Lactic acid levels are associated with morbidity, length of stay, and total treatment costs in urban trauma patients with lower extremity long bone fractures.

INTRODUCTION: Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population. METHODS: Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression. RESULTS: A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0 years old, with patients remaining hospitalized for 8.8 ± 9.5 days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008). CONCLUSION: High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone. LEVEL OF EVIDENCE: III.

Geriatric Distal Femur Fractures Treated with Arthroplasty Are Associated with Lower Mortality but Greater Costs Compared with Open Reduction and Internal Fixation at 30 Days.

Distal femur fractures (DFFs) are common injuries with significant morbidity. Surgical options include open reduction and internal fixation (ORIF) with plates and/or intramedullary devices or a distal femur endoprosthesis (distal femur replacement [DFR]). A paucity of studies exist that compare the two modalities. The present study utilized a 1:2 propensity score match to compare 30-day outcomes of geriatric patients with DFFs who underwent an ORIF or DFR. The National Surgical Quality Improvement Program data from 2008 to 2019 were utilized to identify all patients who sustained a DFF and underwent either ORIF or DFR. This yielded 3,197 patients who underwent an ORIF versus 121 patients who underwent a DFR. A final sample of 363 patients (242 patients with ORIF vs. 121 with DFR) was obtained after a 1:2 propensity score match. Costs were obtained from the National Inpatient Sample database using multiple regression analysis and validated with a 7:3 train-test algorithm. Independent samples t-tests and chi-square analysis were conducted to assess cost and outcome differences, respectively. Patients who received a DFR had higher transfusion rates than ORIF (p = 0.021) and higher mean inpatient hospital costs (p = 0.001). Subgroup analysis for patients 80 years of age or older revealed higher 30-day unplanned readmission (0 vs. 18.2%; p < 0.001) and 30-day mortality (0 vs. 18.2%; p < 0.001) rates for patients undergoing ORIF compared with DFR. The total number of DFR cases needed to prevent one ORIF-related 30-day mortality for DFR for patients 80 years of age was 6 (95% confidence interval: 3.02-19.9). The mean hospital costs associated with preventing one case of death within 30 days from operation by undergoing DFR compared with ORIF was $176,021.39. Our results demonstrate higher rates of transfusion and increased inpatient costs among the DFR cohort compared with ORIF. However, we demonstrate lower rates of mortality for patients 80 years and older who underwent DFR versus ORIF. Future studies randomized controlled trials are necessary to validate the results of this study.

The clinical and economic burden of proximal femur periprosthetic fractures.

BACKGROUND: The number of hip replacements is constantly and progressively increasing, resulting in an increase in periprosthetic fractures. The main aim of this study is to analyze costs and outcomes of surgical treatment for those fractures. MATERIALS AND METHODS: A retrospective study was performed on periprosthetic proximal femur fracture presented a single-level I trauma center. Medical records were reviewed in terms of demographic data, diagnosis (according to Vancouver classification), type of surgical treatment, hospitalization length and follow-up. Patients were interviewed about number of consultations after discharge, medications and physiotherapy sessions. Clinical outcome was evaluated with WOMAC score at the last follow-up, and patient health status was evaluated with the EQ5D5L score pre-trauma and at the last follow-up. Patients were divided into two groups according to surgical treatment: reduction and internal fixation alone and revision plus fixation. A further group was also considered: patients underwent a Girdlestone procedure. Global costs for each group were calculated. RESULTS: We initially recruited 117 patients, 17 of them were lost at follow-up. Furthermore, 19 patients (19%) died during the follow-up, and 81 of them were therefore included in the study. Mean follow-up was 26.5 months. Mean postoperative WOMAC score was 39.44, and EQ5D5L score was 9.12 for the preoperative period and 12.35 at the last follow-up. A significant worsening of clinical conditions was found comparing the period before fracture to the last follow-up (p < 0.01). Quality of life after surgery resulted to be poor or fair in 40% of the patients at a mean follow-up of 26.5 months. No significant differences between groups were found according to patients' health status. Mean global costs for mayor surgeries were 18,822 Euros; mean costs for fixation alone were 17,298 Euros while for fixation and revision were 20,966 Euros, but no statistically difference was found between these two groups. Mean cost for Girdlestone group was 12,664 Euros. CONCLUSIONS: In proximal femur periprosthetic fractures, either fixation or revision plus fixation presents high costs but patients' postoperative quality of life is poor.

Definitive surgical femur fracture fixation in Northern Tanzania: implications of cost, payment method and payment status.

INTRODUCTION: Kilimanjaro Christian Medical Centre (KCMC) covers major orthopaedic trauma for a catchment population of 12.5 million people in northern Tanzania. Femur fractures, the most common traumatic orthopaedic injury at KCMC (39%), require open reduction and internal fixation (ORIF) for definitive treatment. It is unclear whether payment affects care. This study sought to explore associations of payment method with episodes of care for femur fracture ORIFs at KCMC. METHODS: we performed a retrospective review of orthopaedic records between February 2018 and July 2018. Patients with femur fracture ORIF were eligible; patients without charts were excluded. Ethical clearance was obtained from the KCMC ethics committee. Statistical analysis utilized descriptive statistics, Chi-squared and Fisher's exact Tests, and Student´s t-tests where appropriate. RESULTS: of 76 included patients, 17% (n=13) were insured, 83% (n=63) paid out-of-pocket, 11% (n=8) had unpaid balance, and 89% (n=68) fully paid. Average patient charge ($417) was 42% of per capita GDP ($998). Uninsured patients had higher bills ($429 vs $356; p=0.27) and were significantly more likely to pay an advance payment (95.2% vs 7.7%; p<0.001). Inpatient care was equivalent regardless of payment. Unpaid patients were less likely to receive follow-up (76.5% vs. 25%; p=0.006) and waited longer from injury to admission (31.5 vs 13.3 days; p<0.001), from admission to surgery (30.1 vs 11.1 days; p<0.001), and from surgery to discharge (18.4 vs 7.1 days; p<0.001). CONCLUSION: equal standard of care is provided to all patients. However, future efforts may decrease disparities in advance payment, timeliness, and follow-up.

The burden of femoral shaft fractures in Tanzania.

BACKGROUND: Road traffic injuries disproportionately affect low- and middle-income countries (LMICs) and are associated with femur fractures that lead to long-term disability. Information about these injuries is crucial for appropriate healthcare resource allocation. The purpose of this study is to estimate the incidence of femoral shaft fractures in Tanzania and describe the unmet surgical burden. METHODS: Study sites included six government hospitals across Tanzania. Investigators collected data from hospital admission and procedural logbooks to estimate femoral shaft fracture incidence and their treatment methods. Semi-quantitative interviews were conducted with relevant hospital personnel to validate estimates obtained from hospital records. Investigators gathered road traffic incident (RTI) statistics from national police reports and calculated femur fracture:RTI ratios. RESULTS: Femoral shaft fracture annual incidence rate ranged from 2.1 to 18.4 per 100,000 people. Median low and high femur fracture:RTI ratio were 0.54 and 0.73, respectively. At smaller hospitals, many patients (5-25%) were treated with traction, and a majority (70-90%) are referred to other centers. Barriers to surgery at each hospital include a lack of surgical implants, equipment, and personnel. CONCLUSIONS: The incidence rate is similar to previous estimations, and it is consistent with an increased femoral shaft fracture incidence in Tanzania when compared to higher income countries. The femur fracture:RTI ratio may be a valid tool for estimating femur fracture incidence rates. There is an unmet orthopaedic surgical burden for femur fractures treatment at rural hospitals in Tanzania, and the barriers to treatment could be targets for future interventions.

The Cost of Intramedullary Nailing Versus Skeletal Traction for Treatment of Femoral Shaft Fractures in Malawi: A Prospective Economic Analysis.

BACKGROUND: In many low- and middle-income countries, non-surgical management of femoral shaft fractures using skeletal traction is common because intramedullary (IM) nailing is perceived to be expensive. This study assessed the cost of IM nailing and skeletal traction for treatment of femoral shaft fractures in Malawi. METHODS: We used micro-costing methods to quantify the costs associated with IM nailing and skeletal traction. Adult patients who sustained an isolated closed femur shaft fracture and managed at Queen Elizabeth Central Hospital in Malawi were followed from admission to discharge. Resource utilization and time data were collected through direct observation. Costs were quantified for procedures and ward personnel, medications, investigations, surgical implants, disposable supplies, procedures instruments and overhead. RESULTS: We followed 38 nailing and 27 traction patients admitted between April 2016 and November 2017. Nailing patient's average length of stay (LOS) was 36.35 days (SD 21.19), compared to 61 (SD 18.16) for traction (p = 0.0003). The total cost per patient was $596.97 ($168.81) for nailing and $678.02 (SD $144.25) for traction (p = 0.02). Major cost drivers were ward personnel and overhead; both are directly proportional to LOS. Converting patients from traction to nailing is cost-saving up to day 23 post-admission. CONCLUSION: Savings from IM nailing as compared with skeletal traction were achieved by shortened LOS. Although this study did not assess the effectiveness of either intervention, the literature suggests that traction carries a higher rate of complications than nailing. Investment in IM nailing capacity may yield substantial net savings to health systems, as well as improved clinical outcomes.

Developing Research to Change Policy: Design of a Multicenter Cost-Effectiveness Analysis Comparing Intramedullary Nailing to Skeletal Traction in Malawi.

INTRODUCTION: The purpose of our study is to prospectively evaluate the cost effectiveness of intramedullary nailing compared with skeletal traction in a resource-limited setting where traction remains the most common definitive treatment. METHODS: This multicenter, prospective multicenter investigation was conducted in Malawi at 2 central hospitals and 3 district hospitals. The project was divided into phases. In phase 1, the EuroQol-5D and SMFA were translated and validated in Chichewa. In phase 2, adult patents with OTA/AO 32 femur shaft fractures were prospectively enrolled, and a comparison of quality of life and functional status was made. In phase 3, a cost-effectiveness analysis was performed between those treated with intramedullary nail and those treated with skeletal traction. CONCLUSION: This study serves as an example of an economic study in orthopaedic surgery conducted in a resource-poor environment through academic collaboration.

The Socioeconomic Implications of Isolated Tibial and Femoral Fractures from Road Traffic Injuries in Uganda.

BACKGROUND: The purpose of this study was to determine the socioeconomic implications of isolated tibial and femoral fractures caused by road traffic injuries in Uganda. METHODS: This prospective longitudinal study included adult patients who were admitted to Uganda's national referral hospital with an isolated tibial or femoral fracture. The primary outcome was the time to recovery following injury. We assessed recovery using 4 domains: income, employment status, health-related quality of life (HRQoL) recovery, and school attendance of the patients' dependents. RESULTS: The majority of the study participants (83%) were employed, and they were the main income earner for their household (74.0%) at the time of injury, earning a mean annual income of 2,375 U.S. dollars (USD). All of the patients had been admitted with the intention of surgical treatment; however, because of resource constraints, only 56% received operative treatment. By 2 years postinjury, only 63% of the participants had returned to work, and 34% had returned to their previous income level. Overall, the mean monthly income was 62% less than preinjury earnings, and participants had accumulated 1,069 USD in debt since the injury; 41% of the participants had regained HRQoL scores near their baseline, and 62% of school-aged dependents, enrolled at the time of injury, were in school at 2 years postinjury. CONCLUSIONS: At 2 years postinjury, only 12% of our cohort of Ugandan patients who had sustained an isolated tibial or femoral fracture from a road traffic injury had recovered both economically and physically. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Relationship between socioeconomic status and mortality after femur fracture in a Korean population aged 65 years and older: Nationwide retrospective cohort study.

Femur fracture is an emerging public health concern in aging societies, owing to the substantially high morbidity and mortality. Because the recent increase in femur fracture incidence in Asian populations is comparable to that in the West, it is necessary to investigate the association between socioeconomic status (SES) and mortality after femur fracture in developed Asian societies.Data were obtained from the National Health Insurance Claims Database. During 2002 to 2013, femur fractures were newly diagnosed in 5441 patients among 1025,340 enrollees. Multiple logistic regression and the Cox proportional model were used to investigate the associations between individual SES and probability of surgery and mortality after femur fracture.Of 5441 patients, 1928 (35.4%) received surgery. Patients with low (odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.75-0.99) and middle (OR = 0.85, 95% CI: 0.74-0.98) income were less likely to undergo surgery than high-income patients. Patients with low (hazard ratio [HR] = 1.12, 95% CI: 1.01-1.24) and middle (HR = 1.20, 95% CI: 1.08-1.33) income had a higher HR for mortality. This difference was more prominent in patients who underwent surgery (low income: HR = 1.07, 95% CI: 0.94-1.21; middle income: HR = 1.18, 95% CI: 1.04-1.33) than in patients with conservative treatment (low income: HR = 1.24, 95% CI: 1.04-1.49; middle income: HR = 1.30, 95% CI: 1.08-1.56).Femur-fracture patients with low SES are less likely to receive surgery for and more likely to die after femur fracture. The difference in mortality risk remained even when only the patients who received surgery were considered, suggesting that we need to consider support measures for these deprived patients.

Association of Osteoporosis Self-Assessment Tool for Asians (OSTA) Score with Clinical Presentation and Expenditure in Hospitalized Trauma Patients with Femoral Fractures.

Background: A cross-sectional study to investigate the association of Osteoporosis Self-Assessment Tool for Asians (OSTA) score with clinical presentation and expenditure of hospitalized adult trauma patients with femoral fractures. Methods: According to the data retrieved from the Trauma Registry System between 1 January 2009 and 31 December 2015, a total of 2086 patients aged ≥40 years and hospitalized for treatment of traumatic femoral bone fracture were categorized as high-risk patients (OSTA < -4, n = 814), medium-risk patients (-1 ≥ OSTA ≥ -4, n = 634), and low-risk patients (OSTA > -1, n = 638). Two-sided Pearson's, chi-squared, or Fisher's exact tests were used to compare categorical data. Unpaired Student's t-test and Mann-Whitney U-test were used to analyze normally and non-normally distributed continuous data, respectively. Propensity-score matching in a 1:1 ratio was performed using Number Crunching Statistical Software (NCSS) software (NCSS 10; NCSS Statistical Software, Kaysville, UT, USA), with adjusted covariates including mechanism and Glasgow Coma Scale (GCS); injuries were assessed based on the Abbreviated Injury Scale (AIS), and Injury Severity Score (ISS) was used to evaluate the effect of OSTA-related grouping on a patient's outcome. Results: High-risk and medium-risk patients were predominantly female, presented with significantly older age and higher incidences of co-morbidity, and were injured in a fall accident more frequently than low-risk patients. High-risk patients and medium-risk patients had a different pattern of femoral fracture and a significantly lower ISS. Although high-risk and medium-risk patients had significantly shorter lengths hospital of stay (LOS) and less total expenditure than low-risk patients did, similar results were not found in the selected propensity score-matched patients, implying that the difference may be attributed to the associated injury severity of the patients with femoral fracture. However, the charge of surgery is significantly lower in high-risk and medium-risk patients than in low-risk patients, regardless of the total population or the selected propensity score-matched patients. This lower charge of surgery may be attributed to a less aggressive surgery applied for older patients with high or medium risk of osteoporosis. Conclusions: This study of hospitalized trauma patients with femoral fracture according to OSTA risk classification revealed that high-risk and medium-risk patients had significantly higher odds of sustaining injury in a fall accident than low-risk patients; they also present a different pattern of femoral bone fracture as well as a significantly lower ISS, shorter hospital LOS, and less total expenditure. In addition, the significantly lower charge of surgery in high-risk and medium-risk patients than in low-risk patients may be because of the preference of orthopedists for less aggressive surgery in dealing with older patients with osteoporotic femoral bone fracture.

Algorithm for the management of femoral shaft fractures in children.

PURPOSE: Pediatric closed femoral shaft fractures are commonly related to a good prognosis. There is no consensus on treatment. We aimed to evaluate the treatment, features, radiological findings and management strategies, creating an algorithm of treatment. MATERIALS AND METHODS: Fifty-two simple femoral shaft fractures in children were retrospectively evaluated for age and gender distribution, side of the fracture, etiology of injuries, limb length discrepancy, range of knee and hip motion and parents satisfaction with a mean clinical and radiographic follow-up of 3 years and 6 months. Twenty-eight patients were treated with reduction and early hip spica cast while 24 patients were treated with external fixation (EF). RESULTS: Nearly 58 % of the cases were caused by traffic accidents and were predominantly male (61.5 %). Most of the fractures were of the middle femoral shaft (57.6 %). Muscle strength was normal (MRC scale) in all patients with no pain (NIPS and PRS scale). Knee and Hip range of motion were similar in both types of treatment. Patients treated with EF had shorter limb length discrepancy compared with SC. There were no reports of re-fracture. We found a higher familiar satisfaction in patients treated with EF. CONCLUSIONS: An algorithm for the management of femoral shaft fractures in the pediatric population is proposed. Results on the study population gave raise to a satisfactory clinical and radiological results.

Cost effectiveness of using surgery versus skeletal traction in management of femoral shaft fractures at Thika level 5 hospital, Kenya.

INTRODUCTION: A prospective quasi experimental study was undertaken at the Thika level 5 hospital. The study aimed to compare the costs of managing femoral shaft fracture by surgery as compared to skeletal traction. METHODS: Sixty nine (46.6%) patients were enrolled in group A and managed surgically by intramedullary nailing while 79 (53.4%) patients were enrolled in group B and managed by skeletal traction. Exclusion criteria included patients with pathological fractures and previous femoral fractures. Data was collected by evaluation of patients in patient bills using a standardized questionnaire. The questionnaire included cost of haematological and radiological tests, bed fees, theatre fees and physiotherapy costs. The data was compiled and analyzed using SPSS version 16. Person's chi square and odds ratios were used to measure associations and risk analysis respectively. RESULTS: A higher proportion of patients (88.4%) in group A were hospitalized for less than one month compared to 20 patients (30.4%) in group B (p, 0.001).Total cost of treatment in group A was significantly lower than in group B. Nineteen (27.9%) patients who underwent surgery paid a total bill of Ksh 5000-7500 compared to 7(10.4%) who were treated by traction. The financial cost benefit of surgery was further complimented by better functional outcomes. CONCLUSION: The data indicates a cost advantage of managing femoral shaft fracture by surgery compared to traction. Furthermore the longer hospital stay in the traction group is associated with more malunion, limb deformity and shortening.

Early femur fracture fixation is associated with a reduction in pulmonary complications and hospital charges: a decade of experience with 1,376 diaphyseal femur fractures.

BACKGROUND: Early fixation (<24 hour) of femur fractures with an intramedullary nail (IMN) has been associated with a decreased incidence of pulmonary complication (PC) in stable trauma patients. Early fixation is in accordance with the "two-hit" hypothesis, that is, an increase in proinflammatory markers during Days 3 to 5 after injury, increases the risk of developing a PC. We hypothesized that early IMN fixation of femur fractures would be associated with a decreased incidence of PC, hospital stay, and overall charges. METHODS: A retrospective review of all trauma patients with diaphyseal femur fractures was performed from January 2000 through December 2010 at an academic Level 1 trauma center. The cohort was divided into those who underwent early fixation (<24 hours) and delayed fixation (≥24 hours). Multivariable logistic regression modeling was used to adjust for the anatomic (Injury Severity Score [ISS]) and physiologic (Revised Trauma Score [RTS]) severity of injury. The primary outcome of interest was PC, defined as the presence of pneumonia (PNA), pulmonary embolism, or adult respiratory distress syndrome. Continuous variables are expressed as mean (SD). The analysis was repeated for patients with an ISS of greater than 15 and an ISS of greater than 25. RESULTS: During the study period, 1,755 patients were admitted with a diaphyseal femur fracture, of whom 1,376 patients underwent primary IMN. A total of 1,032 (75%) underwent early fixation (median, 7.4 hours; interquartile range [IQR], 3.7-12.9 hours), and 344 (25%) underwent delayed fixation (median, 40.9 hours; IQR, 31.0-64.9 hours). The early fixation group had lower ISS (median [IQR], 10 [10-19] vs. 17.5 [10-27]; p < 0.001) and a higher RTS (median [IQR], 7.84 [7.84-7.84] vs. 7.84 [7.84-7.84]; p < 0.001). PC were reduced in the early fixation group, (3.9% vs. 13.4%, p < 0.001). Specifically, there was a decreased incidence of PNA (2% vs. 11%, p < 0.001), pulmonary embolism (2% vs. 4%, p < 0.21), and adult respiratory distress syndrome (0.002% vs. 0.02%, p < 0.001). After adjustment for anatomic (ISS) and physiologic (RTS) indices of injury severity, early fixation was independently associated with a reduction in PC (odds ratio, 0.43; 95% confidence interval, 0.25-0.72; p = 0.002). The early fixation group also had a decrease in hospital length of stay (median [IQR], 6 [4-11] vs. 10 [6-17]; p < 0.001), ventilator days (median [IQR], 0 [0-0] vs. 0 [0-4]; p < 0.001), and hospital charges (median [IQR], $59,561 [$38,618-$106,780] vs. $97,018 [48,249-205,570]; p < 0.001). Mortality was low in both groups (0.4% vs. 1.7%, p < 0.01). Similar results were seen in patients with an ISS of greater than 15 and ISS of greater than 25. CONCLUSION: Controlling for anatomic and physiologic severity of injury, early femoral IMN was associated with an almost 60% reduction in odds of developing PCs. Early fixation was also associated with a reduction ventilator days, hospital length of stay, and overall hospital charges. As the list of "never events" continues to expand and improving quality of care while reducing costs is emphasized, early (<24 hours) definitive operative intervention seems to decrease complications, achieve early hospital discharge, and reduce hospital charges. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The impact of injury severity and transfer status on reimbursement for care of femur fractures.

BACKGROUND: This study investigates the impact of injury severity, patient origin, and payer on charges and payments associated with treatment of femoral fractures at a Level I trauma center. We hypothesized that transfer patients and patients with minor injury would be underinsured, whereas reimbursement rate would be higher for patients with severe injury. METHODS: Medical and financial records of 420 adult patients treated for femoral fractures at a public, urban Level I trauma center were reviewed. Facility and professional charges and payments were determined. Reimbursement rate was defined as the ratio of payment to charge. Payer groups included Medicare, Medicaid, commercial, managed care, workers' compensation, and self-pay. Severe injury was defined by Injury Severity Score of 18 or higher. RESULTS: Patients with Injury Severity Score of less than 18 were more often uninsured compared with the severe injury group (25% vs. 14%, p = 0.005). Patients with severe injury had higher facility (0.47 vs. 0.39, p = 0.005) and total reimbursement rates (0.41 vs. 0.34, p = 0.002) compared with patients with minor injury. Likewise, transfer patients trended toward higher overall reimbursement rate compared with nontransfer patients (0.42 vs. 0.37, p = 0.056). Patients with severe injury were more likely to have commercial insurance (28 vs. 20%, p = 0.06), and transferred patients were more likely to have insurance (88% vs. 79%, p = 0.034). CONCLUSION: The higher proportion of self-pay in the nontransfer group may be caused by the large population of uninsured patients in the area surrounding our trauma center. Favorable payer mix and higher facility reimbursement rate for patients with severe injury may be an incentive for trauma centers to continue providing care for patients with multiple injuries. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III. Economic analysis, level IV.

Is reconstruction nailing of all femoral shaft fractures cost effective? A decision analysis.

OBJECTIVES: Femoral shaft fractures are usually treated with anterograde or retrograde nails that typically do not provide femoral neck fixation. Ipsilateral femoral neck fractures occur with 2.5%-10% of femoral shaft fractures; 19%-55% of associated femoral neck fractures are missed with plain films and 5%-22% with computed tomography (CT). This study was performed to determine if routine reconstruction nailing of all femoral shaft fractures with or without occult femoral neck fractures is cost effective. METHODS: A decision tree model examined the cost effectiveness of reconstruction nailing over standard intramedullary nailing for all femoral shaft fractures in which an associated femoral neck fracture was not identified on plain radiographs. As a base model, we assumed that 5% of shaft fractures had an ipsilateral femoral neck fracture, and 37% were missed and required further surgery. We assigned a small morbidity and additional cost ($680) for the use of a reconstruction nail and 2 screws. Model inputs including costs, clinical outcome probabilities, and health utilities were derived from the literature, estimated from institutional data, or assumed by the authors. Sensitivity analyses evaluated the effect of the rate of associated femoral neck fracture, the rate of missed femoral neck fracture, the complication rate of reconstruction screws, the cost of the extra reconstruction screws, and the utilities of each outcome on the incremental cost effectiveness (ICER) of both strategies. Current practice in cost-effectiveness analysis uses a threshold of $100,000 per quality-adjusted life year gained as cost effective. A secondary analysis of the use CT scans to reduce missed femoral neck fractures was also performed. RESULTS: The base model showed that the placement of reconstruction nails in all isolated femur fractures was not cost effective. Sensitivity analysis demonstrated that the ICER was most sensitive to the cost of the reconstruction nail, hemiarthroplasty, and a missed femoral neck fracture. The ICER was affected by the rate of femoral neck fracture and the rate of missed femoral neck fracture. If the rate of missed femoral neck fractures was >38%, then reconstruction nailing was a cost-effective strategy. If the probability of an ipsilateral femoral neck fracture was >7%, then reconstruction nailing was cost effective. Protocolized CT scans had an ICER >$100,000. If the additional cost of the reconstruction nails was <$650, then it was cost effective to perform reconstruction nailing for all femoral shaft fractures. CONCLUSIONS: Reconstruction nailing of femoral shaft fractures can be a cost-effective method to reduce the risks and morbidity of missed femoral neck fractures if the incremental implant costs are <$650. Routine reconstruction nailing is cost effective if the rate of associated femoral neck fracture is >7% or the rate of missed femoral neck fracture is >38%. CT scans are not a cost-effective strategy to reduce the risk and morbidity of missed femoral neck fractures if the cost is >$243. Weaknesses of this study include the reliance on low-powered studies and on estimations of some utilities and costs. To prevent the morbidity of missed or occult femoral neck fractures, the use of reconstruction nails for femoral shaft fractures is cost effective when the incremental costs of implants are <$650. LEVEL OF EVIDENCE: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

[Examples of erroneous coding in trauma surgery]. / Beispiele für fehlerhafte Kodierung in der Unfallchirurgie.

The G-DRG-System is complex, mistakes in accounting are common. Therefore diagnosis with CCL-value are important because of the possibility of increasing revenues. Also procedures may lead to DRGs with a higher cost weight. So their acquisition is mandatory. The exact medical documentation is essential. High revenues have to be understood according to unvoidable expenditures.

Fraturas do fêmur proximal no idoso: estudo de custo da doença sob a perspectiva de um hospital público no Rio de Janeiro, Brasil / Hip fractures in the elderly: cost of illness study in a public hospital perspective, Rio de Janeiro, Brazil

O artigo visa a estimar o custo direto médico do tratamento hospitalar de pacientes idosos com fraturas de fêmur proximal, no Hospital Municipal Lourenço Jorge, na cidade do Rio de Janeiro. Estudo observacional, prospectivo, para estimar a utilização de recursos e custos diretos médicos associados à hospitalização por fratura de fêmur proximal em idosos, em 2007 e 2008, sob a perspectiva do prestador de serviços. Foi utilizado um instrumento de coleta de dados através do qual foram registrados recursos identificados na revisão prospectiva dos prontuários. Aos recursos utilizados foram atribuídos custos em reais (R$) baseando-se em valores do ano 2010. Foram realizadas análises descritivas dos custos e utilização de recursos, bem como avaliada a associação de variáveis clínicas e demográficas com o custo final observado. Foram incluídos 82 pacientes, 81,7 por cento do sexo feminino, idade média de 76,96 anos, hospitalização média de 12,66 dias. A mediana de custo por paciente foi de R$ 3.064,76 (IC95 por cento: 2.817,63 a 3.463,98). Hospitalização clínica e procedimento cirúrgico foram responsáveis por 65,61 por cento e 24,94 por cento dos custos, respectivamente. Pacientes submetidos ao tratamento cirúrgico até o quarto dia de hospitalização apresentaram mediana de custos menor do que pacientes submetidos após o quarto dia (R$ 2.136,31 e R$ 3.281,45, p<0,00001). Observou-se também diferença significativa nos custos finais por tipo de procedimento cirúrgico realizado. O custo do tratamento das fraturas de fêmur proximal no idoso foi significativamente maior nos pacientes submetidos à cirurgia após o quarto dia de hospitalização. Hospitalização clínica e procedimento cirúrgico foram os principais componentes do custo final observado.

This paper aims to assess direct medical costs associated to hospital treatment of hip fractures in the elderly in the Municipal Hospital Lourenço Jorge (HMLJ), Rio de Janeiro. Observational, prospective study to assess resource utilization and direct medical costs associated to elderly hip fracture hospitalization in 2007 and 2008, under the health care provider perspective. A standard data collection instrument was used to register identified resources during prospective medical charts review. The resource utilization was converted into Brazilian Real (R$), based on 2010 prices. Descriptive analysis of costs and resource utilization and their association with clinical and demographic variables were performed. Eighty two patients were included, 81.7 percent female, mean age of 76.96 years, hospitalization mean time of 12.66 days. Median total costs per patient were R$ 3,064.76 (IC95 percent: 2,817.63 - 3,463.98). Clinical hospitalization and surgical procedure were responsible for 65.61 percent and 24.94 percent of costs, respectively. Median costs for patients submitted to surgical procedure until the fourth day of hospitalization were lower than median costs for patients submitted after the fourth day (R$ 2,136.45 and R$ 3,281.45, respectively, p<0.00001). A significant difference in average costs per type of surgical procedure was also observed. Cost associated to inpatient treatment of hip fractures in the elderly was higher in patients who performed surgery after the fourth day of hospitalization. Clinical hospitalization and surgical procedure were the main cost components observed.

Tecnologias de prevenção secundária e tratamento da fratura de fêmur osteoporótica em mulheres na pós menopausa no Brasil – análise de custo-efetividade como ferramenta de gestão / Technologies of secondary prevention and treatment of osteoporotic hip fractures in women after menopause in Brazil - cost-effectiveness as a management tool

O objetivo deste estudo foi elaborar procedimentos gerenciais para o SistemaÚnico de Saúde (SUS) relativos à incorporação e difusão de tecnologias dirigidas à atenção ao problema fratura de fêmur osteoporótica (FFO) em mulheres com 65 anos ou mais. Para isso, tomou-se como base as evidências resultantes da comparação entre as razões de custo-efetividade e de custo-utilidade referentes aos processos,mais e menos efetivos, de assistência ao paciente com FFO e referentes à atençãopreventiva (com anti-osteoporóticos) versus a atenção curativa (atenção à FFO no SUS). O horizonte temporal considerado foi de cinco anos.Foram estabelecidos dois recortes para análise de custo-efetividade/custoutilidade(ACE/ACU). O primeiro recorte refere-se à avaliação de tecnologias deprevenção secundária da FFO, considerando como alternativas de intervenção: 1.Tecnologia de rastreamento de densidade mineral óssea seguida de administração de antiosteoporótico; 2. Suplementação de cálcio e vitamina D sem rastreamento; 3. Não adoção de medidas de prevenção (conduta expectante/tradicional). O segundorecorte refere-se ao tratamento da fratura de fêmur osteoporótica, sendo considerado como alternativas tecnológicas: o tratamento tradicional da FFO realizado no âmbito do SUS e o tratamento da FFO realizado em serviços que apresentem alta efetividade técnica, ou seja, em serviços considerados centros de referência de nível internacional pelas inovações tecnológicas e esforços contínuos de melhoria da efetividade.

Nos resultados da análise de custo-efetividade conduzida para o primeirorecorte, observou-se um custo incremental de R$ 65.700,00 por fratura evitada, considerando a alternativa com melhor relação de custo-efetividade, ou seja, para uma coorte de 1.000 mulheres com idade igual ou superior a 65 anos, a alternativa deprevenção secundária – suplementação de cálcio associado à vitamina D sem arealização de screening, significaria um custo adicional no SUS de R$328.500,00para evitar 5 fraturas. Para o segundo recorte, quando comparada à alternativa de baixa efetividade, ou seja, tratamento cirúrgico realizado no SUS, a alternativa de alta efetividadetécnica, foi observado um custo incremental de R$ 362,36 por ano de vida salvo e de R$ 141,48 por QALY ganho. Quando comparados os dois recortes, considerando como desfecho anos de vida salvos e QALY ganhos, observou-se que não adotar medida de prevenção secundária e realizar o tratamento da FFO em um serviço de alta efetividade, apresenta-se como mais efetiva e com menor custo. Assim, conclui-se que, considerando as evidências disponíveis e os recortes analisados, o momento maisapropriado para interferir na história natural da fratura de fêmur osteoporótica seria na fase de tratamento e reabilitação.

Dynamic skeletal traction spica casts for paediatric femoral fractures in a resource-limited setting.

The objective of this study was to compare elastic intramedullary nailing (EIN) with dynamic skeletal traction spica casting (DSTSC) in terms of postoperative radiographic angulations, length of hospital stay, and cost in a resource-limited setting. We prospectively studied 51 children, five to twelve years of age, with femoral fractures treated with either EIN (n = 26) or DSTSC (n = 25). Children treated with EIN had significantly longer hospital stays (17 +/- 8.0 days) than those treated with DSTSC (6.0 +/- 2.5 days). Financial constraints in acquiring supplies caused a significant increase in time from admission to surgery (EIN 9.5 +/- 2.3 days; DSTSC 1.1 +/- 0.3 days), and cost was about 400% higher for EIN compared with DSTSC. At twelve weeks follow-up, all patients in both groups had acceptable radiographic angulations. In resource-limited healthcare settings, DSTSC is an effective alternative to EIN with comparable post-op radiographic angulations, decreased hospital stays, and lower cost.