- Email: [email protected]
Acetabular fractures in the UK. What are the numbers?
Injury, Int. J. Care Injured (2007) 38, 329—333
www.elsevier.com/locate/injury
Acetabular fractures in the UK. What are the numbers? J.M. Geoghegan a,*, E.J. Longdon b, K. Hassan a, D. Calthorpe a a b
Department of Trauma and Orthopaedics, Derbyshire Royal Infirmary, Derby DE1 2QY, United Kingdom Basic Surgical Training Programme, Nottingham, United Kingdom
Accepted 26 September 2006
KEYWORDS Acetabular fracture; Acetabular fracture surgical numbers; Surgeon directory; OPCS-4 codings; ICD-10 codings
Summary We have established a nationwide directory of the specialist surgical units and their Lead Consultants with expertise in acetabular fracture surgery throughout the UK. Our directory has facilitated an estimation of the total numbers of operative acetabular fracture cases managed annually in the UK, as reported by those actually providing this specialist service. Previously the total number of acetabular injuries admitted and operated on in the UK was not known and there was no directory of acetabular surgeons in the UK. The introduction and accuracy of the OPCS codings will have massive financial implications for the DoH at a local and national level in the planning and provision of adequate health care resources. We have performed a questionnaire study to validate the DoH data for acetabular fracture surgery. Data was compiled using the ICD-10 for diagnosis of fracture of the acetabulum, and the OPCS-4 codes for the surgical procedures used for fracture fixation for the year 2003—2004. The Department of Health (DoH) data identified 44 units that had OPCS-4 coding for acetabular fracture fixation. We had a 95% (42 out of 44 units) response to our questionnaire. A total of 9 units contacted had actually performed no surgery, whereas the DoH coded these as having performed a maximum of 35 cases. The DoH data showed a total of 1825 admissions to 311 NHS hospitals for acetabular fractures, including 258 operative cases performed in 44 NHS hospitals in the UK. Our study has found that 748 acetabular fracture fixation cases were performed at 33 NHS hospitals in the UK in this study period. The total difference between the DoH operated cases and those confirmed by our study was 490. The hospital care for an operative acetabular fracture case may cost approximately £14,830, if the actual numbers are under-reported to or by the DoH are 490, then approximately £7,266,700 has been lost by these centres due to incorrect proportioning of resources. # 2006 Elsevier Ltd. All rights reserved.
* Corresponding author at: 8 Cumbria Grange, Gamston, Nottingham NG2 6LZ, United Kingdom. Tel.: +44 1332347141; fax: +44 1332254950. E-mail address: [email protected] (J.M. Geoghegan). 0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.09.015
330
J.M. Geoghegan et al.
Introduction
Table 1 ICD-10 and OPCS-4 coding for acetabular fracture fixation
Acetabular and pelvic injuries require specialist management at appropriately dedicated Orthopaedic Trauma Units. There is no comprehensive or coordinated national approach to the management of acetabular injuries throughout the UK. Currently there is no published directory of dedicated pelvic and acetabular surgeons in the UK. The total number of acetabular injuries admitted and operated on in the UK is not known. There has been a recent emphasis on Operational Procedural Codes System (OPCS) and its generation of tariff for payment-byresults for treating hospitals. The accuracy of the OPCS codings therefore, has massive financial implications for the Department of Health at both a local and national level in the planning and provision of adequate health care resources. We have undertaken a study to compare the Department of Health figures using the ICD-10 and OPCS-4 codings for acetabular fracture cases that required operative fixation with figures provided by the treating surgeons themselves. This has enabled us to establish a nationwide directory of the specialist surgical units and their Lead Consultants with expertise in this field throughout the UK. Our directory has facilitated an estimation of the total numbers of operative acetabular fracture cases managed annually in the UK, as reported by those actually providing this specialist service.
ICD10 code Fracture of the acetabulum = S32.4 Secondary procedure code of Z75.6 acetabulum Operative fracture fixation procedures codes applicable include W19 primary open reduction of fracture of bone and intramedullary fixation W20 primary open reduction of fracture of bone and extramedullary fixation W21 primary open reduction of intraarticular fracture of bone W22 other primary open reduction of fracture of bone W23 secondary open reduction of fracture of bone W24 closed reduction of fracture of bone and internal fixation W25 closed reduction of fracture of bone and external fixation W26 other closed reduction of fracture of bone W28 other internal fixation of bone W29 skeletal traction of bone W30 other external fixation of bone W57 excision reconstruction of joint W65 primary open reduction of traumatic dislocation of joint W66 primary closed reduction of traumatic dislocation of joint W67 secondary reduction of traumatic dislocation of joint W77 stabilising operations on joint W81 other open operations on joint W91 other manipulation of joint W92 other operations on joint
Methods For the completeness of data in the National Health Service (NHS) for the numbers of acetabular injuries requiring surgery for the financial year 2003—2004, we accessed through the Department of Heath (DoH) the four agencies that cover the United Kingdom: Hospital Episode Statistics, England; Health Solutions, Wales; ISD, Scotland; and Department of Health & Social Security, Northern Ireland. The data was compiled using the International Code of Diseases version 10 (ICD-10) for diagnosis of fracture of the acetabulum, and the OPCS-4 codes for the surgical procedures used for fracture fixation (Table 1). Data was requested to determine the total number of acetabular fractures operated on by NHS Trust. Data supplied by Hospital Episode Statistics (England) were subject to masking, in line with the DoH ‘Protocol on Confidentiality’. Any figure between 1 and 5 was suppressed and replaced at source by an asterisk (*) symbol, so individual patients could not be identified. For our purposes such units in England were counted as having operated upon five cases, to ensure under-reporting of
the DoH figures was not due to our own data processing. From this list of NHS Trusts, we identified the individual hospitals within these Trusts and ‘‘Lead Surgeons’’ providing this service. A letter was then sent to all ‘‘Lead Surgeons’’ requesting the exact numbers of surgical cases in the study period in order to validate the DoH data. Each centre was given their respective number of operative cases as per the DoH data for the study period to encourage accurate data checking and reporting from the surgical units themselves. Non-responders were further contacted by letter and telephone. Further nonresponders received up to seven further postings and numerous follow-up telephone calls. Data were recorded on a Microsoft Excel Spreadsheets.
Results The DoH data identified 44 units that had OPSC-4 coding for acetabular fracture fixation. We had a 95% (42 out of 44 units) response to our questionnaire. A total of 9 units contacted had performed no
Acetabular fractures in the UK
331
Table 2 Department of health and study data comparison Country
DoH–—centres performing acetabular fixation
Confirmed centres by study
DoH–— operative figures
Centre operative figures
Discrepancy in total operated cases
England Northern Ireland Scotland Wales Total in UK
34 2 6 2 44
26 1 5 1 33
222 15 15 6 258
616 19 91 22 748
394 4 76 16 490
surgery, whereas the DoH coded these units as having performed between 19 and 35 cases. This range is due to 4 of these units in England having masked data (see Methods) and they may represent between 1 and 20 cases in this study period. The two units that did not respond to our questionnaire were masked in the DoH data. We have shown a massive discrepancy between the DoH figures for operative acetabular fracture fixation and the data derived from these units directly (Table 2). For the year 2003—2004, in the UK the DoH figures showed a total of 1825 admissions for acetabular fractures to 311 NHS hospitals, and 258 acetabular fracture cases that were operated on in 44 NHS hospitals in the UK. Our study has found that 748 acetabular fracture fixation cases were performed at 33 NHS hospitals in the UK in this study period. The total difference between the DoH operated cases and those confirmed by our study was 490. The DoH figures include the two non-responders to our questionnaire from England, which were masked in the DoH data (i.e. number of 1 to 5). As it is not possible to ascertain whether this represents 2 or 10 cases the total numbers from these 2 centres were still included, and this will represent a potential under-reporting of cases actually performed by our study centres. The biggest discrepancies occurred at our largest and busiest centres in the UK. The largest discrepancy at one unit was 70 cases in the study period.
Discussion Using data from the Department of Health, we have identified all centres in the UK that provide surgical expertise in the operative fixation of acetabular fractures. We have developed a nationwide directory of all surgical units and their respective Lead Consultants specialising in this field. We have attempted to validate the DoH data using a questionnaire to ascertain the total number of acetabular injuries in the UK that are surgically reconstructed for the year 2003—2004. There is a surprisingly large discrepancy in the
data acquired from our study and that as held by the DoH with respect to the total number of acetabular fracture cases treated surgically in this study period. We have identified 33 NHS Trauma & Orthopaedic Units in the UK which have performed acetabular fracture fixation in the year 2003—2004. We have no data as to whether or not these units received their cases as tertiary referral centres or whether cases presented directly. There is no available data as to how or where inter-hospital referrals are made or occur from the DoH to tertiary referral centres. It is also unclear from the DoH as to who the tertiary units for this specific injury are throughout the UK. The number of cases performed per unit ranged from 2 to 98 in the year 2003—2004. Although this is only a snap-shot of practice throughout the UK in a 12-month period and does not represent overall experience, this does pose the question of how many cases a surgeon should be performing per year to be competent and to keep skills up to date. We did not study the time to surgery from injury, as this data is not available from the DoH. Our previous study suggests that the mean time to surgery from injury was 8.5 days with a large range from unit to unit (2— 19 days) in the UK.4 We previously identified 21 units throughout the UK which operated on 872 acetabular fractures in the year 2003.4 These were the best data available at that time. We believe that the data we present in this paper is more accurate. The questionnaire stated the numbers of surgical cases performed by each respective unit as per the data held by the DoH to encourage accurate data checking and reporting by each unit to us. We appreciate that this does not exclude inaccurate data in our study. Four units in the UK still reported their figures as <5 instead of exact numbers. We acknowledge the limitations of a postal/telephone questionnaire, and accept that conclusions from this can only provide a broad scope of current clinical practice. The DoH data represents a period of patient care under one consultant within one healthcare provider, and the figures do not represent the numbers of patients, as a person may have more than
332
J.M. Geoghegan et al.
one episode of care within the year (Hospital Episode Statistics, England). It is however, unlikely that one patient would have two or more admissions for operative acetabular fracture surgery in 1 year, but this is a potential source of error. The DoH liaises closely with NHS Trusts in order to ensure that data quality is enhanced wherever possible, and acknowledge that there are some shortcomings in the data, but their goal is to minimise inaccuracies and bring about improvements over time (Hospital Episode Statistics, England). The DoH data made available for this study had not been adjusted for shortfalls in data. However, this does not explain the huge discrepancies in the data we present. Due to the advent of OPCS coding and the rapid introduction of tariff and payment by results, coding accuracy at source and by the DoH is vital for current and future provision of sufficient resources to realise an effective and safe trauma service throughout the UK. The ICD-10 was published in 1998 to replace ICD-9 as this system did not allow new procedures to be coded adequately with the rapidly advancing technologies and incorporation of new interventions.2 Previous studies have assessed the accuracy of ICD codings and found that the accuracy for major procedures was approximately 70%.5 Alexander et al., studied inpatient coding performed by clerks who found subtlety of medical terms confusing, leading to miscoding.1 They suggested closer cooperation between the medical clerks and clinicians. Farhan et al., found a close correlation between accuracy of coding and good medical records. Sixty percent of the notes they reviewed were coded accurately.3 There is an obvious need for clinicians and medical clerks to work together to
ensure that coding is accurate to ensure that practice and subsequent renumeration are valid. This will also help in providing adequate resources. If we consider that the hospital care for an operative acetabular fracture case may cost in the region of £14,830 (costing agreed by our local purchaser and provider) and the actual numbers are underreported to or by the DoH are 490, then approximately £7,266,700 has been lost by these centres due to incorrect proportioning of resources. The actual costing of acetabular fracture fixation is very difficult to calculate due to the considerable variation in the complexity of the injury and associated injuries (see Table 3). This is in itself an area of considerable debate.
Conclusion We have tried to validate the DoH figures for acetabular fracture surgery using a postal and telephone questionnaire directed towards the Lead Surgeon at the centres identified by the DoH data. We acknowledge the limitations of a postal/telephone questionnaire, and accept that conclusions from this can only provide a broad scope of current clinical practice. These figures however are the best currently available in the UK. This study provides the greatest insight into hitherto unanswered questions of total numbers of operated cases and locations of centres throughout the UK. There is at this time no published directory of dedicated pelvic and acetabular surgeons in the UK. There are current efforts to develop a National and European Society of Pelvic and Acetabular Surgeons and we hope that our data can assists in this by identifying centres and Lead Surgeons in the UK.
Table 3 Approximate costings for acetabular fracture fixation Average length of stay for operated patients Daily cost of Trauma Unit
18 days
Conflicts of interest
£320.52
None declared.
Cost of operative time Per minute Per hour
£22.90 £1374
Operative time 5—6 h (operative time = time from entering anaesthetic room to entering theatre recovery) Basic costing
£6870—8244
£12,639—14,013 a
Costing data kindly supplied by Audit Office, Department Trauma & Orthopaedics, QMC, Nottingham University Hospitals NHS Trust. a Additional significant variable costs NOT included = polytrauma, radiology and laboratory investigations, blood products, implants, high dependency/intensive care, etc.
Acknowledgements Mrs. Anne Cannon for her secretarial support and patience. Mr. David Hahn for his helpful comments and direction and Mr. Philip Radford, Consultant Orthopaedic and Trauma Surgeons, Queens Medical Centre, Nottingham. Mr. Chris Boulton, Audit CoOrdinator Trauma & Orthopaedics Queen’s Medical Centre, Nottingham. All Pelvic and Acetabular Consultants throughout the UK who assisted us in this study by completing the postal questionnaire and
Acetabular fractures in the UK responding to our phone calls. Thanks to the staff at Hospital Episode Statistics, England; Health Solutions, Wales; ISD, Scotland; and the Department of Health & Social Security, Northern Ireland for their help and advice with this study.
References 1. Alexander S, Conner T, Slaughter T. Overview of inpatient coding. Am J Health Syst Pharm 2003;60(Suppl 6):S11—4.
333 2. Averill RF, Mullin RL, Barbara MD, et al. 3M HIS Working Paper 598 Development of the ICD-10 Procedure Coding System (ICD10-PCS). 3. Farhan J, Al-Jummana S, Al-Rajhi A, et al. Documentation and coding of medical records in a tertiary care centre; a pilot study. Ann Saudi Med 2004;25(1):46—9. 4. Geoghegan JM, Hassan K, Calthorpe D. Thromboprophylaxis for acetabular injuries in the UK. What prophylaxis is used? Injury 2006;37:806—12. 5. Quan H, Parsons GA, Ghali WA. Validity of procedure codes in international classification of diseases, 9th revision, clinical modification administrative data. Med Care 2004; 42(8).
www.elsevier.com/locate/injury
Acetabular fractures in the UK. What are the numbers? J.M. Geoghegan a,*, E.J. Longdon b, K. Hassan a, D. Calthorpe a a b
Department of Trauma and Orthopaedics, Derbyshire Royal Infirmary, Derby DE1 2QY, United Kingdom Basic Surgical Training Programme, Nottingham, United Kingdom
Accepted 26 September 2006
KEYWORDS Acetabular fracture; Acetabular fracture surgical numbers; Surgeon directory; OPCS-4 codings; ICD-10 codings
Summary We have established a nationwide directory of the specialist surgical units and their Lead Consultants with expertise in acetabular fracture surgery throughout the UK. Our directory has facilitated an estimation of the total numbers of operative acetabular fracture cases managed annually in the UK, as reported by those actually providing this specialist service. Previously the total number of acetabular injuries admitted and operated on in the UK was not known and there was no directory of acetabular surgeons in the UK. The introduction and accuracy of the OPCS codings will have massive financial implications for the DoH at a local and national level in the planning and provision of adequate health care resources. We have performed a questionnaire study to validate the DoH data for acetabular fracture surgery. Data was compiled using the ICD-10 for diagnosis of fracture of the acetabulum, and the OPCS-4 codes for the surgical procedures used for fracture fixation for the year 2003—2004. The Department of Health (DoH) data identified 44 units that had OPCS-4 coding for acetabular fracture fixation. We had a 95% (42 out of 44 units) response to our questionnaire. A total of 9 units contacted had actually performed no surgery, whereas the DoH coded these as having performed a maximum of 35 cases. The DoH data showed a total of 1825 admissions to 311 NHS hospitals for acetabular fractures, including 258 operative cases performed in 44 NHS hospitals in the UK. Our study has found that 748 acetabular fracture fixation cases were performed at 33 NHS hospitals in the UK in this study period. The total difference between the DoH operated cases and those confirmed by our study was 490. The hospital care for an operative acetabular fracture case may cost approximately £14,830, if the actual numbers are under-reported to or by the DoH are 490, then approximately £7,266,700 has been lost by these centres due to incorrect proportioning of resources. # 2006 Elsevier Ltd. All rights reserved.
* Corresponding author at: 8 Cumbria Grange, Gamston, Nottingham NG2 6LZ, United Kingdom. Tel.: +44 1332347141; fax: +44 1332254950. E-mail address: [email protected] (J.M. Geoghegan). 0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.09.015
330
J.M. Geoghegan et al.
Introduction
Table 1 ICD-10 and OPCS-4 coding for acetabular fracture fixation
Acetabular and pelvic injuries require specialist management at appropriately dedicated Orthopaedic Trauma Units. There is no comprehensive or coordinated national approach to the management of acetabular injuries throughout the UK. Currently there is no published directory of dedicated pelvic and acetabular surgeons in the UK. The total number of acetabular injuries admitted and operated on in the UK is not known. There has been a recent emphasis on Operational Procedural Codes System (OPCS) and its generation of tariff for payment-byresults for treating hospitals. The accuracy of the OPCS codings therefore, has massive financial implications for the Department of Health at both a local and national level in the planning and provision of adequate health care resources. We have undertaken a study to compare the Department of Health figures using the ICD-10 and OPCS-4 codings for acetabular fracture cases that required operative fixation with figures provided by the treating surgeons themselves. This has enabled us to establish a nationwide directory of the specialist surgical units and their Lead Consultants with expertise in this field throughout the UK. Our directory has facilitated an estimation of the total numbers of operative acetabular fracture cases managed annually in the UK, as reported by those actually providing this specialist service.
ICD10 code Fracture of the acetabulum = S32.4 Secondary procedure code of Z75.6 acetabulum Operative fracture fixation procedures codes applicable include W19 primary open reduction of fracture of bone and intramedullary fixation W20 primary open reduction of fracture of bone and extramedullary fixation W21 primary open reduction of intraarticular fracture of bone W22 other primary open reduction of fracture of bone W23 secondary open reduction of fracture of bone W24 closed reduction of fracture of bone and internal fixation W25 closed reduction of fracture of bone and external fixation W26 other closed reduction of fracture of bone W28 other internal fixation of bone W29 skeletal traction of bone W30 other external fixation of bone W57 excision reconstruction of joint W65 primary open reduction of traumatic dislocation of joint W66 primary closed reduction of traumatic dislocation of joint W67 secondary reduction of traumatic dislocation of joint W77 stabilising operations on joint W81 other open operations on joint W91 other manipulation of joint W92 other operations on joint
Methods For the completeness of data in the National Health Service (NHS) for the numbers of acetabular injuries requiring surgery for the financial year 2003—2004, we accessed through the Department of Heath (DoH) the four agencies that cover the United Kingdom: Hospital Episode Statistics, England; Health Solutions, Wales; ISD, Scotland; and Department of Health & Social Security, Northern Ireland. The data was compiled using the International Code of Diseases version 10 (ICD-10) for diagnosis of fracture of the acetabulum, and the OPCS-4 codes for the surgical procedures used for fracture fixation (Table 1). Data was requested to determine the total number of acetabular fractures operated on by NHS Trust. Data supplied by Hospital Episode Statistics (England) were subject to masking, in line with the DoH ‘Protocol on Confidentiality’. Any figure between 1 and 5 was suppressed and replaced at source by an asterisk (*) symbol, so individual patients could not be identified. For our purposes such units in England were counted as having operated upon five cases, to ensure under-reporting of
the DoH figures was not due to our own data processing. From this list of NHS Trusts, we identified the individual hospitals within these Trusts and ‘‘Lead Surgeons’’ providing this service. A letter was then sent to all ‘‘Lead Surgeons’’ requesting the exact numbers of surgical cases in the study period in order to validate the DoH data. Each centre was given their respective number of operative cases as per the DoH data for the study period to encourage accurate data checking and reporting from the surgical units themselves. Non-responders were further contacted by letter and telephone. Further nonresponders received up to seven further postings and numerous follow-up telephone calls. Data were recorded on a Microsoft Excel Spreadsheets.
Results The DoH data identified 44 units that had OPSC-4 coding for acetabular fracture fixation. We had a 95% (42 out of 44 units) response to our questionnaire. A total of 9 units contacted had performed no
Acetabular fractures in the UK
331
Table 2 Department of health and study data comparison Country
DoH–—centres performing acetabular fixation
Confirmed centres by study
DoH–— operative figures
Centre operative figures
Discrepancy in total operated cases
England Northern Ireland Scotland Wales Total in UK
34 2 6 2 44
26 1 5 1 33
222 15 15 6 258
616 19 91 22 748
394 4 76 16 490
surgery, whereas the DoH coded these units as having performed between 19 and 35 cases. This range is due to 4 of these units in England having masked data (see Methods) and they may represent between 1 and 20 cases in this study period. The two units that did not respond to our questionnaire were masked in the DoH data. We have shown a massive discrepancy between the DoH figures for operative acetabular fracture fixation and the data derived from these units directly (Table 2). For the year 2003—2004, in the UK the DoH figures showed a total of 1825 admissions for acetabular fractures to 311 NHS hospitals, and 258 acetabular fracture cases that were operated on in 44 NHS hospitals in the UK. Our study has found that 748 acetabular fracture fixation cases were performed at 33 NHS hospitals in the UK in this study period. The total difference between the DoH operated cases and those confirmed by our study was 490. The DoH figures include the two non-responders to our questionnaire from England, which were masked in the DoH data (i.e. number of 1 to 5). As it is not possible to ascertain whether this represents 2 or 10 cases the total numbers from these 2 centres were still included, and this will represent a potential under-reporting of cases actually performed by our study centres. The biggest discrepancies occurred at our largest and busiest centres in the UK. The largest discrepancy at one unit was 70 cases in the study period.
Discussion Using data from the Department of Health, we have identified all centres in the UK that provide surgical expertise in the operative fixation of acetabular fractures. We have developed a nationwide directory of all surgical units and their respective Lead Consultants specialising in this field. We have attempted to validate the DoH data using a questionnaire to ascertain the total number of acetabular injuries in the UK that are surgically reconstructed for the year 2003—2004. There is a surprisingly large discrepancy in the
data acquired from our study and that as held by the DoH with respect to the total number of acetabular fracture cases treated surgically in this study period. We have identified 33 NHS Trauma & Orthopaedic Units in the UK which have performed acetabular fracture fixation in the year 2003—2004. We have no data as to whether or not these units received their cases as tertiary referral centres or whether cases presented directly. There is no available data as to how or where inter-hospital referrals are made or occur from the DoH to tertiary referral centres. It is also unclear from the DoH as to who the tertiary units for this specific injury are throughout the UK. The number of cases performed per unit ranged from 2 to 98 in the year 2003—2004. Although this is only a snap-shot of practice throughout the UK in a 12-month period and does not represent overall experience, this does pose the question of how many cases a surgeon should be performing per year to be competent and to keep skills up to date. We did not study the time to surgery from injury, as this data is not available from the DoH. Our previous study suggests that the mean time to surgery from injury was 8.5 days with a large range from unit to unit (2— 19 days) in the UK.4 We previously identified 21 units throughout the UK which operated on 872 acetabular fractures in the year 2003.4 These were the best data available at that time. We believe that the data we present in this paper is more accurate. The questionnaire stated the numbers of surgical cases performed by each respective unit as per the data held by the DoH to encourage accurate data checking and reporting by each unit to us. We appreciate that this does not exclude inaccurate data in our study. Four units in the UK still reported their figures as <5 instead of exact numbers. We acknowledge the limitations of a postal/telephone questionnaire, and accept that conclusions from this can only provide a broad scope of current clinical practice. The DoH data represents a period of patient care under one consultant within one healthcare provider, and the figures do not represent the numbers of patients, as a person may have more than
332
J.M. Geoghegan et al.
one episode of care within the year (Hospital Episode Statistics, England). It is however, unlikely that one patient would have two or more admissions for operative acetabular fracture surgery in 1 year, but this is a potential source of error. The DoH liaises closely with NHS Trusts in order to ensure that data quality is enhanced wherever possible, and acknowledge that there are some shortcomings in the data, but their goal is to minimise inaccuracies and bring about improvements over time (Hospital Episode Statistics, England). The DoH data made available for this study had not been adjusted for shortfalls in data. However, this does not explain the huge discrepancies in the data we present. Due to the advent of OPCS coding and the rapid introduction of tariff and payment by results, coding accuracy at source and by the DoH is vital for current and future provision of sufficient resources to realise an effective and safe trauma service throughout the UK. The ICD-10 was published in 1998 to replace ICD-9 as this system did not allow new procedures to be coded adequately with the rapidly advancing technologies and incorporation of new interventions.2 Previous studies have assessed the accuracy of ICD codings and found that the accuracy for major procedures was approximately 70%.5 Alexander et al., studied inpatient coding performed by clerks who found subtlety of medical terms confusing, leading to miscoding.1 They suggested closer cooperation between the medical clerks and clinicians. Farhan et al., found a close correlation between accuracy of coding and good medical records. Sixty percent of the notes they reviewed were coded accurately.3 There is an obvious need for clinicians and medical clerks to work together to
ensure that coding is accurate to ensure that practice and subsequent renumeration are valid. This will also help in providing adequate resources. If we consider that the hospital care for an operative acetabular fracture case may cost in the region of £14,830 (costing agreed by our local purchaser and provider) and the actual numbers are underreported to or by the DoH are 490, then approximately £7,266,700 has been lost by these centres due to incorrect proportioning of resources. The actual costing of acetabular fracture fixation is very difficult to calculate due to the considerable variation in the complexity of the injury and associated injuries (see Table 3). This is in itself an area of considerable debate.
Conclusion We have tried to validate the DoH figures for acetabular fracture surgery using a postal and telephone questionnaire directed towards the Lead Surgeon at the centres identified by the DoH data. We acknowledge the limitations of a postal/telephone questionnaire, and accept that conclusions from this can only provide a broad scope of current clinical practice. These figures however are the best currently available in the UK. This study provides the greatest insight into hitherto unanswered questions of total numbers of operated cases and locations of centres throughout the UK. There is at this time no published directory of dedicated pelvic and acetabular surgeons in the UK. There are current efforts to develop a National and European Society of Pelvic and Acetabular Surgeons and we hope that our data can assists in this by identifying centres and Lead Surgeons in the UK.
Table 3 Approximate costings for acetabular fracture fixation Average length of stay for operated patients Daily cost of Trauma Unit
18 days
Conflicts of interest
£320.52
None declared.
Cost of operative time Per minute Per hour
£22.90 £1374
Operative time 5—6 h (operative time = time from entering anaesthetic room to entering theatre recovery) Basic costing
£6870—8244
£12,639—14,013 a
Costing data kindly supplied by Audit Office, Department Trauma & Orthopaedics, QMC, Nottingham University Hospitals NHS Trust. a Additional significant variable costs NOT included = polytrauma, radiology and laboratory investigations, blood products, implants, high dependency/intensive care, etc.
Acknowledgements Mrs. Anne Cannon for her secretarial support and patience. Mr. David Hahn for his helpful comments and direction and Mr. Philip Radford, Consultant Orthopaedic and Trauma Surgeons, Queens Medical Centre, Nottingham. Mr. Chris Boulton, Audit CoOrdinator Trauma & Orthopaedics Queen’s Medical Centre, Nottingham. All Pelvic and Acetabular Consultants throughout the UK who assisted us in this study by completing the postal questionnaire and
Acetabular fractures in the UK responding to our phone calls. Thanks to the staff at Hospital Episode Statistics, England; Health Solutions, Wales; ISD, Scotland; and the Department of Health & Social Security, Northern Ireland for their help and advice with this study.
References 1. Alexander S, Conner T, Slaughter T. Overview of inpatient coding. Am J Health Syst Pharm 2003;60(Suppl 6):S11—4.
333 2. Averill RF, Mullin RL, Barbara MD, et al. 3M HIS Working Paper 598 Development of the ICD-10 Procedure Coding System (ICD10-PCS). 3. Farhan J, Al-Jummana S, Al-Rajhi A, et al. Documentation and coding of medical records in a tertiary care centre; a pilot study. Ann Saudi Med 2004;25(1):46—9. 4. Geoghegan JM, Hassan K, Calthorpe D. Thromboprophylaxis for acetabular injuries in the UK. What prophylaxis is used? Injury 2006;37:806—12. 5. Quan H, Parsons GA, Ghali WA. Validity of procedure codes in international classification of diseases, 9th revision, clinical modification administrative data. Med Care 2004; 42(8).