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1.
Eur J Orthop Surg Traumatol ; 34(5): 2773-2778, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-38771369

RESUMEN

PURPOSE: Determine if anterior internal versus supra-acetabular external fixation of unstable pelvic fractures is associated with care needs or discharge. METHODS: A retrospective cohort study was performed at two tertiary trauma referral centers. Adults with unstable pelvis fractures (AO/OTA 61B/61C) who received operative fixation of the anterior and posterior pelvic ring by two orthopedic trauma surgeons from October 2020 to November 2022 were included. The primary outcome was discharge destination. Secondary outcomes included intensive care unit (ICU) or ventilator days, length of stay, and hospital charges. RESULTS: Eighty-three eligible patients were 38.6% female, with a mean age of 47.2 ± 20.3 years and BMI 28.1 ± 6.4 kg/m2. Fifty-nine patients (71.1%) received anterior pelvis internal fixation and 24 (28.9%) received external fixation. External fixation was associated with weight-bearing restrictions (91.7% versus 49.2%, p = 0.01). No differences in demographic, functional status, insurance type, fracture classification, or injury severity measures were observed by treatment. Internal versus external anterior pelvic fixation was not associated with discharge to home (49.2% versus 29.2%, p = 0.10), median ICU days (3.0 [interquartile range (IQR) 7.8 versus 5.5 [IQR 4.3], p = 0.14, ventilator days (0 [IQR 6.0] versus 0 [IQR 2.8], p = 0.51), length of stay (13.0 [IQR 13.0] versus 17.5 (IQR 20.5), p = 0.38), or total hospital charges (US dollars 180,311 [IQR 219,061.75] versus 243,622 [IQR 187,111], p = 0.14). CONCLUSIONS: Anterior internal versus supra-acetabular external fixation of unstable pelvis fractures was not significantly associated with discharge destination, critical care, hospital length of stay, or hospital charges. This sample may be underpowered to detect differences between groups. LEVEL OF EVIDENCE: Therapeutic Level IV.


Asunto(s)
Cuidados Críticos , Fijación Interna de Fracturas , Fijación de Fractura , Fracturas Óseas , Precios de Hospital , Tiempo de Internación , Alta del Paciente , Huesos Pélvicos , Humanos , Femenino , Tiempo de Internación/estadística & datos numéricos , Persona de Mediana Edad , Masculino , Estudios Retrospectivos , Alta del Paciente/estadística & datos numéricos , Huesos Pélvicos/lesiones , Precios de Hospital/estadística & datos numéricos , Fracturas Óseas/cirugía , Fijación Interna de Fracturas/economía , Fijación Interna de Fracturas/métodos , Cuidados Críticos/economía , Cuidados Críticos/estadística & datos numéricos , Fijación de Fractura/métodos , Fijación de Fractura/economía , Adulto
2.
Injury ; 55(7): 111587, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-38761709

RESUMEN

AIM: to assess the small-scale 3D printing feasibility and cost estimation of a device for controlled dynamization. MATERIALS AND METHOD: The two-part device previously developed by our research group was printed with a carbon fiber-reinforced nylon filament (Gen3 CarbonX™ PA6+CF, 3DXTECH Additive Manufacturing) by a professional 3D printer (FUNMAT HT, Intamsys). Electricity, material, and labor costs for production in a Brazilian city in the Santa Catarina state were calculated. RESULTS: The devices for controlled dynamization were successfully printed in accordance with the planned design and dimensions. Six out of 38 printed devices presented defects in the bolt hole and were discarded. The average printing time per device was 1.9 h. The average electricity, material, and labor costs per printed device were respectively US$0.71, US$13.55, and US$3.04. The total production cost per device reaches approximately US$20 by adding the average cost of defective devices (15 %). CONCLUSION: 3D printing of the controlled dynamization device is feasible and its cost seems affordable to most healthcare services, which could optimize the consolidation of diaphyseal fractures and reduce treatment time for patients.


Asunto(s)
Estudios de Factibilidad , Impresión Tridimensional , Impresión Tridimensional/economía , Humanos , Diseño de Equipo , Fijadores Externos/economía , Fijación de Fractura/instrumentación , Fijación de Fractura/métodos , Fijación de Fractura/economía , Brasil , Fracturas Óseas/cirugía
3.
Bone Joint J ; 106-B(6): 623-630, 2024 06 01.
Artículo en Inglés | MEDLINE | ID: mdl-38821496

RESUMEN

Aims: The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius. Methods: A within-trial economic evaluation was conducted from the UK NHS and personal social services (PSS) perspective, as well as a broader societal point of view. Health resources and quality of life (the youth version of the EuroQol five-dimension questionnaire (EQ-5D-Y)) data were collected, as part of the Forearm Recovery in Children Evaluation (FORCE) multicentre randomized controlled trial over a six-week period, using trial case report forms and patient-completed questionnaires. Costs and health gains (quality-adjusted life years (QALYs)) were estimated for the two trial treatment groups. Regression was used to estimate the probability of the new treatment being cost-effective at a range of 'willingness-to-pay' thresholds, which reflect a range of costs per QALY at which governments are typically prepared to reimburse for treatment. Results: The offer of a soft bandage significantly reduced cost per patient (saving £12.55 (95% confidence interval (CI) -£5.30 to £19.80)) while QALYs were similar (QALY difference between groups: 0.0013 (95% CI -0.0004 to 0.003)). The high probability (95%) that offering a bandage is a cost-effective option was consistent when examining the data in a range of sensitivity analyses. Conclusion: In addition to the known clinical equivalence, this study found that the offer of a bandage reduced cost compared with rigid immobilization among children with a torus fracture of the distal radius. While the cost saving was small for each patient, the high frequency of these injuries indicates a significant saving across the healthcare system.


Asunto(s)
Análisis Costo-Beneficio , Alta del Paciente , Fracturas del Radio , Humanos , Niño , Fracturas del Radio/terapia , Fracturas del Radio/economía , Adolescente , Femenino , Masculino , Preescolar , Vendajes/economía , Años de Vida Ajustados por Calidad de Vida , Reino Unido , Inmovilización/métodos , Fijación de Fractura/economía , Fijación de Fractura/métodos , Calidad de Vida , Análisis de Costo-Efectividad
4.
Am Surg ; 89(11): 4521-4530, 2023 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-35981540

RESUMEN

OBJECTIVE: The objective of this study was to investigate if race is associated with the likelihood of operative management of acute fractures. METHODS: A systematic review of the literature was performed using the PubMed, EMBASE, and Cochrane databases to identify studies associated with social disparities and acute orthopedic trauma. Peer-reviewed studies commenting on social disparities and the decision to pursue operative or non-operative management of acute fractures were identified for detailed review. Study characteristics and odds ratios were extracted from each article. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. A quality analysis of the data was also performed. RESULTS: In total, 13 studies were identified and 8 were included in the meta-analysis totaling 743,846 fractures. Hip, distal radius, pelvic, tibial plateau, clavicle, femoral neck, and femoral shaft fractures were represented in this patient population. The meta-analysis demonstrated that White race is associated with a higher likelihood of operative intervention compared to all other races pooled together (odds ratio, 1.31; 95% confidence interval 1.16 to 1.47; p < .0001) as well as Black race (odds ratio 1.39; 95% confidence interval 1.12 to 1.72; p = .0025). CONCLUSIONS: Non-White race and Black race are associated with a lower likelihood of receiving surgical management of acute orthopedic trauma. Surgeons and health systems should be aware of these inequities and consider strategies to mitigate bias and ensure all patients receive appropriate and timely care regardless of race.


Asunto(s)
Fijación de Fractura , Fracturas Óseas , Disparidades en Atención de Salud , Humanos , Población Negra/estadística & datos numéricos , Fracturas del Fémur , Fijación de Fractura/economía , Fijación de Fractura/métodos , Fijación de Fractura/estadística & datos numéricos , Oportunidad Relativa , Población Blanca/estadística & datos numéricos , Disparidades en Atención de Salud/etnología , Disparidades en Atención de Salud/estadística & datos numéricos , Fracturas Óseas/economía , Fracturas Óseas/epidemiología , Fracturas Óseas/etnología , Fracturas Óseas/cirugía
5.
Am J Surg ; 223(1): 22-27, 2022 01.
Artículo en Inglés | MEDLINE | ID: mdl-34332746

RESUMEN

BACKGROUND: For-profit (FP) trauma centers (TCs) charge more for trauma care than not-for-profit (NFP) centers. We sought to determine charges, length of stay (LOS), and complications associations with TC ownership status (FP, NFP, and government) for three diagnoses among patients with overall low injury severity. METHODS: Adult patients treated at TCs with an International Classification of Diseases-based injury severity score (ICISS) survival probability ≥ 0.85 were identified. Only those who with a principal diagnosis of femur, tibial or rib fractures were included. RESULTS: Total charges were significantly higher at FP centers than NFP and lower at government centers (89.6% and -12.8%, respectively). FP TCs had a 12.5% longer LOS and government TCs had a 20.4% longer LOS than NFP TCs. CONCLUSION: Patients presenting to FP TCs with mild/moderate femur, tibial, or rib fractures experienced higher charges and increased LOS compared with government or NFP centers. There was no difference in overall complication rates.


Asunto(s)
Fijación de Fractura/economía , Fracturas Óseas/cirugía , Propiedad/economía , Complicaciones Posoperatorias/epidemiología , Centros Traumatológicos/estadística & datos numéricos , Adolescente , Adulto , Femenino , Fijación de Fractura/efectos adversos , Fijación de Fractura/estadística & datos numéricos , Fracturas Óseas/diagnóstico , Fracturas Óseas/economía , Programas de Gobierno/economía , Programas de Gobierno/estadística & datos numéricos , Precios de Hospital/estadística & datos numéricos , Hospitales Privados/economía , Hospitales Privados/estadística & datos numéricos , Hospitales Públicos/economía , Hospitales Públicos/estadística & datos numéricos , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/etiología , Centros Traumatológicos/economía , Centros Traumatológicos/organización & administración , Adulto Joven
6.
Bone Joint J ; 103-B(7): 1277-1283, 2021 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-34192942

RESUMEN

AIMS: The aim of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was to determine the optimal treatment for adults with a bicortical undisplaced or minimally displaced fracture of the waist of the scaphoid, comparing early surgical fixation with initial cast immobilization, with immediate fixation being offered to patients with nonunion. METHODS: A cost-effectiveness analysis was conducted to assess the relative merits of these forms of treatment. The differences in costs to the healthcare system and quality-adjusted life years (QALYs) of the patients over the one-year follow-up of the trial in the two treatment arms were estimated using regression analysis. RESULTS: Our base case analysis found that patients randomized to early surgical fixation had statistically significantly higher mean costs to the NHS of £1,295 more than for the cast immobilization arm (p < 0.001), primarily due to the cost of surgery. They also had a marginally better quality of life, over the period, of 0.0158 QALYs; however, this was not statistically significant (p = 0.379). The mean combined cost per additional QALY was £81,962, well above the accepted threshold for cost-effectiveness used in the UK and internationally. The probability of early surgery being cost-effective in this setting was only 5.6%. CONCLUSION: Consistent with the clinical findings of SWIFFT, these results indicate that initial cast immobilization of minimally displaced scaphoid fractures, with immediate fixation only offered to patients with nonunion, is the optimal form of treatment, resulting in comparable outcomes with less cost to the healthcare system. Cite this article: Bone Joint J 2021;103-B(7):1277-1283.


Asunto(s)
Moldes Quirúrgicos , Análisis Costo-Beneficio , Fijación de Fractura/economía , Fijación de Fractura/métodos , Fracturas Óseas/terapia , Años de Vida Ajustados por Calidad de Vida , Hueso Escafoides/lesiones , Adulto , Anciano , Femenino , Fracturas Óseas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Reino Unido
7.
Bone Joint J ; 103-B(2): 271-278, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-33517719

RESUMEN

AIMS: Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare surgical wait times, mortality, length of stay (LOS), and healthcare costs for similar hip fracture patients evaluated with and without preoperative echocardiograms. METHODS: A population-based, matched cohort study of all hip fracture patients (aged over 45 years) in Ontario, Canada between 2009 and 2014 was conducted. The primary exposure was preoperative echocardiography (occurring between hospital admission and surgery). Mortality rates, surgical wait times, postoperative LOS, and medical costs (expressed as 2013$ CAN) up to one year postoperatively were assessed after propensity-score matching. RESULTS: A total of 2,354 of 42,230 (5.6%) eligible hip fracture patients received a preoperative echocardiogram during the study period. Echocardiography ordering practices varied among hospitals, ranging from 0% to 23.0% of hip fracture patients at different hospital sites. After successfully matching 2,298 (97.6%) patients, echocardiography was associated with significantly increased risks of mortality at 90 days (20.1% vs 16.8%; p = 0.004) and one year (32.9% vs 27.8%; p < 0.001), but not at 30 days (11.4% vs 9.8%; p = 0.084). Patients with echocardiography also had a mean increased delay from presentation to surgery (68.80 hours (SD 44.23) vs 39.69 hours (SD 27.09); p < 0.001), total LOS (19.49 days (SD 25.39) vs 15.94 days (SD 22.48); p < 0.001), and total healthcare costs at one year ($51,714.69 (SD 54,675.28) vs $41,861.47 (SD 50,854.12); p < 0.001). CONCLUSION: Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality at 90 days and one year but not at 30 days. Preoperative echocardiography is also associated with increased surgical delay, postoperative LOS, and total healthcare costs at one year. Echocardiography should be considered an urgent test when ordered to prevent additional surgical delay. Cite this article: Bone Joint J 2021;103-B(2):271-278.


Asunto(s)
Ecocardiografía , Fijación de Fractura , Cardiopatías/diagnóstico por imagen , Fracturas de Cadera/cirugía , Cuidados Preoperatorios/métodos , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Ecocardiografía/economía , Femenino , Estudios de Seguimiento , Fijación de Fractura/economía , Cardiopatías/complicaciones , Fracturas de Cadera/complicaciones , Fracturas de Cadera/economía , Fracturas de Cadera/mortalidad , Costos de Hospital/estadística & datos numéricos , Humanos , Tiempo de Internación/economía , Modelos Logísticos , Masculino , Persona de Mediana Edad , Ontario , Cuidados Preoperatorios/economía , Puntaje de Propensión , Medición de Riesgo , Tiempo de Tratamiento
8.
J Trauma Acute Care Surg ; 90(3): 451-458, 2021 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-33559982

RESUMEN

BACKGROUND: Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest. METHODS: This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios. RESULTS: Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest. CONCLUSIONS: Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study. LEVEL OF EVIDENCE: Economic/decision, level II.


Asunto(s)
Tórax Paradójico/complicaciones , Tórax Paradójico/cirugía , Fijación de Fractura/economía , Fracturas de las Costillas/complicaciones , Fracturas de las Costillas/cirugía , Factores de Edad , Anciano , Análisis Costo-Beneficio , Femenino , Tórax Paradójico/economía , Humanos , Tiempo de Internación , Masculino , Cadenas de Markov , Persona de Mediana Edad , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos , Fracturas de las Costillas/economía , Sensibilidad y Especificidad , Resultado del Tratamiento
9.
Clin Orthop Relat Res ; 479(1): 9-16, 2021 01 01.
Artículo en Inglés | MEDLINE | ID: mdl-32833925

RESUMEN

BACKGROUND: Critical access hospitals (CAHs) play an important role in providing access to care for many patients in rural communities. Prior studies have shown that these facilities are able to provide timely and quality care for patients who undergo various elective and emergency general surgical procedures. However, little is known about the quality and reimbursement of surgical care for patients undergoing surgery for hip fractures at CAHs compared with non-CAH facilities. QUESTIONS/PURPOSES: Are there any differences in 90-day complications, readmissions, mortality, and Medicare payments between patients undergoing surgery for hip fractures at CAHs and those undergoing surgery at non-CAHs? METHODS: The 2005 to 2014 Medicare 100% Standard Analytical Files were queried using ICD-9 procedure codes to identify Medicare-eligible beneficiaries undergoing open reduction and internal fixation (79.15, 79.35, and 78.55), hemiarthroplasty (81.52), and THA (81.51) for isolated closed hip fractures. This database was selected because the claims capture inpatient diagnoses, procedures, charged amounts and paid claims, as well as hospital-level information of the care, of Medicare patients across the nation. Patients with concurrent fixation of an upper extremity, lower extremity, and/or polytrauma were excluded from the study to ensure an isolated cohort of hip fractures was captured. The study cohort was divided into two groups based on where the surgery took place: CAHs and non-CAHs. A 1:1 propensity score match, adjusting for baseline demographics (age, gender, Census Bureau-designated region, and Elixhauser comorbidity index), clinical characteristics (fixation type and time to surgery), and hospital characteristics (whether the hospital was located in a rural ZIP code, the average annual procedure volume of the operating facility, hospital bed size, hospital ownership and teaching status), was used to control for the presence of baseline differences in patients presenting at CAHs and those presenting at non-CAHs. A total of 1,467,482 patients with hip fractures were included, 29,058 of whom underwent surgery in a CAH. After propensity score matching, each cohort (CAH and non-CAH) contained 29,058 patients. Multivariate logistic regression analyses were used to assess for differences in 90-day complications, readmissions, and mortality between the two matched cohorts. As funding policies of CAHs are regulated by Medicare, an evaluation of costs-of-care (by using Medicare payments as a proxy) was conducted. Generalized linear regression modeling was used to assess the 90-day Medicare payments among patients undergoing surgery in a CAH, while controlling for differences in baseline demographics and clinical characteristics. RESULTS: Patients undergoing surgery for hip fractures were less likely to experience many serious complications at a critical access hospital (CAH) than at a non-CAH. In particular, after controlling for patient demographics, hospital-level factors and procedural characteristics, patients treated at a CAH were less likely to experience: myocardial infarction (3% (916 of 29,058) versus 4% (1126 of 29,058); OR 0.80 [95% CI 0.74 to 0.88]; p < 0.001), sepsis (3% (765 of 29,058) versus 4% (1084 of 29,058); OR 0.69 [95% CI 0.63 to 0.78]; p < 0.001), acute renal failure (6% (1605 of 29,058) versus 8% (2353 of 29,058); OR 0.65 [95% CI 0.61 to 0.69]; p < 0.001), and Clostridium difficile infections (1% (367 of 29,058) versus 2% (473 of 29,058); OR 0.77 [95% CI 0.67 to 0.88]; p < 0.001) than undergoing surgery in a non-CAH. CAHs also had lower rates of all-cause 90-day readmissions (18% (5133 of 29,058) versus 20% (5931 of 29,058); OR 0.83 [95% CI 0.79 to 0.86]; p < 0.001) and 90-day mortality (4% (1273 of 29,058) versus 5% (1437 of 29,058); OR 0.88 [95% CI 0.82 to 0.95]; p = 0.001) than non-CAHs. Further, CAHs also had risk-adjusted lower 90-day Medicare payments than non-CAHs (USD 800, standard error 89; p < 0.001). CONCLUSION: Patients who received hip fracture surgical care at CAHs had a lower risk of major medical and surgical complications than those who had surgery at non-CAHs, even though Medicare reimbursements were lower as well. Although there may be some degree of patient selection at CAHs, these facilities appear to provide high-value care to rural communities. These findings provide evidence for policymakers evaluating the impact of the CAH program and allocating funding resources, as well as for community members seeking emergent care at local CAH facilities. LEVEL OF EVIDENCE: Level III, therapeutic study.


Asunto(s)
Fijación de Fractura/normas , Accesibilidad a los Servicios de Salud/normas , Fracturas de Cadera/cirugía , Hospitales/normas , Indicadores de Calidad de la Atención de Salud/normas , Servicios de Salud Rural/normas , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Fijación de Fractura/efectos adversos , Fijación de Fractura/economía , Fijación de Fractura/mortalidad , Costos de la Atención en Salud/normas , Accesibilidad a los Servicios de Salud/economía , Fracturas de Cadera/diagnóstico por imagen , Fracturas de Cadera/economía , Fracturas de Cadera/mortalidad , Humanos , Reembolso de Seguro de Salud/normas , Masculino , Medicare/economía , Medicare/normas , Persona de Mediana Edad , Readmisión del Paciente , Complicaciones Posoperatorias/mortalidad , Indicadores de Calidad de la Atención de Salud/economía , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Servicios de Salud Rural/economía , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos
10.
PLoS One ; 15(10): e0240377, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33031472

RESUMEN

AIM: To investigate the cost-effectiveness of Volar Locking Plate (VLP) compared to External Fixation (EF) for unstable dorsally displaced distal radius fractures in a 3-year perspective. METHODS: During 2009-2013, patients aged 50-74 years with an unstable dorsally displaced distal radius fracture were randomised to VLP or EF. Primary outcome was the incremental cost-effectiveness ratio (ICER) for VLP compared with EF. Data regarding health effects (Quality-adjusted life years, QALYs) was prospectively collected during the trial period until 3 years after surgery. Cost data was collected retrospectively for the same time period and included direct and indirect costs (production loss). RESULTS: One hundred and thirteen patients (VLP n = 58, EF n = 55) had complete data until 3 years and were used in the analysis. At one year, the VLP group had a mean incremental cost of 878 euros and a gain of 0.020 QALYs compared with the EF group, rendering an ICER of 43 900 euros per QALY. At three years, the VLP group had a mean incremental cost of 1 082 euros and a negative incremental effect of -0.005 QALYs compared to the EF group, which means that VLP was dominated by EF. The probability that VLP was cost-effective compared to EF at three years, was lower than 50% independent of the willingness to pay per QALY. CONCLUSION: Three years after distal radius fracture surgery, VLP fixation resulted in higher costs and a smaller effect in QALYs compared to EF. Our results indicate that it is uncertain if VLP is a cost-effective treatment of unstable distal radius fractures compared to EF.


Asunto(s)
Análisis Costo-Beneficio , Fijación de Fractura/economía , Fracturas del Radio/cirugía , Anciano , Placas Óseas , Fijadores Externos , Femenino , Estudios de Seguimiento , Fijación de Fractura/métodos , Humanos , Persona de Mediana Edad , Años de Vida Ajustados por Calidad de Vida , Estudios Retrospectivos
11.
J Bone Joint Surg Am ; 102(23): 2049-2059, 2020 Dec 02.
Artículo en Inglés | MEDLINE | ID: mdl-32947595

RESUMEN

BACKGROUND: The purpose of the present study was to estimate the cost-effectiveness of treating displaced, intra-articular distal radial fractures with volar locking plate fixation compared with augmented external fixation. METHODS: A cost-utility analysis was conducted alongside a randomized, clinical trial comparing 2 surgical interventions for intra-articular distal radial fractures. One hundred and sixty-six patients were allocated to either volar locking plate fixation (84 patients) or external fixation (82 patients) and were followed for 2 years. Health-related quality of life was assessed with the EuroQol-5 Dimensions and was used to calculate patients' quality-adjusted life-years (QALYs). Resource use was identified prospectively at the patient level at all follow-up intervals. Costs were estimated with use of both a health-care perspective and a societal perspective. Results were expressed in incremental cost-effectiveness ratios, and uncertainty was assessed with use of bootstrapping methods. RESULTS: The average QALY value was equivalent between the groups (1.70463 for the volar locking plate group and 1.70726 for the external fixation group, yielding a nonsignificant difference of -0.00263 QALY). Health-care costs were equal between the groups, with a nonsignificant difference of &OV0556;52 (p = 0.8) in favor of external fixation. However, the external fixation group had a higher loss of productivity due to absence from work (5.5 weeks in the volar locking plate group compared with 9.2 weeks for the external fixation group; p = 0.02). Consequently, the societal costs were higher for the external fixation group compared with the volar locking plate group (&OV0556;18,037 compared with &OV0556;12,567, representing a difference of &OV0556;5,470; p = 0.04) in favor of the volar locking plate group. Uncertainty analyses showed that there is indifference regarding which method to recommend from a health-care perspective, with volar locking plate treatment and external fixation having a 47% and 53% likelihood of being cost-effective, respectively. From the societal perspective, volar locking plate treatment had a 90% likelihood of being cost-effective. CONCLUSIONS: External fixation was less cost-effective than volar locking plate treatment for distal radial fractures from a societal perspective, primarily because patients managed with external fixation had a longer absence from work. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.


Asunto(s)
Placas Óseas/economía , Fijación de Fractura/economía , Fracturas del Radio/economía , Traumatismos de la Muñeca/economía , Análisis Costo-Beneficio , Fijadores Externos/economía , Femenino , Fijación de Fractura/métodos , Costos de la Atención en Salud , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Fracturas del Radio/cirugía , Traumatismos de la Muñeca/cirugía
12.
J Orthop Surg Res ; 15(1): 247, 2020 Jul 06.
Artículo en Inglés | MEDLINE | ID: mdl-32631381

RESUMEN

BACKGROUND: External fixation improves open fracture management in emerging countries. However, sophisticated models are often expensive and unavailable. We assessed the biomechanical properties of a low-cost external fixation system in comparison with the Hoffmann® 3 system, as a reference. METHODS: Transversal, oblique, and comminuted fractures were created in the diaphysis of tibia sawbones. Six external fixators were tested in three modes of loading-axial compression, medio-lateral (ML) bending, and torsion-in order to determine construction stiffness. The fixator construct implies two uniplanar (UUEF1, UUEF2) depending the pin-rods fixation system and two biplanar (UBEF1, UBEF2) designs based on different bar to bar connections. The designed low-cost fixators were compared to a Hoffmann® 3 fixator single rod (H3-SR) and double rod (H3-DR). Twenty-seven constructs were stabilized with UUEF1, UUEF2, and H3-SR (nine constructs each). Nine constructs were stabilized with UBEF1, UBEF2, and H3-DR (three constructs each). RESULTS: UUEF2 was significantly stiffer than H3-SR (p < 0.001) in axial compression for oblique fractures and UUEF1 was significantly stiffer than H3-SR (p = 0.009) in ML bending for transversal fractures. Both UUEFs were significantly stiffer than H3-SR in axial compression and torsion (p < 0.05), and inferior to H3-SR in ML bending, for comminuted fractures. In the same fracture pattern, UBEFs were significantly stiffer than H3-DR (p = 0.001) in axial compression and torsion, while only UBEF1 was significantly stiffer than H3-DR in ML bending (p = 0.013). CONCLUSIONS: The results demonstrated that the stiffness of the UUEF and UBEF device compares to the reference fixator and may be helpful in maintaining fracture reduction. Fatigue testing and clinical assessment must be conducted to ensure that the objective of bone healing is achievable with such low-cost devices.


Asunto(s)
Ahorro de Costo/economía , Diáfisis/lesiones , Fijadores Externos/economía , Fijación de Fractura/economía , Fijación de Fractura/instrumentación , Fijación de Fractura/métodos , Fracturas Conminutas/cirugía , Tibia/lesiones , Fracturas de la Tibia/cirugía , Fenómenos Biomecánicos , Diseño de Equipo , Curación de Fractura , Humanos , Ensayo de Materiales , Modelos Anatómicos
13.
J Surg Res ; 252: 183-191, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32278973

RESUMEN

BACKGROUND: Timing of surgical treatment of facial fractures may vary with the patient age, injury type, and presence of polytrauma. Previous studies using national data sets have suggested that trauma patients with government insurance experience fewer operations, longer length of hospital stay (LOS), and worse outcomes compared with privately insured patients. The objective of this study is to compare treatment of facial fractures in patients with and without Medicaid insurance (excluding Medicare). METHODS: All adults with mandibular, orbital, and midface fractures at a Level 1 Trauma Center between 2009 and 2018 were included. Statistical analyses were performed to assess the differences in the frequency of surgery, time to surgery (TTS), LOS, and mortality based on insurance type. RESULTS: The sample included 1541 patients with facial fractures (mandible, midface, orbital), of whom 78.8% were male, and 13.1% (208) were enrolled in Medicaid. Mechanism of injury was predominantly assault for Medicaid enrollees and falls or motor vehicle accidents for non-Medicaid enrollees (P < 0.001). Patients with mandible and midface fractures underwent similar rates of surgical repair. Medicaid enrollees with orbital fractures underwent less frequent surgery for facial fractures (24.8% versus 34.7%, P = 0.0443) and had higher rates of alcohol and drug intoxication compared with non-Medicaid enrollees (42.8% versus 31.6%, P = 0.008). TTS, LOS, and mortality were similar in both groups with facial fractures. CONCLUSIONS: Overall, the treatment of facial fractures was similar regardless of the insurance type, but Medicaid enrollees with orbital fractures experienced less frequent surgery for facial fractures. Further studies are needed to identify specific socioeconomic and geographic factors contributing to these disparities in care.


Asunto(s)
Fijación de Fractura/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Fracturas Orbitales/cirugía , Centros Traumatológicos/estadística & datos numéricos , Adulto , Intoxicación Alcohólica/epidemiología , Comorbilidad , Femenino , Fijación de Fractura/economía , Mortalidad Hospitalaria , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Massachusetts/epidemiología , Persona de Mediana Edad , Fracturas Orbitales/economía , Fracturas Orbitales/mortalidad , Estudios Retrospectivos , Tiempo de Tratamiento/economía , Tiempo de Tratamiento/estadística & datos numéricos , Centros Traumatológicos/economía , Estados Unidos
14.
J Am Acad Orthop Surg ; 28(18): 772-779, 2020 Sep 15.
Artículo en Inglés | MEDLINE | ID: mdl-31996608

RESUMEN

INTRODUCTION: It is unclear whether cost-based decisions to improve the value of surgical care (quality:cost ratio) affect patient outcomes. Our hypothesis was that surgeon-directed reductions in surgical costs for tibial plateau fracture fixation would result in similar patient outcomes, thus improving treatment value. METHODS: This was a prospective observational study with retrospective control data. Surgically treated tibial plateau fractures from 2013 to October 2014 served as a control (group 1). Material costs for each case were calculated. Practices were modified to remove allegedly unnecessary costs. Next, cost data were collected on similar patients from November 2014 through 2015 (group 2). Costs were compared between groups, analyzing partial articular and complete articular fractures separately. Minimum follow-up (f/u) was 1-year. Outcomes data collected include Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference domains, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog pain scale, infection, nonunion, unplanned return to surgery, demographics, injury characteristics, and comorbidities. RESULTS: Group 1 included 57 partial articular fractures and 57 complete articular fractures. Group 2 included 37 partial articular fractures and 32 complete articular fractures. Median cost of partial articular fractures decreased from $1,706 to $1,447 (P = 0.025), and median cost of complete articular fractures decreased from $2,681 to $2,220 (P = 0.003). Group 1 had 55 patients who consented to clinical f/u, and group 2 had 39. Median PROMIS PF score was 40 for group 1 and was 43 for group 2 (P = 0.23). There were no significant differences between the groups for any clinical outcomes, demographics, injury characteristics, or comorbidities. Median f/u in group 1 was 31 months compared with 15 months in group 2 (P < 0.0001). DISCUSSION: We have demonstrated that surgeons can improve value of surgical care by reducing surgical costs while maintaining clinical outcomes.


Asunto(s)
Ahorro de Costo , Fijación de Fractura/economía , Fijación de Fractura/métodos , Cirujanos Ortopédicos/economía , Pautas de la Práctica en Medicina/economía , Pautas de la Práctica en Medicina/normas , Calidad de la Atención de Salud/economía , Fracturas de la Tibia/economía , Fracturas de la Tibia/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del Tratamiento
15.
J Foot Ankle Surg ; 59(3): 502-506, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-31685364

RESUMEN

Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p < .001), myocardial infarction (0.9% versus 1.8%; p = .005), acute renal failure (2.2% versus 5.3%; p < .001), urinary tract infections (7.4% versus 12.3%; p < .001), and pressure ulcers (0.9% versus 2.0%; p = .001). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%; p < .001) and emergency department visits (13.8% versus 16.2%; p = .028). Last, overall 90-day costs for outpatient ankle fractures were nearly $9000 lower than costs for inpatient ankle fractures ($12,923 versus $21,866; p < .001). Based on our findings, it appears that outpatient treatment of ankle fractures can be deemed safe and feasible in a select cohort of patients.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/economía , Fracturas de Tobillo/cirugía , Fijación de Fractura/economía , Costos de la Atención en Salud , Hospitalización/economía , Complicaciones Posoperatorias/epidemiología , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Femenino , Fijación de Fractura/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
16.
J Am Acad Orthop Surg ; 28(9): 377-382, 2020 May 01.
Artículo en Inglés | MEDLINE | ID: mdl-31305356

RESUMEN

OBJECTIVE: In the current healthcare environment, providing cost-efficient care is of paramount importance. One emerging strategy is to use community hospitals (CHs) rather than tertiary care hospitals (TCHs) for some procedures. This study assesses the costs of performing closed reduction percutaneous pinning (CRPP) of pediatric supracondylar humerus fractures (SCHFs) at a CH compared with a TCH. METHODS: A retrospective review of 133 consecutive SCHFs treated with CRPP at a CH versus a TCH over a 6-year period was performed. Total encounter and subcategorized costs were compared between the procedures done at a CH versus those done at a TCH. RESULTS: Performing CRPP for a SCHF at a CH compared with a TCH saved 44% in costs (P < 0.001). Cost reduction of 51% was attributable to operating room costs, 19% to anesthesia-related costs, 16% to imaging-related costs, and 7% to supplies. DISCUSSION: Performing CRPP for a SCHF at a CH compared with a TCH results in a 44% decrease in direct cost, driven largely by surgical, anesthesia, and radiology-related savings.


Asunto(s)
Costos y Análisis de Costo , Fijación de Fractura/economía , Hospitales Comunitarios , Fracturas del Húmero/economía , Fracturas del Húmero/cirugía , Centros de Atención Terciaria , Niño , Preescolar , Femenino , Fijación de Fractura/métodos , Humanos , Masculino
17.
J Surg Res ; 246: 123-130, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31569034

RESUMEN

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.


Asunto(s)
Organizaciones Responsables por la Atención/estadística & datos numéricos , Fijación de Fractura/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Fracturas de la Columna Vertebral/cirugía , Organizaciones Responsables por la Atención/economía , Anciano , Anciano de 80 o más Años , Ahorro de Costo/economía , Ahorro de Costo/estadística & datos numéricos , Etnicidad , Femenino , Fijación de Fractura/efectos adversos , Fijación de Fractura/economía , Gastos en Salud/estadística & datos numéricos , Disparidades en Atención de Salud/organización & administración , Mortalidad Hospitalaria , Humanos , Masculino , Medicare/economía , Medicare/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad/estadística & datos numéricos , Grupos Raciales/estadística & datos numéricos , Factores Socioeconómicos , Fracturas de la Columna Vertebral/economía , Estados Unidos/epidemiología
19.
Clin Orthop Relat Res ; 477(12): 2620-2628, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31764322

RESUMEN

BACKGROUND: Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate. QUESTIONS/PURPOSES: (1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time? METHODS: A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios. RESULTS: After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001). CONCLUSIONS: We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance-as well as among men and white patients compared with women and patients of color-may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient's insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics. LEVEL OF EVIDENCE: Level III, therapeutic study.


Asunto(s)
Clavícula/lesiones , Fijación de Fractura/economía , Fracturas Óseas/cirugía , Disparidades en Atención de Salud/economía , Cobertura del Seguro/economía , Adulto , Anciano , Clavícula/cirugía , Femenino , Estudios de Seguimiento , Fracturas Óseas/economía , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores Socioeconómicos , Estados Unidos , Adulto Joven
20.
J Orthop Trauma ; 33 Suppl 7: S11-S15, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31596778

RESUMEN

There is increasing recognition of both the impact and value of trauma care in low- and middle-income countries (LMICs). However, data supporting the value of musculoskeletal trauma care specifically are lacking. This review discusses methods of economic analysis relevant to low-resource settings and provides a review of cost studies related to orthopaedic trauma care in these settings. In general, microcosting methods are preferred in LMICs because of the lack of databases with aggregate cost data. It is important that studies use a societal perspective that includes the indirect costs of treatment in addition to direct costs of medical care. Cost-effectiveness studies most commonly report cost per disability-adjusted life year, particularly in LMICs, but quality-adjusted life years are an acceptable alternative that is based on more empiric data. There are solid economic data supporting potential cost savings and improved outcomes with intramedullary nailing for femoral shaft fractures. Trauma care hospitals and educational initiatives have also been found to be highly cost-effective. However, very little data exist to support other interventions in orthopaedic trauma. Orthopaedic surgeons should strive to understand these methodologies and support the conduct of rigorous economic analysis to better establish the value of musculoskeletal trauma care in LMICs.


Asunto(s)
Países en Desarrollo , Fijación de Fractura/economía , Fracturas Óseas/terapia , Pobreza , Análisis Costo-Beneficio , Fracturas Óseas/economía , Humanos
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