World J Surg DOI 10.1007/s00268-016-3496-z
ORIGINAL SCIENTIFIC REPORT
The Cost of Intramedullary Nailing for Femoral Shaft Fractures in Dar es Salaam, Tanzania Erik J. Kramer1 • David W. Shearer1 • Elliot Marseille2,3 • Billy Haonga4 Joshua Ngahyoma4 • Edmund Eliezer4 • Saam Morshed1,3
•
Ó Socie´te´ Internationale de Chirurgie 2016
Abstract Background Femoral shaft fractures are one of the most common injuries seen by surgeons in low- and middleincome countries (LMICs). Surgical repair in LMICs is often dismissed as not being cost-effective or unsafe, though little evidence exists to support this notion. Therefore, the goal of this study is to determine the cost of intramedullary nailing of femoral shaft fractures in Tanzania. Methods We used micro-costing methods to estimate the fixed and variable costs of intramedullary nailing of femoral shaft fractures. Variable costs assessed included medical personnel costs, ward personnel costs, implants, medications, and single-use supplies. Fixed costs included costs for surgical instruments and administrative and ancillary staff. Results 46 adult femoral shaft fracture patients admitted to Muhimbili Orthopaedic Institute between June and September 2014 were enrolled and treated with intramedullary fixation. The total cost per patient was $530.87 (SD $129.99). The mean variable cost per patient was $419.87 (SD $129.99), the largest portion coming from ward personnel $144.47 (SD $123.30), followed by implant $134.10 (SD $15.00) medical personnel $106.86 (SD $28.18), and medications/supplies $30.05 (SD $12.28). The mean fixed cost per patient was $111.00, consisting of support staff, $103.50, and surgical instruments, $7.50. Conclusions Our study provides empirical information on the variable and fixed costs of intramedullary nailing of femoral shaft fractures in LMICs. Importantly, the lack of surgical capacity was the primary driver of the largest cost for this procedure, preoperative ward personnel time. Our results provide the cost data for a formal cost-effectiveness analysis on this intervention.
& Erik J. Kramer
[email protected] 1
Institute for Global Orthopedics and Traumatology, University of California San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
2
Health Strategies International, Oakland, CA, USA
3
Global Health Economics Consortium, University of California San Francisco, San Francisco, CA, USA
4
Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
Introduction The most recent report on the Global Burden of Disease (GBD) found that there is a growing burden of non-communicable diseases and injuries, a substantial portion of which occurs in low- and middle-income countries [1]. In 2010, injuries alone accounted for 11.2 % of ill health in the global adult population. Many of these injuries are surgically treatable, yet a widespread perception persists that surgery is inordinately expensive presents a major barrier to
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the implementation of surgery in the global health agenda [2, 3]. However, recent studies have demonstrated strong evidence that surgery, including orthopaedic intervention, is often as cost-effective as many non-surgical interventions in widespread use in LMICs [4–7]. Musculoskeletal injuries contributed heavily to this growing burden as a result of the proliferation of access to motorized transportation and corresponding increases in morbidity and mortality in LMICs [8, 9]. The incidence of musculoskeletal injury in LMICs has been estimated to be between 1000 and 2600 per 100,000 persons [1]. Specifically, femoral shaft fractures are a major contributor to the global musculoskeletal injury burden. It has been estimated that 17 % of all musculoskeletal injuries in LMICs are femoral shaft fractures [10]. Agarwal-Harding et al. have estimated that LMICs have a femoral shaft fracture incidence of 15.7–45.5 per 100,000 people per year, a rate more than double that of high-income countries [11]. When left untreated or treated improperly, these fractures can be disabling. Femoral shaft fractures carry a disability weight of 0.272, which is higher than the disability weight for malaria (0.191) and on par with untreated tuberculosis (0.271) [12]. Although intramedullary nailing is the standard of care in high-income countries (HICs), conservative treatment using skeletal traction remains commonplace in LMICs due to the perceived high cost of surgery and other systemic barriers including implant unavailability and lack of technical expertise [13, 14]. There are currently very limited data evaluating either cost-effectiveness or the cost of treating femoral shaft fractures surgically or with traction. As a first step in an economic analysis of treatment for femoral shaft fractures, we conducted a cost analysis including a ‘time-and-motion’ study to determine the total direct and indirect costs of intramedullary nailing.
Materials and methods Research setting This study was designed as a prospective observational economic analysis conducted at Muhimbili Orthopaedic Institute (MOI) in Dar es Salaam, Tanzania. Institutional review board approval was obtained from our institution and from MOI. MOI is the largest orthopaedic tertiary care centre in Tanzania with 150 hospital beds (30 private, 120 general). In 2014, the hospital had 11,245 inpatient stays and 38,984 outpatient visits. There are twenty-one orthopaedic surgeons, five anaesthesiologists, one radiologist, forty-eight medical residents, 115 operating room and ward nurses, one radiology technician, and eighty hospital assistants who assist directly in delivering care for patients undergoing femoral shaft fixation at MOI.
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Patients In this non-randomized study, skeletally mature patients who sustained an isolated femoral shaft fracture managed with intramedullary nailing at Muhimbili Orthopaedic Institute (MOI) between June 2014 and September 2014 were considered eligible. Patients were excluded if they had ipsilateral fracture of the lower limb, preoperative evidence of infection at the surgical site, clinical or radiographic evidence of pathologic fracture, or prior surgery involving the affected femur. Patients were treated at the surgeon’s discretion with the SIGN intramedullary nail (IM-SIGN Fracture Care Intl., Richland, WA, USA) or the Universal Femoral Nail (UFN-DePuy Synthes, West Chester, PA, USA) intramedullary nailing systems. Upon admission, written consent was acquired from all patients. Patient age, sex, fracture and wound type, cause of injury, time from injury, anaesthetic method used, implant make, and surgical approach were recorded. All patients underwent radiography before and after surgery, and all were placed in preoperative skin traction. Postoperatively, patients received supportive care and were discharged when medically stable and able to mobilize. Procedure With the patient supine on an operating table, general anaesthesia or subarachnoid spinal nerve block was administered. The fracture site was routinely opened using a direct lateral incision for reduction. The procedure was executed following the manufacturer’s recommendations for intramedullary nail implantation [15]. For antegrade approaches, an incision was made proximal to the greater trochanter in line with the gluteus maximus fibres. For retrograde approaches, either a medial parapatellar or patellar tendon splitting incision was used. The femoral canal was opened using an awl and reamed manually until cortical ‘‘chatter’’. Typically a nail diameter 2 mm smaller than the largest reamer was selected. The nail was inserted into the intramedullary canal using a mallet. For the SIGN nail system, the target arm was used to insert proximal and distal interlocking screws without fluoroscopic guidance. Depending on the fracture pattern and surgeon preference, one to four interlocking screws were inserted. For the Universal Femoral Nail, no interlocking screws were inserted. All wounds were closed with prolene sutures. Fluoroscopically guided ‘‘free-hand’’ technique was not routinely used for targeting interlocking screws. Variable costs Medical personnel costs The unit cost of an intramedullary nail fixation procedure is the sum of the variable costs and fixed costs. Variable costs
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were defined as the sum of the medical personnel costs, ward personnel costs, implants, medications, and single-use supplies. All costs are expressed in 2014 US Dollars (US$) after adjusting for inflation and conversion from Tanzanian Shilling (TZS) at an exchange rate of 1773 TZS: to 1 US$ [16]. Time and motion analysis was used to measure the costs associated with staff who were directly involved with delivering treatment to the patient—the medical personnel cost (Fig. 1). A data-entry form (Microsoft Excel, Redmond, WA, USA) with twenty-one itemized steps of the fixation procedure beginning with transport from the ward to the theatre and including all care until transport back to the ward was used (Appendix). On the form, each member of the medical team was categorized into one of seven categories: attending orthopaedic surgeon, anaesthesiologist, medical resident, nurse anaesthetist, nurse, radiology technician, or hospital assistant. There were twenty-two steps in the surgical procedure (Appendix). The total time for each step was recorded and the members of the surgical team involved with each specific step were noted, by a trained research assistant. The time for each step in which a staff member was involved was summed to calculate the total time he or she spent working during a procedure. If multiple staff of the same category were present, their time spent was summed to represent an aggregate person-hours total for that category. The person-hours expended in the theatre staging area and recovery area required a different approach because there were often several nurses caring for several patients, all of whom spent varying amounts of time in each area. Therefore, time spent by the attending orthopaedic surgeon, anaesthesiologist, medical residents, and nurse anaesthetists was recorded using individual stopwatches. Time spent by nurses was captured by the formula ‘‘T ¼ ntp’’ where T is the person-hours spent by a Fig. 1 Time and motion work flow for calculating medical personnel costs for a single procedure. Category 1 includes physicians, residents, and nurse anaesthetists, category 2 includes all non-anaesthetist nurses, and category 3 includes hospital assistants. T personhours, n number of nurses in preop/postop area, p number of patients in preop/postop area, t time spent in preop/postop area
single nurse, n is the number of nurses present in area, p is the number of patients present in area, and t is the time spent in area for a single nurse. The total person-hours per staff member were found by summing the times for the procedure steps they were involved with and either the product of the formula the formula ‘‘T ¼ ntp’’ for nurses or the stopwatch times for all other personnel. Wage multipliers for each of the personnel were calculated from salary data provided by MOI (Appendix). Equation 1 was then used to calculate the surgical personnel costs per patient (Appendix). Ward personnel costs Ward personnel costs were found by summing normal-hour personnel costs (6AM-6PM) and off-hour personnel costs (6PM-6AM). MOI patients are assigned to general or private wards depending on their ability to pay. The average number of staff and patients was found by counting staff and patients present in the ward during patient enrollment. It was assumed that staffing levels dropped by 50 % during off-hours. Equation 2 was then used to calculate the ward personnel costs per patient (Appendix). Implant costs Two types of intramedullary nails were used in this study: the SIGN intramedullary nail and the DePuy Synthes universal femoral nail (UFN). SIGN is a non-profit company which began manufacturing and donating orthopaedic implants in 1999 [17]. The SIGN system is unique because it allows interlocking screws to be placed without fluoroscopy or power instruments. Importantly, because
Category 1 Preoperative
Direct patient care time
Operative
Active time spent on each step
Postoperative
Interactive time via stopwatch
Wages
Total time
Category 2 "
Category 3 Active time spent on each step
Active time spent on each step
"
Active time spent on each step
Total time
Total time
Total personnel cost, single procedure
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patients in most developing countries must pay out-ofpocket for implants prior to surgery, the SIGN system allows access to the benefits of intramedullary nailing where it would otherwise be unaffordable. The costs of the nails, interlocking screws, and instrumentation were obtained from manufacturers directly and thus include manufacture, packaging, and shipping but do not reflect distributors’ markup.
Table 1 Descriptive patient data Total patients
46
Male
38 (83 %)
Female
8 (17 %)
Age range
18–68
Mean age (SD)
32.4 (13.7)
Fracture cause Motorcycle
Disposable supply costs The quantities of supplies and medications used in each procedure were recorded. Thirty-seven of 44 (84 %) disposable supply costs were taken from the medication cost database recommended by the WHO, the International Drug Price Indicator Guide [18]. For details on the costs of disposable supplies, see Appendix.
15 (33 %)
Motor vehicle
12 (26 %)
Pedestrian
11 (24 %)
Fall
6 (13 %)
Other
1 (2 %)
Work related injury
4 (9 %)
Not work related injury
42 (91 %)
Open fractures
45 (98 %)
Closed fractures
1 (2 %)
Fixed costs Table 2 Treatment data
The cost of femoral nailing-specific instrument sets and administrative and ancillary staff were defined as fixed costs. The cost for femoral nailing-specific instrument sets was determined using costs given by suppliers and Eq. 6 (Appendix). To estimate the cost per patient associated with the MOI administrative and ancillary staff, salaries were summed to find a total annual staff expenditure. Following the ‘‘adjusted patient day’’ or ‘‘patient-day equivalents’’ (PDE) method, annual administrative and ancillary staff expenditure was divided by MOI’s total PDE from 2014 as per Eq. 7 (Appendix) [19]. Prorated and amortized building costs, electricity usage, and equipment costs were excluded from this analysis.
Results Forty-six eligible patients were enrolled in the study (Table 1). Of these, 38 (83 %) were males and 8 (17 %) were females with a mean age of 32.4 years (range 18–68; SD 13.7). The majority of the fractures were caused by vehicular accidents: 15 (33 %) occurred while the patient was driving or riding a motorcycle, 12 (26 %) occurred while driving or riding in a car, and 11 (24 %) were caused by the patient being struck by an automobile while walking; 6 (13 %) were caused by falls, and 1 (2 %) was caused by a collapsing wall. Four (9 %) fractures occurred while the patient was working, and 42 (91 %) occurred while the patient was not at work. Of the 46 fractures, studied, 45 (98 %) were closed fractures and 1 (2 %) was an open fracture. The patient’s attending surgeon made all treatment decisions (Table 2). The mean time from injury to
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Days from injury range
3–80
Mean days from injury (SD)
19.6 (±17.1)
Nail make: SIGN IM
42 (91 %)
Nail make: UFN
4 (9 %)
Antegrade approach
22
Retrograde approach
24
Anaesthetic method: general
26 (57 %)
Anaesthetic method: spinal
20 (43 %)
Mean days to discharge (SD)
6.1 (12.2)
Days to discharge range
1–60
Mean length of stay (days; SD)
24.9 (21.3)
Length of stay range (days)
4–92
intervention was 19.6 days (range 3–80; SD 17.1). Fortytwo (91 %) patients received the SIGN IM nail, and 4 (9 %) patients received the DePuy Synthes UFN nail. Surgeons used an antegrade approach in 22 (48 %) of cases and a retrograde approach in 24 (52 %) of cases, while general anaesthesia was used in 26 (57 %) of the cases, and spinal nerve blocks were used in 20 (43 %) cases. The time from surgery to discharge was skewed strongly in the positive direction with a mean time of 6.1 days (range 1–60; SD 12.2). The length of stay was also skewed positively with a mean time of 24.9 days (range 4–92; SD 21.3). The mean total time for the 46 procedures was 315.6 min (range 183–479; SD 72.1) or 5.26 h. Operative time was the longest segment and had the least variability. The preoperative segment had far higher variability than the operative or postoperative segments. This was in part due to a lack of stretchers at the hospital and because patients were sometimes brought to the theatre long before
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the previous surgery had been completed. The postoperative segment was, on average, the shortest of the three. The mean preoperative time elapsed for the 46 procedures was 106.9 min (range 27–205; SD 45.6), the mean operative time was 130.4 min (range 64–215; SD 30.6), and the mean postoperative time was 78.4 min (range 34–196; SD 32.4). Variable costs The mean total medical personnel time (person-hours) per patient was 1022.7 min (range 516.7–1608.4; SD 221) or 17.05 h, and the mean total medical personnel cost was $106.86 (range $49.40–$184.96; SD $28.18) (Fig. 2;
Assistants, 178, 17%
Physicians, 173, 17%
Residents, 252, 24% Nurses, 429, 42%
Fig. 2 Medical personnel times in minutes and percent of total time per patient (total time = 1023 min)
Table 3). Nurses spent the most time per patient followed by residents, together contributing 681.4 min (67 %) of the total 1022.7 min and accounting for $60.80 of the total $106.86 personnel costs. Attending orthopaedic surgeons and anaesthesiologists were the most costly per unit time. Attending surgeons spent 112.6 min (SD 49) on average and cost $22.06 (SD $9.61) per patient, anaesthesiologists spent 60.8 min (SD 58.6) and cost $13.20 (SD $12.66), residents spent 252.3 min (SD 87.7) and cost $29.65 (SD $10.31), nurse anaesthetists spent 105.6 min (SD 105.6) and cost $8.81 (SD $5.66), nurses spent 323.5 min (SD 73.7) and cost $26.35 (SD $6.20), radiology technicians spent 7.8 min (SD 2.99) and cost $0.51 (SD $0.19), and hospital assistants spent 171.1 min (SD 48.6) and cost $6.27 (SD $1.78). The mean ward personnel cost was $144.47 (SD $123.30), ranging from $22.33 to $513.49. This cost introduced a great degree of variability in the total cost of the procedure and was directly correlated with patient length of stay. The cost of the intramedullary nails and interlocking screws accounted for 79.6 % of the total supply and medication cost. Each intramedullary nail cost $95.00 while each interlocking screw cost $15.00. On average 2.6 interlocking screws were thus contributing a cost of $39.10 (range $0–$60.00; SD $15.00). The mean cost of non-implanted supplies was $13.49 (range $10.11–$19.15; SD $1.45). The most costly of these items were the materials used for postoperative X-rays at $5.80 per patient. The mean cost of medications was $20.92 (range $6.55–$53.81; SD $12.34). The most costly medication was a 500 mL blood transfusion costing $17.72, and $0.77 per patient on average. Combined, the total implant, supply, and medication cost was $168.55 (range $115.49–$207.17; SD $19.72).
Table 3 Medical personnel time spent and personnel costs per patient (2014 US dollars) Position
Mean time in minutes (SD)
Mean annual salaryb
Mean hourly wagec
Total cost in $US (SD)
Attending surgeon
112.6 (49.0)
$21,600
$11.76
$22.06 ($9.61)
Anaesthesiologist
60.8 (58.6)
$23,900
$12.96
$13.20 ($12.66)
Residents
252.3 (87.7)
$13,000
$7.05
$29.65 ($10.31)
Nurse anaesthetists
105.6 (67.8)
$10,900
$5.92
$8.81 ($5.66)
Nurses
a
323.5 (73.7)
$9,300
$5.05
$26.35 ($6.20)
Radiology technicians
6.9 (4.0)
$4,900
$2.65
$0.51 ($0.19)
Hospital assistants
171.1 (48.6)
$4,000
$2.19
$6.27 ($1.78)
Total
1022.7 (221)
Total
$106.86 ($28.18)
a
Does not include nurse anaesthetists
b
Rounded to nearest hundred dollar
c
Assuming 1840 work hours per year (8 h 9 [365–104 weekends–15 sick days–16 holidays])
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Instruments; $7.50 ; 1%
Physicians; $35.26 ; 7%
Residents; $29.65 ; 6%
Ancillary Staff; $59.56 ; 11%
Administrative Staff; $43.94; 8%
Nurses; $35.16 ; 7% Assistants; $6.78 ; 1%
Medications; $20.92 ; 4% Other Supplies; $13.49 ; 3%
Ward Staff; $144.47 ; 27%
Interlocking Screws; $39.10 ; 7% IM Nail; $95.00 ; 18%
Fixed costs The total cost of the femur fracture fixation-specific instrument sets was $70,275. With an expected life span of 10 years, the cost per patient for these instrument sets was $7.50. The total support staff salary expenditure for 2013–2014 was $1,274,426. For each femur fixation procedure, the administrative staff cost was $43.94; the ancillary staff cost was $59.56, giving a total support staff cost of $103.50. Thus, the total fixed cost was $111.00 per procedure. Total cost
Table 4 Variable and fixed costs per patient (2014 US dollars) Category
Unit cost
Mean cost per patient (SD)
Medical personnel
N/A
$106.86 ($28.18)
Ward personnel
N/A
$144.47 ($123.30)
IM nail
$95.00
$95.00
Interlocking screws
$15.00
$39.10 ($15.00)
Single-use supplies
N/A
$13.49 ($1.45)
Medications
N/A
$20.92 ($12.34)
Variable cost
$419.87 ($129.99)
Category
Cost per patient
$7,560
$7.50
Fixed costs per patient Femur instruments
Summing all variable costs and fixed costs gives a mean total cost of $530.87 (SD $129.99) per patient (Fig. 3; Table 4).
Total cost per year
Administrative staff
$587,103
$43.94
Ancillary staff
$796,100
$59.56
Total support staff
$1,383,400
$103.50
Fixed cost
$111.00
Total cost
$530.87 ($129.99)
Discussion In this study, we estimated the variable and fixed costs associated with treating adult femoral shaft fractures with intramedullary nailing in a LMIC setting. To our knowledge, this is the first study to use a micro-costing approach to estimating the variable and fixed costs for this type of procedure. On average, the variable costs were $419.87 and the fixed costs were $111.00, giving a mean total cost of $530.87 per patient. The largest contributor to cost was ward personnel cost, which accounted for 27.2 % of the total. This cost is directly correlated with patient length of stay. For each day,
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an additional $5.58 (general ward) or $6.72 (private ward) was accrued. The prolonged length of stay was most commonly caused by limited operating room availability. Patients waited an average of 19.6 days for surgery and were discharged 6.1 days (median: 2 days) following fixation. Thus, lack of surgical capacity was the primary driver of the largest cost for this study. Reducing preoperative hospitalization by increasing surgical capacity and efficiency would significantly decrease this cost component.
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Reducing the preoperative length of stay would have no negative effects on patient outcomes and decrease the largest driver of cost. Earlier surgery could reduce the likelihood of infection and operative time given less interval healing that impedes fracture reduction. Using the salary parameters of the current study, if the average preoperative length of stay were reduced to 5 days, the ward personnel cost would be $19.26 per patient, or 13.3 % of the realized cost. In this scenario, the total cost per patient would fall to $405.66, a 23.6 % cost reduction. If the average preoperative length of stay were reduced to 1 day, the associated cost would be $3.85 per patient (2.7 % realized cost), giving a total cost of $390.25, or a 26.5 % cost reduction. The second largest variable cost was intramedullary implant and interlocking screws at $134.10 or 25.3 % of the total cost. There may be potential for a large reduction in cost through the expansion of the intramedullary nail manufacturing and supply chain. The intramedullary nail is a simple stainless steel rod that need not be manufactured at high levels of precision. It is reasonable to assume that as intramedullary nailing becomes more widely used in LMICs, the market will expand, creating the opportunity for greater competition including the introduction of lower cost rods and screws, and potentially economies of scale. This in turn may incentivize local production of nailing equipment in sub-Saharan Africa, further lowering cost by reducing manufacturing costs and shipping fees. Therefore, greater utilization of this technology could improve patient outcomes while lowering costs and increasing access. It is worth noting that the majority of implants at the study institution were donated by a philanthropic organization, SIGN Fracture Care International (SIGN). While local sustainable manufacturing may be the ideal solution to the high cost of surgical implants, it is important to consider the potential impact of philanthropic organizations in overcoming this barrier to surgical treatment. It is also conceivable that these data could be used to advocate for coverage of implant cost by public or private insurance programs, similar to what occurs in most high-income countries. The third largest contributor was the cost of medical personnel—those involved directly in providing the surgical intervention, which accounted for 20.1 % of the total cost. From direct observation, the most important driver of long procedure length and medical personnel cost was hospital inefficiency. The greatest additions to procedure time and medical personnel costs came from delays in transporting the patient from the ward to the operating room, delays in intubating the patient, having improperly assembled instrumentation kits, and searching for appropriate intramedullary implants during the operation. Much
of this time might be reduced through better management and training. In 2009, Gosselin et al. reported that the total cost for femoral nailing with the SIGN nail system in Cambodia was ‘‘cost-effective’’ at $820 per patient, or $566 when standardized to Tanzanian gross domestic product (GDP) per capita [20, 21]. Our results thus indicate that femoral nailing may be even more cost-effective in Tanzania than in Cambodia. This analysis did not attempt to assess societal costs or lost wages. A systematic review of traction for femoral shaft fractures in LMICs suggests that the mean length of stay for conservative treatment is 55.4 days [20, 22–29]. Patients in the present study were hospitalized for a total of 24.9 days on average, nearly a month shorter than patients treated in traction. Therefore, in addition to the direct medical costs associated with prolonged hospitalization, there is likely a large economic burden from the lost productivity and travel for family members who frequently tend to the injured daily for the duration of their hospital stay. Additionally, data from a prospective study of operative fixation of femoral shaft fractures at MOI suggest that the complication rate of intramedullary nailing is approximately 5 % [30]. This compares favourably to skeletal traction, which may have up to a 49 % complication rate. Observed complications include malunion, non-union, and infection, which had an estimated incidence of 20, 5, and 13 %, respectively [31]. There may therefore be substantial indirect economic benefit from intramedullary nailing because patients treated with surgery are able to return to work more quickly and achieve a higher level of function compared to non-operative treatment. There were several limitations to this study. First, the study was conducted at only one location which may limit the generalizability of our estimation of procedure length, labour-hours, and personnel costs. Second, we did not incorporate an estimation of the costs associated with follow-up care or associated complications; this will be an important topic for future investigation. Third, the intramedullary nails and instrumentation sets used in this study are not representative of the full range femoral shaft fixation equipment used at other sites. Fourth, we did not include overhead costs such as prorated building costs, electricity usage, and equipment costs. Given the volume of procedures (c. 15,000 per annum) and the use of buildings and equipment far beyond their expected longevity, we determined that their contribution to the overall cost would be trivial. Finally, in calculating the patient-day equivalents, we were forced to use the average length of stay for the patients enrolled in the present study to impute an average length of stay for all patients at the hospital due to a lack of hospital data.
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surgical implants and increasing access to operating rooms to reduce the overall hospital length of stay.
Conclusion While intramedullary nailing has proven to be a reliable and highly effective treatment in developed countries, sparse data exist on the cost and outcomes of surgical fixation of femoral shaft fractures in LMICs. Our study provides empirical information on direct medical costs associated with surgery and will serve as a foundation for future economic analyses that compare surgical and nonsurgical interventions and incorporate health benefits in a formal cost-effectiveness analysis. In addition, these data indicate several important avenues to reduce the cost of surgical treatment. Specifically, substantial gains could be made by reducing the cost and increasing the availability of
Acknowledgments Dr. Rondall Lane (UCSF), Associate Professor of Anesthesia, UCSF School of Medicine, for assistance in developing anaesthetic medicine cost equations. Compliance with ethical standards Conflict of interest report.
No potential or real conflicts of interest to
Appendix: equations and assumptions See Table 5.
Table 5 Processes comprising time and motion analysis Stage
Activity
Typical staff
Preoperative
1. Transporting patient to waiting area
Assistants
2. Attending/observation in waiting area
Nurses, nurse anaesthetists
3. Transporting patient to theatre
Residents, anaesthesiologists, nurse anaesthetists
4. Intubation/sedation
Anaesthesiologists, nurse anaesthetists
5. Preparing OR for procedure
Surgeons, residents, nurses,
Operative
6. Patient positioning and preparing surgical site
Surgeons, residents
7. Debridement and irrigation
All OR staff present (surgeons, residents, nurses, nurse anaesthetists, anaesthesiologists) All OR staff present
8. Open reduction of fracture
Postoperative
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9. Incision and reduction of fracture
All OR staff present
10. Canal opening and reaming
All OR staff present
11. Rod insertion
All OR staff present
12. Interlocking screw placement
All OR staff present
13. Wound closure
All OR staff present
14. Cleaning and dressing wound
Residents, nurses
15. Extubation
Anaesthesiologists, nurse anaesthetists
16. Transporting patient to recovery
Residents, Anaesthesiologists, nurse anaesthetists
17. Writing postop report and orders
Surgeons, residents
18. Attending/observation in recovery area
Nurses, nurse anaesthetists
19. Transporting patient to imaging room
Nurses, assistants
20. Postoperative X-ray
Radiology technicians, assistants
21. Transport to ward and transfer to bed
Assistants
22. OR clean-up
Nurses, assistants
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Disposable supply cost details The median supplier cost given in the database was used in this analysis with the exception of midazolam for which only a buyer median price was reported. For medications packaged in large multiuse vials, the total volume per unit was divided by the volume used and multiplied by the unit cost to assess the cost used in each procedure. The unit cost of gauze, scalpels, and needles
Capital CPL ¼
where #workers1 is the number of staff during normal hours (6AM–6PM), #workers2 is the number of staff during off-hours (6PM–6AM), a is the mean wage of ward staff, b is the patient length of stay, and c is the number of patients in ward. Equation 3: Oxygen capital cost per litre (CPL)
ðOxygen generator cost þ building cost þ piping costsÞ þ ðMaintenance 10 yearsÞ : Total litres produced 10 years
were obtained from MOI. The cost of single-use X-ray materials were estimated from a 2008 study in Botswana [32]. The unit cost of a 500 mL transfusion was taken from a 1999 study in Tanzania [33]. The cost per litre (CPL) of oxygen gas produced from a central oxygen generator using grid electricity was estimated using the parameters of a 2010 cost study in Papua New Guinea and Eqs. 3 and 4 [34]. The cost of halothane or isoflurane used in each procedure was calculated with Eq. 5. For each patient, the costs of each supply used was summed to give a total supply and medication cost per patient. Equation 1: Surgical personnel costs per patient (CPP) Salaries were separated into nine occupational categories (attending orthopaedic surgeon, anaesthesiologist, medical resident, nurse anaesthetist, nurse, radiology technician, or hospital assistant): X Total surgical CPP ¼ ðPerson hours categoryi wagea Þ ð1Þ where a is the mean wage of ward staff, calculated by dividing the mean annual salary by 1840, the product of 8 h days and 230 working days per year (365–104 weekend days–15 sick days and 16 holidays). Equation 2: Ward personnel CPP calculated for general and private wards separately Ward personnel CPP ¼
#Workers1 þ #workers2 2 Wagea 24 h LOSb ; #Patientsc
ð3Þ
Equation 4: Oxygen electrical cost per litre (CPL)
Electrical CPL ¼
Running powera 0:63b $0:07=kWhc Maximum hourly capacity ðLÞd ð4Þ
where a is the (([{#Beds 9 0.75} ? {all ORs 9 10}] 9 peak hours/week 9 60 min 9 52 weeks) ? ([{#beds 9 0.75} ? {emergency OR 9 10}] 9 non-peak hours/ week 9 60 min 9 52 weeks)) 9 10, b is the capacity factor based on litres needed during peak/non-peak hours, c is the TANESCO price/kWh for high power users (December 2014 prices), and d is the assuming system is designed for operation at calculated peak need ?10 %, (6000 L/h). Equation 5: Liquid volume of halothane and isoflurane used in anaesthesia Vl ¼
QO2 tMP ; 22:4q
ð5Þ
where QO2 is the oxygen flow rate (L/min), P is the percent by gaseous volume of the compound, M is the molecular weight of the compound (g/mol), and t is the time (min) and q is the density of the compound (g/mL) at 20 °C. Equation 6: Femur fixation-specific instrument set costs per patient (CPP) Instrument CPP ¼
ð2Þ
Instrument set cost #sets ; Procedures per yeara lifespan
ð6Þ
where a is the Femoral shaft fixation procedures per year.
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Equation 7: Administrative and ancillary staff costs per patient, patient-day equivalent (PDE) method Outpatient visits Inpatient equivalence ratioa #Patients LOS ; ðiiÞFemur PDEs ¼ Total PDE Total staff cost Femur PDEs ðiiiÞCost per patient ¼ #Femur cases ð7Þ ðiÞTotal PDEs ¼ Inpatient daysþ
where a is the inpatient equivalence ratio (IER) built by averaging the IERs of three previously published cost studies (3, 3.77, 4) [35–37].
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