The Financial Burden of Mandibular Trauma

Does Alcohol Use Influence Hospitalization Outcomes in Adults Suffering Craniomaxillofacial Fractures From Street Fighting?

Study Design

This retrospective cohort study utilized the National Inpatient Sample (NIS) database for the years 2016-2018. Incidences of street fighting were identified using the corresponding ICD-10 codes.

Objective

To determine whether alcohol use (measured by blood alcohol content (BAC)) in patients sustaining maxillofacial trauma from hand-to-hand fighting influence hospitalization outcomes.

Methods

The primary predictor variable was BAC stratified into six categories of increasing magnitude. The primary outcome variable was mean length of hospital stay (days). The secondary outcome variable was total hospital charges (US dollars).

Results

Our final sample consisted of 3038 craniomaxillofacial fractures. Each additional year in age added +$545 in hospital charges (P < .01). Non-elective admissions added $14 210 in hospital charges (P < .05). Patients admitted in 2018 experienced approximately $7537 more in hospital charges (P < .01). Le Fort fractures (+$61 921; P < .01), mandible fractures (+$13 227, P < .01), and skull base fractures (+$22 170; P < .05) were all independently associated with increased hospital charges. Skull base fractures added +7.6 days to the hospital stay (P < .01) and each additional year in patient age added +.1 days to the length of the hospital stay (P < .01).

Conclusions

BAC levels did not increase length of stay or hospitalization charges. Le Fort fractures, mandible fractures, and skull base fracture each independently increased hospital charges. This reflects the necessary care (ie, ICU) and treatment (ie, ORIF) of such fractures. Older adults and elderly patients are associated with increased length of stay and hospital charges-they are likely to struggle in navigating the healthcare system and face socioeconomic barriers to discharge.

Is Insurance Payer Associated With Hospital Admission of Emergency Department Patients With Mandible Fractures?

BACKGROUND

There is a lack of consensus on the optimal triage pathway for emergency department (ED) patients with mandibular fractures. It remains unclear if patient insurance payers predict hospital admission given potentially competing logistical and health system incentives.

PURPOSE

To generate nationally representative estimates of the frequency of hospital admission and its association with primary insurance payers for ED patients with mandible fractures.

METHODS

This retrospective cohort study used the 2018 Nationwide Emergency Department Sample, the largest all-payer database in the United States, to identify patients with mandible fractures. The database includes a stratified sample with discharge weights to generate nationally representative estimates. Patients with other facial fractures and/or concomitant injuries that independently warranted admission were excluded.

PREDICTOR

The primary predictor variable was primary payer (public, private, self-pay, and other/no charge).

OUTCOME VARIABLE

The primary outcome variable was hospital admission (yes/no).

COVARIATES

Covariates included patient-, medical/injury-, and hospital-related variables.

ANALYSES

Descriptive statistics, along with bivariate and multivariate logistic regression with Bonferroni correction, were used to produce national estimates and identify predictors of admission. P < .01 was considered significant.

RESULTS

The cohort included 27,238 weighted encounters involving isolated mandible fractures, of which 5,345(20%) were admitted. The payers for admitted patients were 46% public, 25% private, 22% self-pay, and 7% no charge/other. In bivariate analyses, public insurance was associated with a higher likelihood of admission than private insurance (RR 1.24, 95% CI 1.06 to 1.45), though there was no association in the multivariate model (OR 1.03, 95% CI 0.83 to 1.28). In multivariate analysis, higher Charlson Comorbidity Index (OR 1.32, 95% CI 1.18 to 1.48), alcohol-related disorder (OR 3.47, 95% CI 2.74 to 4.39), substance-related disorder (OR 1.43, 95% CI 1.20 to 1.71), and more mandible fractures (OR 3.08, 95% CI 2.65 to 3.59) were associated with admission. Compared to body fractures, subcondylar (OR 3.83, 95% CI 2.39 to 6.14), angle (OR 3.53, 95% CI 2.84 to 6.09), and symphysis (OR 4.14, 95% CI 2.84 to 6.09) fractures had higher odds of admission. Finally, level I (OR 4.11, 95% CI 2.41 to 6.98) and level II (OR 3.16, 95% CI 1.85 to 5.39) trauma centers had higher odds of admission.

CONCLUSIONS

In 2018, 20% of ED patients with isolated mandible fractures were admitted. Several patient and hospital characteristics were predictors of admission. Insurance status was not associated with admission.

Mandibular fractures in Kano, Northwest Nigeria: etiology and pattern of presentation

BACKGROUND

Mandibular fractures are universal in distribution, but its etiologies and presentation patterns differ from one country to another because of varying socioeconomic, cultural and geographical factors. We analyzed the etiological factors and presentation patterns of mandibular fractures in a tertiary hospital at Nigeria's second largest city.

METHODS

Patients with isolated mandibular fractures at Aminu Kano Teaching Hospital, Kano were prospectively reviewed over a 12-months period. Patients' demographic information and fracture characteristics (etiology, site, pattern and number of fracture) were recorded and analyzed.

RESULTS

One hundred and forty-eight patients presented with 180 mandibular fractures. There were eight-fold higher men with mandibular fractures than women (M: F =8.3:1) with highest incidence in third decade of life. Road traffic accidents (84.46%) was the major etiology while iatrogenic fracture (0.68%) was found in one patient. Mandibular body was the most fractured site (41.11%) with parasymphyseal and angle regions accounting for 27.78% and 23.89% of total recorded fractures respectively.

CONCLUSIONS

Mandibular fractures in Kano, Northwest Nigeria occurred predominantly in men in the third decade and are mostly caused by road traffic accidents. The majority of these fractures involved the mandibular body.

Mandible Fractures Undergoing Transfer Rarely Require Acute Intervention

Study Design

A retrospective review was conducted of all patients with mandibular fractures who were evaluated by plastic surgery at a Level I trauma center between January 1, 2017 and May 1, 2020. Data including demographic characteristics, mechanism of injury, type of presentation (e.g., primary or transfer), treatment plan, and time to intervention were recorded.

Objective

Mandibular fractures are common traumatic injuries. Because these injuries are managed by surgical specialists, these patients are often emergently transferred to tertiary care hospitals. This study aims to assess the benefits of emergent transfer in this patient group.

Methods

Variables were summarized using descriptive statistics. The relationship with initial disposition was assessed via tests of association, including Student's t-test, Fisher's exact test, or chi-square tests. Significance was set to p values less than 0.05. Multivariate regression analysis was conducted to determine predictors of presentation to outside hospital followed by transfer to our institution.

Results

Records from 406 patients with isolated mandibular fractures were evaluated. 145 (36%) were transferred from an outside hospital specifically for specialty evaluation. One patient required intervention in the Emergency Department (ED). Of the 145 patients that were transferred to our facility, eight (5.5%) were admitted for operative management. Patients with open injuries and pediatric patients showed benefit from transfer.

Conclusions

Patients are frequently transferred to tertiary care facilities for specialty service evaluation and treatment. However, when isolated mandible fractures were evaluated, only one patient required intervention in the ED. Patients with grossly open fractures and pediatric patients were more frequently admitted specifically for operative management. This practice of acute interfacility transfer represents an unnecessary cost to our health system as isolated mandible fractures can be managed on an outpatient basis. We suggest that pediatric patients and patients with open fractures be transferred for urgent evaluation and management, whereas most patients would be appropriate for outpatient evaluation.

Have Incidence and Severity of Craniomaxillofacial Fractures Changed Since SARS-CoV-2?

BACKGROUND

An increase in severity and a decrease in incidence of craniomaxillofacial fractures (CMFs) were identified during the first several months of the SARS-CoV-2 pandemic. It is unclear if these changes have persisted in the current timeframe.

PURPOSE

The investigators hypothesize that the incidence and severity of CMF will not return to baseline prepandemic (control) levels as the pandemic stabilizes and becomes endemic.

STUDY DESIGN, SETTING, SAMPLE

This retrospective cohort study enrolled subjects who presented to Harborview Medical Center a Level 1 trauma center for the evaluation and management of CMF. Inclusion criteria were 1) Presentation timeline 2018 through 2022, 2) CMF identified by the 10th International Classification of Disease. Exclusion criteria were: 1) Undocumented etiology of facial fracture and 2) inadequate/unclear documentation otherwise.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

The predictor variable was year of injury relating to the start of the pandemic. The groups were the prepandemic (2018, 2019) and postpandemic (2020, 2021. 2022).

MAIN OUTCOME VARIABLES

The primary outcome variable was the CMF diagnosis identified using the corresponding International Classification of Disease, 10th Edition codes. The secondary outcome variables were mechanism of injury and injury severity.

COVARIATES

The covariates were age, sex, race/ethnicity, admission status, alcohol intoxication, toxicology screen, reimbursement source, abuse reported, and abuse investigated.

ANALYSES

Univariate and bivariate analyses were performed with statistical significance at P < .05.

RESULTS

The sample was composed of 5203 subjects. The annual volumes of subjects presenting with CMF were consistent over the study period (2018, 2019, 2020, 2021, 2022 n = 1018, 963, 1020, 1062, 1140, respectively). The incidence of Hispanics increased (2018, 2019, 2020, 2021, 2022: 11.1, 9.6, 12.2, 13.9, 13.2% (P < .05)) as did firearm CMF injuries (2018, 2019, 2020, 2021, 2022: 4.13, 4.98, 4.71, 7.16, 6.75% (P < .05)). The Injury Severity Score and Abbreviated Injury Scale were both lower postpandemic compared to prepandemic; mean Injury Severity Score post [18.27 ± 12.46] versus pre [19.25 ± 12.89] (P < .05), mean Abbreviated Injury Scale post [2.94 ± 1.15] versus pre [3.04 ± 1.14] (P < .05).

CONCLUSIONS AND RELEVANCE

While the severity of CMF decreased postpandemic, Hispanic and firearm CMF increased. The overall CMF incidence remained the same. The significant rise in firearm injuries warrants further study.

The Effect of Duration of Antibiotic Prophylaxis on Infections Following Open Reduction and Internal Fixation of Mandibular Fractures: A Prospective Randomized Clinical Trial

AIM

To evaluate the benefits of a long-term prophylactic antibiotic regimen following treatment of fractured mandibles with open reduction and internal fixation.

MATERIAL AND METHODS

A prospective, randomized controlled trial was undertaken at Wits Oral Health Centre. Patients with mandibular fractures who were managed with open reduction and internal fixation using miniplates were randomized into 2 groups. The control group, the perioperative antibiotic (POA) group, was composed of patients who received intravenous (IV) antibiotic cover intraoperatively and a further 3 IV doses 24 hours postoperatively. The study group, the extended postoperative antibiotic (EPOA), was composed of patients who received similar doses as the control group but with an additional 5 days of oral antibiotics upon discharge. The patients were then evaluated for evidence of infection 1, 4, and 6 weeks postoperatively.

RESULTS

A total of 77 patients were included in the study, 41 in the POA and 36 in the EPOA groups. Fourteen patients had evidence of infection noted within the 6-week follow-up period (10 in the POA and 4 in the EPOA groups). Statistical analysis with the Pearson Chi-square and Student t test showed no statistically significant difference ( P =0.399) between POA and EPOA groups. There were no significant differences between the groups with respect to site and etiology of fracture, duration of operation, and presence of infection ( P >0.05) during the 6-week review period.

CONCLUSIONS

The extended use of antibiotic prophylaxis when managing mandibular fractures with open reduction and internal fixation offers no additional benefit in reducing postoperative infections.

Interfacility Emergency Department Transfer for Midface Fractures in the United States

PURPOSE

Interfacility hospital transfer for isolated midfacial fractures is common but rarely clinically necessary. The purpose of this study was to generate nationally representative estimates regarding the incidence, risk factors, and cost of transfer for isolated midface fractures.

METHODS

This was a retrospective cohort study using the Nationwide Emergency Department Sample 2018 to identify patients with isolated midface fractures. The primary predictor variable was hospital trauma center designation (Level I, Level II, Level III, and nontrauma center). The primary outcome variable was hospital transfer. Total emergency department (ED) charges were also assessed. Covariates were demographic, medical, injury-related, and hospital characteristics. Descriptive, bivariate, and multiple logistic regression statistics were used to evaluate the incidence and predictors of interfacility transfer.

RESULTS

During the study period, there were 161,022 ED encounters with a midface fracture as primary diagnosis, of which 5,680 were transferred (3.53%). In an unadjusted analysis, evaluation at a nontrauma center, level III trauma center, nonteaching hospital, and numerous demographic, medical, and injury-related variables were associated with transfer (P ≤ .001). In the adjusted model, the strongest independent predictors for hospital transfer were evaluation at a nontrauma center (odds ratio [OR] = 16.2, 95% confidence interval [CI] = 13.6-19.4), level III trauma center (OR = 13.4, 95% CI = 11.1-16.1) or level II trauma center (OR = 3.25, 95% CI = 2.66-3.98), any Le Fort fracture (OR = 12.0, 95% CI = 10.4-14.0), orbital floor fracture (OR = 3.73, 95% CI = 3.48-4.00), history of cerebrovascular event (OR = 2.74, 95% CI = 2.18-3.45), and cervical spine injury (OR = 5.87, 95% CI = 4.79-7.20) (P ≤ .001). The average ED charge per encounter was $7,206 ± 9,294 for a total nationwide charge of approximately 1.16 billion dollars. Transferred subjects had total ED charges of $97 million, not including additional charges at the recipient hospital.

CONCLUSION

Isolated midface fractures are transferred infrequently, but given the high incidence have substantial healthcare costs. Predictors of transfer were mixed rather than clustered within one variable type, although it is likely that transfers are driven in part by lack of access to maxillofacial specialists given the predominance of hospital covariates. Programs evaluating necessity of transfer and facilitating specialist evaluation in the outpatient setting may reduce healthcare expenditures for these injuries.

Trauma clinic follow-up: Predictors of nonattendance and patient-reported reasons for no show

Introduction

The objectives of this study were to identify factors associated with nonattendance to follow-up in patients seen for traumatic hand and facial injuries at an urban Level 1 trauma center and to elucidate patient-reported reasons for nonattendance.

Methods

A retrospective chart review was performed for all patients seen for hand and facial trauma at our institution over a 2-year period. Demographic data, including race, insurance status, and incomes based on zip code data, were collected for all patients. Injury patterns, interventions, and patient disposition were analyzed. A binomial multivariate logistic regression was conducted to identify predictors of nonattendance to follow-up. All patients who were lost to follow-up over the last 12-month period were contacted via phone to identify reasons for nonattendance to determine whether they had followed up with another provider and to analyze long-term injury sequelae.

Results

After exclusion criteria were applied, there were 889 patients included in the analysis, with 31% of patients lost to follow-up. Factors significantly associated with follow-up nonattendance included patients who sustained injuries from gunshot wounds or assault, had no insurance or were out of network, and who received no acute intervention for their injuries. Forearm, wrist, and fingers fractures; facial fractures and lacerations; performing a procedure in the ED or operating room; and commercial insurance were all independent predictors of clinic attendance. The most common reasons for nonattendance cited by patients were “did not feel the need” (28%), lack of transportation (20%), and scheduling conflicts (19%).

Conclusions

Clinic follow-up for patients sustaining hand and facial trauma at a Level 1 trauma center is impacted by the socioeconomic factors that make this patient population particularly vulnerable to injury.

Does the Geographical Distribution of Facial Trauma Surgeons Correspond to Facial Trauma Burden? A Nationwide Population-Level Analysis

ABSTRACT

It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x[Combining Tilde] = 2330.6 PMP), 28,004 surgeons (x[Combining Tilde] = 83.5 PMP), and 746 training positions (x[Combining Tilde] = 1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P < 0.01), surgeon (70.8 versus 98.8, P < 0.01), training positions (0 versus 3.4, P < 0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density (P < 0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP (P < 0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.

Treatment costs of mandibular fractures in a Nigerian hospital

PURPOSE

To determine the cost of surgically treated mandibular fractures, methods of payments, and the relationship between socioeconomic status of subjects and payment methods in a Nigerian tertiary hospital.

METHODS

A retrospective review of 100 subjects who sustained 148 isolated mandibular fractures was conducted between November 2014 and October 2019. Demographics, socioeconomic status, mechanism of injury, fracture sites, type of treatment, and cost of treatment with methods of payments were obtained from medical records and hospital billing sheets of eligible subjects. The relationship between independent variables (age, sex, payment method, and treatment methods) and dependent variable (income class) was analyzed.

RESULTS

The mean age of the subjects was 31.8 ± 10.9 years; age range 17-63 years. The majority (75/100) belonged to the middle-income class. The costs of mandibular fractures repairs were ₦42,900 ($119.17) and ₦132,500 ($386.05) for closed reduction (CRMMF) and open reduction and rigid internal fixation (ORIF) respectively. All subjects in the low-income class (4/100) paid out of pocket for their treatment compared with 93% and 62% of the middle- and high-income classes respectively (p = 0.001). Half of the subjects in the low-income class had ORIF compared with 31% and 62% of the middle- and high-income classes respectively.

CONCLUSIONS

The treatments costs of mandibular fractures were ₦42,900 ($119.17) and ₦132,500 ($386.05) for CRMMF and ORIF respectively. The treatment costs were mostly out-of-pocket expenditure meaning that the subjects in the low-and middle-income classes bore the financial burden of their injuries.

The impact of COVID-19 on the injury pattern for maxillofacial fracture in Daegu city, South Korea

Background

This study aimed to analyze the impact of COVID-19 on oral and maxillofacial fracture in Daegu by comparing the demographic data in 2019 and 2020, retrospectively. We collected data from all patients having trauma who visited the emergency room for oral and maxillofacial fractures.

Methods

This retrospective study was based on chart review of patients who visited the emergency department of Kyungpook National University Hospital in Daegu, South Korea from January 1, 2019, to December 31, 2020. We conducted a comparative study for patients who presented with maxillofacial fractures with occlusal instability during pre-COVID-19 era (2019) and COVID-19 era (2000) with demographics and pattern of injuries.

Results

After the outbreak of COVID-19, the number of monthly oral and maxillofacial fractures, especially sports-related oral and maxillofacial fractures, decreased significantly. Also, the number of alcohol-related fractures increased significantly. In addition, as the number of monthly confirmed cases of COVID-19 increases, the incidence of fracture among these cases tends to decrease.

Conclusions

The COVID-19 pandemic has changed the daily life in Korea. Identifying the characteristics of patients having trauma can provide a good lead to understand this long-lasting infectious disease and prepare for future outbreaks.

Interfacility Transfers for Isolated Craniomaxillofacial Trauma: Perspectives of the Facial Trauma Surgeon

STUDY DESIGN

Secondary overtriage is a burden to the medical system. Unnecessary transfers overload trauma centers, occupy emergency transfer resources, and delay definitive patient care. Craniomaxillofacial (CMF) trauma, especially in isolation, is a frequent culprit.

OBJECTIVE

The aim of this study is to assess the perspectives of facial trauma surgeons regarding the interfacility transfer of patients with isolated CMF trauma.

METHODS

A 31-item survey was developed using Likert-type scale and open-ended response systems. Internal consistency testing among facial trauma surgeons yielded a Cronbach's α calculation of .75. The survey was distributed anonymously to the American Society of Maxillofacial Surgeons, the North American Division of AO Craniomaxillofacial, and the American Academy of Facial Plastic and Reconstructive Surgery. Statistical significance in response plurality was determined by nonoverlapping 99.9% confidence intervals (P < .001). Sum totals were reported as means with standard deviations and z scores with P values of less than .05 considered significant.

RESULTS

The survey yielded 196 responses. Seventy-seven percent of respondents did not believe that most isolated CMF transfers required emergency surgery and roughly half (49%) thought that most emergency transfers were unnecessary. Fifty-four percent of respondents agreed that most patients transferred could have been referred for outpatient management and 87% thought that transfer guidelines could help decrease unnecessary transfers. Twenty-seven percent of respondents had no pre-transfer communication with the referring facility. Perspectives on the transfer of specific fracture patterns and their presentations were also collected.

CONCLUSION

Most facial trauma surgeons in this study believe that emergent transfer for isolated CMF trauma is frequently unnecessary. Such injuries rarely require emergent surgery and can frequently be managed in the outpatient setting without activating emergency transfer services. The fracture-specific data collected are a representation of the national, multidisciplinary opinion of facial trauma surgeons and correlate with previously published data on which specific types of facial fractures are most often transferred unnecessarily. The results of this study can serve as the foundation for interfacility transfer guidelines, which may provide a valuable resource in triaging transfers and decreasing associated health-care costs.

Effectiveness of Prophylactic Preoperative Antibiotics in Mandible Fracture Repair: A National Database Study

OBJECTIVE

This is the first database study to assess the effectiveness of prophylactic preoperative antibiotics (PPAs) in mandible fracture repair.

STUDY DESIGN

Retrospective cohort.

SETTING

Database study using US inpatient and outpatient insurance claims submitted from July 2006 to March 2015.

METHODS

The IBM MarketScan Commercial Database was queried for adults aged 18 to 64 years who had undergone first-time mandible fracture repair according to Current Procedural Terminology codes for open and closed repair. Primary outcomes included surgical revision, local infection, and osteomyelitis. Rates were compared between cohorts based on whether or not patients had filled antibiotic prescriptions during the preoperative period alone. The effects of drug abuse and type of mandible repair (open vs closed) were explored. Multivariate Poisson regression models were used to calculate adjusted relative risk estimates, and 95% CIs were used to determine statistically significant differences.

RESULTS

A total of 2676 patients were included, with 847 (31.7%) filling PPAs and 1829 (68.3%) filling no antibiotics. Rates were 38.9% for revision, 5.8% for local infection, and 2.1% for osteomyelitis. After multivariate analysis, exposure to PPAs was not associated with surgical revision (adjusted relative risk, 1.04; 95% CI, 0.94-1.15), local infection (1.16; 0.82-1.64), or osteomyelitis (1.21; 0.68-2.14). Patients were more likely to fill PPAs if they underwent open repair (35.3%) versus closed (26.6%) (proportion difference, 8.7%; 95% CI, 5.2%-12.2%), but exposure to antibiotics did not predict outcomes on subgroup analysis.

CONCLUSION

PPAs do not improve mandible repair outcomes, regardless of repair type.

Is Outpatient Management of Mandibular Fractures Associated With Inflammatory Complications? An ACS-NSQIP Study

PURPOSE

Timing of mandibular fracture repair has long been debated. The purpose of the present study was to assess the incidence of postoperative inflammatory complications (POICs) following open repair of mandibular fractures managed non-urgently in the outpatient setting versus urgently in the inpatient setting.

METHODS

The authors utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to enroll a sample of patients with mandibular fractures who underwent open repair. The primary independent variable was treatment protocol: outpatient (elective) versus inpatient (urgent/non-elective). The primary dependent variable was POIC (yes/no). Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between treatment protocol and POICs.

RESULTS

The study cohort was comprised of 1,848 subjects with 1,134 outpatients and 714 inpatients. The incidence of POICs was 6.53% for the outpatient group compared to 8.96% for the inpatient group, with no significant difference between groups (P= .052). However, subjects treated as inpatients were 1.51 times more likely to experience any complication (P = .008) due to an increase in non-POICs (P = .028), in particular urinary tract infections (P = .035). After adjusting for age, hypertension requiring medical treatment, and smoking, classification as ASA II (P = .046, OR = 2.21, 95% CI 1.01 to 4.83), ASA III (P = .020, OR = 2.88, 95% CI 1.18 to 7.02), diabetes (P = 0.004, OR = 3.11, 95% CI 1.43 to 6.74), and preoperative hematocrit (P = 0.010, OR = 0.950, 95% CI 0.913 to 0.988) were independent predictors of POICs. Length of stay was 0.83 ± 2.61 days compared to 2.36 ± 3.63 days for the outpatient and inpatient groups, respectively (P ≤ .001).

CONCLUSIONS

There was no significant difference in POICs between patients treated as outpatients versus inpatients, though outpatients had fewer non-POICs and a shorter length of hospital stay.

Is Distance Between Home and Treatment Site a Risk Factor for Complications After Treating Mandibular Fractures?

PURPOSE

Our level I trauma center provides care over a large geographic area including Alaska, Washington, Idaho, Montana, and Wyoming, with many patients traveling hundreds of miles to receive care. Distance to a treatment site is documented to be an independent risk factor for complications after multisystem trauma, but it is unclear if it is a risk factor for isolated mandibular fractures. The study purpose was to measure the association between distance to treatment site and risk for postoperative complications after treatment of isolated mandibular fractures.

MATERIALS AND METHODS

The investigators designed and implemented a retrospective cohort study and enrolled a sample derived from patients treated for isolated mandibular fractures at Harborview Medical Center by the oral and maxillofacial surgery service between June 2012 and December 2016. The primary predictor variable was distance (miles) between the patient's residence and site of treatment (Harborview Medical Center). The primary outcome variable was postoperative complication (yes or no), subcategorized as major and minor. Secondary outcome variables were time to treatment between injury and operative treatment (days) and length of hospital stay (LOS) (days). Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between distance to treatment site and postoperative complications, time to treatment, and LOS. The level of statistical significance was set at P ≤ .05.

RESULTS

The study sample was composed of 403 subjects with a mean age of 32.6 ± 14.3 years and 80% were men. The average distance from the patient's residence to treatment site was 44.8 ± 128.6 miles (range, 0 to 1,440 miles; median, 20.4 miles). Major complications occurred in 11.6% of patients. The average distance between patients with and without postoperative complications was not significantly different (42.3 ± 55.8 miles vs 45.5 ± 141.7 miles; P = .8). Increasing distance was significantly associated with longer LOS (r = 0.16; P < .001) but not time to treatment (r = .04; P = .4).

CONCLUSIONS

In contrast to other studies regarding multisystem trauma, complications after treating isolated mandible fractures were not associated with increasing distance to treatment site. Increasing distance may be associated with longer LOS but not time to treatment.

What Is the Effect of COVID-19-Related Social Distancing on Oral and Maxillofacial Trauma?

Purpose

The purpose of this study was to understand the impact of social distancing policies enacted during the COVID-19 pandemic on the epidemiology of oral and maxillofacial fractures at an urban, Level I trauma center in the United States.

Materials and Methods

The investigators designed a retrospective cohort study and enrolled a sample of 883 subjects who presented for evaluation of oral and maxillofacial fractures (OMF) between March 1 and June 30 in the years 2018 through 2020. The primary predictor variable was the evaluation of OMF during a period with social distancing policies (2020 – experimental group) or without social distancing policies in place (2018 or 2019 – control group). The primary outcome variables were the facial fracture diagnosis, the abbreviated injury scale (AIS), injury severity score (ISS), and the mechanism of injury. Appropriate univariate and bivariate statistics were computed, and the level of significance was set at P < .05 for all tests.

Results

The number of subjects presenting with OMF was lower during the period of social distancing (n = 235 in 2020) than during the periods without (2018: n = 330; 2019: n = 318). During the period of social distancing, there were more individuals who presented secondary to assault, whereas fewer individuals presented secondary to falls (P = .05). On average, those who presented in 2020 had more severe oral and maxillofacial injuries (mean AIS = 3.2 ± 1.2 in 2020 vs 3.0 ± 1.1 in 2019 and 3.0 ± 1.1 in 2018. P = .03) and more overall injuries (mean ISS = 20.7 ± 13.1 in 2020 vs 19.2 ± 12.5 in 2019; 17.8 ± 12.8 in 2018. P = .03).

Conclusions

The investigators found that during the period of social distancing through the COVID-19 pandemic, the number of OMF cases decreased but that the severity of oral and maxillofacial and overall injuries was higher.

National Disparities in Insurance Coverage of Comprehensive Craniomaxillofacial Trauma Care

Background:

Comprehensive craniomaxillofacial trauma care includes correcting functional deficits, addressing acquired deformities and appearance, and providing psychosocial support. The aim of this study was to characterize insurance coverage of surgical, medical, and psychosocial services indicated for longitudinal facial trauma care and highlight national discrepancies in policy.

Methods:

A cross-sectional analysis of insurance coverage was performed for treatment of common functional, appearance, and psychosocial facial trauma sequelae. Policies were scored for coverage (3), case-by-case coverage (2), no mention (1), and exclusion (0). The sum of points determined coverage scores for functional sequelae, acquired-appearance sequelae, and psychosocial sequelae, the sum of which generated a Comprehensive Coverage Score.

Results:

Medicaid earned lower comprehensive coverage scores and lower coverage scores for psychosocial sequelae than did private insurance (P = 0.02, P = 0.02). Medicaid CCSs were lowest in Oklahoma, Arkansas, and Missouri. Private insurance CCSs and psychosocial sequelae were highest in Colorado and Delaware, and lowest in Wisconsin. Coverage scores for functional sequelae and for acquired-appearance sequelae were similar for Medicaid and private policies. Medicaid coverage scores were higher in states that opted into Medicaid expansion (P = 0.04), states with Democrat governors (P = 0.02), states with mandated paid leave (P = 0.01), and states with >40% total population living >400% above federal poverty (P = 0.03). Medicaid comprehensive coverage scores and coverage scores for psychosocial sequelae were lower in southeastern states. Private insurance coverage scores for functional sequelae and for ASCSs were lower in the Midwest.

Conclusions:

Insurance disparities in comprehensive craniomaxillofacial care coverage exist, particularly for psychosocial services. The disparities correlate with current state-level geopolitics. There is a uniform need to address national and state-specific differences in coverage from both Medicaid and private insurance policies.

Substance Use and Maxillofacial Trauma: A Comprehensive Patient Profile

PURPOSE

Maxillofacial trauma confers an increased risk of long-term clinical sequelae with a substantial economic burden on the health care system. Substance use has long been correlated with an increased risk of trauma, yet to date, a comprehensive profile of substance users incurring facial fractures has not been established. We aimed to establish patterns and trends of substance use and specific substances in the setting of maxillofacial trauma.

PATIENTS AND METHODS

A retrospective chart review was conducted at our institution examining patients with maxillofacial fractures from 2016 to 2017. Information on age, gender, race, urine drug screen status, setting of presentation, mechanism of injury, trauma history, and injury severity was collected and examined for associations with particular substances.

RESULTS

We included 388 patients for analysis. Patients with positive urine drug screen results were significantly more likely to be men, present in an urban setting, incur poly-facial trauma, and have a history of facial trauma. In addition, alcohol use correlated significantly with injury severity in the context of polytrauma. Living in an urban setting and using phencyclidine were both significantly associated with a history of maxillofacial trauma.

CONCLUSIONS

Patients with comorbid maxillofacial trauma and substance use exhibit particular patterns in presentation and history. Establishing a profile for these patients allows for the development of prevention and rehabilitation programs.

The Healthcare Cost of Mandibular Nonunions

The aim of this retrospective cohort study was to compare the costs and characteristics between isolated mandible fractures and mandibular nonunions. From October 2015 to December 2016, the National Inpatient Sample (NIS) was searched for patients admitted with a primary diagnosis of a mandible fracture. The sample was divided between those admitted for an initial evaluation of an isolated fracture and a fracture nonunion. Demographic descriptors, injury characteristics, and inpatient factors were recorded. A total of 1432 patients were included in the final sample, of whom 51 (3.6%) were admitted for a nonunion. Nonunion patients were significantly older (P < 0.01), and nonunions were more often localized to the body (24 vs 11%; P = 0.02). Compared to that of isolated fractures, a greater proportion of nonunions required open reduction and internal fixation (86 vs 59%; P < 0.01) and bone grafting (37 vs 1.4%; P < 0.01), and nonunions imparted +32.6% greater hospitals costs (median: $10,680 vs 14,162; P < 0.01). In conclusion, compared to isolated mandible fractures, mandibular nonunions occurred in older patients, had a higher frequency in body of the mandible, and utilized significantly more hospital resources per admission.

The Characteristics and Cost of Le Fort Fractures: A Review of 519 Cases From a Nationwide Sample

PURPOSE

The aims were to report the characteristics of Le Fort fractures and to quantify the associated hospital costs.

MATERIALS AND METHODS

From October 2015 to December 2016, the National Inpatient Sample was searched for patients admitted with a primary diagnosis of a Le Fort fracture. Predictor variables were drawn from demographic, admission, and injury characteristics. The outcome variable was hospital cost. Summary statistics were calculated and compared among Le Fort patterns. Univariate comparisons and multivariate regression analyses were conducted to determine predictors associated with cost.

RESULTS

A total of 519 patients were identified in this cohort. Associated injuries included skull fractures (28%), intracranial hemorrhage (13%), cervical spine injury (9.8%), and concussion (9.1%). Seventy-three percent of patients received open reduction and internal fixation (ORIF) for their facial fractures during their admission, 13% received a tracheostomy, and 10% were mechanically ventilated for at least 1 day. The ventilation (P < .01) and tracheostomy (P < .01) rates increased with Le Fort complexity, as did length of stay (LOS; P < .01), costs (P < .01), and charges (P < .01). The mean costs of treating Le Fort I, II, and III fractures were $25,836, $28,415, and $47,333, respectively. Increased cost was independently associated with younger age, male gender, African-American ethnicity, Le Fort II and III patterns, motor vehicle accident etiology, mechanical ventilation requirement, tracheostomy, ORIF, transfer to an outside facility, and increased LOS.

CONCLUSIONS

The prevalence of head injuries and the need for respiratory support substantially increased with Le Fort complexity. Hospital costs were not markedly influenced by the diagnosis and management of associated injuries. Instead, costs were predominantly driven by fracture complexity and the need for necessary procedures, such as ORIF, tracheostomy, and mechanical ventilation.

What is the role of nutrition counseling in the management of isolated mandible fractures?

OBJECTIVE

Providing perioperative nutrition counseling may improve operative outcomes. It is unclear, however, whether this benefit translates to oral and maxillofacial surgery patients. The purpose of this study was to measure the effect of nutrition counseling on operative outcomes and patient satisfaction in those undergoing surgery for mandible fractures.

STUDY DESIGN

The investigators implemented a retrospective cohort study. The predictor variable was perioperative nutrition counseling by a registered dietitian (RD). The main outcome variables were weight change, postoperative complications, and results of a survey that evaluated the perioperative experience.

RESULTS

Statistical analyses were conducted on a sample of 200 patients (mean age: 34 ± 14 years; 87% males). Overall, there was no difference in percent weight change between those who received nutrition counseling and those who did not (P = .46). Those who received nutrition counseling had fewer postoperative complications (3% vs 11%; adjusted P = .038). Patients who received nutrition counseling from an RD were more satisfied with the nutrition advice they received (P = .0375).

CONCLUSIONS

The results suggest that perioperative nutrition counseling by an RD in the management of isolated mandible fractures has no effect on weight change but is associated with decreased postoperative complications and increased patient satisfaction with the nutrition advice they receive.

Retrospective analysis of postoperative interventions in mandibular fractures: a shift towards outpatient day surgery care

The management of fractured mandibles typically involves admission and operation at the time of presentation. While this should involve only a short stay in hospital these patients are surgically stable, and so priority is often given to more urgent cases. We retrospectively evaluated the postoperative medical requirements of patients who were operated on at Fiona Stanley Hospital, Perth, Western Australia between 1 January 2015 and 31 December 2016. Patients were excluded if they had had multiple facial fractures, multiple injuries, had fractures that were comminuted or in edentulous mandibles, and those who had been in hospital for preoperative medical investigations and care. We also excluded fractures in children aged 16 years and under. The results showed that of a total of 173 patients, 12 had had medical consultations during their hospital stay, and only four had required intervention. The mean (range) preoperative time was 37 (1 - 46) hours and that from operation to discharge 21.5 (2 - 93) hours. While traditional management involves emergency admission and open reduction and internal fixation as soon as possible, delays of up to five days were not associated with appreciably worse outcomes. This, together with the negligible requirements for medical management perioperatively, provides a strong argument for a selected group to be treated as outpatients.

Is Treating Oral and Maxillofacial Trauma Profitable? An Analysis of Hospital and Surgeon Reimbursement at an Academic Medical Center

PURPOSE

During the past 2 decades, there has been a marked decrease in the willingness of community-based oral and maxillofacial surgeons to participate in trauma call. Although many factors can influence the decision not to take trauma call, 1 primary disincentive is the perception that managing facial trauma might be profitable for the hospital, but not profitable for the surgeon. The purpose of this study was to compare the profitability of facial trauma management for the hospital and the surgeon at the Virginia Commonwealth University (VCU) Medical Center (Richmond, VA).

MATERIALS AND METHODS

In this retrospective cohort study, records were collected for patients who were seen for primary trauma management by the Department of Oral and Maxillofacial Surgery at VCU (VCUOMS) from June 2011 through July 2014. Cost and reimbursement data were analyzed for these patients from the VCU Health System (VCUHS) and the VCUOMS. For the hospital, actual cost data were provided; for the surgeon, cost was calculated based on an average overhead of 50%. For uniformity, patients were excluded if they remained in the hospital for longer than a 23-hour observation period. Patients younger than 18 years also were excluded.

RESULTS

In total, 169 patients met the inclusion criteria. There was a statistically relevant difference in the percentage of costs recouped and the actual profit. The average percentage of costs recouped was 230% for the VCUHS versus 47% for the VCUOMS. This amounts to an average profit per case of $3,461 for the hospital versus a loss of $1,162 for the surgeon.

CONCLUSIONS

The results of this study indicate that in the VCU Medical Center, maxillofacial trauma yields a net profit for the hospital and a net loss for the operating surgeon. Although the results are limited to outpatient management at 1 academic institution, they suggest that hospitals in some settings might be in a position to incentivize surgeons for trauma management.

Opportunity Cost of Surgical Management of Craniomaxillofacial Trauma

The provision of trauma care is a financial burden, continually associated with low reimbursement, and shifts the economic burden to major trauma centers and providers. Meanwhile, the volume of craniomaxillofacial (CMF) trauma and the number of surgically managed facial fractures are unchanged. Past financial analyses of cost and reimbursement for facial trauma are limited to mandibular and midface injuries, consistently revealing low reimbursement. The incurred financial burden also coincides with the changing landscape of health insurance. The goal of this study is to determine the opportunity cost of operative management of facial trauma at our institution. From our CMF database of greater than 3,000 facial fractures, the physician charges, collections, and relative value units (RVUs) for CMF trauma per year from 2007 to 2013 were compared with a general plastic surgery and otolaryngology population undergoing operative management during this same period. Collection rates were analyzed to assess if a significant difference exists between reimbursement for CMF and non-CMF cases. Results revealed a significant difference between the professional collection rate for operative CMF trauma and that for other operative procedures (17.25 vs. 29.61%, respectively; p < 0.0001). The average number of RVUs billed per provider for CMF trauma declines significantly, from greater than 700 RVUs to 300 over the study period, despite a stable volume. Surgical management of CMF trauma generates an unfavorable financial environment. The large opportunity cost associated with offering this service is a potential threat to the sustainability of providing care for this population.

Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice

Efficacy of prophylactic antibiotics in craniofacial fracture management is controversial. The purpose of this study was to compare evidence-based literature recommendations regarding antibiotic prophylaxis in facial fracture management with expert-based practice. A systematic review of the literature was performed to identify published studies evaluating pre-, peri-, and postoperative efficacy of antibiotics in facial fracture management by facial third. Study level of evidence was assessed according to the American Society of Plastic Surgery criteria, and graded practice recommendations were made based on these assessments. Expert opinions were garnered during the Advanced Orbital Surgery Symposium in the form of surveys evaluating senior surgeon clinical antibiotic prescribing practices by time point and facial third. A total of 44 studies addressing antibiotic prophylaxis and facial fracture management were identified. Overall, studies were of poor quality, precluding formal quantitative analysis. Studies supported the use of perioperative antibiotics in all facial thirds, and preoperative antibiotics in comminuted mandible fractures. Postoperative antibiotics were not supported in any facial third. Survey respondents (n = 17) cumulatively reported their antibiotic prescribing practices over 286 practice years and 24,012 facial fracture cases. Percentages of prescribers administering pre-, intra-, and postoperative antibiotics, respectively, by facial third were as follows: upper face 47.1, 94.1, 70.6; midface 47.1, 100, 70.6%; and mandible 68.8, 94.1, 64.7%. Preoperative but not postoperative antibiotic use is recommended for comminuted mandible fractures. Frequent use of pre- and postoperative antibiotics in upper and midface fractures is not supported by literature recommendations, but with low-level evidence. Higher level studies may better guide clinical antibiotic prescribing practices.

The Cost and Inpatient Burden of Treating Mandible Fractures

Objective

To discuss patient demographics, hospitalization characteristics, and costs associated with the treatment of mandible fractures.

Study Design

Cross-sectional study.

Setting

The 2009 Nationwide Inpatient Sample (NIS) database.

Subjects/Methods

Patient demographics, hospital characteristics, fracture locations, and common comorbidities for patients with isolated mandible fractures were analyzed, and variables associated with increased cost and length of hospitalization stay were ascertained.

Results

A total of 1481 patients were identified with isolated mandible fractures. The average age was 32, 85.4% were male, 39% were Caucasian, and 25% African American. Forty percent were from the lowest median household income quartile, and 77% were uninsured or government funded. The average length of stay (LOS) was 2.65 days, and average hospitalization cost was $35,804. A statistically significant increased LOS was associated with alcohol abuse, drug abuse, mental illness, diabetes mellitus type 2, cardiovascular disease, HIV, and age over 40. There was a statistically significant increased total cost associated with drug abuse, alcohol abuse, mental illness, cardiovascular disease, and age over 40.

Conclusion

The average cost for treatment of mandible fractures was $35,804 per person with increased expenditures for older patients and those with a history of mental illness, cardiovascular disease, or substance abuse. To improve outcomes and reduce hospital charges, outpatient resources and inpatient protocols should be implemented to address the factors we identified as contributing to higher costs and increased hospital stay.

Facial fracture management in northwest Nigeria

Background:

Facial fracture is gradually become a public health problem in our community due to the attendant morbidity and mortality. Hence, the aim of this study was to determine the pattern of facial fracture in Dental and Maxillofacial Surgery Department of Usmanu Danfodiyo University Teaching Hospital. This cross-sectional study was undertaken to provide information regarding gender, age, etiology, and diagnosis of patients with maxillofacial fractures.

Materials and Methods:

A 1-year review of patients diagnosed and treated for facial fractures in Usmanu Danfodiyo University Teaching Hospital between January 2011 and December 2011. The diagnosis was based on radiographic data and clinical examination. The main analysis outcome measures were etiology, age, gender, site, and treatment. Data were organized and presented by means of descriptive statistics and Pearson's Chi-square test. The level of significance adopted was 5%.

Results:

A total of 40 patients were treated in this period. Over 95% were male, 81% were caused by road traffic crash (RTC) and 86.4% were in the 21-30 years group. Most patients (52%) had mandibular fractures, and the most common site was the body. Most patients with midfacial fractures had fractures of the zygomaticomaxillary region (36%), while fractures of the parasymphyseal region were more common in the mandible 156 (31%). The most common treatment for jaw fractures was mandibulomaxillary fixation (MMF). Stable zygomatic complex fractures were reduced (elevated) intraorally, and unstable ones were supported by antral packs.

Conclusions:

This study highlights facial fractures secondary to RTC as a serious public health problem in our environment. Preventive strategies remain the cheapest way to reduce direct and indirect costs of the sequelae of RTC. It also bring to the fore the necessity to shift to open reduction and internal fixation (ORIF) of fractures.

The cause of cost in the management of odontogenic infections 1: a demographic survey and multivariate analysis

PURPOSE

The purpose of this retrospective cohort study was to describe the demographics of patients with odontogenic infections and to evaluate the costs associated with the demographic, social, treatment, and hospital course variables in patients hospitalized for odontogenic infections.

MATERIALS AND METHODS

A retrospective chart review was conducted in patients admitted for odontogenic infections at Harborview Medical Center from July 1, 2001, through June 30, 2011.

RESULTS

In total, 318 patient charts were reviewed and included. The unsponsored portion of the patient population increased from 14.7-61.9% over the course of the study. The average hospital bill per patient in this study was $17,053. Of the $5,422,854 billed, only $1,528,869 was received by the hospital in payment for services rendered, equating to $3,893,985 in lost potential revenue. The variables location of treatment, length of stay, length of stay in the intensive care unit, additional use of the operating room, and antibiotic regimen accounted for 90.2% of the variation in the hospital bill.

CONCLUSION

Unsponsored patients constituting 61.9% of the patient population represent an enormous challenge for hospitals and providers. To maintain the standard of care for all patients and still be able to provide care to patients without insurance, county hospitals and academic institutions must seek to improve cost efficiency. The present findings reinforce the need to be vigilant about the decision to admit, take to the operating room, admit to an intensive care unit, and discharge to lower the costs to the patient, hospital, and society for the management of odontogenic infections.