What Is the Financial Impact of Orthopaedic Sequelae of Intravenous Drug Use on Urban Tertiary-care Centers?

Abstract

Background Orthopaedic sequelae such as skin and soft-tissue abscesses are frequent complications of intravenous drug use (IVDU) and comprise many of the most common indications for emergency room visits and hospitalizations within this population. Urban tertiary-care and safety-net hospitals frequently operate in challenging economic healthcare environments and are disproportionately tasked with providing care to this largely underinsured patient demographic. Although many public health initiatives have been instituted in recent years to understand the health impacts of IVDU and the spreading opioid epidemic, few efforts have been made to investigate its economic impact on healthcare systems. The inpatient treatment of orthopaedic sequelae of IVDU is a high-cost healthcare element that is critically important to understand within the current national context of inflationary healthcare costs. Questions/purposes (1) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of extraspinal orthopaedic sequelae of IVDU? (2) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of spinal orthopaedic sequelae of IVDU? (3) How did patient insurance status effect the economic burden of orthopaedic sequelae of IVDU? Methods An internal departmental record of all successive patients requiring inpatient treatment of orthopaedic sequelae of IVDU was initiated at Boston Medical Center (Boston, MA, USA) in 2012 and MetroHealth Medical Center (Cleveland, OH, USA) in 2015. A total of 412 patient admissions between 2012 to 2017 to these two safety-net hospitals (n = 236 and n = 176, respectively) for orthopaedic complications of IVDU were included in the study. These sequelae included cellulitis, cutaneous abscess, bursitis, myositis, tenosynovitis, septic arthritis, osteomyelitis, and epidural abscess. Patients were included if they were older than 18 years of age, presented to the emergency department for management of a musculoskeletal infection secondary to IVDU, and required inpatient orthopaedic treatment during their admission. Exclusion criteria included all patients presenting with a musculoskeletal infection not directly secondary to active IVDU. Patients presenting with an epidural abscess (Boston Medical Center, n = 36) were evaluated separately to explore potential differences in costs within this subgroup. A robust retrospective financial analysis was performed using internal financial databases at each institution which directly enumerated all true hospital costs associated with each patient admission, independent of billed hospital charges. All direct, indirect, variable, and fixed hospital costs were individually summed for each hospitalization, constituting a true “bottom-up” micro-costing approach. Labor-based costs were calculated through use of time-based costing; for instance, the cost of nursing labor care associated with a patient admission was determined through ascription of the median hospital cost of a registered nurse within that department (that is, compensation for salary plus benefits) to the total length of nursing time needed by that patient during their hospitalization. Primary reimbursements reflected the true monetary value received by the study institutions from insurers and were determined through the total adjusted payment for each inpatient admission. All professional fees were excluded. A secondary analysis was performed to assess the effect of patient insurance status on hospital costs and reimbursements for each patient admission. Results The mean healthcare cost incurred for the treatment of extraspinal orthopaedic sequelae of IVDU was USD 9524 ± USD 1430 per patient admission. The mean hospital reimbursement provided for the treatment of these extraspinal sequelae was USD 7678 ± USD 1248 per patient admission. This resulted in a mean financial loss of USD 1846 ± USD 1342 per patient admission. The mean healthcare cost incurred at Boston Medical Center for the treatment of epidural abscesses secondary to IVDU was USD 44,357 ± USD 7384 per patient. Hospital reimbursements within this subgroup were highly dependent upon insurance status. The median (range) reimbursement provided for patients possessing a unique hospital-based nonprofit health plan (n = 4) was USD 103,016 (USD 9022 to USD 320,123), corresponding to a median financial gain of USD 24,904 (USD 2289 to USD 83,079). However, the mean reimbursement for all other patients presenting with epidural abscesses (n = 32) was USD 30,429 ± USD 5278, corresponding to a mean financial loss of USD 5768 ± USD 4861. A secondary analysis demonstrated that treatment of extraspinal orthopaedic sequelae of IVDU for patients possessing Medicaid insurance (n = 309) resulted in a financial loss of USD 2813 ± USD 1593 per patient admission. Conversely, treatment of extraspinal orthopaedic sequelae for patients possessing non-Medicaid insurance (n = 67) generated a mean financial gain of USD 2615 ± USD 1341 per patient admission. Conclusions Even when excluding all professional fees, the inpatient treatment of orthopaedic sequelae of IVDU resulted in substantial financial losses driven primarily by high proportions of under- and uninsured people within this patient population. These financial losses may be unsustainable for medical centers operating in challenging economic healthcare landscapes. The development of novel initiatives and support of existing programs aimed at mitigating the health-related and economic impact of IVDU must remain a principal priority of healthcare providers and policymakers in coming years. Advocacy for the expansion of Medicaid accountable care organizations and national syringe service programs (SSPs), and the development of specialized outpatient wound and abscess clinics at healthcare centers may help to substantially alleviate the economic burden of the orthopaedic sequelae of IVDU. Level of Evidence Level, IV, economic and decision analyses.

The Burden of Patients With Lower Limb Amputations in a Community Safety-net Hospital

“…6 Physician fees tend to be a smaller proportion of costs relative to facility costs, 40 and a lack of availability of physician fees is a common limitation in cost analyses. 6,18,19 Likewise, the percentage of costs attributable to prosthetics has been limited or not reported in previous studies, and our comorbid cohort likely had lower utilization than previously documented rates after trauma-related amputations. Overall, our cost estimates underestimate the total true costs.…”

“…17 Examples of indirect costs include administrative, building, maintenance, housekeeping, dietary, medical records, and resident salaries. Costs associated with these hospitalizations that were not captured by this methodology include physician fees—which are commonly unavailable in cost analyses, 6,18,19 outpatient rehabilitation, and prosthetic costs. The application of cost center-based CCRs to total charges is used by hospitals for cost-based reimbursement claiming because it reasonably estimates the average costs associated with hospital services.…”

Cervical wound dehiscence following internal fixation of the cervical and thoracic spine: a report of three cases

“…In case 1, the patient had a history of IV drug abuse and smoking that likely contributed to his postoperative MSSA infection. Although the patient’s last use of IV drugs was unknown, IV drug abuse is associated with various musculoskeletal infections including skin and soft tissue complications ( 8 ). The association between cigarette smoking and delayed wound healing is well-studied in the literature ( 9 , 10 ).…”

Does Operative Management of Epidural Abscesses Increase Healthcare Expenditures up to 1 Year After Treatment?

“…These findings may stem from other medical and behavioral health comorbidities that are associated with IVDU alone, thus reaching beyond interventions specific to the treatment of spinal epidural abscesses. Nonetheless, Dwivedi et al [11] reported that the treatment of spinal epidural abscesses in patients with IVDU resulted in financial losses of USD 5768 per patient for the institutions providing care. Viewed in this light, the use of nonoperative management when it is indicated for patients with IVDU who have spinal epidural abscesses may result in savings for health centers treating these individuals and more efficient allocation of resources to other aspects of care such as cessation of drug use and treatment of associated medical comorbidities and mental health concerns.…”

“…In addition to surgical management, IVDU is another factor whose effect on long-term charges associated with the care of spinal epidural abscesses is unknown. Intravenous drug users tend to be underinsured, and care of IVDU-associated infections is associated with financial costs to healthcare systems [11,29]. It is unknown if charges specific to spinal epidural abscesses are higher in patients with active IVDU and whether these differences persist in long-term management.…”