Costs and renumeration of osteomyelitis treatment involving free flaps: implications of return to theatre

Abstract

Aim: This study aimed to define the costs of surgical management of chronic osteomyelitis where free tissue transfer was required in addition to debridement of bone, particularly the increased costs incurred by a return to theatre. We hypothesised that there would be a significantly greater cost when patients required re-exploration for vascular compromise. Method: We retrospectively analysed the costs of a consecutive series of sixty patient episodes treated at the Bone Infection Unit in Oxford from 2012 to 2015. Treatment involved excision of osteomyelitis with free tissue transfer for immediate soft tissue cover. We compared the costs of uncomplicated cases with those who returned to theatre and determined the profit / loss for the hospital from renumeration through the UK National Health Service Tariff Structure. Results: Hospital income according to UK HRG tariff was compared to the actual cost of treatment and these 60 cases were significantly underfunded overall (P < 0.005). In just 1 case, the cost to the hospital was completely covered by tariff. Six patients (10%) returned to theatre for urgent flap re-exploration with five flaps salvaged and one failed, requiring another free flap reconstruction (1.7%). These six patient episodes had a significantly higher mean cost compared to the uncomplicated cases. The average financial loss to the hospital for patients who did return to theatre was £19401 (range £8103 to £48380) and in those who did not was £9600 (range - £600 to £23717). The case requiring further free tissue transfer cost a total of £74158, £48380 more than the hospital was paid: the most extreme discrepancy. The overall loss for this group of 60 patients was £610 090. Conclusions: Surgery for chronic osteomyelitis is multidisciplinary, complex and therefore expensive with a significant risk of complications. However, this study demonstrates that the hospital currently makes a financial loss on almost all patients but especially if flap complications occur. This study has implications for the long term viability of specialist units treating this important disease.

Keywords: Cost analysis; Free flap failure; Healthcare Resource Group; Osteomyelitis; Return to theatre.

Figure 1

Graph to show variation of mean costs in pounds paid to the trust and the actual cost of the treatment in uncomplicated cases (columns A and B) and those requiring further surgery (columns C and D)

Figure 2

showing variation in budget: the tariff received by the trust and expenditure. The tariff received is shown in blue and the actual cost in red. The first two columns are mean costs for the 56 uncomplicated cases, the second two are mean values for the five salvaged cases and the last columns are the figures for the one cases requiring a second free flap.

Figure 3

Cost of patient episode compared to total loss to the hospital. Compared to total: The one patient who had a failed free flap and required another free flap is a gross outlier, it was the most expensive episode, just over £74 000 and had the highest deficit, more than £48 000. This scattergraph shows there is a correlation between the cost of an episode and the short fall in funding: more expensive episodes are more underfunded. One of the 60 episodes made a profit for the hospital.