Medical economics has progressed to the point where musculoskeletal physicians and surgeons cannot ignore the financial implications of their decisions. Unfortunately, in most practice locations it is difficult, if not impossible, to ascertain the downstream costs to patients and insurers of our postsurgical orders for imaging, laboratory testing, and physical therapy (PT). In the April 18, 2018 issue of The Journal, Egol et al. present results from a well-designed and adequately powered randomized trial of outcomes after patients with minimally or nondisplaced radial head or neck fractures were referred either to outpatient PT or to a home exercise program focused on elbow motion.
At all follow-up time points (from 6 weeks to an average of 16.6 months), the authors found that patients receiving formal PT had DASH scores and time to clinical healing that were no better than the outcomes of those following the home exercise program. In fact, the study showed that after 6 weeks, patients following the home exercise program had a quicker improvement in DASH scores than those in the PT group.
The minor limitations with this study design (such as the potential for clinicians measuring elbow motion becoming aware of the treatment arm to which the patient was assigned) should not prevent us from implementing these findings immediately into practice. Each patient going to physical therapy in this scenario would have cost the healthcare system an estimated $800 to $2,400.
I wonder how many other pre- and postsurgical decisions that we routinely make would change if we had similar investigations into the value of ordering postoperative hemoglobin levels, surgical treatment of minimally displaced distal fibular fractures, routine postoperative radiographs for uncomplicated hand and wrist fractures, and PT after routine carpal tunnel release. These are just some of the reflexive decisions we make on a daily basis that probably have little to no value when it comes to patient outcomes. Whenever possible, we need to think about the downstream costs of such decisions and support the appropriate scientific evaluation of these commonly accepted, but possibly misguided, practices.
Marc Swiontkowski, MD
One thought on “Keeping a Clinical Eye on Downstream Costs”
As a now retired, “old” orthopedist, I find the recommendations are no more than “know your patient” as taught in the past. Most don’t need formal PT for minor injuries, some will require formal instruction once or twice, and a few will require close PT and office follow-up. Some things are necessary for medical-legal documentation. Other times they are justifiable for avoiding surprises or verification of one’s clinical judgment.
I’m sure we’ve all read of lawsuits whereby “if only this inexpensive, easily obtained test had been performed……” accusation. Further, the reward(s) for judgment, time, and risk to decrease cost generally doesn’t accrue with any significance to the physician. Change the system, reward the physician for practicing his art; otherwise don’t complain of increased costs and expanded patient expectation.
There are many more cost drivers. Studies proving what the conscientious, astute, properly trained physician already knows are unlikely to effect even change in philosophy, let alone let alone reduce costs.