1. This study analyzed direct and indirect costs of ankle sprain patients based on their Foot and Ankle Outcome Scores (FAOS) at 1 month post-injury. 2. Patients were categorized into low, moderate, and good recovery groups based on their FAOS scores. 3. Results found no significant differences in direct healthcare costs between groups. However, indirect costs from missed work, assistance, etc. were highest for the low recovery group and lowest for the good recovery group.

1. OBJECTIVES
RESULTS
Table 1: Patient Characteristics by FAOS Score
STUDY COHORT
METHODS
Study population:
• From a randomized controlled trial (RCT) on the efficacy of a physical therapy intervention
for ankle sprains (P.I.: Drs. R. Brison and B. Brouwer). [4] Inclusion criteria: patients (≥16
years old) who presented at an Emergency Department (ED) in Kingston, Ontario, with a
grade I or II ankle sprain.
• Exclusion criteria: patients with grade III injury or fracture, other soft-tissue injuries, unrelated
mobility limiting conditions; baseline FAOS > 450; or those who arranged for physiotherapy.
Data sources:
• FAOS was collected at baseline and at 1 month follow-up. Patient characteristics were
collected by interviewers at baseline. Travel, lost income from missed work days, paid and
unpaid assistance, medication, support treatments, ED, family physician (FP), and specialist
physician visit data were obtained at 1 month using the Productivity Questionnaire.
Physician fees were obtained from OHIP Schedule of Benefits for Physician Services.
Average ED costs (nursing care, diagnostic testing, overhead costs) for Hotel Dieu Hospital
(HDH) and Kingston General Hospital (KGH) ankle-related visits were obtained using the
Ontario Case Costing Initiative (OCCI)5
.
Analysis:
• All patient characteristics except for physical activity were categorized and described by
FAOS score. The analysis was conducted from the payer’s perspective and costs were
reported in 2013 Canadian dollars (2013 CAD). Direct healthcare costs and healthcare
utilization associated with initial ED visits, subsequent ED visits, and physician visits (family
physician and specialist) were compared between the three recovery groups using ANOVA
(α=0.05). Indirect costs associated with travel, lost income from missed work days, paid and
unpaid assistance, medication, and support treatments were compared between the three
groups using Kruskal-Wallis test (α=0.05).
Recovery Status (FAOS)
Low Moderate Good
Variable Value N % N % N % p-value
Age 16 – 20 26 15.9 50 29.1 64 40.3 <0.01
20 – 30 49 30.1 55 32.0 54 34.0
30 – 40 37 22.7 31 18.0 13 8.2
40 – 50 32 19.6 16 9.3 12 7.6
50+ 19 11.7 20 11.6 16 10.1
Gender Male 55 33.7 81 47.1 84 53.8 <0.01
Female 108 66.3 91 52.9 75 48.1
Sprain Grade I 37 22.8 46 27.2 62 39.5 <0.01
II 125 77.2 123 72.8 95 60.5
Occupation Sedentary 39 21.9 35 20.5 40 24.1 <0.01
Status* Low Risk
High Risk
Unemployed
53
21
65
29.8
11.8
36.5
54
19
63
31.6
11.1
36.8
61
18
47
36.8
10.8
28.3
1. Childs, S.G.(2012) Syndesmotic ankle sprain. National Association of
Orthopaedic Nurses. 31(3)
2. Hupperets, M.D.W., Verhagen, E.A.L.M., Heymans, M.V., Bosmans, J.E.,
van Tulder, M.W., van Mechelen, W. (2010) Potential savings of a
program to prevent ankle sprain recurrence. The American Journal of
Sports Medicine. 38 (11)
3. Cooke, M.W., Marsh, J.L., Clark, M., Nakash, R., Jarvis, R.M., Hutton,
J.L., Szczepura, A., Wilson, S., Lamb, S.E. (2009) Treatment of severe
ankle sprain: a pragmatic randomized controlled trial comparing the
clinical effectiveness and cost-effectiveness of three types of mechanical
ankle support with tubular bandage. Health Technology Assessment. 13
(13).
4. R, Brison., B, Brouwer et al. Efficacy of a physical therapy intervention for
the early treatment of acute ankle sprains identified in the emergency
department (2009). Randomized Controlled Trial Proposal.
5. http://ophid.scholarsportal.info/details/view.html?
q=Image&uri=/phirn/occi_PHIRN_e.xml
This study was supported by the Canadian Institutes of Health
Research (www.cihr-irsc.gc.ca). The authors would like to thank all of
the study participants, research co-investigators and staff. A special
thank you to the KGH Clinical Research Centre Student Group.
Figure 1: Study Participants
Direct and Indirect Costs of Ankle Sprain Patients
Lee, R., B.Sc.1
; Bielska, I.A., M.Sc.2
; Fong, R.K., M.Sc.2
; Brison, R., M.D., M.Sc.3
; Brouwer, B., Ph.D.4
; Johnson, A.P., Ph.D.2
1
Dept. of Kinesiology and Health Studies; 2
Dept. of Public Health Sciences; 3
Dept. of Emergency Medicine; 4
School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario
• Ankle sprains are one of the most common soft-tissue injuries worldwide and can result in
lingering symptoms for the patients up to 6 months post-injury. [1]
• Patients who are older, female and with ankle sprain history have the highest risk of injury. [2]
• $279 million (2013 USD) is associated with ankle sprains where 80% of these costs are due to
productivity loss which is $223.2 million (2013 USD). [2]
• Few studies on patients with ankle sprains have considered the effect of demographic
characteristics on their recovery.
Definitions:
FAOS – The Foot and Ankle Outcome Score assesses self-perceived ankle function. [3] 500 is
the total score which consists of the sum of 5 subcategories scores: pain, symptoms, quality of
life, active daily living, and functionality in sport and recreation.
Healthcare utilization – The measure of the population’s use of healthcare services available
to them.
Ankle sprain – Injury to the lateral or medial ligament of the ankle joint.
BACKGROUND
1. To describe the demographic (age, gender, occupation status) and clinical characteristics
(FAOS Score, sprain grade, physical activity profile) for patients with ankle sprains at 1
month post-injury.
2. To compare direct and indirect costs between the three recovery groups determined by
FAOS score (0-309- low, 310-375 – moderate, 376-500 - good).
Patients eligible for the RCT study
Patients who agreed to participate in the RCT study
Patients who completed the one-month follow-up
*Occupation Status – This variable was categorized based on similar occupation-related risk for ankle sprains. Low risk - minimal
environmental impact on ankle sprain risk such as a waiter. High risk – high environmental impact on ankle sprain such as construction.
$249
$244
$241
Figure 2: Average Total Cost of Healthcare
Visits (ED*, Specialist, and FP) Per
Participant by recovery (FAOS) (2013 CAD)
*Total cost = initial and subsequent ED billing (physician, nursing, diagnostic
imaging) and follow-up with family physician and/or specialist physician p=0.09
KEY FINDINGS
STRENGTHS & LIMITATIONS
• Data were based on a RCT with a large
sample size of individuals with grade I and II
ankle sprains.
• 95% of patients followed up at 1 month.
• One month post-injury may be too early to
identify significant recovery in all ankle
sprain patients.
• Due to limited published information on
categorizing FAOS cut-off scores for full
recovery, tertiles were used in the current
analysis.
IMPLICATIONS
• Current treatment methods on ankle sprains
still produce a burden of indirect costs on
patients within the 1 month recovery time.
• Better preventative ankle sprain programs
and treatment methods are needed to reduce
the direct and indirect costs associated with
ankle sprains.
ACKNOWLEDGMENTS
REFERENCES
2067
504
491
336
28
Yes No
Figure 3: Total indirect cost by
recovery (2013 CAD)
0-309 310-375 376-500
FAO
S
2000
1500
1000
500
0
IndirectCost($)
$596
$330
$185
Figure 4: Boxplot of the indirect cost by recovery (2013 CAD)