Abstract
Background
The SickKids Paediatric Orthopaedic Pathway (SKPOP) for proximal humerus fractures may safely reduce the number of radiographs and follow-up assessments for children with these injuries. The study objective was to examine potential cost-savings of the SKPOP from the perspective of the Ministry of Health and Long-term Care (MOHLTC).
Methods
Two sets of resource profiles, based on direct health care costs were created for a cohort of patients treated at our institution: the first based on actual follow-up assessment values, and the other based on follow-up assessments according to the SKPOP. Differences between the two profiles represent potential cost-savings. A decision-analysis and associated probabilistic sensitivity analysis (PSA) were performed.
Results
In a cohort of 239 patients treated between 2009 and 2014, 92.9% (222) would have met SKPOP eligibility. Management according to this pathway would have reduced orthopaedic assessments and shoulder radiograph series by 83.6% (470/562) and 70.8% (367/589), respectively. For the cohort examined, a potential cost-savings of $30,040.56 ($135.32/patient) was observed. A PSA, accounting for variable SKPOP adherence and health care utilization, yielded cost-savings in 96.5% of the iterations run through the decision-analysis model and an average cost-savings of $57.82/patient. Based on these results and the annual provincial incidence rate of eligible patients (n=575), the MOHLTC could potentially save $33,249.45 annually with province-wide implementation.
Conclusions
Implementation of the SKPOP for a cohort of patients managed at our institution could have resulted in cost-savings due to substantial reductions in health care utilization. Cost-savings are likely to occur with provincial implementation of the SKPOP for proximal humerus fractures.
Keywords: Clinical care pathways, Cost savings, Decision analysis, Paediatric fractures
The vast majority of paediatric proximal humerus fractures are managed nonoperatively with minimal intervention and without complication (1–3). Approximately 80% of the longitudinal growth of the humerus occurs at the proximal physis (1,3–5), which permits extensive remodelling and accounts for the low complication rate associated with nonoperative management. Despite the success of minimal intervention (2,3), close follow-up and repeat radiographic assessments comprise traditional nonoperative care for these injuries. For example, although the choice of operative versus nonoperative intervention was made on the initial visit for nearly all patients treated for proximal humerus fractures at our institution between 2009 and 2014, the mean number of fracture clinic visits and radiographs was 2.6 ± 1.2 (mean ± standard deviation) and 8.4 ± 3.9, respectively (6). Specifically, only one treatment decision changed (one late operation) among 225 patients in this cohort after initial orthopaedic consultation (6). Close follow-up and radiographic assessment may not be necessary for an injury for which complications rarely develop and treatment decisions do not change after initial consultation.
The SickKids Paediatric Orthopaedic Pathway (SKPOP) for proximal humerus fractures was developed to simplify and safely guide follow-up and radiographic assessments for patients with these injuries (7) (see Figure 1). The intent is to reduce the frequency of unnecessary radiographs and follow-up assessments in busy orthopaedic fracture clinics. By simplifying care of these injuries, implementing this pathway may result in more efficient care with substantial cost savings. Furthermore, clinical pathways may act as an important educational resource for clinicians, as traditional information guiding treatment decisions for paediatric trauma care has been shown to be significantly inferior to clinical guidelines (8). Clinical guidelines and pathways addressing a wide range of paediatric fracture scenarios have been published by the American Academy of Orthopaedic Surgeons and the Royal Children’s Hospital in Melbourne, Australia (9–11). However, the economic consequences of implementing these pathways have not been described. Therefore, the primary purpose of this study is to estimate the cost savings of implementing the SKPOP for proximal humerus fractures in a cohort of patients cared for at our institution and to extrapolate our findings to the province of Ontario, Canada.
Figure 1.
Chart depicting SKPOP eligibility categories by age, sex and fracture displacement with matched emergency department and orthopaedic follow-up care pathways. SKPOP SickKids Paediatric Orthopaedic Pathway.
METHODS
Setting
Potential resource and cost savings of the SKPOP for proximal humerus fractures were determined for healthy patients between 0 and 18 years of age presenting to the Hospital for Sick Children with uncomplicated proximal humerus fractures. Complicated fractures were defined as those associated with bone cysts or pathological lesions, birth trauma, nonaccidental injuries, open or multiple fractures or associated neurovascular injuries. Patients with these injuries were excluded. A retrospective review of this cohort was performed by Gladstein et al., which included 239 patients (6). These authors searched a hospital-based database (ISYS, Odyssey Development, Inc) of x-ray reports between October 2009 and August 2014 for the terms ‘proximal humerus fracture’ or ‘proximal humeral fracture.’ All identified patients were then screened against eligibility criteria (Figure 2).
Figure 2.
Flowchart illustrating the systematic process utilized to determine eligibility for the SKPOP for proximal humerus fractures, modified from Gladstein et al. (6). SKPOP SickKids Paediatric Orthopaedic Pathway.
In the cohort described by Gladstein et al., only one treatment decision (0.4%; 1/225) changed as result of serial orthopaedic follow-up assessments (6). This patient underwent a proximal humerus epiphysiodesis 365 days after their date of injury for the development of a partial growth arrest. For all other patients undergoing surgery (5.9%; 14/239), the decision to operate was made at a patient’s initial orthopaedic assessment (6). No complications were reported for patients managed nonoperatively (6). Based on these results, we assumed that traditional and SKPOP follow-up assessment strategies had equivocal clinical effectiveness. Therefore, it was worthwhile to examine the difference each care pathway had on the stream of costs.
Cohort inclusion
Patients eligible for management according to the SKPOP were selected from the cohort described by Gladstein et al. (6). Eligibility for management according to the pathway is limited to these categories: 1) girls 10 years or younger, 2) boys 12 years or younger, as well as 3) girls older than 10 years with 50% or less fracture displacement and 4) boys older than 12 years with 50% or less fracture displacement (Figures 1 and 2).
Data collection
Patient data including age, sex and date of injury were recorded. Fracture displacement, expressed as a percentage, as measured by an orthopaedic surgery trainee on the initial shoulder radiograph series was used to determine patient eligibility for the SKPOP. Health care resource utilization including the number of orthopaedic clinic visits and shoulder radiograph series obtained were included for each patient. Other data recorded included initial and final treatment decisions (operative versus nonoperative treatment), and treatment complications. Data were extracted from electronic medical records by an orthopaedic surgery trainee and reviewed by two orthopaedic surgeons with fellowship level training in paediatric orthopaedic surgery. The data collected by Gladstein et al. was used to determine when treatment decisions were made and not for the purpose of evaluating the SKPOP (6); data extraction was blinded to SKPOP eligibility categories and treatment pathways.
Outcomes
The economic evaluation was from the perspective of the Ontario Ministry of Health and Long-term Care (MOHLTC), with direct costs related to patient health care utilization considered. The MOHLTC is the single payer of all medically necessary public health care services in Ontario. Costs considered were initial and repeat follow-up orthopaedic assessments, shoulder radiographic series, and associated radiologist assessments. Cost data were obtained from current (2015) sources published by the MOHLTC (12,13). Relevant physician services and diagnostic imaging unit costs are displayed in the Appendix. All costs are reported in 2015 Canadian dollars ($1.00 CAN = $0.86 US; January 1, 2015). Costs incurred from procedures and medications were not taken into account; these are not expected to differ between traditional care and the SKPOP for proximal humerus fractures. Resource profiles for each patient were based on actual counts of follow-up orthopaedic assessments and shoulder radiograph series performed. A shoulder radiographs series was assumed to include two standard (anterior–posterior and transcapular lateral) views of the shoulder. Costs were calculated as the product between the resource count and its unit cost.
Statistical analysis
Resource profiles based on recommended SKPOP follow-up assessments were determined for each patient. Potential resources saved and associated cost savings as a result of pathway implementation could be compared. Estimated cost savings for Ontario, based on conservative provincial incidence rates for simple paediatric proximal humerus fractures, were also calculated.
Descriptive data are presented as means, and associated standard deviations, and frequency counts and associated percentages, for continuous and categorical variables, respectively. Additionally, both numerical (Shapiro-Wilk statistic) and graphical (histogram, boxplot and Q-Q plot) measures were used to assess the normality of continuous variables. Statistical analyses were performed using SAS Studio 9.3 University Edition (SAS Institute, NC), with statistical significance defined as P<0.05.
Sensitivity analysis
A probabilistic sensitivity analysis (PSA) was conducted to account for variable SKPOP adherence and health care utilization (orthopaedic and radiographic assessments) among patients with proximal humerus fractures. A decision tree was constructed with TreeAge Pro 2015 (Williamstown, MA). Adherence was assumed to follow a normal distribution and conservative parameters (mean of 50%, standard deviation of 10%) were entered into the model (14). Health care utilization values for nonadherent patients in the model were estimated based on the actual distribution of health care utilization for the cohort of patients treated at our institution with proximal humerus fractures between 2009 and 2014.
This investigation received approval from our institution’s research ethics board.
RESULTS
Baseline characteristics
Of the 239 simple paediatric proximal humerus fractures managed at our institution between October 2009 and August 2014, 222 patients (92.9%) would have been eligible for management according to the SKPOP for proximal humerus fractures (Figure 2). Characteristics of eligible patients with respect to age, sex and fracture displacement are displayed in Table 1, as well as the proportion of those in each eligibility category. Five females older than 10 years of age and 12 males older than 12 years of age with greater than 50% fracture displacement were ineligible for SKPOP management and excluded from the analysis (29.4% [5/17] and 70.6% [12/17] of excluded patients, respectively). One patient who had surgery at the time of initial presentation, an 8-year-old male with 100% fracture displacement, would have been eligible for nonoperative treatment according to the SKPOP for proximal humerus fractures; this case was included in our cost analysis.
Table 1.
Characteristics of children with proximal humerus fractures eligible for standardized care according to SKPOP
| Characteristics | Value |
|---|---|
| N | 222 |
| Age, years (mean ± SD) | 9.86 ± 4.0 |
| Sex, Males | 130 (58.6%) |
| Fracture displacement on initial radiographs (mean ± SD) | 17.5 ± 26.7% |
| 0 to ≤25% | 170 (76.6%) |
| >25 to ≤50% | 30 (13.5%) |
| >50 to ≤75% | 7 (3.2%) |
| >75 to 100% | 15 (6.8%) |
| Eligibility categories | |
| Females ≤10 years old | 49 (22.1%) |
| Males ≤12 years old | 81 (36.5%) |
| Females >10 and ≤50% fracture displacement | 43 (19.3%) |
| Males >12 and ≤50% fracture displacement | 49 (22.1%) |
All values represent frequency counts and percentages unless otherwise stated.
SD Standard deviation; SKPOP SickKids Paediatric Orthopaedic Pathway
Outcomes
Implementation of SKPOP among eligible patients could have reduced the number of follow-up shoulder radiograph series by 83.6% (470 radiograph series saved/562 radiograph series in the traditional follow-up cohort) and orthopaedic assessments by 70.8% (367 assessments saved/589 assessments in the traditional follow-up cohort). Accordingly, SKPOP pathway implementation among eligible patients treated for proximal humerus fractures at our institution between 2009 and 2014 could have resulted in a cost-savings of $30,040.56 ($135.32 per patient). The greatest opportunity for resource reduction is among males under 12 years of age; SKPOP management could have saved 214 shoulder radiograph series (100% reduction; 214/214) and 145 orthopaedic assessments (64.2% reduction; 145/226) in this group. Resource and cost savings data for each eligible subgroup is displayed in Table 2.
Table 2.
Resource and cost savings associated with SKPOP
| A) Estimated comparison of physician services and radiographs accrued with SKPOP vs. traditional care for paediatric proximal humerus fractures at our institution between 2009 and 2014 | |||||
|---|---|---|---|---|---|
| Categories | Traditional follow-up assessments | Proposed SKPOP follow-up assessments | Potential resources saved | ||
| Females ≤10 years old (n=49) | |||||
| Number of shoulder series x-rays | 116 | 0 | 116 | ||
| Mean ± SD x-ray series per patient | 2.4 ± 1.5 | 0 | 2.37 | ||
| Number of orthopaedic assessments | 116 | 49 | 67 | ||
| Mean ± SD orthopaedic assessments per patient | 2.4 ± 1.0 | 1 | 1.37 | ||
| Males ≤12 years old (n=81) | |||||
| Number of shoulder series x-rays | 214 | 0 | 214 | ||
| Mean ± SD x-ray series per patient | 2.7 ± 1.5 | 0 | 2.7 | ||
| Number of orthopaedic assessments | 226 | 81 | 145 | ||
| Mean ± SD orthopaedic assessments per patient | 2.8 ± 1.3 | 1 | 1.8 | ||
| Females >10 years old and ≤50% fracture displacement (n=43) | |||||
| Number of shoulder series x-rays | 97 | 43 | 54 | ||
| Mean ± SD x-ray series per patient | 2.3 ± 1.0 | 1 | 1.3 | ||
| Number of orthopaedic assessments | 107 | 43 | 64 | ||
| Mean ± SD orthopaedic assessments per patient | 2.5 ± 1.2 | 1 | 1.5 | ||
| Males >12 years old and ≤50% fracture displacement (n=49) | |||||
| Number of shoulder series x-rays | 135 | 49 | 86 | ||
| Mean ± SD x-ray series per patient | 2.8 ± 1.3 | 1 | 1.8 | ||
| Number of orthopaedic assessments | 140 | 49 | 91 | ||
| Mean ± SD orthopaedic assessments per patient | 2.9 ± 1.2 | 1 | 1.9 | ||
| All patients (N=222) | |||||
| Number of shoulder series x-rays | 562 | 92 | 470 | ||
| Mean ± SD x-ray series per patient | 2.5 ± 1.4 | 0.4 | 2.1 | ||
| Number of orthopaedic assessments | 589 | 222 | 367 | ||
| Mean ± SD orthopaedic assessments per patient | 2.7 ± 1.2 | 0.4 | 2.2 | ||
| B) Estimated cost minimization for SKPOP versus traditional care for paediatric proximal humerus fractures at our institution between 2009 and 2014. | |||||
| Categories | Traditional follow-up assessments | Proposed SKPOP follow-up assessments | Cost savings | Cost savings per patient | |
| Females ≤10 years old (n=49) | $10,957.84 | $4,121.90 | $6,835.94 | $139.51 | |
| Males ≤12 years old (n=81) | $19,948.77 | $6, 813.10 | $13,135.67 | $162.17 | |
| Females >10 years old and ≤50% fracture displacement (n=43) | $9,548.93 | $5,550.29 | $3,998.64 | $92.99 | |
| Males >12 years old and ≤50% fracture displacement (n=49) | $12,394.77 | $6,324.47 | $6,070.30 | $123.88 | |
| Totals | $52,850.32 | $22,809.76 | $30,040.56 | $135.32 | |
SKPOP SickKids Paediatric Orthopaedic Pathway
Sensitivity analyses
A Monte Carlo PSA was performed with 1000 iterations, which accounted for variable pathway adherence and health care utilization within the decision analysis model. This resulted in mean ± standard deviation costs per patient for the SKPOP and traditional care pathways of $160.03 ± 36.40 and $217.85 ± 65.10, respectively; yielding an average cost savings of $57.82/patient. Furthermore, cost savings occurred with SKPOP for 96.5% of the iterations run through the model.
Province-wide analysis
Escott et al. reported an annual incidence of 619 simple paediatric proximal humerus fractures in the province of Ontario between April 1, 2003 and March 31, 2004 (15). Assuming 92.9% of these 619 patients would have been eligible for standardized follow-up, as in our cohort, provincial cost savings would be $33,249.45 based on the rates of adherence and health care utilization in our PSA. Alternatively, complete adherence to the pathway would result in provincial cost savings of $77,815.90 annually.
DISCUSSION
Principal findings
This economic evaluation demonstrates the significant cost and health care resource savings that are likely to result from implementing the SKPOP for proximal humerus fractures in a single-payer health care system. More specifically, the MOHLTC could potentially save $33,249.45 (or $77,815.90 with 100% adherence assumed) annually with province-wide implementation of the SKPOP. Fewer unnecessary radiographs and orthopaedic follow-up assessments accounted for the reduced costs.
Limitations
Limitations of this study bear consideration. First, the intrinsic value of follow-up to patients and their parents was not accounted for. By allotting patients a consultation with an orthopaedic surgeon in the clinical pathway, however, our recommendations allow surgeons to exclude rare injuries associated with proximal humerus fractures such as a fracture-dislocation, lesser tuberosity avulsion or pathologic fracture (1). On the other hand, several opportunity costs incurred by patients, surgeons and society that favour limiting intervention for these injuries were also excluded. This study did not examine parents’ out-of-pocket expenses such as child care, parking and time-off of work. Repeat follow-up assessments occupy time and resources, lengthening waiting times for other patients. The pathway also has the potential to limit radiation exposure. Due to these opportunity costs, adding indirect costs associated with follow-up to this analysis would likely further favour limiting intervention for these injuries.
Several assumptions enabled us to conduct this economic analysis. Although we initially assumed perfect compliance with the clinical pathway’s recommendations for the cohort examined, in the PSA a modest adherence rate of 50% was used. For example, parent preference and requirements for returning to sport may influence adherence. Definitive conclusions in regards to the cost consequences of implementation must wait until after implementation, when the actual costs incurred can be compared to pre-implementation costs. In the meantime, this economic analysis is helpful for individual physicians, hospital administrators and health care policy makers, as they decide how to manage children with these injuries. For example, the conservative estimate of proximal humerus fracture incidence in Ontario (575 per year) may have excluded several patient populations to which our clinical pathway applies (15). Also, indirect costs likely favouring pathway implementation were not considered. Despite these conservative assumptions, the cost savings of implementing the clinical pathway in Ontario are still significant.
Costs, not utilities, were compared in our cost-savings analysis for several reasons. Cost-utility analysis was not appropriate for this study because treatment according to pathway recommendation is expected to be as clinically effective as traditional care, but less costly. Utilities, as expressed by quality-adjusted life-years, are also difficult to measure for children with acute fractures (16,17). Cost-utility analyses are controversial in health care systems, such as Ontario’s, where patients do not pay directly for treatment (18). Also, cost-savings are simple to understand and may be more likely to influence decision making in clinical practice (19); the ultimate goal of this study is to influence policy and individual treatment decisions.
Implications
‘Scaling up’ and implementing a recommendation that deescalates traditional care involves several challenges, particularly from individual patients and surgeons (20,21). Implementation also incurs costs that were not included in our analysis, but by linking performance to funding, the ‘quality-based procedure’ paradigm is an example of a concrete way policymakers may enact change and implement new practices (22). The Choosing Wisely initiative in Canada and the U.S.A. also signals systematic movement to strengthen prudent health care decision-making among individual patients and physicians (21). Widespread implementation of the SKPOP for proximal humerus fractures in other jurisdictions may lead to similar reductions of unnecessary radiographs, follow-up assessments and costs.
Although costs vary in other health care systems, cost savings after implementing this clinical pathway are likely to be accrued independent of the health care model. In a privately funded health care system where beneficiaries of implementation are different from our single-payer system, patients and insurance companies will pay less for radiographs and follow-up visits. Other health care jurisdictions have already developed similar pathways to reduce the frequency of unnecessary radiographs and follow-up assessments in overburdened orthopaedic fracture clinics (11). However, the consequences of implementing these pathways have not been described.
It is important to note that prior work at our institution has shown only one treatment decision changed in this cohort after their initial orthopaedic consultation (<1% of the time) (6). Physicians should be reassured that implementing this pathway will not compromise quality of care provided for these injuries.
CONCLUSION
This economic evaluation is the first to demonstrate the significant cost savings and other clinical consequences likely to result from implementing our clinical pathway for proximal humerus fractures in a single-payer health care system. Implementation of these treatment recommendations in Ontario would be expected to save Ontario’s MOHLTC, $33,249.45 (or $77,815.90 with 100% adherence assumed) with equivalent effectiveness of traditional care. Since evidence supports minimal intervention for several other fracture types (23–29), future work may use similar methods to investigate cost savings associated with implementing clinical pathways for other paediatric fracture types. Adherence to practice according to these pathways should be evaluated, if implemented.
Acknowledgments
The authors are grateful to Arahon Gladstein and Alexander Schade for extracting data and creating the database used for this investigation.
Appendix
Table A1. Unit costs for physician services and diagnostic imaging
| Item | Unit Cost (CAD$) | Source |
|---|---|---|
| Initial orthopaedic consultation in fracture clinic | 83.10 | 13 |
| Repeat orthopaedic consultation in fracture clinic | 24.05 | 13 |
| Shoulder x-rays (2 or 3 views) | 19.33 | 12 |
| Radiologist fee | 25.60 | 13 |
This study received Research Ethics Board Approval from the Hospital for Sick Children, which was where the work originated.
Presented in part at: Canadian Orthopaedic Resident Association, 2016 Annual Meeting, June 2016, Quebec City, Canada, Poster Presentation.
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