Safety and Cost-Efficacy of Surgical Fixation of Isolated Ankle Fractures in a Free-Standing Ambulatory Surgical Center (ASC) vs. Hospital-Owned Outpatient Facility (HOPD)

Abstract

Category: Ankle, Trauma Introduction/Purpose: Free-standing Ambulatory Surgical Centers (ASCs) typically provide uncomplicated surgical procedures in a non-hospital setting, and function as ‘focused factories’ that replicate the delivery of quality care while achieving lower costs as compared to hospital-owned outpatient facilities (HOPD). Despite an increasing interest towards outpatient foot and ankle surgery, few studies have compared the safety and cost-savings associated with surgical fixation of isolated ankle fractures in a free-standing ASC vs. a HOPD. Methods: The 2007-2014 Humana Administrative Claims (HAC) database was queried using Current Procedural Terminology codes to identify patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (27766, 27769, 27792), bi-malleolar (27814) and tri-malleolar (27822, 27823) ankle fractures. Patients with polytrauma or those undergoing a concurrent surgical fixation of the upper extremity, hip, femur, knee or tibia were removed from the study to capture a relevant cohort of isolated ankle fracture patients. Location of surgery was identified using Service Location codes 22 (HOPD) and 24 (ASC). Propensity- score matching and multi-variate regression analyses were used to compare differences in 90-day complications, ED-visits and readmissions between the two groups. A 90-day cost comparison was also carried out to assess savings associated with surgery in an ASC vs. HOPD. Results: A total of 4,832 (80.1%) ankle fractures treated in a HOPD and 1,198 (19.9%) in a free-standing ASC were included in the study. Following propensity-score matching to account for differences in baseline demographics and clinical characteristics, each group consisted of 1,138 patients. Following multi-variate analyses, undergoing surgery in a free-standing ASC vs. a HOPD was not associated with a higher rate of 90-day complications (0.73 [95% CI 0.54 -1.00]; p=0.05), ED visits (OR 0.86 [95% CI 0.64- 1.16]; p=0.331) and readmissions (0.79 [95% CI 0.53 -1.18]; p=0.251). Furthermore, undergoing surgery in a free-standing ASC was associated with nearly $2500 cost-savings/case over the 90-day episode of care (ASC = $8,058 vs. HOPD = $10,619; p<0.001). Conclusion: Using national administrative claims of Commercial insurance beneficiaries, the results of the study show that performing surgical fixation of ankle fractures in a free-standing ASC is a safe and cost-effective option in a carefully selected patient population.