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A Mixed-Methods Assessment of Patient Costs Following Hand Trauma
Heather Baltzer, MD, MSc, FRCSC1; Melissa Roy, MD2; Catherine McMillan, MSc3; Christine B. Novak, PT, PhD1; Steven J. McCabe, MD1; Paul A. Binhammer, MD, MSc, FRCSC3; Herb von Schroeder, MD, MSc, FRCSC1
1Hand & Upper Extremity Program, Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada; 2Division of Plastic and Reconstructive Surgery, McGill University, Montreal, QC, Canada; 3Division of Plastic Surgery Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada

Introduction: It is recommended that cost utility analyses have a societal perspective, including costs to the patient, health care system and third-party payers. These analyses are becoming more common in hand surgery yet a common limitation is patient cost reporting. The objective of the current study is to conduct the preliminary steps for developing a patient-reported outcome measure for accurate prospective assessment of patient costs following hand trauma.

Methods: This is a prospective, mixed-methods cost of illness study conducted at a level 1 trauma centre. All hospital and physician fees covered by the provincial health care plan. Following institutional research board approval and signed informed consent, upper extremity trauma patients were recruited within the four weeks of injury. Demographic and injury data were collected and a Hand Injury Severity Score (HISS) was calculated. Patients maintained a cost diary, and completed a narrative questionnaire between 4-8 weeks post-injury. Descriptive statistics and qualitative (grounded theory) analyses were performed to disaggregate and describe patient costs, which were then organized into cost categories. Recruitment was stopped upon reaching saturation in the qualitative thematic analysis.

Results: Fourteen participants (mean HISS = 15, range: 2-64) were included in the analysis reporting 8 cost categories (patient and caregiver lost income, rehabilitation costs, medications, travel, accommodation, food and adaptive devices) and 21 cost items. Direct income loss and indirect caregiver income losses were reported by 42% (n =6 ) and 50% (n = 7), respectively. Direct income losses ranged from decreased work productivity to months of unemployment. The average out-of-pocket cost within 4 weeks of injury was $521. Rehabilitation costs (hand therapy and splints) accounted for 61% of out-of-pocket costs ($342) and were the most commonly reported (64%), followed by travel (56%).

Conclusions: Upper extremity trauma patients experience a wide range of costs with rehabilitation costs representing a major economic burden. Our understanding of their costs and resource use may formulate the basis for future cost assessments and practice and policy changes aimed at decreasing the economic impact for hand trauma and hand surgery patients. The findings of this study will provide the foundation for developing a patient-reported measure to prospectively capture these costs. Not only will this provide an outcome measure meaningful to patients, physicians and policy makers, but also allow for more robust cost analyses in the hand surgery literature.

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