Want to save the healthcare system time and money? Forget the follow-up and make the emergency department the last stop for a range of simple injuries. First up: broken toes.
Definitive management? Aren’t we capable of finishing anything we start? In a different place, in a different time, in a world where common sense outweighs defensive medicine, we should be the last stop for certain conditions.
Toe fractures are an excellent place to start. Let’s assume that complications are expected with toe fractures. How bad could they be? Even if there is a non-union, you have nine others! Clearly, many patients cannot receive definitive management in the ED, either due to the need for specialized care (i.e., complex fracture management), assessment for response to treatment (i.e., community acquired pneumonia or cellulitis) or the need for further diagnostic evaluation (i.e., low risk chest or undifferentiated abdominal pain). In contrast to a toe, chest pain patients only have one heart, and that organ trumps a toe any day.
I have no idea how many toe fractures are seen annually in U.S. EDs. However, I would venture to guess it’s more than a baker’s dozen. Thus, the impact for providing more efficient and cost-effective care by providing definitive management for toe fractures is likely to be substantial. About a year and a half ago, I dropped a trailer hitch on my right 5th toe. I knew upon impact it was broken. I’m not a swearing man. However, I consulted the socially unacceptable thesaurus on that one. It hurt. It swelled, and it wasn’t back to normal for about 5 weeks, but I didn’t seek medical attention for it. In my “N” of one, the outcome has been good and the cost of care was $0.00. Not withstanding the lack of value of radiographic evaluation, buddy taping and buying a post-op shoe, follow-up care wouldn’t have changed the outcome.
Not only is definitive management of toe fractures a reasonable consideration, with respect to incorporating cost-saving strategies for healthcare reform, using less diagnostics makes sense also. So, what are we worried about? Sure. It’s broken. So, the reflex is to order an x-ray. However, when you already know it’s broken and you won’t do anything different with the test you’re considering ordering, just say no. In my opinion, too many radiographs are ordered due to culture and not used to improve care. Most patients want an answer, not a test. So, if you can give them a definitive answer without order a radiograph, you both might be happier.
Although there is much data on this topic, let’s just discuss one contemporary article by Van Vliet-Koppert. The investigators reviewed 339 patients with toe fractures. 75.6% were from “Stubbing” or crush injuries, no surprises there. 38% of fractures involved the great toe and 30% involved the 5th. More than 95% were displaced less than 2 mm. All patients were treated with conservative management (non-surgical). Thus, buddy taping, pain meds, post-op shoes or whatever reasonable care we provide for these fractures is probably acceptable. What is reassuring, at least to me, is that despite the toe involved, which phalanx, the number of fractures, the location of fracture (even intraarticular), fracture type, age, co-morbidity or body mass index (BMI), there was no difference in outcome (Van Vliet-Koppert ST. Demographics and functional outcome of toe fractures. J Foot Ankle Surg. 2011 May-Jun;50(3):307-10. Epub 2011 Mar 25.)
Another reason to provide definitive management is that definitive care fracture codes provide an opportunity for us to enhance our reimbursement. By providing definitive management, reimburse is a bit better than providing initial management only. The EP must provide “definitive or restorative care” (not requiring any additional care) and not just “supportive or temporary care,” which requires follow up to complete the management of the fracture. The “definitive care” codes utilized for toe fractures are: 28510 ( Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation), 28490 (Closed treatment of fracture great toe, phalanx or phalanges; without manipulation), 28515 (Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation), and 28495 (Closed treatment of fracture great toe, phalanx or phalanges; with manipulation). Each are associated with an additional 3.34, 3.47, 4.05 and 4.30 RVUs, respectively. Keeping in mind that the dollar amounts assigned to an RVU are approximately $39 per RVU, depending on where you are located in the country. Splinting is bundled into the definitive care code, and thus, cannot be billed separately. However, in addition to the E&M level of service code for the visit, somewhere in the neighborhood of $120 to $160 can be billed for your definitive care. Costs associated with multiple follow up visits to an orthopedist would be much greater than that.
This concept is worthy of consideration as the healthcare system demands more and more efficiency. For clinical entities that are low risk (e.g., toe fractures), definitive care may prove to be time efficient for the patien and ultimately, cost effective, despite the fact that the emergency physician’s reimbursement may actually improve.
Dr. Kevin Klauer is the editor-in-chief of Emergency Physicians Monthly, the CMO of Emergency Medicine Physicians, and the vice speaker of the ACEP Council.