A Telemedicine Solution to Minimize Unnecessary Emergency Department Transfers for Low-acuity Pediatric Orthopaedic Patients: A Model for Cost Minimization.
Journal
The Journal of the American Academy of Orthopaedic Surgeons
ISSN: 1940-5480
Titre abrégé: J Am Acad Orthop Surg
Pays: United States
ID NLM: 9417468
Informations de publication
Date de publication:
03 Nov 2023
03 Nov 2023
Historique:
received:
10
12
2021
accepted:
24
08
2023
pubmed:
4
10
2023
medline:
4
10
2023
entrez:
4
10
2023
Statut:
aheadofprint
Résumé
Unnecessary emergency department (ED) transfers represent a notable source of excess costs and misutilization of healthcare resources, particularly with management of acute pediatric musculoskeletal injuries. This study used institutional data to create a model investigating the expected costs of a formal peer-to-peer telemedicine intervention designed to triage pediatric orthopaedic transfers, which we hypothesized would decrease healthcare costs by minimizing unwarranted ED-to-ED transfers. In this retrospective modeling analysis, 350 pediatric orthopaedic trauma patients transferred to two in-network referral hospitals from outside facilities were identified and stratified into three groups representing how patients theoretically optimally could have been treated. Group 1 patients required ambulance transfer, group 2 patients required ED-level care but no ambulance transfer, and group 3 patients did not require ED-level care. Base case estimates for the proportions of patients in each group, probability of ambulance transport, and direct costs of care for each patient were derived from the database. A decision tree was developed to evaluate the expected costs of two triaging strategies: (1) transfer everyone or (2) triage first using e-consultation. Probabilistic sensitivity analyses were used to determine how the results of the decision analysis varied across ranges of cost and probability estimates. In the base case analysis, the telemedicine triage strategy was cheaper than the transfer-all strategy ($4,858 versus $6,610). In a 2-way sensitivity analysis comparing cost of a telemedicine visit and proportion of telemedicine triaged patients requiring ambulance transport, the telemedicine triage strategy remained cheaper than the transfer-all strategy across almost all possibilities for both variables. Additional potential benefits of triage before transfer, such as decreased length of time to completion of ED visit, cost to the family, and patient comfort and satisfaction, were not incorporated into this analysis. The potential for misdiagnosis related to telehealth and its potential costs were not included. We revealed substantial cost savings for the healthcare system from implementing a telehealth platform for peer-to-peer consultation when considering patient transfer for musculoskeletal trauma. Initial peer-to-peer e-consultations cost less than reflexive ambulance transfer in most situations. Economic Level II.
Identifiants
pubmed: 37793173
doi: 10.5435/JAAOS-D-21-01201
pii: 00124635-990000000-00812
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
Copyright © 2023 by the American Academy of Orthopaedic Surgeons.
Références
Huang I-A, Tuan P-L, Jaing T-H, et al.: Comparisons between full-time and part-time pediatric emergency physicians in pediatric emergency department. Pediatr Neonatal 2016;57:371-377.
American Association of Orthopaedic Surgeons: Position statement: Emergency orthopedic care. Available at: https://www.aaos.org/contentassets/1cd7f41417ec4dd4b5c4c48532183b96/1172-emergency-orthopaedic-care.pdf . Accessed December 12, 2020.
Institute of Medicine: Emergency Care for Children: Growing Pains. The National Academies Press, 2007.
Tripod M, Tait M, Bracey J, Sexton K, Beck W, Wyrick TO: The use of telemedicine decreases unnecessary hand trauma transfers. Hand (N Y) 2020;15:422-427.
Natafgi N, Shane D, Ullrich F, Mackinney A, Bell A, Ward M: Using tele-emergency to avoid patient transfers in rural emergency departments: An assessment of costs and benefits. J Telemed Telecare 2017;24:193-201.
Medford-Davis LN, Holena DN, Karp D, Kallan MJ, Delgado MK: Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury. Am J Emerg Med 2018;36:797-803.
Gattu RK, De Fee A-S, Lichenstein R, Teshome G: Consideration of cost of care in pediatric emergency transfer—an opportunity for improvement. Pediatr Emerg Care 2017;33:334-338.
Eastwood K, Smith K, Morgans A, Stoelwinder J: Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: A retrospective cohort study. BMJ Open 2017;7:e016845.
Varma S, Schinasi DA, Ponczek J, et al.: A retrospective study of children transferred from general emergency departments to a pediatric emergency department: Which transfers are potentially amenable to telemedicine? J Pediatr 2021;230:126-132.e1.
Prada C, Izquierdo N, Traipe R, Figueroa C: Results of a new telemedicine strategy in traumatology and orthopedics. Telemed J E Health 2020;26:665-670.
Harno K, Arajärvi E, Paavola T, Carlson C, Viikinkoski P: Clinical effectiveness and cost analysis of patient referral by videoconferencing in orthopaedics. J Telemed Telecare 2001;7:219-225.
Lai L, Liddy C, Keely E, et al.: The impact of electronic consultation on a Canadian tertiary care pediatric specialty referral system: A prospective single-center observational study. PLoS One 2018;13:e0190247.
Ohinmaa A, Vuolio S, Haukipuro K, Winblad I: A cost-minimization analysis of orthopaedic consultations using videoconferencing in comparison with conventional consulting. J Telemed Telecare 2002;8:283-289.
McGill A, North J: An analysis of an ongoing trial of rural videoconference fracture clinics. J Telemed Telecare 2012;18:470-472.
Atanda A, Pelton M, Fabricant PD, Tucker A, Shah SA, Slamon N: Telemedicine utilisation in a paediatric sports medicine practice: Decreased cost and wait times with increased satisfaction. J ISAKOS 2018;3:94-97.
Sathiyakumar V, Apfeld JC, Obremskey WT, Thakore RV, Sethi MK: Prospective randomized controlled trial using telemedicine for follow-ups in an orthopedic trauma population: A pilot study. J Orthopaedic Trauma 2015;29:e139-e145.
Sultan AA, Acuña AJ, Samuel LT, et al.: Utilization of telemedicine virtual visits in pediatric spinal deformity patients: A comparison of feasibility and patient satisfaction at a large academic center. J Pediatr Orthopaedics 2020;40:e712-e715.
Jenkins JM, Halai M: What evidence is available for the continued use of telemedicine in orthopaedic surgery in the post-COVID-19 era? Clin Orthop Relat Res 2021;479:747-754.
Hardin AP, Hackell JM, Committee on Practice and Ambulatory Medicine: Age limit of pediatrics. Pediatrics 2017;140:e20172151.
Curran DM, Kim BY, Withers N, Shepard DS, Brady CJ: Telehealth screening for diabetic retinopathy: Economic modeling reveals cost savings. Telemed J E Health 2022;28:1300-1308.
Kiritharan S, Johanson MV, Jensen MB, Thomsen JNL, Andersen CA, Jensen CE: A cost-minimisation analysis of performing point-of-care ultrasonography on patients with vaginal bleeding in early pregnancy in general practice: A decision analytical model. BMC Health Serv Res 2022;22:55.
Low YL, Finkelstein E: Cost-effective analysis of dual-energy computed tomography for the diagnosis of occult hip fractures among older adults. Value Health 2021;24:1754-1762.
Glennie RA, Urquhart JC, Koto P, et al.: Microdiscectomy is more cost-effective than a 6-month nonsurgical care regimen for chronic radiculopathy. Clin Orthop Relat Res 2022;480:574-584.
The Center for Medicare & Medicaid Services: Physician fee schedule. Available at: https://www.cms.gov/medicare/physician-fee-schedule/search?Y=2&T=0&HT=2&CT=0&H1=G0425&H2=G0427&M=5 , Accessed February 18, 2023.
Husereau D, Drummond M, Augustovski F, et al.: Consolidated health economic evaluation reporting standards (CHEERS) 2022 explanation and elaboration: A report of the ISPOR CHEERS II good practices task force. Value Health 2022;25:10-31.
Kamiński B, Jakubczyk M, Szufel P: A framework for sensitivity analysis of decision trees. Cent Eur J Oper Res 2018;26:135-159.
Husereau D, Drummond M, Augustovski F, et al., CHEERS 2022 ISPOR Good Research Practices Task Force: Consolidated health economic evaluation reporting standards 2022 (CHEERS 2022) statement: Updated reporting guidance for health economic evaluations. BMJ 2022;376:e067975.
Hughes AJ, Feeley IH, Crowley M, Conlon B, Merghani K, Sheehan EC: Upscaling virtual fracture clinic use is a safe, effective measure in the delivery of trauma care. J Orthop Trauma 2020;34:e349-e352.
O' Reilly M, Breathnach O, Conlon B, Kiernan C, Sheehan E: Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland. Injury 2019;50:898-902.
Rizzi AM, Polachek WS, Dulas M, Strelzow JA, Hynes KK: The new “normal”: Rapid adoption of telemedicine in orthopaedics during the COVID-19 pandemic. Injury 2020;51:2816-2821.
Lau BC, WIttstein JR, Anakwenze OA: How are orthopaedic sports medicine physicians triaging cases and using telehealth in response to COVID-19? A survey of AOSSM membership. Orthop J Sports Med 2021;9:232596712199092.
Hoaglin MC, Brenner LH, Teo W, Bal BS: Medicolegal sidebar: Telemedicine-new opportunities and new risks. Clin Orthop Relat Res 2021;479:1671-1673.