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BMJ Open. 2017 Sep 7;7(9):e014509. doi: 10.1136/bmjopen-2016-014509.

Cost comparison of orthopaedic fracture pathways using discrete event simulation in a Glasgow hospital.

Author information

Department of Management Science, University of Strathclyde Business School, Glasgow, UK.
Department of Orthopaedic Surgery, Glasgow Royal Infirmary, Glasgow, UK.
Quality and Efficiency Support Team, Scottish Government, Glasgow, UK.



Healthcare faces the continual challenge of improving outcome while aiming to reduce cost. The aim of this study was to determine the micro cost differences of the Glasgow non-operative trauma virtual pathway in comparison to a traditional pathway.


Discrete event simulation was used to model and analyse cost and resource utilisation with an activity-based costing approach. Data for a full comparison before the process change was unavailable so we used a modelling approach, comparing a virtual fracture clinic (VFC) with a simulated traditional fracture clinic (TFC).


The orthopaedic unit VFC pathway pioneered at Glasgow Royal Infirmary has attracted significant attention and interest and is the focus of this cost study.


Our study focused exclusively on patients with non-operative trauma attending emergency department or the minor injuries unit and the subsequent step in the patient pathway. Retrospective studies of patient outcomes as a result of the protocol introductions for specific injuries are presented in association with activity costs from the models.


Patients are satisfied with the new pathway, the information provided and the outcome of their injuries (Evidence Level IV). There was a 65% reduction in the number of first outpatient face-to-face (f2f) attendances in orthopaedics. In the VFC pathway, the resources required per day were significantly lower for all staff groups (p≤0.001). The overall cost per patient of the VFC pathway was £22.84 (95% CI 21.74 to 23.92) per patient compared with £36.81 (95% CI 35.65 to 37.97) for the TFC pathway.


Our results give a clearer picture of the cost comparison of the virtual pathway over a wholly traditional f2f clinic system. The use of simulation-based stochastic costings in healthcare economic analysis has been limited to date, but this study provides evidence for adoption of this method as a basis for its application in other healthcare settings.


costs; fracture clinic; orthopaedics; outpatients; patient outcomes

[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

Competing interests: LAR, PJJ and GHA are in receipt of an unrestricted grant from the Scottish Government, Quality and EfficiencySupport Team as part of the Whole system patient flow programme. DAM works for the Scottish Government which funded the research.

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