Costing report for a new
diagnostic test for the
detection of acute
compartment syndrome.
Report detailing the estimated cost implications to the UK
health services of adopting a new diagnostic tool for the
identification and thus the timely treatment of acute
compartment syndrome, an example applied to the case of
tibial fractures.
Prepared by: Dwayne Boyers
Contact:
Dwayne Boyers,
Health Economics Research Unit
Health Services Research Unit
University of Aberdeen, UK
Tel: 01224437850;
Email: [email protected]
May 22nd 2012
This document was prepared by a researcher working at The Health Economics (HERU) and Health Services
Research Units (HSRU) at the University of Aberdeen. HERU and HSRU are funded by the Chief Scientist’s Office
(CSO) of the Scottish government. The views expressed in this report are those of the authors and not necessarily
HERU, HSRU or CSO. All errors and omissions are the responsibility of the authors.
Page |1
Background:
Acute Compartment Syndrome (ACS) is an under diagnosed problem that occurs when pressure
within fibrous compartments (that include groups of muscles and nerves) and within the muscles
themselves builds to dangerous levels. This pressure rise results in a decrease in blood flow, which
prevents oxygen and other nutrients from reaching the already traumatised and increasingly
susceptible nerve and muscle cells, resulting in tissue death. ACS is painful and on occasions limb
and life threatening, occurring most often after fractures or soft tissue crushing injuries of the
forearm and lower leg. The most clearly defined and researched case is compartment syndrome
occurring after tibial shaft (diaphyseal) fractures. The earlier a definitive diagnosis can be made, the
earlier contingency measures can be taken and appropriate treatment procedures initiated, thus
reducing the amount of permanent muscle and nerve damage, and increasing the chances of
avoiding longer term complications, the need for limb salvage or amputation, and in extreme cases,
death.
Costing Methods:
The following piece of work aims to quantify the potential costs of acute compartment syndrome (at
various stages of diagnosis). This example of costing is applied to the case of tibial shaft fractures.
We compare resource use and costs of the current best practice diagnostic strategy (pressure
monitoring) with those for diagnosis with the new proposed pH probe system. Based upon the
results of clinical research, it is envisaged that the technology being presented will allow earlier
diagnosis, thereby increasing the number of potential ACS patients being diagnosed earlier, and thus
incurring fewer complications and less health care resource use consumption. We have conducted a
relatively simple costing analysis to give an indication of the magnitude of cost implications.
Estimates of health care resource use over the first year after diagnosis are taken from a clinical
expert opinion1 and the scenarios presented are a guideline of potential resource use at 5 stages of
diagnosis ranging from “earliest” to “latest – and missed” diagnosis for scenarios 1-5 respectively
(table 1 and appendix A1-A5). Costs are applied to these estimates of resource use, using standard
national average costing sources where possible. These are applied as follows: Inpatient care
(Information Services Division (ISD) Scotland2), outpatient care (ISD Scotland2), Primary care
(Personal Social Services Research Unit (PSSRU), Curtis, 20113), re-operations over the course of 1
year (Information Services Division (ISD) Scotland2). These form the main proportion of costs
incurred by the health services. Additional component costs of prosthetics and equipment are
sourced locally from the Mobility and Rehabilitation Services at Woodend Hospital, Aberdeen. For
inpatient care, we have elected to use a bottom up costing approach, based on estimated time in
Page |2
theatre for various procedures, combined with the estimated length of stay on the hospital ward.
An alternative option may have been to use national average unit costs for various procedures.
However, we have chosen a bottom up approach as Health Research Group (HRG) codes are not
sufficiently sensitive to capture differences in the procedures we are interested in. Despite the
potentially large resource impact, HRG unit costs for surgery may not be appropriate as all variations
may fall within one wide bracket of care, and so would not be an appropriate fit to the scenarios we
are interested in. The inappropriateness of HRG unit costs to this scenario is in part due to the
exploratory nature of scenarios 1 and 2 presented (See appendix tables A1&A2), and as such no
relevant HRG exists. It is the author’s view that the costing method used for this analysis is the most
appropriate and accurate reflection of the decision problem presented in this document. Our
costing analysis is from the perspective of the NHS, and can be adapted to suit any health care
decision maker’s needs. Costs are presented in UK pounds sterling, 2010, unless otherwise stated.
Where costs are presented in a different currency, these are translated using standard exchange
rates, (e.g. 1USD = 0.63GBP).
Table 1 outlines the cost implications on a per patient basis for the first year after diagnosis of 5
potential strategies of care which the patient may require. Which stage a patient falls into is based
predominantly on how early an accurate diagnosis of ACS is made. A detailed breakdown of
resource use and costing calculations for each scenario are presented in appendices to this report.
While resource use estimates are based on clinical expert opinion at one particular hospital1, it is
unlikely that practice would differ significantly across the UK, and indeed our resource use estimates
are likely to be generalisable across many countries. Costs are then extrapolated to the general UK
population (See table 2) using published estimates of tibial shaft fractures and acute compartment
syndrome. Cost estimates are based on costs incurred over the first year after diagnosis. The
justification for this is that it is over the first year when the most significant health care resources
will be incurred. The relative diagnostic costs of the proposed and current kits are considered in
table 2, taking account of the number of tests required to achieve a positive diagnosis (i.e. testing all
tibial shaft fractures in the UK). Due to the uncertainty in our estimates, key assumptions regarding
costs are tested in sensitivity analysis (table 3). We also test a scenario where stage 1 is neither
realistic nor achievable by any currently available diagnostic tools, or indeed the new technology
being proposed. These analyses are not necessarily intended to be likely scenarios of care, but
rather an illustration of the sensitivity of our results to the assumptions we have made. Additional
estimates for lifetime costs of amputation and limb salvage and the potential costs of litigation are
commented on in the discussion section.
Page |3
Results:
The proposed cost of the diagnostic probe is expected to be approximately £150 per test once
development is complete and the probe is in routine use in the NHS. The current cost in a research
setting is about £300 per test. Should the test be manufactured widely for use in the NHS, the
manufacturer will avail of substantial economies of scale, hence the lower unit cost of £150 per test.
We have taken a pragmatic approach and used this as our base case cost, considering a higher cost
of £300 per test in sensitivity analysis. The cost of the current best practice diagnostic tool is
approximately £50 per test1. This is described elsewhere, but in brief, current best practice uses
pressure measurements as opposed to a pH system to detect compartment syndrome. As the pH
system tool is more reactive than the currently used pressure systems, it becomes possible to make
a diagnosis earlier, before muscle damage occurs or by limiting the extent of muscle damage. This of
course assumes that the patient presents at the Accident and Emergency department in a timely
manner.
These additional diagnostic costs must be considered in the broader context of costs to the health
services, namely surgical costs and costs of following patients over an extended time period. We
explicitly model costs over one year, but acknowledge the likely longer-term cost implications also,
in terms of continued care requirements, especially for those receiving amputations. Scenarios 1
and 2 represent the benefits of earlier stage diagnosis, while scenario 3 represents current practice.
For example, if a patient presents early to Accident and Emergency and thus the hospital, these
scenarios represent potential savings from using a faster and more efficient diagnostic tool. The
analyses presented here assume that sensitivity and specificity of the proposed diagnostic probe are
equal to one (i.e. the new test would generate no false positive or false negative results). This is
based on current research observations, however, would require formal research to definitively
prove this statement correct. Scenarios 4 and 5 on the other hand represent the more extreme
cases that require limb salvage and / or amputation. It is anticipated that when patients present late
to the emergency room (e.g. after serious road traffic collisions where time to hospital is reduced
due to extraction difficulties), the new diagnostic tool may allow a more rapid diagnosis, keeping a
greater proportion of patients in scenario 3 as opposed to 4 or even 5.
Page |4
Table 1: Summary of costing scenarios considered.
Scenario Description
Total cost to health services
(first year post diagnosis) (£)
Scenario 1:
Earliest possible diagnosis – no significant muscle damage
4,690
Scenario 2:
Appropriate diagnosis with moderate muscle damage
11,559
Scenario 3:
Current practice – late but correct diagnosis
17,064
Scenario 4:
Missed acute compartment syndrome. (Limb salvage)
36,787
Scenario 5:
Missed acute compartment syndrome (Limb amputation required)
40,360
The incidence of tibial fractures (open and closed) in the UK has been estimated at about 23/100,000
per year of the general population4. Assuming a UK population of about 63 million5, this would
equate to a total of 14,490 cases in the UK annually. Sensitivity analysis explores the impact on our
results of using a high (30/100,000) and a low incidence (17/100,000) of tibial shaft fractures. There
is much uncertainty in the literature regarding the incidence of compartment syndrome among tibial
shaft fracture patients, with one review quoting an incidence of up to 30.4%6. Another source
suggests about 20%7. We have taken a conservative estimate of 15% for our base case analysis, and
explore lower and higher proportions of 5% and 30% respectively. Of those 14,490 tibial fractures,
an estimate of 15% equates to 2,174 cases of compartment syndrome after tibial fractures in the UK
annually. However, this is likely to be an underestimate of the true incidence of ACS, as current
diagnostic systems are only about 65% accurate1. Therefore the true number of ACS for tibial shaft
fractures is potentially greater than reported in the literature.
It is estimated that about 10% of all ACS cases of tibial fracture1 will progress to stages 4/5 using
current systems (i.e. these cases will be diagnosed too late to prevent amputation or limb salvage).
The proposed diagnostic test is assumed to be 100% sensitive and will pick up all these cases earlier,
thus preventing the need for amputation / salvage due to compartment syndrome in those
presenting to the ward in a timely manner after injury.
Based on these figures, 217 cases will
unnecessarily progress to stages 4 or 5 as a result of failures of current systems. Assuming a 60/40
split between salvage and amputation for the “serious” missed cases, 130 / 87 cases will go to
scenarios 4 and 5 respectively. It is assumed that the probe will identify all potential cases. It is
assumed that those currently at stages 4 or 5, will be captured at stage 3 using the new technology,
with the remaining cases split evenly between stages 1 and 2. The division of cases of ACS among
Page |5
the 5 stages outlined are sourced from clinical expert opinion1. Our costing and probabilities are
based on the strong assumption that all patients will arrive at the emergency room in time for an ontime diagnosis to be possible. Sensitivity analysis tests the impact of these strong assumptions on
our results (See Table 3).
Using the assumed number of UK cases of tibial shaft fractures and acute compartment syndrome,
we have developed an estimated cost to the UK health services over the first year of treatment (See
Table 2). It is assumed that the majority of costs to the health services occur over this time period.
However, it is important to note, that lifelong costs of amputation and limb salvage are significant
and should also be considered as an important factor and these are considered in the discussion
section.
Table 2:
Estimated potential cost savings of adopting new strategy.
Current care pathway
Proposed care pathway
(N=1350)
(N=1350)
N
Unit cost
(£)*
14,490
50
Stage 1
0
4,690
0
978
Stage 2
0
11,559
0
978
11,559 11,304,702
Stage 3
1956
17,064 33,377,184
217
17,064
3,702,888
Stage 4
130
36,787
4,782,310
0
36,787
0
Stage 5
87
40,360
3,511,320
0
40,360
0
Intervention
Total cost
Total cost
(£)*
N
Unit cost
(£)*
Total cost
(£)*
724,500 14,490
150
2,173,500
4,690
4,586,820
42,395,314
21,767,910
Estimate
cost
difference
(£)*
20,627,404
*costs rounded to the nearest whole £.
We have adopted a conservative approach to our costing method, due to the high level of
uncertainty, and the requirement for further research into the use of this technology. Table 3 shows
a range of sensitivity analyses designed to explore uncertainty in our estimates.
Page |6
Table 3:
Sensitivity analysis around cost estimates
Analysis
Current (£)
Proposed (£)
Difference (£)
Base case costs:
42,395,314
21,767,910
20,627,404
Assume no additional patients could be
prevented going to stages 4/5 with the
probe. (I.e. all would be captured at stage
3, regardless of technology used).
Assume stage 1 would never be
achievable with the probe
37,804,572
19,828,039
17,976,534
42,395,314
28,485,792
13,909,522
Cost of the new diagnostic test will not
reduce to £150 per test and will remain at
£300, the research cost of the probe.
(unlikely but possible)
Low incidence of tibial fractures (17/100k)
42,395,314
23,941,410
18,453,904
31,324,636
16,084,767
15,239,869
High incidence
(30/100k)
55,306,798
28,397,836
26,908,962
Low incidence of ACS (5%)
14,602,509
8,699,282
5,903,227
High incidence of ACS (30%)
84,102,915
41,379,384
42,723,531
of
tibial
fractures
The results in Table 3 show substantial differences in the potential cost savings, however, all cases
suggest that the pH probe system is cost saving to a health care provider. In particular, analyses 5-8
demonstrate the impact of uncertainty in incidence rates on our results. We can conclude that the
incidence of ACS among tibial shaft fracture cases is a key driver of the magnitude of potential cost
savings, ranging from savings of £5.9m to £42.7m for incidences of 5% and 30% respectively. A
threshold analysis indicates that, all else held constant, based on our calculations and assumptions,
the true incidence of ACS would be required to be about 1% of all tibial shaft fractures before our
model predicts additional cost to the NHS of adopting the new test. Therefore, if the most plausible
estimate is >1%, it is likely that the new probe is cost saving. This is because the additional costs of
the proposed test are small in magnitude compared to the substantial cost savings generated by an
earlier diagnosis. As discussed, the results remain uncertain and open to potential biases as these
estimates are not based on published sources. However, there appears (based on the assumptions
made) a potential for significant cost savings by utilising this technology.
Page |7
Quality of life implications:
The key measure of benefit for the health economic appraisal of new technologies is the Quality
Adjusted Life Year (QALY). The QALY is used in routine decision making by a number of health care
decision making authorities throughout the world, including the National Institute for health and
Clinical Excellence (NICE) in the UK. QALY gains of adopting a new intervention can be estimated as
a combination of the reduction in mortality (additional life years) and health related quality of life of
a patient during those life years. For example, if an amputee patient were to gain an extra 1 year of
life as a result of a procedure, but only had 20 functioning across the measures of quality of that life
year, then his / her QALY score would be 0.2 (1*.2).
In the case of our analysis, the authors are not aware of any studies which explicitly measure QALY
implications for diagnostic tools for acute compartment syndrome. However, it is likely that the
implications would be substantial, especially the quality of life implications for preventing an
amputation.
One study has aimed to illustrate the health burden associated with traumatic
amputations, measured using the SF-36 quality of life instrument8. The study found that, in
particular, physical functioning scores averaged 37.5 points less relative to the general population,
representing a statistically significant difference. Role limitations, bodily pain and general health
scores all showed statistically significantly worse outcomes for the amputee group. The study also
showed a significantly lower proportion of amputees were employed in the workplace, further
adding to the likely emotional and psychological implications. An additional study (the LEAP study)9
found that, after running a simulation to incorporate the probabilities of complication, that utilities
(health outcomes) were lower for amputee patients even compared to those undergoing limb
salvage (0.954 vs. 0.969). This represented a QALY loss of 0.016 per year for amputation compared
with limb salvage.
Due to a lack of published data fitting to our research question, we have refrained from making
predictions of the magnitude of QALY implications. However, based on the predicted clinical benefit
of early diagnosis, it is highly likely that this would translate into substantial gains in patient quality
of life. Future research is required to investigate such QALY implications in this context and in order
to accurately quantify the impact for the use in economic evaluation of such new and emerging
technologies. The consideration of such QALY aspects would likely improve the cost-effectiveness
case still further, generating improved quality of life at a cost saving to health care providers. The
additional health benefits (QALYs) and cost savings could be expected to accumulate over a longer
period (in the case of an amputation prevented – a patients whole lifetime).
Page |8
Discussion:
Our analysis, whilst comprehensive in resources included, is surrounded by considerable uncertainty
in the magnitude of those resource requirements, especially as some of the scenarios are
exploratory and further work is required to establish the exact level of resource use. As the
diagnostic tool is not currently available right across the UK, the potential reductions in cases and
the hypothesised stages of care are best guesses and estimates are not intended to be 100%
accurate. They are however, an indication of the magnitude of cost associated with this clinical area
and suggest, at the very least, that on economic grounds alone, this intervention warrants further
investigation to establish its true accuracy, and ultimately an investigation of its cost-effectiveness
with a view to implementation into routine care. Therefore, this costing exercise, while illustrative
and important, should be interpreted with caution.
Specifically, our analysis has been conservative and has not accounted for a number of potentially
high value cost considerations, which may significantly increase the cost savings of using the
technology, but which are difficult to estimate with precision. A number of key issues to be
considered alongside the analysis are:
1. Life time costs of treating a patient to the health services:
Our analysis is over a 12 month time horizon post hospital discharge and does not account
for life-time follow up of limb salvage or amputation patients. The resource use associated
with this is likely to be substantial, and the total impact to the NHS is of course dependant
on the age of the patient. One study in the USA has estimated that, for a 20 year old male
needing a “below the knee” amputation, life time (undiscounted) costs are estimated at
$680,000 USD (approximately = £429,000)9, taking account the time value of money and
discounting at a rate of 3.5% per annum, the estimated cost (in today’s money), would be
about $325,000 USD (approximately = £205,000) per case. For a limb salvage patient (stage
4 in our analysis), the same study estimated the life-time costs for a 20 year old male at
approximately $200,000, and a discounted lifetime cost of $125,000 (or £78,750)9.
Therefore, based on our predicted numbers and these cost estimates, the lifetime cost
savings to the NHS are likely to be significantly higher than those reported, perhaps as much
as £33.5m cost savings [(£205,000*130) + (£78750*87)] for the prevention of stages 4 and 5
alone.
Page |9
2. Costs presented are only for 1 year.
The costs presented in the analysis in table 2 are for annual incidences only. It could be
expected that these incidences of fractures will recur year on year. Therefore, based on the
lifetime costs of (1) above, over a 10 year period, the cost savings to the NHS for ACS in tibial
fractures alone could be over £335 million.
3. A wider case for use of the probe:
As this example of costing is applied to the case of tibial shaft fractures (which only
represent about 35% of ACS cases presenting to the orthopaedic ward1), our analysis does
not account for cost savings which may be generated from other injuries and scenarios
where this test would also be useful (e.g. Complex knee injuries, forearm shaft fractures and
other injuries caused, for example, as a result of road traffic accidents). Such cases may
require even greater numbers of amputations if ACS is missed, and may incur similar or
greater cost and quality of life implications. For example, it is possible that the quality of life
implications of an amputated forearm are as severe as or worse than a below the knee
amputation.
4. Costs to society:
There are considerable costs to society in terms of benefit payments, lost days from work,
retraining and supporting amputee patients. The exact costs are dependent on the work in
which the patient is involved. For example, the costs of time off work, retraining, developing
new skills etc may be much higher for a manual labourer than an office worker; however
they are likely to be substantial in magnitude.
5. Costs to patients and family:
There may be substantial costs to patients, and their families in terms of adapting their life
and adjusting to a poorly functioning limb or the loss of a limb. We have highlighted some of
the potential QALY implications in the previous section. Emotional stress as well as physical
limitations will have impact on not only patient quality of life, but also on their families,
carers and the impact on their daily lives. The loss of a job, and the difficulties this creates
would likely magnify both the financial and psychological burden to patients, families and
their carers.
P a g e | 10
6. Litigation costs:
In addition to avoiding the sequelae of missed diagnosis, there is also an urgency to reduce
the number of malpractice claims. The impact of litigation costs from a missed diagnosis of
compartment syndrome is substantial. One particular US study10 has found that the average
indemnity payment for compartment syndrome was approximately $426,000 (over
£268,000). This was considerably higher than the average orthopaedic indemnity payment
of $136,000. The study found that 75% of malpractice claims for orthopaedic surgeons are
closed in favour of the surgeon, only 7/16 compartment syndrome cases resulted in the
same conclusion. This study has thus shown compartment syndrome represents an area of
increased liability in orthopaedic care10.
The exact magnitude of cost and QALY implications will need to be confirmed in a future definitive
trial of the intervention, before clear recommendations can be made to health care professionals.
Combining the health services costs explored in table 2 with those outlined in discussion points
above, we can see that the potential overall cost savings to the health services are likely to be
substantial over a 10 year period. Our work indicates that this new simple and inexpensive piece of
kit has the potential to be highly cost-effective and may also have significant implications on long
term quality of life gains from a correct and early diagnosis of acute compartment syndrome.
Conclusion:
The simplistic and pragmatic nature of this device suggests that if its effectiveness is proven, there is
great potential for this diagnostic probe to be implemented in routine practice across the UK and
further afield at significant cost savings to health care providers and decision makers such as NICE
and SIGN. Sensitivity analysis indicates the variation in these cost savings based on the assumptions
made, however, given the highlighted limitations, there is still great potential for the costeffectiveness of this intervention, with likely quality of life (QALY) gains accruing at substantial cost
savings to the health services. These should be considered alongside the savings to the patient (e.g.
time lost at work) and to society in general (in terms of benefit payments over a lifetime). While this
work indicates great potential, further work is required to confirm our results, establish diagnostic
accuracy compared to gold standard pressure measures, and hence a robust measure of costeffectiveness.
P a g e | 11
References:
1. Clinical expert opinion, Professor Alan Johnstone, NHS Grampian and University of Aberdeen,
2012.
2. Information services division. Scotland, Speciality costs, codes R040 – R046; 2011 [accessed April
2012]. URL: http://www.isdscotland.org/Health-Topics/Finance/Costbook/Speciality-Costs
3. Curtis L. Unit Costs of Health and Social Care. Kent: Personal Social Services Research Unit,
University of Kent; 2011 [accessed April 2012]. URL:
http://www.pssru.ac.uk/uc/uc2011contents.htm.
4. Court-Brown CM, McBirnie J.The Epidemiology of tibial fractures. J Bone Joint Surg 1995; 77B:417-21
5. Office for National Statistics. Annual mid year population estimates 2010, June 2011 online
[accessed May 2012]. URL:
http://www.agediscrimination.info/SiteCollectionDocuments/ONS%20mid%20year%20estimate
s%202010.pdf
6. Reverte MM, Dimitriou R, Kanakaris N, Giannoudis PV. What is the effect of compartment
syndrome and fasciotomies on fracture healing in tibial fractures? Injury, Int J. Care Injured 42
(2011) 1402-1407
7. Wheeles C. Wheeles’ textbook of orthopaedics, 2009. Online [accessed May 2012]. URL:
http://www.wheelessonline.com/
8. Pezzin L, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term outcomes of persons
with trauma-related amputations. Archives of physical medicine and rehabilitation 2000; 81 (3)
292-300.
9. Chung K, Sadawi-Konefka BS, Hasse S, Kaul G. A cost-utility analysis of amputation versus
salvage for Gustilo IIIB and IIIC Open Tibial Fractures. Plast Reconstr Surg. 2009 December; 124
(6): 1965:1973.
P a g e | 12
10. Bhattacharyya T, Vrahas M. The medical-legal aspects of compartment syndrome. 2004, The
journal of bone and joine surgery 86-A (4) 864-867.
Appendix:
Detailed breakdown of scenario costs to the health services over the first year of
treatment.
Table A1:
Best case scenario 1 (earliest possible diagnosis – no significant muscle damage).
Resource
Unit cost Total Costs
Source
use
(£)
(£)
Initial fracture surgery – theatre
(hours*)
2
969
1,938.00
ISD R142X
Hospital stay (nights**)
4
577
2,308
ISD R040
Physio consultations (N)
2
22.09
44.18
PSSRU 2011
Orthopaedic O/P (N)
4
73
292.00
ISD R044
GP consultations (N)
3
36
108.00
PSSRU 2011
Total costs
£4,690.18
O/P = outpatients; Physio = physiotherapist; GP=General practitioner; ISD = Information services division; PSSRU = personal and social
services research unit.
*
Surgery time in an orthopaedic theatre.
**
Number of nights spent in hospital (on an orthopaedic ward)
Table A2:
Best case scenario 2 (appropriate diagnosis with moderate muscle damage).
Proportion Resource Unit cost
Total
Source
use
(£)
Costs (£)
Initial surgery & fasciotomy –
1
3
969
2,907.00
ISD R142X
hours*
2nd procedure –skin graft (hours*)
1
2
969
1,938.00
ISD R142X
Hospital stay (nights**)
1
10
577
5,770.00
ISD R040
Physio consultations (N)
1
4
22.09
88.36
PSSRU 2011
Orthopaedic O/P (N)
1
6
73
438.00
ISD R044
Gp consultations (N)
1
3
36
108.00
PSSRU 2011
Future plastic surgery (hours***)
0.1
2
969
193.80
ISD R142X
Future plastic surgery (nights***)
0.1
2
577
115.40
ISD R040
Total costs
£11,558.56
P a g e | 13
O/P = outpatients; Physio = physiotherapist; GP=General practitioner; ISD = Information services division; PSSRU = personal and social
services research unit.
*
Surgery time in an orthopaedic theatre.
**
Number of nights spent in hospital (on an orthopaedic ward)
***
refers to the assumed length of surgery and number of nights spent as a hospital inpatient for an average case receiving this
care / procedure, and is assumed similar to resource use in an orthopaedic care setting.
P a g e | 14
Table A3:
Current practice – late but correct diagnosis
Proportion Resource Unit cost
use
(£)
Initial surgery & fasciotomy
1
3
969
(hours)*
2nd procedure –inspection
1
2
969
(hours*)
3rd procedure – skin graft
1
2
969
(hours*)
Hospital stay (nights**)
1
12
577
Total
Costs (£)
2,907.00
Source
ISD R142X
1,938.00
ISD R142X
1,938.00
ISD R142X
6,924.00
ISD R040
Physio consultations (N)
1
26
22.09
574.34
PSSRU 2011
Ortho O/P (N)
1
12
73
876.00
ISD R044
GP consultations
1
6
36
216.00
PSSRU 2011
Future plastic surgery (hours***)
0.25
2
969
484.50
ISD R142X
Future plastic surgery (nights***)
0.25
2
577
288.50
ISD R040
Future ortho surgery (hours***)
0.25
2
969
484.50
ISD R142X
Future ortho surgery (nights***)
0.25
3
577
432.75
ISD R040
Total costs
£17,063.59
O/P = outpatients; Physio = physiotherapist; GP=General practitioner; ISD = Information services division; PSSRU = personal and social
services research unit; ortho = orthopaedics.
*
Surgery time in an orthopaedic theatre.
**
Number of nights spent in hospital (on an orthopaedic ward)
***
refers to the assumed length of surgery and number of nights spent as a hospital inpatient for an average case receiving this
care / procedure, and is assumed similar to resource use in an orthopaedic care setting.
P a g e | 15
Table A4:
Potential costs of missed acute compartment syndrome. (Limb salvage)
Proportion: Resource
Unit Total Costs
use cost (£)
(£)
Initial surgery & fasciotomy
1
3
969
2,907.00
(hours)*
2nd procedure –inspection
1
2
969
1,938.00
(hours*)
2nd procedure –inspection
1
2
969
1,938.00
(hours*)
2nd procedure –inspection
1
2
969
1,938.00
(hours*)
5th procedure – skin graft (hours*)
1
2
969
1,938.00
Source
ISD R142X
ISD R142X
ISD R142X
ISD R142X
ISD R142X
ICU (nights**)
0.2
1
1,623
324.60
ISD R040
HDU (nights**)
0.5
2
580
580.00
ISD R040
Hospital stay - ward (nights**)
1
25
577
14,425.00
ISD R040
Physio consultations (N)
1
52
22.09
1,148.68
PSSRU 2011
Ortho O/P (N)
1
15
73
1,095.00
ISD R044
Plastic – O/P (N)
1
15
73
1,095.00
ISD R044
GP consultations (N)
1
6
36
216.00
PSSRU 2011
Future plastic surgery (hours*)
0.5
2
969
969.00
ISD 142X
Future plastic surgery (nights**)
0.5
2
577
577.00
ISD R040
Future Ortho surgery (hours***)
0.5
3
969
1,453.50
ISD 142X
Future Ortho surgery (nights ***)
0.5
3
577
865.50
ISD R040
0.25
3
969
726.75
ISD R142X
0.25
3
577
432.75
ISD R040
1
3
73
219.00
ISD R044
1
2
1,000
2,000.00
MARS,
Woodend
hospital
Future surgery – foot / ankle
deformities (hours***)
Future surgery – foot/ankle
deformities (nights***)
Orthotic O/P (N)****
Ankle / Foot orthoses
(component costs)
Total costs
£36,786.78
O/P = outpatients; Physio = physiotherapist; GP=General practitioner; ISD = Information services division; MARS = Mobility and
rehabilitation services; PSSRU = personal and social services research unit; ortho = orthopaedics.
*
Surgery time in an orthopaedic theatre.
**
Number of nights spent in hospital (on an orthopaedic ward)
***
refers to the assumed length of surgery and number of nights spent as a hospital inpatient for an average case receiving this
care / procedure, and is assumed similar to resource use in an orthopaedic care setting.
****
Orthotic outpatient department assumed to incur the same costs as orthopaedic.
P a g e | 16
Table A5:
Potential costs of missed acute compartment syndrome (Limb amputation
required)
Proportion Resource
Unit Total Costs
Source
use
Cost (£)
(£)
Initial surgery & fasciotomy
1
3
969
2,907.00
ISD R142X
(hours)*
2nd procedure – inspection
1
2
969
1,938.00
ISD R142X
(hours*)
3rd procedure – inspection
1
2
969
1,938.00
ISD R142X
(hours*)
4th procedure – inspection (hours*)
1
2
969
1,938.00
ISD R142X
Amputation (hours*)
1
2
969
1,938.00
ISD R142X
HDU (nights **)
0.5
2
580
580.00
ISD R040
ICU (nights**)
0.2
1
1,623
324.60
ISD R040
Hospital stay (nights)
1
25
577
14,425.00
ISD R040
Physio consultations (N)
1
52
22.09
1,148.68
PSSRU 2011
Ortho O/P (N)
1
20
73
1,460.00
ISD R044
GP consultations (N)
1
6
36
216.00
PSSRU 2011
Future surgery-stump problems
(hours***)
Future surgery-stump problems
(nights***)
Prosthetic O/P to fit prosthesis
****
Component cost of prosthetics
(above knee)^
0.5
2
969
969.00
ISD R142X
0.5
3
577
865.50
ISD R040
1
1
73
73
ISD R044
0.2
2
5,000
2,000.00
Component cost of prosthetics
(below knee)^
0.8
2
2,500
4,000.00
Socket cost for limb
1
2
1,000
2,000.00
Rehabilitation for prosthetic limb
(1st appt)
Follow up appointments for
prosthesis.
Powered wheelchair
1
1
277
277.00
1
5
233
1,165.00
0.10
1
402
40.20
MARS,
Woodend
hospital
MARS,
Woodend
hospital
MARS,
Woodend
hospital
NHS ref
costs
NHS
refcosts
PSSRU
0.9
1
174
156.60
PSSRU
Regular wheelchair
Total costs
£40,359.58
O/P = outpatients; Physio = physiotherapist; GP=General practitioner; HDU = High Dependancy Unit; ICU = Intensive Care Unit; ISD =
Information services division; MARS = Mobility and rehabilitation service; PSSRU = personal and social services research unit; ortho =
orthopaedics.
*
Surgery time in an orthopaedic theatre.
**
Number of nights spent in hospital (on an orthopaedic ward)
***
refers to the assumed length of surgery and number of nights spent as a hospital inpatient for an average case receiving this
care / procedure, and is assumed similar to resource use in an orthopaedic care setting.
****
prosthetic outpatient department assumed to incur the same costs as orthopaedic for fitting of prosthesis procedure.
^
Component costs are calculated as follows: Each amputation requires the provision of 2 artificial legs, one for wearing and one
spare.