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Patterson JT, Cook SB, Firoozabadi R. Early hip survival after open reduction internal fixation of acetabular fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1209-1216. [PMID: 35536488 DOI: 10.1007/s00590-022-03273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/20/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To estimate survival of acetabular fracture repair by tracking patients across healthcare encounters. We hypothesized that hip survival estimated this way would be lower than reported by single-surgeon or single-center series not capturing censored reoperations. METHODS Retrospective health insurance administrative database cohort study. All claimed healthcare encounters for employer-sponsored health insurance beneficiaries aged 18-65 years without pre-existing hip pathology with a newly diagnosed acetabular fracture were identified between October 1, 2015, through December 31, 2018. The intervention was open reduction internal fixation of acetabular fracture during index admission. The primary outcome was survival of the acetabular fracture repair to subsequent reoperation by arthroscopy, arthrotomy for drainage of infection, implant removal, revision acetabular fixation, hip arthroplasty, hip resection, or arthrodesis. RESULTS 38 reoperation procedures on the fractured acetabulum in 852 patients occurred within 2 years (incidence 4.5%). Total hip arthroplasty (2.5%) and revision internal fixation (1.5%) accounted for most early reoperations. Multivariable Cox regression identified an association between reoperation and increasing patient age (hazard ratio = 1.4 per decade, p < 0.01). The prevalence of any mental health condition was 29%. CONCLUSIONS Non-elderly adults with employer-sponsored insurance who sustain acetabular fractures have a greater burden of mental health disease than similarly insured patients without these injuries. Survival of the native acetabulum after fracture fixation exceeded 95% at 2 years and decreased with increasing patient age. LEVEL OF EVIDENCE Level III, Prognostic Study.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, 90033-5322, USA.
| | - Sara B Cook
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, WA, USA
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA
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Minetos PD, Karamian BA, Kothari P, Jeyamohan H, Canseco JA, Patel PD, Thaete L, Singh A, Campbell D, Kaye ID, Woods BI, Kurd MF, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Impact of the Affordable Care Act on Insurance Status of Spine Patients Presenting to the Emergency Department. Am J Med Qual 2022; 37:207-213. [PMID: 34787591 DOI: 10.1097/jmq.0000000000000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P < 0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P < 0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P < 0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P < 0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.
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Affiliation(s)
- Paul D Minetos
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Obey MR, Clever DC, Bechtold DA, Stwalley D, McAndrew CM, Berkes MB, Wolinsky PR, Miller AN. In-Hospital Morbidity and Mortality With Delays in Femoral Shaft Fracture Fixation. J Orthop Trauma 2022; 36:239-245. [PMID: 34520446 PMCID: PMC8918437 DOI: 10.1097/bot.0000000000002271] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate trends in the timing of femur fracture fixation in trauma centers in the United States, identify predictors for delayed treatment, and analyze the association of timing of fixation with in-hospital morbidity and mortality using data from the National Trauma Data Bank. METHODS Patients with femoral shaft fractures treated from 2007 to 2015 were identified from the National Trauma Data Bank and grouped by timing of femur fixation: <24, 24-48 hours, and >48 hours after hospital presentation. The primary outcome measure was in-hospital postoperative mortality rate. Secondary outcomes included complication rates, hospital length of stay (LOS), days spent in the intensive care unit LOS (ICU LOS), and days on a ventilator. RESULTS Among the 108,825 unilateral femoral shaft fractures identified, 74.2% was fixed within 24 hours, 16.5% between 24 and 48 hours, and 9.4% >48 hours. The mortality rate was 1.6% overall for the group. When fixation was delayed >48 hours, patients were at risk of significantly higher mortality rate [odds ratio (OR) 3.60; 95% confidence interval (CI), 3.13-4.14], longer LOS (OR 2.14; CI 2.06-2.22), longer intensive care unit LOS (OR 3.92; CI 3.66-4.20), more days on a ventilator (OR 5.38; CI 4.89-5.91), and more postoperative complications (OR 2.05; CI 1.94-2.17; P < 0.0001). CONCLUSIONS Our study confirms that delayed fixation of femoral shaft fractures is associated with increased patient morbidity and mortality. Patients who underwent fixation >48 hours after presentation were at the greatest risk of increased morbidity and mortality. Although some patients require optimization/resuscitation before fracture fixation, efforts should be made to expedite operative fixation. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mitchel R. Obey
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
| | - David C. Clever
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
| | | | - Dustin Stwalley
- Center for Administrative Data Research, Washington University, St. Louis, MO
| | | | | | | | - Anna N. Miller
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
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Smithson KB, Parham SG, Mears SC, Siegel ER, Crawley L, Sachleben BC. Transfers of pediatric patients with isolated injuries to a rural Level 1 Orthopedic Trauma Center in the United States: are they all necessary? Arch Orthop Trauma Surg 2022; 142:625-631. [PMID: 33394179 DOI: 10.1007/s00402-020-03679-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/28/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Pediatric fractures are difficult to manage and often result in expensive urgent transfers to a pediatric trauma center. Our study seeks to identify patients transferred with isolated acute orthopedic injuries to a Level 1 center in which no procedure occurred and the patient was discharged home. We sought to examine all patients who are transferred to a Level 1 pediatric trauma center for care of isolated orthopedic injuries, and to determine how often no procedure is performed after transfer. Identification of this group ahead of time could potentially lead to less avoidable transfers. METHODS AND METHODS A retrospective chart review of all patients with isolated orthopaedic injuries who were transferred to a Level 1 pediatric trauma center in a rural state within the United States over a 5-year period beginning January, 2011 and ending December, 2015. Demographic factors were collected for each patient as well as diagnosis and treatment at the trauma center. Patients were divided into two groups, those who underwent an operation or fracture reduction after admission and those that had no procedure performed. Patient demographics, fracture types and presentation characteristics were examined to attempt to determine factors related to the potentially avoidable transfers. RESULTS 1303 patients were identified who were transferred with isolated orthopedic fractures. Of these, 1113 (85.6%) patients underwent a procedure for their injuries, including 821 treated with surgical intervention and 292 treated with closed reduction of their fracture. 190 of 1303 (14.6%) of the patients transferred with isolated injuries had neither surgery nor a reduction performed. Identifying characteristics of the non-operative group were that they contained a substantially higher percentage of females, transfers by ambulance, fractures involving only the tibia, fracture types classified as other, and fractures from motor-vehicle accidents. DISCUSSION Approximately 14.6% of patients transferred to a pediatric Level 1 trauma center for isolated orthopedic injury underwent no surgery or fracture reductions and were discharged directly home. In particular, isolated tibia fractures were more frequently treated without reduction or surgery. In the future, telemedicine consultation for these specific injury types may limit unnecessary and costly transfers to a Level 1 pediatric trauma hospital.
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Affiliation(s)
- Kaleb B Smithson
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Sean G Parham
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Simon C Mears
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA.
| | - Eric R Siegel
- Department of Biostatistics, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Lee Crawley
- Department of Pediatric Emergency Medicine, Arkansas Children's Hospital, 1 Children's Way, Slot 512-16, Little Rock, AR, 72032, USA
| | - Brant C Sachleben
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA.,General Surgery Unit3D, Arkansas Children's Hospital, ACH Sturgis Building, Floor 3, Little Rock, AR, 72202, USA
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The Curtis Hand Injury Matrix Score: Determining the Need for Specialized Upper Extremity Care. J Hand Surg Am 2022; 47:43-53.e4. [PMID: 34561135 DOI: 10.1016/j.jhsa.2021.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 05/24/2021] [Accepted: 07/28/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Given the limited impact of transfer guidelines and the lack of comparative metrics for upper extremity trauma, we introduced the Curtis Hand Injury Matrix (CHIM) score to evaluate upper extremity injury acuity from the specialist perspective. Our goal was to evaluate the CHIM score as an indicator of complexity and specialist need by correlating the score with arrival mode, length of stay (LOS), discharge disposition, and procedure location. METHODS We identified all hand and upper extremity emergency room visits at our institution in 2018 and 2019. On initial evaluation, our institution's hand surgery team assigned each patient an alphanumeric score with a number (1-5) and letter (A-H) corresponding to injury severity and pathology, respectively. Patients were divided into 5 groups (1-5) with lower scores indicating greater severity. We compared age, LOS, discharge disposition, procedure location, transfer status, and arrival mode between groups and assessed the relationships between matrix scores and discharge disposition, procedure performed, and LOS. RESULTS There were 3,822 patients that accounted for 4,026 upper extremity evaluations. There were significant differences in LOS, discharge dispositions, procedure locations, transfer status, and arrival modes between groups. Patients with more severe scores had higher rates of admission and more operating room procedures. Higher percentages of patients who arrived via helicopter, ambulance, or transfer had more severe scores. Patients with more severe scores were significantly more likely to have a procedure, hospital admission, and longer hospital stay. CONCLUSIONS The CHIM score provides a framework to catalog the care and resources required when covering specialized hand and upper extremity calls and accepting transfers. This clinical validation supports considering broader use. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Appropriateness of patients transferred with orthopedic injuries: experience of a level I trauma center. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:551-554. [DOI: 10.1007/s00590-018-2134-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/17/2018] [Indexed: 12/23/2022]
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Petkovic D, Wongworawat MD, Anderson SR. Factors Affecting Appropriateness of Interfacility Transfer for Hand Injuries. Hand (N Y) 2018; 13:108-113. [PMID: 29291655 PMCID: PMC5755853 DOI: 10.1177/1558944716675147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Transfers of patients with higher acuity injuries to trauma centers have helped improve care since the enactment of Emergency Medical Treatment and Active Labor Act. However, an unintended consequence is the inappropriate transfer of patients who do not truly require handover of care. METHODS We retrospectively reviewed the records of all patients transferred to our level I trauma center for injuries distal to the ulnohumeral joint between April 1, 2013, and March 31, 2014; 213 patients were included. We examined the records for appropriateness of transfer based on whether the patient required the care of the receiving hospital's attending surgeon (appropriate transfer) or whether junior-level residents treated the patient alone (inappropriate transfer) and calculated odds ratios. We performed logistic regression to identify factors associated with appropriateness of transfer; these factors included specialist evaluation prior to transfer, age, insurance status, race, injury type, sex, shift time, distance traveled, and median income. RESULTS The risk of inappropriate transfers was 68.5% (146/213). Specialist evaluation at the referring hospital was not associated with a lower risk of inappropriate transfers (odds ratio 1.62 [95% CI: 0.48-5.34], P = .383). Only evening shift (15:01 to 23:00) was associated with inappropriate transfers. Amputations and open fractures were associated with appropriate transfers. CONCLUSION Second shift and type of injury (namely, amputations and open fractures) were significant factors to appropriateness of transfer. No significant association was found between specialist evaluation and appropriate transfers. Future studies may focus on finding reasons and aligning incentives to minimize inappropriate transfers and associated systems costs.
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Affiliation(s)
- Djuro Petkovic
- Loma Linda University, CA, USA,Djuro Petkovic, Department of Orthopedic Surgery, Loma Linda University Medical Center, 11406 Loma Linda Drive, Suite 213, Loma Linda, CA 92354, USA.
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Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue. J Orthop Trauma 2016; 30:306-11. [PMID: 26741643 DOI: 10.1097/bot.0000000000000524] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay. DESIGN Prospective consecutive series. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0. INTERVENTION Femur, pelvis, or spine fractures treated surgically. MAIN OUTCOME MEASUREMENTS Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded. RESULTS Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days). CONCLUSIONS Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue. J Orthop Trauma 2016. [DOI: 10.1097/00005131-201606000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Aprato A, Joeris A, Tosto F, Kalampoki V, Stucchi A, Massè A. Direct and indirect costs of surgically treated pelvic fractures. Arch Orthop Trauma Surg 2016; 136:325-30. [PMID: 26660303 DOI: 10.1007/s00402-015-2373-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Pelvic fractures requiring surgical fixation are rare injuries but present a great societal impact in terms of disability, as well as economic resources. In the literature, there is no description of these costs. Main aim of this study is to describe the direct and indirect costs of these fractures. Secondary aims were to test if the type of fracture (pelvic ring injury or acetabular fracture) influences these costs (hospitalization, consultation, medication, physiotherapy sessions, job absenteeism). MATERIALS AND METHODS We performed a retrospective study on patients with surgically treated acetabular fractures or pelvic ring injuries. Medical records were reviewed in terms of demographic data, follow-up, diagnosis (according to Letournel and Tile classifications for acetabular and pelvic fractures, respectively) and type of surgical treatment. Patients were interviewed about hospitalization length, consultations after discharge, medications, physiotherapy sessions and absenteeism. RESULTS The study comprised 203 patients, with a mean age of 49.1 ± 15.6 years, who had undergone surgery for an acetabular fracture or pelvic ring injury. The median treatment costs were 29.425 Euros per patient. Sixty percent of the total costs were attributed to health-related work absence. Median costs (in Euros) were 2.767 for hospitalization from trauma to definitive surgery, 4.530 for surgery, 3.018 for hospitalization in the surgical unit, 1.693 for hospitalization in the rehabilitation unit, 1.920 for physiotherapy after discharge and 402 for consultations after discharge. Total costs for treating pelvic ring injuries were higher than for acetabular fractures, mainly due to the significant higher costs of pelvic injuries regarding hospitalization from trauma to definitive surgery (p < 0.001) and hospitalization in the surgical unit (p = 0.008). CONCLUSIONS Pelvic fractures are associated with both high direct costs and substantial productivity loss.
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Affiliation(s)
| | - Alexander Joeris
- Clinical Investigation and Documentation (C.I.D.) Department, AO Foundation, Dübendorf, Switzerland
| | | | - Vasiliki Kalampoki
- Clinical Investigation and Documentation (C.I.D.) Department, AO Foundation, Dübendorf, Switzerland
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