Cost-effectiveness of direct discharge from the emergency department of patients with simple stable injuries in the Netherlands

Thijs H Geerdink; Niek J Geerdink; Johanna M van Dongen; Robert Haverlag; J Carel Goslings; Ruben N van Veen; Virtual Fracture Care Study Collaborative

doi:10.1136/tsaco-2021-000763

Cost-effectiveness of direct discharge from the emergency department of patients with simple stable injuries in the Netherlands

Trauma Surg Acute Care Open. 2021 Oct 26;6(1):e000763. doi: 10.1136/tsaco-2021-000763. eCollection 2021.

Authors

Thijs H Geerdink^{1

2}, Niek J Geerdink¹, Johanna M van Dongen³, Robert Haverlag¹, J Carel Goslings^{1

2}, Ruben N van Veen¹; Virtual Fracture Care Study Collaborative

Collaborators

Virtual Fracture Care Study Collaborative:
Bas A Uijterwijk, Ruth J Stoffels

Affiliations

¹ Department of Trauma Surgery, OLVG, Amsterdam, The Netherlands.
² Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
³ Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.

Abstract

Background: Approximately one-third of musculoskeletal injuries are simple stable injuries (SSIs). Direct discharge (DD) from the emergency department (ED) of patients with SSIs reduces healthcare utilization, without compromising patient outcome and experience, when compared with "traditional" care with routine follow-up. This study aimed to determine the cost-effectiveness of DD compared with traditional care from a societal perspective.

Methods: Societal costs, including healthcare, work absenteeism, and travel costs, were calculated for patients with an SSI, 6 months before (pre-DD cohort) and after implementation of DD (DD cohort). The pre-DD cohort was treated according to local protocols. The DD cohort was treated using orthoses, discharge leaflet, smartphone application, and telephone helpline, without scheduling routine follow-up. Effect measures included generic health-related quality of life (HR-QoL; EuroQol Five-Dimensional Questionnaire); disease-specific HR-QoL (functional outcome, different validated questionnaires, converted to 0-100 scale); treatment satisfaction (Visual Analog Scale (VAS), 1-10); and pain (VAS, 1-10). All data were assessed using a 3-month postinjury survey and electronic patient records. Incremental cost-effectiveness ratios were calculated and uncertainty was assessed using bootstrapping techniques.

Results: Before DD, 144 of 348 participants completed the survey versus 153 of 371 patients thereafter. There were no statistically significant differences between the pre-DD cohort and the DD cohort for generic HR-QoL (0.03; 95% CI -0.01 to 0.08), disease-specific HR-QoL (4.4; 95% CI -1.1 to 9.9), pain (0.08; 95% CI -0.37 to 0.52) and treatment satisfaction (-0.16; 95% CI -0.53 to 0.21). Total societal costs were lowest in the DD cohort (-€822; 95% CI -€1719 to -€67), including healthcare costs (-€168; 95% CI -€205 to -€131) and absenteeism costs (-€645; 95% CI -€1535 to €100). The probability of DD being cost-effective was 0.98 at a willingness-to-pay of €0 for all effect measures, remaining high with increasing willingness-to-pay for generic HR-QoL, disease-specific HR-QoL, and pain, and decreasing with increasing willingness-to-pay for treatment satisfaction.

Discussion: DD from the ED of patients with SSI seems cost-effective from a societal perspective. Future studies should test generalizability in other healthcare systems and strengthen findings in larger injury-specific cohorts.

Level of evidence: II.

Keywords: cost-benefit analysis; efficiency; fracture; patient satisfaction.