Patient estimates of healthcare costs in trauma and orthopaedics
The cost of treating trauma and musculoskeletal conditions per head of population in Wales in 2007–2010 increased from £183 to £236, representing an increase in National Health Service total expenditure of 13.11 %. This study was set up to determine whether the public is aware of the general costs of treatment within the trauma and orthopaedic department.
Patients completed a questionnaire asking them what they thought the cost was for common orthopaedic treatments, investigations and implants. This questionnaire was completed whilst they were waiting to be seen in clinic.
We had 183 completed questionnaires from patients with an average age of 43.47 years (range, 18–85 years). All patients were members of the public, with no previous experience of NHS work or costing. The inter-rater reliability was 0.39(95 % CI, 0.178–0.559). A product was accurately assessed if the estimates were between 50 and 200 % of the true cost. Costs of arm slings and crutches were well estimated by >80 % of the respondents. Approximately 60 % accurately estimated the cost of a fracture clinic visit, hospital transport and physiotherapy and lower limb plaster. Only 22.5 % accurately estimated the cost of a knee X-ray with 37.6 % overestimating the cost by more than tenfold. Other expenses that were underestimated by patients were the costs of a total hip replacement (in 58.3 %), fixation of an ankle fracture (in 32.2 %) and an overnight inpatient stay (in 10.9 %).
Whilst the costs of physical products were well estimated by our cohort of patients, the costs of less tangible products, such as radiology and operations, were poorly estimated. Our study shows that there is a poor public perception of the true cost for investigation and operative treatment of common trauma and orthopaedic conditions.
The National Health Service (NHS) has had its budget substantially reduced by the current economic climate [1, 2]. The challenge for the service is to maintain the excellent patient care whilst becoming more cost-effective and efficient. In trauma and orthopaedics, the largest area of expense is on implants making this area a potential source of cost savings. Unfortunately, as technology advances in terms of bearing surfaces and implant design, the research and development expenses are passed on to the consumer. The overall expenditure in Wales for orthopaedics per head of population increased from £183 to £236 from 2007 to 2010. This represented a total expenditure of 13.3 % of the whole NHS Wales budget  that signifies the largest expenditure per speciality. In the current austere times, it is important to see that patients are provided with cost-effective patient care.
From anecdotal evidence in our clinics, it appears that patients are unaware of the actual cost for simple procedures and investigations.
We set out to confirm our null hypothesis that patients are unaware of the true cost of trauma and orthopaedic treatments.
We performed a questionnaire survey of patients attending a tertiary referral teaching hospital’s outpatient clinic. Patients were asked to estimate the cost of a fracture clinic appointment, hospital transport to and from clinic, a pair of crutches, broad arm sling, surgical fixation of an ankle fracture, total hip replacement, application of a lower limb plaster of Paris, knee X-ray, a physiotherapy appointment and an overnight stay in hospital. Inclusion criteria were any patients attending clinic aged 18 years or older. Exclusion criteria included previous employment within the NHS or the private healthcare setting aged under 18 years or inability to complete the questionnaire due to language or cognitive ability.
We collected responses from 183 individuals (92 females, 87 males, mean age 42 years, range 18–85 years; 4 incomplete demographics) who completed the following questionnaire whilst in the fracture clinic waiting room at three different hospitals. They were not aware of the costs of each product (highlighted).
The inter-rater reliability was 0.390 (95 % CI 0.178–0.559).
A product was accurately assessed if the estimates were between 50 and 200 % of the true cost (i.e. one price bracket above or below the highlighted box). This estimation was based on a logarithmic scale enabling the product to be estimated at both the low- and high-end price rackets.
The costs of arm slings or crutches were well estimated by >80 % of the group. Approximately 60 % correctly estimated the cost of a fracture clinic visit, hospital transport, physiotherapy and a lower leg plaster. Only 22.5 % accurately estimated the cost of a knee X-ray with 37.6 % overestimating it by more than tenfold. In contrast, 58.3 % thought a total hip replacement cost less than £2,000 (true cost £6,000). Ankle fracture fixation was also underestimated by 32.2 %, whereas 24.1 % over- and 10.9 % underestimated an overnight stay in hospital (£365).
Analysis was not performed for age, sex or occupation—put this sentence in the discussion as a potential weakness or the reviewers might ask for this subanalysis.
The cost of treating musculoskeletal conditions is amongst the highest in the Western healthcare system . The largest expenditure of the orthopaedic department’s budget is the increased cost of implants which have been developed as technology and understanding of musculoskeletal conditions improves.
Our study demonstrates that the general public are able to estimate the cost of orthopaedic hardware such as broad arm slings and crutches with reasonable accuracy. The public are unable to gauge accurately the cost of a total hip replacement or the cost of a stay in hospital. This illustrates that the lay population have no understanding of orthopaedic expenditure. A similar study by Smolders et al.  confirmed that the public had a poor estimation of the overall cost of total knee replacement and over estimated the fee that the surgeons would receive as a result of this. This is unsurprising when the results of Schilling’s 2009 survey are considered. Schilling posed a questionnaire to 30 emergency department physicians about the cost of investigations and treatments specific to the diagnosis of pulmonary embolism. They found that the physicians only accurately assessed the cost in 28 % of the cases . Another survey performed by Silcock et al.  looking at general practitioners ability to estimate the cost of drugs found that only 1/3 where able to estimate within 25 % of the cost of the drugs. This serves to highlight that the public are more than likely going to struggle to grasp the true cost of health care resources.
One potential reason that the public struggle with the cost of orthopaedic procedures is the lack of public reporting of these. A study from Harvard showed that the public reporting of orthopaedic cost, outcomes and quality information was poor in orthopaedic surgery compared to other surgical practices, that is, cardiothoracic surgery . Reasons for this may be numerous; for example, joint registries are a relatively new concept in the UK and are yet to be fully set-up in other developed countries.
To our knowledge, this is the first study that has investigated the public’s perception of cost for different trauma and orthopaedic equipment and procedures. It shows that for physical products, the public are able to estimate the cost quite accurately. When it comes to more tangible services such as radiological investigations, hospital beds and operative procedures, the public perform worse in the accuracy of their estimations. This could be due to the lack of understanding of the expense of an MRI scanner and the time that it would require to scan an area of the body. Another reason why they might struggle to grasp the cost of operations is due to the cost of the implants used. As technology has advanced, the cost of available implants can vary dramatically depending on what type is used. The added expense of sterilization for the surgical implants may also be overlooked by the patient.
A weakness of this study was that all the patients were being treated for a fracture and, therefore, may have been using some of the physical products such as a broad arm sling or crutches. Our range for correct estimate of cost is broad, but we felt that this allowed for both low- and high-end products to be included rather than an average. The questionnaire was not validated; however, the importance of this is debatable.
Our questionnaire confirms that the public struggle to estimate the expense of orthopaedic procedures such as a total hip replacement and ankle fracture fixation. The public are able to assess accurately the cost of common physical orthopaedic expenditure such as crutches, broad arm sling and hospital transport. Public education into the cost of their health care treatment may improve the cost-effectiveness of treatments and patient satisfaction.
Conflict of interest