The Journal is receiving an increasing number of manuscripts related to value assessments and cost-effectiveness analyses of treatments for orthopaedic pathologies. This line of investigation is crucial to helping the larger healthcare system lower costs while improving patient outcomes. One aspect of determining the total cost of a musculoskeletal intervention is the impact of so-called indirect costs. Components of indirect costs include lost patient wages from not working, higher transportation costs, and extra dollars spent by the individual or family to manage household chores and self-care.
In the December 16, 2020 issue of The Journal, Noback et al. examine the total, direct, and indirect costs of care among 60 patients with a lateral malleolar fracture that was treated either nonsurgically or surgically. They found that in many cases, indirect costs exceeded the direct cost of delivering medical/surgical care. Not surprisingly, this was especially true in nonoperatively treated patients, where three-quarters of the total cost were indirect costs (see Figure).
I believe that our community needs to more widely appreciate and study the impact of patients’ lost wage-earning opportunities and out-of-pocket expenditures. Every treatment recommendation we make in clinical practice involves these financial implications for our patients. Noback et al. go so far as to claim that “any cost-effectiveness analysis… must assess indirect costs or it risks drastically mischaracterizing a treatment’s value.”
We therefore should continue pushing our treatment and rehabilitation strategies to more aggressively limit time lost to full weight-bearing or use of the upper limb. Also, orthopaedic research should be directed toward strategies that limit the impact of indirect costs and family burdens as we seek to continuously improve care for our patients.
Marc Swiontkowski, MD
Remember when a “dashboard” referred to the display just behind a car’s steering wheel? In today’s digital universe, the word has come to mean any number of visual information displays. At the same time, the meaning of the word “value” has narrowed somewhat. In relation to health care, “value” is defined quite precisely as the quality of patient outcomes per dollar spent on healthcare services.
In the November 4, 2020 issue of The Journal of Bone & Joint Surgery, Reilly et al. explain how they created a “value dashboard” for total hip and knee arthroplasty (THA and TKA) at a tertiary-care medical center in New England. The goal: track and display the surgeon-level cost and quality of these procedures against institutional benchmarks to identify opportunities for improving value.
The 7 quality metrics that Reilly et al. used included both clinical and patient-reported outcomes, weighted by surgeons using a modified Delphi process. Average direct costs per surgeon were calculated from the medical center’s billing system, and data were collected over a 15-month period from 2017 to 2018 to ensure at least 1 year of outcomes. Six surgeons were included in the TKA value dashboard, and 5 were included in the THA dashboard.
Relative to the institutional benchmarks:
- Value for TKA by surgeon ranged from 7% below benchmark to 12% above.
- Value for THA by surgeon ranged from 12% below benchmark to 7% above.
The dashboard itself (see Figure above) displays quality, cost, and overall value so viewers can see at a glance which metrics are driving the value score for each surgeon, whose procedural volume is also depicted. The authors cite as one limitation of this study the fact that the quality metrics were weighted by local surgeons only, and they say that “ideally the weighting would be informed by a panel of national experts and several stakeholder groups,… including patients.”