in slow-track. We did not consider hospital investment costs for establishing an interdisciplinary medical team, and were only able to roughly describe the cost saving potential and benefits on a societal perspective. With the fast-track concept, the DRG receipts were reduced by a mean of 10 831 € per patient, which was higher for hip prostheses than for knee prostheses. Even though fast-track treatment cost 1159 € less than slow-track treatment, the hospital lost 8498 € per fast-track patient, because of the loss of the second surgery reimbursement. For each fast-track patient, the payers save one G-DRG reimbursement plus the costs for any care during the prosthesis-free interval, as occurred in the slow-track. Fast-track patients benefit from the reduced period of functional treatment, of about 10 weeks. The current G-DRG reimbursement system paradoxically rewards slow-track intervals for two-stage revisions and jeopardizes the implementation of beneficial fast-track intervals in clinical routine. Patients treated with slow-track therapy experience longer and more debilitating treatment, accompanied by greater healthcare costs for both payers and hospitals. New treatment concepts which offer better care at lower cost should attract the attention of policy makers, clinicians, and the public.