Orthopaedic Urgent Care Versus the Emergency Department: Cost Implications for Low-Energy Fracture Care

Christian A. Pean, MD, MS; Mackenzie L. Bird, BA; Daniel B. Buchalter, MD; S. Steven Yang, MD, MPH; Kenneth A. Egol, MD

Disclosures

J Am Acad Orthop Surg. 2022;30(3):e371-e374. 

In This Article

Abstract and Introduction

Abstract

Introduction: This study compared costs, length of visit, and utilization trends for patients with fractures seen in an immediate care orthopaedic center (I-Care) versus the emergency department (ED) in a major metropolitan area.

Methods: A retrospective chart review of consecutive patients seen on an outpatient basis in the ED and I-Care over a 6-month period was conducted. Patient demographics, procedures done, care category, estimated costs, and disposition information were included for statistical analysis. Within the low-acuity fracture care group, a cost-comparison analysis was conducted.

Results: A total of 610 patients met inclusion criteria with 311 seen in I-Care and 299 in the ER. I-Care patients were more likely to have low-acuity injuries compared with ED patients (60.1% versus 18.1%, P < 0.001). The length of visit was longer for patients seen in the ED compared with I-Care (6.1 versus 1.43 hours, P value < 0.001). A cost analysis of low-acuity patients revealed that an estimated $62,150 USD could have been saved in healthcare costs by the initial diversion of low-acuity patients seen in the ER to I-Care during the study period.

Discussion: These results suggest that the I-Care orthopaedic urgent care model is a more cost-effective and more efficient alternative to the ED for patients with fractures requiring procedural treatment and low-acuity patients managed on an outpatient basis.

Introduction

The United States spent an estimated $3.2 trillion USD on health care in 2015, representing 18% of the country's gross domestic product.[1] In recent history, paradigm shifts in American health care continue to emphasize transitions to value-based care systems and the prioritization of high quality, cost-efficient care. Efforts to improve patient quality of care and containing expenditures include eliminating redundant healthcare services, reducing patient wait times, and minimizing expensive visits to the emergency department (ED) for ambulatory care sensitive conditions (ACSCs).[2]

Historically, up to 30% of urgent care visits and local ED visits are related to musculoskeletal injuries.[3] Recently, there has been a surge in ED visits of 32%, from 103 to 136 million per year. These ED visits often serve patients who present with nonemergent ACSCs in addition to those in need of immediate care, such as patients with cardiac arrest, stroke, or trauma.[3,4] Over time, the number of emergent patients seen within target periods has also decreased. These overcrowded facilities have long wait times and high patient dissatisfaction scores. These trends may reflect a higher number of patients seeking nonemergent care for ACSCs in the ED, and efforts to divert patients to ambulatory facilities and urgent cares have increased.[5] Urgent care facility costs and fees are historically much lower than ED facilities costing an average of $168 as compared with hospital-based ED visits costing an average of $2,259.[6] Development of orthopaedic-specific urgent care facilities may aid in these diversion efforts and improve quality of care, and in fact, they have already been shown to decrease wait times and improve time to follow-up.[7] However, the utilization of orthopaedic urgent cares has not been well researched, and the question remains as to whether some degree of redundant additive care rather than efficient substitutive care is being delivered by urgent care facilities.

At our institution, a profitable orthopaedic urgent care facility called "Orthopedic Immediate Care" (I-Care) has been in place for 30 years and caters exclusively to patients with musculoskeletal complaints. Although its structure and staffing have changed over the years, it is currently staffed by an orthopaedic resident who is overseen by an emergency medicine attending with an on-call orthopaedic attending on standby for the escalation of care. Orthopaedic residents perform 32 I-Care shifts (8 AM to 10:30 PM) during their second year of residency, which is a scheduled part of the adult reconstructive, sports, and pediatrics rotations. This study sought to compare costs, acute length of visit (LOV), and utilization trends for patients with fracture seen in the I-Care versus the ED in a major metropolitan area. It was hypothesized that LOV would be shorter and estimated costs would be lower for patients with fracture seen in the I-Care setting.

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