Cost Efficiency of Ankle Fracture ORIF at an Ambulatory Surgical Center vs Hospital
Authors: Allen John R. , Hoch Caroline P. , Gross Christopher E. , Scott Daniel J. 
Published: November 2022

Category: Ankle; Trauma Introduction/Purpose: Ankle fracture open reduction and internal fixation (ORIF) is one of the most commonly performed orthopaedic surgeries, which can be performed at a variety of surgical locations. However, there is very little data exploring the cost and efficiency of ankle fracture ORIF in different operative settings. Time-Driven Activity Based Costing (TDABC) is a novel accounting method used to accurately assign costs for various procedures by creating a process map of all personnel interactions as a patient moves through a care event. Further, it has been shown to more accurately allocate costs, as compared to traditional accounting systems. Our purpose is to evaluate cost and efficiency differences in ankle fracture ORIF at an outpatient ambulatory surgery center (ASC) versus a hospital setting. Methods: A prospective cohort study was performed at a single academic medical center involving four orthopaedic surgeons. Patients were enrolled with uni-, bi-, or tri-malleolar displaced ankle fractures undergoing ORIF. According to TD-ABC methodology, a process map was created for each peri-operative platform and hand-timed data was collected at each location (ASC=5, hospital=5) by a single observer. In addition, retrospective cost data was obtained from 181 surgical cases using our institution's existing cost accounting system (ASC=34, hospital=147). Average event times and care costs were calculated for both locations, and a process map outlining the steps of care was created for each surgical site, according to TDABC methodology. Data were analyzed to investigate the effects of surgical site on labor cost, efficiency, and provider time. Results: Overall, total direct cost was similar between locations (ASC=$10,837.43, hospital=$9,377.80; p=.114), although there were significantly higher direct costs in the hospital: perioperative/anesthesia (ASC=$2,532.61, hospital=$4,594.20; p<.001), pharmacy (ASC=$112.18, hospital=$349.74; p<.001), radiology (ASC=$17.67, hospital=$227.98; p<.001), and therapy (ASC=$28.23, hospital=$130.91; p<.001). However, medical supply costs, including implant costs, were significantly higher at the ASC (ASC=$7,835.14, hospital=$2,459.60; p<.001). Preoperatively, nurse assessment of the patient was significantly quicker in the hospital (ASC=14.65 min, hospital=5.10 min; p=.030), while patient transport to the operating room was significantly quicker in the ASC (ASC=1.20 min, hospital=2.60 min; p=.014). Case duration was significantly longer in the ASC (ASC=138.60 min, hospital=56.60 min; p=.005), which may have been influenced by case complexity, as there were more tri-malleolar fractures (n=2) and concomitate ankle arthroscopies (n=3) in that cohort. Conclusion: Overall, direct costs appear to be lower at the ASC than the main hospital, although efficiency of care delivery seems similar. Generally, there were small differences in the care continuum between the main hospital and ASC, though areas where improvement could be obtained include preoperative nurse assessment of the patient and efficacy of regional nerve block administration. Going forward, larger studies will be needed to further investigate these results.