The Increasing Cost of Health Care: Do Sutures Require a Specialist? Protection Status
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by Michel H.E. Hermans, MD

The 10 year old son of friends of mine incurred a gash in his right knee. After the injury, he was able to walk without pain in the leg (the gash did hurt, of course) but was taken to the hospital by ambulance. There, an X-ray of the knee was taken which did not show any fractures or other non-skin injuries. The gash was sutured and the patient was referred to an orthopedic surgeon for regular checks of the sutures and for suture removal. Sutures were to be removed 14 days after the accident. On that day, the orthopedic surgeon had no office hours.

The next day, the family was to leave early in the day for a two-week trip abroad: the orthopedic surgeon suggested having the sutures removed upon return to the U.S., in which case they would have been in situ for more than four weeks. Fortunately, another solution was found for suture removal on post-op day 14.

The Cost of Care for an Acute Wound: A Case Example

knee_injury.jpgThe family received the following invoices, with the amount billed and the amount insurance paid in parentheses:
Ambulance: $1199.00 ($1079.10)
Radiology: $28.00 ($10.83)
Emergency department: $2165.00 ($465.00)
Emergency physician suturing: $926.00 ($766.00)
Orthopedic surgeon for checking wound 1x: $190.00 ($93.35)
Orthopedic surgeon for checking wound 2x: $115.00 ($0.00)
and suture removal 2x: $115.00 ($29.87)

My friends have a good (and expensive) medical insurance. Had they not been insured, the bill would have been more than $4500 for the repair (granted, no doubt with layered suturing) of a gash in the skin of a knee.

The story raises a number of questions:

  • Was the X-ray necessary given that the boy could walk without a problem and had no pain in the joint? Visual inspection of the wound would not have indicated involvement of the joint or the capsule.
  • Why was the emergency physician allowed to charge these amounts for suturing a skin lesion? A very good friend of mine is a renowned professor of orthopedic surgery in Europe and receives just a bit more money (than the insurance payment quoted here) for a total knee replacement.
  • Why was the patient referred to an orthopedic surgeon for check-ups of the wound and for suture removal?

The answers to the first two questions are, sort of, implicit. On question 3: there is no rationale for having the follow up done by an orthopedic surgeon: there is nothing wrong with orthopedic surgeons (on the contrary) but they have no special expertise in the healing of sutured wounds, at least not more than a general surgeon or a suturing general physician in rural areas where (s)he is the only doctor in 1000 square miles.
This particular orthopedic surgeon even suggested that the sutures could stay in for a month which, for several reasons, is simply wrong.

Reducing Health Care Costs: When to See a Specialist

In the U.S. we have the tendency to see a specialist for everything which is often unnecessary and drives up cost of health care. Why go to a pediatrician with an ear or throat infection or a gynecologist for a PAP-smear? Properly trained GPs and, nowadays, a lot of the health clinics in drugstores and pharmacies can easily deal with a large percentage of the common health complaints (including checking a sutured wound), leaving the specialist more time for the "real stuff" while reducing overall cost of care.

About the Author
Michel H.E. Hermans, MD, is an expert in wound care and related topics, trained in general surgery, trauma care and burn care in the Netherlands. He has more than 25 years of senior management experience in the wound care industry. He has conducted a large number of clinical trials relating to devices and drugs aimed at wound care and related indications and diseases. Dr. Hermans speaks internationally and has authored many published works relating to wound management.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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I see more frequently that patients are referred to orthopedists for simple wound care....this may just be another one of those situations. I agree with you wholeheartedly regarding specialty care being misused.

This is SO true, and it is such an important topic. We need to be cost conscious and rational when making decisions, including followup recommendations. X-rays, scans, and blood tests should be performed only when the results could influence treatment decisions. Specialists should be called in only when their special knowledge would be beneficial.

The family should have been instructed to be alert for signs of infection or poor healing. In many cases, this would eliminate the need for an intermittent followup visit prior to suture removal.

And, shouldn't the patient have been referred to his family physician for followup, so that his primary care provider could be kept in the loop?

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