COMPARISON OF HOSPITAL COSTS AND DURATION OF TREATMENT WITH TWO DIFFERENT CLUBFOOT PROTOCOLS

INTRODUCTION

In Brazil, clubfoot has traditionally been treated by serial manipulation and casting over a period of several months with the Kite technique. In most cases, complete correction was not achieved and posteromedial release was required.^2,3 In 2003, the University Hospital at the University of Sao Paulo (Campus Universitary City) changed their clubfoot treatment protocol to the Ponseti technique.^1,5,6,7 This was due to the dissemination of this technique in the medical literature. In 2004, the Ponseti technique was recognized by the Brazilian Orthopaedic Society Guidelines Book as a recommended way to treat clubfoot⁸

The authors retrospectively compared the hospital costs in the treatment of five consecutive patients with the previous protocol (Kite technique and posteromedial release) with the hospital costs for treatment of five consecutive patients with the new protocol (the Ponseti technique).

The objective of this study was to compare direct hospital costs and duration of treatment from these two different protocols.

METHODS

This is a retrospective study of ten children under one year of age with bilateral clubfoot, treated in Hospital Universitario at the University of Sao Paulo, Brazil. The first five children (age range from two weeks to eight months; average, three months) were treated by the Kite method followed by posteromedial release, as was commonly done until 2005

As described in the original Kite report,⁴ the Kite method consists of nine to 14 casts (11 on average) intending to sequentially correct the adduction, cavus, varus and equinus alterations of clubfoot. Because correction of the deformity was usually not complete, a posteromedial release was then indicated (age range

from four to 14 months; average, six months). In this group, posteromedial release was performed using a Cincinnati circular incision,² release of medial, posterior and lateral structures and pinning with two Kirschner wires. (Posteromedial releases were performed for only one foot at a time, with the second procedure occurring one to two months after the first.)

Two months after the posteromedial release, each patient was taken to the operating room for removal of the two Kirschner wires and application of a long-leg cast under anesthesia. About four weeks after that, the plaster cast was removed and orthopaedic shoes were recommended.

Five other children were treated consecutively by the Ponseti method. This treatment consisted of four to six casts (average 4.8 casts) followed by a percutaneous tenotomy of the Achilles tendon under local anesthesia, with a new cast to be worn for three more weeks. After this treatment, the feet were considered corrected and an abduction brace was then recommended to maintain the correction.

Direct hospital costs for the first protocol, the Kite technique followed by posteromedial release, included preoperative casts, preoperative examinations (including blood tests and radiographic films), anesthesia medical charges, surgical clubfoot treatment (related to the posteromedial release), postoperative medications in the hospital, the cost of three days in the hospital, cast removal, removal of sutures and Kirschner wires, anesthesia for this procedure, and day-hospital taxes for this procedure. These costs also included two postoperative casts and orthopaedic shoes.

Direct hospital costs for the second protocol, the Ponseti technique, included casts, a percutaneous tenotomy and abduction braces. All costs are reported in the monetary unit of Brazil, the real (R$).

The duration of treatment was recorded, from the first cast to the day the correction was considered complete in both feet. Complete correction for the Kite protocol was considered achieved after removal of the postoperative cast following surgery on the second foot. Complete correction for the Ponseti protocol was considered achieved after removal of the post-tenotomy cast.

TABLE 1.

Patients from first protocol (Kite and posteromedial release)

Patient	DIAG	Age at 1st visit	N° CASTS	Age at 1st surgery	Age at 2nd surgery	Total Treatment Duration
1	Bilateral clubfoot	259 days	14	435 days	491 days	267 days
2	Bilateral clubfoot	43 days	12	139 days	160 days	160 days
3	Bilateral clubfoot	90 days	9	201 days	285 days	242 days
4	Bilateral clubfoot	15 days	10	126 days	147 days	182 days
5	Bilateral clubfoot	51 days	11	166 days	279 days	278 days
AVERAGE		91.6 days	11.2	213.4 days	272.4 days	225.8 days

Table 2.

Patients from Ponseti protocol

NAME	DIAG	Age at 1st visit	N° CASTS	Age at Tenotomy	Total Treatment Duration
1	Bilateral clubfoot	28 days	6	71 days	65 days
2	Bilateral clubfoot	35 days	5	71 days	56 days
3	Bilateral clubfoot	9 days	4	37 days	49 days
4	Bilateral clubfoot	40 days	5	78 days	59 days
5	Bilateral clubfoot	109 days	4	136 days	49 days
AVERAGE		44.2 days	4.8	78.6 days	55.6 days

Table 3.

Ponseti Method Costs

Casts (5x28,24)	R$ 142.10
Percutaneous tenotomy under local anesthesia	R$ 28.24
Orthosis	R$ 170.000

Table 4.

Kite Method Costs

Pre-op casts (11)	R$ 28.42	312.62	R$
Pre-op exams (blood and TX)	R$ 5.79 + R$ 6.78	12.57	R$
Anesthesia		284 06	R$
Surgical treatment of clubfeet with fixation
Pos-op medication
3 days of stay in Hospital
Removal of cast sutures and Kirschner wires		15167	R$
Anesthesia
Day Hospital
Pos-op casts (2)	R$ 28.42	56.84	R$
Orthopedics shoes		130.00	R$
	TOTAL (1 foot)		R$ 947.76
	TOTAL (2 feet)		R$ 1.895.52

RESULTS

The average number of casts was 11.2 (nine to 14) in the first protocol (Kite and posteromedial release) and 4.8 (four to six) in the second protocol (Ponseti). The age at the beginning of treatment was a little higher in the first protocol group, but the difference was not statistically significant (Mann Witney test, p-value =0.465; significance level 0.05, confidence interval 95%).

Treatment costs using the Kite protocol totaled R$947.56 for one clubfoot and R$1895.52 for bilateral clubfeet. Treatment costs using the Ponseti protocol totaled R$340.34 for the treatment of one foot, and R$510.68 for treatment of bilateral clubfeet. Costs were about 2.5 times lower in the Ponseti protocol than with the Kite protocol. The duration of treatment to complete correction was, on average, 225.8 days with the Kite protocol and an average of 55.6 days with the Ponseti protocol.

The reported costs were taken from the table of coded procedures of Brazilian Health System and applied to the Hospital Universitario in 2004, when this research was performed.

DISCUSSION

Indirect costs such as patient transportation and out-of-work days for caretakers were not included in the cost estimates. The Kite group had more casts and more hospital visits, which would further increase the costs for this group if these variables had been taken into consideration. It is also important to consider that for each foot procedure in the Kite group, at least three hours of hospital operative time were required; thus, there were six fewer available operative-room hours for treatment of other orthopaedic or surgical problems in this secondary medical center.

Another important consideration is that the Kite group had only 11 casts on average. This is not commonly seen in orthopaedic centers which have adopted this method of treatment The more typical situation would be for a patient to undergo six months to a year of casting (every one to two weeks), for an expected total of 24 to 48 casts. This would increase costs even further for the Kite group. The unusually low number of casts applied in this hospital is thought to be secondary to the indication for surgery (posteromedial release) at a younger age.

This limited study should not be considered a complete analysis of costs from these two protocols; the number of patients is small and many indirect costs were not included. Also, this study does not take into consideration the clinical results for these patients, but data in the literature suggest the Ponseti protocol has better long-term clinical and functional results.¹ However, this limited study highlights the striking differences in costs and duration of treatment for patients treated with these two different protocols. Our hope is that this may help raise awareness in public health professionals, aid in decision-making, and lead to health policy changes regarding the treatment of clubfoot.