Jackson Taylor J, Blumberg Todd J, Shah Apurva S, Sankar Wudbhav N
The Children's Hospital of Philadelphia, Division of Orthopaedics.
The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
J Pediatr Orthop. 2018 Mar;38(3):e128-e132. doi: 10.1097/BPO.0000000000001132.
Musculoskeletal injuries are among the most common reasons for emergency department (ED) visits in the pediatric population. Many such injuries can be managed with a single follow-up outpatient visit. However, untimely (ie, premature) referrals by emergency physicians to orthopaedic surgeons are common and may inadvertently create need for a second visit, generating unnecessary expenditures. We sought to elucidate the cost of premature musculoskeletal follow-up visits to the patients, families, and the health care system.
We performed a retrospective review of pediatric patients with acute musculoskeletal injuries referred from our ED (without a formal orthopaedic consult) to our outpatient clinic. Patients were retrospectively reviewed in a consecutive fashion. The appropriateness of the recommended follow-up time interval was determined for each patient, and the direct and indirect cost of the inappropriate services were calculated utilizing a combination of traditional cost accounting techniques and time-driven activity-based costing. The characteristics of patients with appropriate and untimely follow-up referrals were compared.
Two hundred consecutive referrals from the ED were reviewed. Overall, 96.5% of the follow-up visits recommended by the ED were premature, which led 106 (53%) patients to require a second visit to complete their clinical care. Patients who required a second visit were significantly younger (P=0.005), more likely to be male (P=0.042), more likely to have a fracture (P<0.001), and less likely to have a sprain (P<0.001) or dislocation/subluxation (P<0.001). Over 40% of second visits were accounted for by 3 diagnoses (distal radius buckle fractures, nondisplaced Salter-Harris 1 fractures of the ankle, and buckle fractures of the finger). Across the whole cohort, the total financial impact of untimely visits was $36,265.78, representing an average cost of $342.93 per patient.
Untimely referrals for follow-up of acute pediatric musculoskeletal conditions are very common and represent a significant financial burden to patients, families, and the health care system. Over 40% of unnecessary visits resulted from just 3 diagnoses. Improved orthopaedic follow-up guidelines, particularly for these readily recognizable conditions, and feedback to referring providers may reduce poorly timed clinic visits and decrease costs in the treatment of common orthopaedic injuries in pediatric patients.
Level III.
肌肉骨骼损伤是儿科人群前往急诊科就诊的最常见原因之一。许多此类损伤只需一次门诊随访即可处理。然而，急诊医生过早地将患者转诊给骨科医生的情况很常见，这可能会无意中导致患者需要再次就诊，从而产生不必要的费用。我们试图阐明过早进行肌肉骨骼损伤随访就诊给患者、家庭和医疗保健系统带来的成本。
我们对从急诊科（未进行正式骨科会诊）转诊至我们门诊的急性肌肉骨骼损伤儿科患者进行了回顾性研究。对患者进行连续的回顾性分析。确定每位患者推荐的随访时间间隔是否合适，并结合传统成本核算技术和时间驱动作业成本法计算不适当服务的直接和间接成本。比较了随访转诊合适和不合适的患者特征。
共回顾了200例来自急诊科的连续转诊病例。总体而言，急诊科推荐的随访就诊中有96.5%为过早转诊，这导致106例（53%）患者需要再次就诊以完成临床治疗。需要再次就诊的患者明显更年轻（P = 0.005），男性比例更高（P = 0.042），发生骨折的可能性更大（P < 0.001），而发生扭伤（P < 0.001）或脱位/半脱位（P < 0.001）的可能性更小。超过40%的再次就诊是由3种诊断引起的（桡骨远端青枝骨折、踝关节无移位的Salter-Harris 1型骨折和手指青枝骨折）。在整个队列中，过早就诊的总经济影响为36,265.78美元，平均每位患者成本为342.93美元。
急性儿科肌肉骨骼疾病的随访转诊过早的情况非常普遍，给患者、家庭和医疗保健系统带来了重大经济负担。超过40%的不必要就诊仅由3种诊断引起。改进骨科随访指南，特别是针对这些易于识别的疾病，并向转诊医生提供反馈，可能会减少就诊时间不当的情况，并降低儿科患者常见骨科损伤的治疗成本。
三级。
