Cost-effectiveness analysis of open reduction/nonrigid fixation and open reduction/rigid fixation to treat mandibular fractures

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.

Comprehensive analysis of patients with failure of mandibular hardware

OBJECTIVE

The purpose of the study was to characterize patients who had failure of mandibular hardware (FMH).

STUDY DESIGN

This retrospective cohort study consisted of patients with mandible fractures (MFs) that required surgical intervention from 2012 to 2020. Patients were included when mandibular hardware failed. Descriptive variables were collected.

RESULTS

During the study period, 57 patients (47 male, average age 38.7 years) met the inclusion criteria. Incidence of FMH was 7.4%. Most patients were African American (n = 45, 78.9%) with American Society of Anesthesiologists classification II (n = 40, 70.2%). Tobacco use (n = 31, 54.4%) and/or alcohol (n = 33, 57.9%). The most common etiology was assault (n = 28, 49.1%). The most common location was the angle of the mandible. Most mandibles had fracture at 1 location (n = 31, 54.4%) and a tooth was involved in the fracture line (n = 44, 77.2%). More than half of patients were treated with transoral surgical approach (n = 35, 61.4%). The majority of patients received preoperative antibiotics (n = 51, 89.4%). Patients had varying levels of compliance with postoperative care, and most were not compliant. Infection (n = 45) was the most common presentation of FMH.

CONCLUSION

High American Society of Anesthesiologists score, smoking, excessive alcohol use, parafunctional habits, and compliance with postoperative instructions may affect surgical outcome.

Economic Evaluations Informed Exclusively by Real World Data: A Systematic Review

Economic evaluations using Real World Data (RWD) has been increasing in the very recent years, however, this source of information has several advantages and limitations. The aim of this review was to assess the quality of full economic evaluations (EE) developed using RWD. A systematic review was carried out through articles from the following databases: PubMed, Embase, Web of Science and Centre for Reviews and Dissemination. Included were studies that employed RWD for both costs and effectiveness. Methodological quality of the studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Of the 14,011 studies identified, 93 were included. Roughly half of the studies were carried out in a hospital setting. The most frequently assessed illnesses were neoplasms while the most evaluated interventions were pharmacological. The main source of costs and effects of RWD were information systems. The most frequent clinical outcome was survival. Some 47% of studies met at least 80% of CHEERS criteria. Studies were conducted with samples of 100-1000 patients or more, were randomized, and those that reported bias controls were those that fulfilled most CHEERS criteria. In conclusion, fewer than half the studies met 80% of the CHEERS checklist criteria.

Cost Analysis of Implants in the Surgical Repair of Orbital Floor Fractures

OBJECTIVE

Options for the management of orbital floor fractures continue to evolve offering both potential advantages as well as higher costs. To date, the effect of implant choice on the cost associated with the repair of orbital floor fractures has not been studied.

METHODS

A retrospective review at a tertiary care, level I trauma center examining all adult, uncomplicated orbital floor fractures that underwent open reduction and internal fixation from 2013 to 2016. Patients with concurrent operative facial fractures were excluded. The main outcomes were overall cost of care from injury to last follow-up and operating room-related costs. Costs were determined using computerized records of charges as well as the hospital Charge Description Master. Kruksal-Wallis rank sum tests were used to analyze for differences between groups.

RESULTS

Twenty-eight patients fulfilled the inclusion criteria. Eight different stock, non-patient specific, implants were used for repair. The cost of individual types of implants ranged from $70.25 to $7 718.00. Total cost of care per patient across all implant types averaged $35 585.57 (range $25 586.26 to $49 985.74, P = .34). Operation-related charges accounted for the vast majority (94.4%) of the total cost of care. One complication occurred requiring operative re-positioning of the implant with an additional $13 042.41 in charges.

CONCLUSIONS

In the setting of uncomplicated orbital floor fractures, surgeons should select an implant that allows them to carry out the repair in a safe, timely fashion. Additional large-scale studies would help to further delineate cost differences.

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.

Open Versus Closed Reduction of Maxillary Fractures: Complications and Resource Utilization

INTRODUCTION

Maxillary fractures are frequently managed depending on the surgeon's preferences, nature of the injury, presence of associated injuries, and comorbidities. Current literature advocates open reduction with plating versus closed techniques. However, data defining associated costs and complications comparing the 2 approaches remains lacking.

METHODS

National Inpatient Sample (2006-2011) was examined for patients undergoing closed or open (76.73-76.74) reduction of maxillary fractures. Treatment-related complications were regarded as re-exploration of surgical site, hemorrhage, hematoma, seroma, wound infection, and dehiscence.

RESULTS

Overall, 22,157 patients were identified. There were 18,874 closed and 3283 open procedures. Median age was 35 (interquartile range 27). Median length of stay (LOS) was 4 days. Median total charges were reported as 51486.80 USD. Males comprised 77% of the cohort. 68% of patients were Caucasian. Private payer/HMO accounted for the largest source of health care coverage (43.5%). On risk-adjusted multivariate analysis, there was no difference in surgical approach regarding incidence of postoperative complications. Males (2.73), nonprivate insurer payer (P = 0.002), South region (2.49), and transferred patients (2.55) had higher incidence of complications. Presence of chronic pulmonary disease (2.87) and coagulopathy (6.62) also increased risk of complications. Length of stay was shorter for open reduction (0.68) versus closed. Total charges were also less for open approach (0.37).

CONCLUSION

While surgical approach did not affect complications, open approach favorably affected LOS and total charges. Future studies should focus on comorbidities, demographics, and associated injuries in relation to resource utilization for maxillary fractures. In current economic environment, such information might further dictate management options.

Comparison of a 2.0-mm locking system with conventional 2.0- and 2.4-mm systems in the treatment of mandibular fractures: a randomized controlled trial

PURPOSE

A comparative study of the use of the 2.0-mm locking fixation system with conventional systems in the treatment of mandibular fractures was performed.

METHODS

For this study, 87 consecutive patients with 112 mandibular fractures were randomized to receive either 2.0-mm locking plates (n = 45) or conventional 2.0- or 2.4-mm plates (n = 42) and had a minimum follow-up of 6 months. Fractures were classified based on the degree of displacement and complexity. Statistical analyses were used to verify possible differences between the groups when separately compared unfavourable and favourable cases (p ≤ 0.050).

RESULTS

Despite randomization, systemic diseases were more frequent in the 2.0-mm locking group in favourable cases. Substance abuse occurred predominantly in the 2.0-mm locking group, in unfavourable and favourable fractures. There were more cases of complex fractures in the conventional group in unfavourable cases. One case involving a major postoperative complication occurred in the locking group (2.2%) and three cases occurred in the conventional group (7.1%) but with no significant difference between groups. In this study, there were no major differences between conventional and locking 2.0-mm locking systems with regard to the outcome of treated mandibular fractures, showing that both are adequate as long as the criteria of their indication and requirements for installation are met.

CONCLUSIONS

It was concluded that the 2.0-mm locking fixation system can replace conventional systems in the treatment of mandibular fractures; in addition, this approach was effective in the treatment of unfavourable fractures that typically require the 2.4-mm conventional system.

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.

Intraoral epimucosal fixation for reducible maxillary fractures of the jaws; surgical considerations in comparison to current techniques

Fractures of the jaw are often treated with rigid and stable internal fixation using plates or miniplates. Early surgery for jaw fractures is the optimal treatment; however, if a late treatment is begun, often the adoption of other protocols is needed. When the jaw fracture has one free bone fragment with 2 full-thickness lesions of mucoperiosteal soft tissues both on the buccal and palatal sides, the risk of resorption or necrosis is very high after elevating a mucoperiosteal flap for rigid fixation. For this reason, we developed an intraoral epimucosal fixation technique using self-locking screws and plates. Substantial advantages of this new technique, in comparison with other commonly used fixation techniques, consisted in the prevention of bone resorption or necrosis by safe and simple screw insertion procedure after manipulation of the fracture for reduction in closed surgery. Major indications for epimucosal fixation in closed surgery are the presence of jaw fractures without dislocation or reducible jaw fractures by manipulation particularly in edentulous patients.

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.

Comparison of intraoral and extraoral approaches to mandibular angle fracture repair with cost implications

OBJECTIVES/HYPOTHESIS

The objective of this study was to analyze outcomes of intraoral and extraoral approaches to mandibular angle fractures and provide cost estimates for comparison.

STUDY DESIGN

A retrospective review from January 2005 to June 2013 was performed of patients who underwent open reduction internal fixation of mandibular angle fractures at a level I trauma center.

METHODS

Patients were treated by three surgical specialties: otolaryngology-head and neck surgery, oral and maxillofacial surgery, and plastic and reconstructive surgery. Inpatient and outpatient medical records were reviewed for pertinent data including age, gender, duration of follow-up, presence of other mandible fractures, surgical approach, surgical team, operative time, and postoperative complications.

RESULTS

Of the 155 patients with mandibular angle fractures, 74% underwent open reduction internal fixation through an intraoral approach, whereas 26% of patients were treated with an extraoral approach. The occurrence of any complication was 69.6% in the extraoral group and 39% in the intraoral group (P = 0.009). In propensity-weighted analysis, however, the occurrence of any complication was less frequent in intraoral cases but no longer statistically significant (odd ratio 0.28; 95% confidence interval, 0.08 to 1.02; P = 0.053). Operating room time was significantly shorter with the intraoral approach. We estimate that the intraoral approach directly saves at least $2,900 per case.

CONCLUSION

We recommend the use of an intraoral approach for the repair of mandibular angle fractures when clinically appropriate. This can result in a comparable rate of success, however, with significant cost savings to the health care system.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:591-595, 2016.

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.

Mandibular fractures treated with small plates and screws reduce treatment cost

PURPOSE

The efficacy of treating mandibular fractures with open reduction and internal fixation (ORIF) using small titanium plates and monocortical screws is well established. The purpose of this study was to determine whether the use of semirigid (small) titanium plates results in lower treatment charges.

PATIENTS AND METHODS

Consecutive patients with mandibular fractures were randomly allocated to ORIF with small or large titanium plates. The primary predictor variable for this secondary subset analysis was plate size. The primary outcome variable was total treatment charges. Other outcomes included length of stay (LOS), operating room charges, hardware charges, LOS charge, and charges related to the treatment of complications.

RESULTS

A total of 127 consecutive patients were enrolled in the study. Fifty-two patients completed the required 6-week follow-up and had data available for analysis. Adjusted total treatment charges suggested a significant difference, with a mean total treatment charge of $15,308 in the semirigid group and a mean total treatment charge of $16,557 in the rigid group (P = .04). Total treatment charges were 8% higher in the rigid group compared with the semirigid group.

CONCLUSIONS

The findings of this study suggest that the overall charges associated with treating mandibular fractures with ORIF are significantly lower when semirigid plates are used.

Do the benefits of rigid internal fixation of mandible fractures justify the added costs? Results from a randomized controlled trial

PURPOSE

Owing to its putative advantages over conventional maxillomandibular fixation (MMF), open-reduction and rigid internal fixation (ORIF) is used frequently to treat mandible fractures, particularly in noncompliant patients. The resource-intensive nature of ORIF, the large variation in its use, and the lack of systematic studies substantiating ORIF attributed benefits compel a randomized controlled investigation comparing ORIF to MMF treatment. The objective of this study was to determine whether ORIF provides better clinical and functional outcomes than MMF in noncomplying type of patients with a similar range of mandible fracture severity.

PATIENTS AND METHODS

From a total of 336 patients who sought treatment for mandible fractures, 142 patients with moderately severe mandible fractures were assigned randomly to receive MMF or ORIF and followed prospectively for 12 months. A variety of clinician and patient-reported measures were used to assess outcomes at the 1, 6, and 12 months follow-up visits. These measures included clinician-reported number of surgical complications, patient-reported number of complaints, as well as cumulative costs of treatment. Pain intensity was measured on a 10-point scale and the 12-item General Oral Health Assessment Index was used to assess the patients' oral health-related quality of life. Because the protocol allowed clinical judgment to overrule the randomly assigned treatment, outcomes were compared on an "intent-to-treat" basis as well as in terms of actual treatment received.

RESULTS

The sociodemographic and clinical characteristics of the injury did not differ among the 2 groups. On an intent-to-treat basis, the difference in complication rates was not significant but favored MMF; 8.1% of patients developed complications with MMF versus 12.5% with ORIF. Differences in the rate of patient complaints were not significant on an intent-to-treat basis, but a significant between-group difference (P = .012) favoring MMF was noted on an as-treated basis at the 1 month recall, with 40% of ORIF patients reporting greater than 1 complaint versus 18.8% of MMF patients. No significant differences were detected between the 2 treatment groups at any time point with respect to oral health-related quality of life reflected by the General Oral Health Assessment Index scores. In-patient days and total costs did not differ significantly on an intent-to-treat basis, but on an as-treated basis, patients treated with MMF had fewer in-patient days on average (1.64 vs 5.50 for ORIF) and lower average costs of treatment ($7,206 vs $26,089 for ORIF). In the intent-to-treat analyses, patients receiving MMF treatment had significantly lower (P = .05) pain scores at the 12-month recall (mean = 0.58, SE = 0.30) compared with patients assigned to ORIF (mean = 1.78, SE = 0.52).

CONCLUSION

Our study did not show a clear overall benefit of the resource-intensive ORIF over conventional MMF treatment in the management of moderately severe mandible fractures in at-risk patients; our data instead suggest some cost as well as oral health quality-of-life advantages for the use of MMF in this patient population.

A financial analysis of operative facial fracture management

BACKGROUND

The financial impact of operative facial fracture management has not been systematically investigated. This study aims to provide a descriptive financial analysis of patients undergoing operative facial fracture management at a single academic medical center and the financial impact on the health system.

METHODS

The records of 202 patients who underwent operative facial fracture management over a 3-year period (2003 to 2005) were analyzed. All physician (professional) and hospital charges related to fracture management were included. Professional charges were subdivided by specialty and by payer type; hospital charges included operating room, recovery room, intensive care unit, hospital bed, supply charges, pharmaceuticals, laboratory charges, and radiographs. For comparison, similar data were obtained for the general plastic surgery population and for orthopedic surgery patients.

RESULTS

The sum of all professional charges billed was $2,478,234 (average, $12,268 per patient). Collections for these professional services totaled $675,434, yielding an overall reimbursement rate of 27 percent. Reimbursement rates ranged from 38 percent for critical care physicians to 24 percent for surgery and neuroradiology. The highest collection rates occurred in children covered by the State Children's Health Insurance Program and in prison inmates (53 percent and 99 percent, respectively). The lowest collection rates were obtained from uninsured patients (10 percent total billing over collections). Total hospital charges were $18,120,027 (average, $89,703 per patient); the total collections were $2,770,115 (15 percent reimbursement rate).

CONCLUSIONS

This study provides a descriptive financial analysis of operative facial fracture management. The unfavorable financial circumstances associated with facial trauma care may present a challenge to academic medical centers and plastic surgeons.

Cost-Effective Management of Isolated Facial Fractures

The purpose of this study was to evaluate the subset of costs incurred for surgical treatment of isolated midface and mandible fractures of patients admitted directly from the emergency department compared with those admitted as outpatients after evaluation and discharge from the emergency department. After institutional review board approval, the records of patients admitted to Wake Forest University Baptist Medical Center were studied retrospectively for patients who underwent surgical repair of an isolated facial fracture between July 1, 1999 and June 30, 2000. Patients were placed into one of two groups: admission from the emergency department versus admission as an out-patient. Total hospital charges were compared, and complications were evaluated. Mechanism of injury, age, and gender were recorded within each group. Forty-two patients met the study criteria. Twenty-eight patients were admitted directly from the emergency department (Group A), and 14 were admitted as outpatients after elective scheduling for operative repair (Group B). Operative charges based on utilization of time and materials showed no statistical significance between Group A (P = 0.275) and Group B (P = 0.393). Patients admitted directly from the emergency department had a mean hospital charge of 3,556.66 dollars higher (P< or = 0.001) and stayed 2 days longer in the hospital as compared with the outpatient group. No differences were noted in complications between the study groups. The results of this study reveal a significant decrease in cost for patients with isolated facial fractures admitted as outpatients on scheduling surgery as compared with immediate admission from the emergency department.

Cost-based analysis of the treatment of mandibular fractures in a tertiary care center

BACKGROUND

The objective of this study was to assess the cost effectiveness of alternative treatment algorithms for the management of isolated mandibular fractures.

METHODS

This is an institutional review board-approved retrospective study consisting of a chart review of 25 patients who underwent operative repair of an isolated mandible fracture between July 1, 1999, and June 30, 2000. Patients were stratified into two groups: patients who were immediately admitted to the hospital from the emergency department (ED) versus patients who were discharged from the ED and who returned for elective scheduled operative repair. Patients' total hospital charges were compared on the basis of operating room (OR) time, operative materials, and hospital charges.

RESULTS

Seventeen of the study patients were directly admitted from the ED, and eight underwent elective scheduled operative repair. Of the patients directly admitted from the ED, the mean age was 34.9 years (range, 19-57 years), and the study population consisted of 16 men and 1 woman. This group had a mean OR time of 161 minutes, a mean OR time charge of $1,978.66, a mean OR supply charge of 1,049.43 US dollars, a mean hospital floor charge of 5,041.02 US dollars, and an average hospital stay of 2.82 days. The treatment group of patients undergoing scheduled operative repair (n = 8) had a mean age of 30.3 years (range, 19-49 years), and all were men. This second treatment group had a mean OR time of 167.1 minutes, a mean OR time charge of 2,162.03 US dollars, a mean OR supply charge of 871.00 US dollars, a mean hospital floor charge of 2,759.38 US dollars, and a mean hospital stay of 0.88 days. Comparison of the two study groups demonstrated operative charges were made on the basis of time and materials and were shown to have no statistically significant difference (p = 0.753 and p = 0.289, respectively). Comparison of hospital charges revealed that patients admitted directly from the ED had a mean charge 2,276.70 US dollars higher (p = 0.019) and stayed 1.95 days longer in the hospital than patients discharged from the emergency department who returned for elective scheduled repair. There were two complications in the study patients; both occurred in the group admitted directly from the emergency room.

CONCLUSION

The results of this study indicate that the most cost-effective management of an isolated mandibular fracture is initial evaluation in the ED with elective interval operative repair. This management protocol is, of course, only applicable if the patient is clinically stable and has no other injuries or comorbidities necessitating in-hospital observation.

A financial analysis of maxillomandibular fixation versus rigid internal fixation for treatment of mandibular fractures

PURPOSE

The aim of this study was to compare the cost-effectiveness of mandibular fracture treatment by closed reduction with maxillomandibular fixation (CRF) with open reduction and rigid internal fixation (ORIF).

PATIENTS AND METHODS

This was a retrospective study of 85 patients admitted to the Oral and Maxillofacial Surgery Service at San Francisco General Hospital and treated for mandibular fractures from January 1 to December 31, 1993. The patients were divided into 2 groups: 1) those treated with CRF and 2) those treated with ORIF. The outcome variables were length of hospital stay, duration of anesthesia, and time in operating room. The charge for primary fracture treatment included the fees for the operation and hospitalization without any complications. Within the group of 85 patients treated for mandibular fractures in 1993, 10 patients treated with CRF and 10 patients treated with ORIF were randomly selected, and hospital billing statements were used to estimate the average charge of primary treatment. The average charge to manage a major postoperative infection also was estimated based on the billing statements of 10 randomly selected patients treated in 1992 (5 treated with CRF, 5 with ORIF) who required hospital admission for the management of a complication. The average total charge was computed by using the average charge for primary treatment plus the incidence of postoperative infection multiplied by the average charge for management of that complication.

RESULTS

Eighty-five patients were included in the study. The average charge for primary treatment was $10,100 for the CRF group and $28,362 for the ORIF group. The average charge for the inpatient management of a major postoperative infection was $26,671 for the CRF group and $39,213 for the ORIF group. The average total charge for management of a mandible fracture with CRF was $10,927; the total charge for the ORIF group was $34,636.

CONCLUSION

The results of this retrospective study suggest that the use of CRF in the management of mandibular fractures at our institution provides considerable savings over treatment by using ORIF. The use of ORIF should be reserved for patients and fracture types with specific indications.

Complication rates associated with different treatments for mandibular fractures

PURPOSE

This study compared the complication rate with different types of mandibular fracture treatment (maxillomandibular fixation, 2-mm miniplates, 2.4-mm AO plates, and 2.7-mm AO plates).

PATIENTS AND METHODS

A total of 245 patients who presented with 386 fractures were retrospectively analyzed. Patient characteristics, type of fracture, severity of fracture, type of treatment used, and occurrence of complications were recorded. Statistical analysis was used to compare complication rates, fracture severity, and type of treatment.

RESULTS

There were no differences in the complication rates for the different types of treatment. There was a significant correlation (P < .05) between fracture severity and the overall complication rate, postoperative infection, and postoperative malocclusion, but there was no significant correlation between these complications and the type of treatment applied.

CONCLUSION

The occurrence of postoperative complications in the treatment of mandibular fractures is fundamentally related to the severity of the fracture rather than to the type of treatment used.

Changes in charges and costs associated with hospitalization of patients with mandibular fractures between 1991 and 1993

PURPOSE

The purpose of the study was to examine the changes in costs, charges, and income related to hospitalization of patients with mandibular fractures treated over a 3-year period.

PATIENTS AND METHODS

The study involved retrospective analysis of data on 97 patients treated by the Department of Oral and Maxillofacial Surgery between 1991 and 1993. Biographical data were obtained from the Trauma Registry, and the financial data were obtained from the Financial Services Administration. The study examined the changes in costs and charges of hospitalization, insurance status, reimbursement, total revenue, and income losses from hospitalization of patients admitted with a primary diagnosis of mandibular fracture. In addition, the study examined the changes in costs of major items involved in treatment. Possible variables such as age, gender, and cause of fracture were also recorded.

RESULTS

Twenty-nine patients were admitted in 1991, 35 in 1992, and 33 in 1993. These patients were predominantly young males. The average cost of treatment decreased by 2% in 1992 and increased by 58% in 1993. The average charge increased by 12.9% in 1992 and by 76.8% in 1993. The total reimbursement increased by 11.2% in 1992 and by 47.7% in 1993. The average payment per patient to the institution by third-party payers decreased by 7.8% in 1992 and increased by 56.6% in 1993. The loss of income to the institution (cost minus reimbursement) increased by 105.9% in 1992 and by 58% in 1993. The average institution income loss from the care for each patient increased by 70.6% in 1992 and by 67.8% in 1993.

CONCLUSIONS

This study showed that there was a continued increase in costs, charges, and income loss for hospitalization of mandibular fracture patients during the years 1991 to 1993, whereas the reimbursement rate decreased from 65% to 47% of the charges. The increase in cost of supplies and use of rigid fixation, the increase in the number of uninsured patients, and the pricing practices of the institution were possible causes of these changes.