Benefits of Rib Fixation Utilizing Low-Cost Materials: A Randomized Pilot Trial.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) using standard rib plating systems has become a norm in developed countries. However, the procedure has not garnered much interest in low-middle-income countries, primarily because of the cost. METHODS: This was a single-center pilot randomized trial. Patients with severe rib fractures were randomized into two groups: SSRF and nonoperative management. SSRF arm patients underwent surgical fixation in addition to the tenets of nonoperative management. Low-cost materials like stainless steel wires and braided polyester sutures were used for fracture fixation. The primary outcome was to assess the duration of hospital stay. RESULTS: Twenty-two patients were randomized, 11 in each arm. Per-protocol analysis showed that the SSRF arm had significantly reduced duration of hospital stay (22.6 ± 19.1 d versus 7.9 ± 5.7 d, P value 0.031), serial pain scores at 48 h and 5 d (median score 5, IQR (3-6) versus median score 7, IQR (6.5-8), P value 0.004 at 48 h and median score 2 IQR (2-3) versus median score 7 IQR (4.5-7) P value 0.0005 at 5 d), significantly reduced need for injectable opioids (9.9 ± 3.8 mg versus 4.4 ± 3.4 mg, P value 0.003) and significantly more ventilator-free days (19.9 ± 8.7 d versus 26.4 ± 3.2 d, P value 0.04). There were no statistically significant differences in the total duration of ICU stay (median number of days 2, IQR 1-4.5 versus median number of days 7, IQR 1-14, P value 0.958), need for tracheostomy (36.4% versus 0%, P value 0.155), and pulmonary and pleural complications. CONCLUSIONS: SSRF with low-cost materials may provide benefits similar to standard rib plating systems and can be used safely in resource-poor settings.

Readmission following surgical stabilization of rib fractures: Analysis of incidence, cost, and risk factors using the Nationwide Readmissions Database.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) has become increasingly common for the treatment of traumatic rib fractures; however, little is known about related postoperative readmissions. The aims of this study were to determine the rate and cost of readmissions and to identify patient, hospital, and injury characteristics that are associated with risk of readmission in patients who underwent SSRF. The null hypotheses were that readmissions following rib fixation were rare and unrelated to the SSRF complications. METHODS: This is a retrospective analysis of the 2015 to 2017 Nationwide Readmission Database. Adult patients with rib fractures treated by SSRF were included. Univariate and multivariate analyses were used to compare patients readmitted within 30 days with those who were not, based on demographics, comorbidities, and hospital characteristics. Financial information examined included average visit costs and national extrapolations. RESULTS: A total of 2,522 patients who underwent SSRF were included, of whom 276 (10.9%) were readmitted within 30 days. In 36.2% of patients, the reasons for readmissions were related to complications of rib fractures or SSRF. The rest of the patients (63.8%) were readmitted because of mostly nontrauma reasons (32.2%) and new traumatic injuries (21.1%) among other reasons. Multivariate analysis demonstrated that ventilator use, discharge other than home, hospital size, and medical comorbidities were significantly associated with risk of readmission. Nationally, an estimated 2,498 patients undergo SSRF each year, with costs of US $176 million for initial admissions and US $5.9 million for readmissions. CONCLUSION: Readmissions after SSRF are rare and mostly attributed to the reasons not directly related to sequelae of rib fractures or SSRF complications. Interventions aimed at optimizing patients' preexisting medical conditions before discharge should be further investigated as a potential way to decrease rates of readmission after SSRF. LEVEL OF EVIDENCE: Epidemiological study, level III.

Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups.

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.

Quantifying the expense of deferring surgical stabilization of rib fractures: Operative management of rib fractures is associated with significantly lower charges.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) remains a relatively controversial operation, which is often deferred because of concern about expense. The objective of this study was to determine the charges for SSRF versus medical management during index admission for rib fractures. We hypothesize that SSRF is associated with increased charge as compared with medical management. METHODS: This is a retrospective chart review of a prospectively maintained database of patients with ≥3 displaced rib fractures admitted to a level 1 trauma center from 2010 to 2019. Patients who underwent SSRF (operative management [OM]) were compared with those managed medically (nonoperative management [NOM]). The total hospital charge between OM and NOM was compared with univariate analysis, followed by backward stepwise regression and mediation analysis. RESULTS: Overall, 279 patients were included. The majority (75%) were male, the median age was 54 years, and the median Injury Severity Scale score (ISS) was 21. A total of 182 patients underwent OM, whereas 97 underwent NOM. Compared with NOM, OM patients had a lower ISS (18 vs. 22, p = 0.004), less traumatic brain injury (14% vs. 31%, p = 0.0006), shorter length of stay (10 vs. 14 days, p = 0.001), and decreased complications. After controlling for the differences between OM and NOM patients, OM was significantly associated with decreased charges (ß = US $35,105, p = 0.01). Four other predictors, with management, explained 30% of the variance in charge (R = 0.30, p < 0.0001): scapular fracture (ß = US $471,967, p < 0.0001), ISS per unit increase (ß = US $4,139, p < 0.0001), long bone fracture (ß = US $52,176, p = 0.01), bilateral rib fractures (ß = US $34,392, p = 0.01), and Glasgow Coma Scale per unit decrease (ß = US $17,164, p < 0.0001). The difference in charge between NOM and OM management was most strongly, although only partially, mediated by length of stay. CONCLUSION: Our analysis found that OM, as compared with NOM, was independently associated with decreased hospital charges. These data refute the prevailing notion that SSRF should be withheld because of concerns for increased cost. LEVEL OF EVIDENCE: Economic, level II.

Early versus late surgical stabilization of severe rib fractures in patients with respiratory failure: A retrospective study.

INTRODUCTION: The timing of surgical stabilization of rib fractures remains controversial. We hypothesized that early surgical stabilization (within 3 days of injury) can improve clinical outcome in patients with severe rib fractures and respiratory failure. The aim of this study was to analyze the impact of early surgical stabilization of rib fractures on the perioperative results, clinical outcomes, and medical costs of patients with severe rib fractures and respiratory failure. METHODS: This was a retrospective comparative study based on a prospectively collected database at a single institute. Patients with severe rib fractures and respiratory failure who underwent surgical stabilization were classified into early (within 3 days of injury) and late (more than 3 days after injury) groups. Outcome measures included operation time, duration of mechanical ventilation, intensive care unit stay, hospital stay, complication rate, mortality rate, and medical cost. RESULTS: A total of 33 patients were enrolled (16 and 17 in the early and late groups, respectively). The demographics, trauma mechanism, associated injuries, and severity of trauma were comparable in both groups. The early group had significantly shorter duration of mechanical ventilation (median 36 vs. 90 hours, p = 0.03), intensive care unit stay (median 123 vs. 230 hours, p = 0.004), and hospital stay (median 12 vs. 18 days, p = 0.005); and lower National Health Insurance costs (median 6,617 vs. 10,017 US dollars, p = 0.031). The early group tended to have lower rates of morbidity and mortality, but the difference was not statistically significant. CONCLUSION: Early surgical stabilization of rib fractures in selected patients may significantly shorten their duration of mechanical ventilation, and intensive care unit and hospital stays, while incurring less medical costs.

The expedited discharge of patients with multiple traumatic rib fractures is cost-effective.

INTRODUCTION: Rib fractures are a cause of significant morbidity and mortality in trauma patients. It is well documented that optimizing pain control, mobilization, and respiratory care decreases complications. However, the impact of these interventions on hospital costs and length of stay is not well defined. We hypothesized patients with multiple rib fractures can be discharged within three hospital days resulting in decreased hospital costs. METHODS: A retrospective review of adult patients (≥18yrs) admitted to our Level 1 trauma center (2011-2013) with ≥2 rib fractures was performed. Patients were excluded if they were intubated, admitted to the ICU, required chest tube placement, or sustained significant multi-system trauma. (n = 202) Demographics, clinical characteristics, hospital costs, and outcome data were analyzed. Patients discharged within three hospital days of admission were considered to have achieved expedited discharge (ED). Univariate and multivariate analyses determined predictors of failure to achieve ED. A p value of <0.05 was considered significant. RESULTS: Study patients (n = 202) were 60 (SD = 19) years of age with an injury severity score (ISS) of 10 (SD = 5), and 4 (SD = 2) rib fractures. Of 202 patients, 127 (63%) achieved ED while 75 (37%) did not. No differences in chest AIS, ISS, smoking status or history of pulmonary disease were identified between the two groups (all p > 0.05). Average LOS (2 (SD = 1) vs. 7 (SD = 4) days; p < 0.001) and hospital costs ($2865 (SD = 1200) vs. $6085 (SD = 3033)); p < 0.001). were lower in the ED group A lower percentage of ED patients required placement in rehabilitation facilities (6% vs. 48%; p < 0.001). There were no readmissions within 30 days in either group. After controlling for potential confounding variables, multiple variable logistic regression analysis revealed that advancing age (OR 1.05 per year, 1.02-1.07) independently predicted failure to achieve ED. CONCLUSION: The majority of patients admitted to the hospital with multiple rib fractures can be discharged within three days. This expedited discharge results in significant cost savings to the hospital. Early identification of patients who cannot meet the goal of expedited discharge can facilitate improvement in management strategies.

Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis.

OBJECTIVES: Flail chest is a common injury sustained by patients who experience high-energy blunt chest trauma and results in severe respiratory compromise because of altered mechanics of respiration. There has been increased interest in operative fixation of these injuries with the intention of restoring the mechanical integrity of the chest wall, and several studies have shown that ventilation requirements and pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate fixation of rib fractures in flail chest injuries using cost-effectiveness analysis, supported by systematic review and meta-analysis. METHODS: This was a 2-part study in which we initially conducted a systematic literature review and meta-analysis on outcomes after operative fixation of flail chest injuries, evaluating intensive care unit (ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and need for tracheostomy. The results were then applied to a decision-analysis model comparing the costs and outcomes of operative fixation versus nonoperative treatment. The validity of the results was tested using probabilistic sensitivity analysis. RESULTS: Operative treatment decreased mortality, pneumonia, and tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well as time in ICU and total LOS (3.3 and 4.8 days, respectively). Operative fixation was associated with higher costs than nonoperative treatment ($23,682 vs. $8629 per case, respectively) and superior outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), giving it an incremental cost-effectiveness ratio of $8577/QALY. CONCLUSIONS: Surgical fixation of rib fractures sustained from flail chest injuries decreased ICU time, mortality, pulmonary complications, and hospital LOS and resulted in improved health care-related outcomes and was a cost-effective intervention. These results were sensitive to overall complication rates, and operations should be conducted by surgeons or combined surgical teams comfortable with both thoracic anatomy and exposures as well as with the principles and techniques of internal fixation. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

[COMPARATIVE STUDY OF THE TACTICS OF SURGICAL FIXATION WITH THE CLOSED INJURY OF THE CHEST: THE VIEW OF THE RESUSCITATOR, ECONOMIC ASPECTS].

The closed injury of chest with the breaks of edges is the vital problem of traumatology, anesthesiology and resuscitation For the change to conservative treatment with the aid of mechanical ventilation of lungs today come the methods of surgical fixation with the closed injury of chest. The conducted investigation showed the clinical and economic expediency of introducing the method of active surgical tactics.

The diagnostic utility of rib series in assessing rib fractures.

Rib series rarely add information to the posteroanterior (PA) film for the diagnosis of rib fractures. In this investigation, we evaluated the utility of rib X-rays using turnaround time (TAT), radiation exposure, and cost-efficiency as the key parameters. This investigation was conducted from January 2008 to December 2012. We included patients who had rib series performed for suspected rib fractures. TAT for patients was calculated from the time exam was ordered by the emergency department (ED) physician/staff to time the report was finalized by the attending radiologist. Effective radiation dose for rib series was calculated as a summation of radiation dose from the standard rib series images for each patient. Cost-efficiency was determined based on the number of interventions that took place as a result of a complicated study. Our investigation consisted of 422 patients, 208 females aged (57 ± 20.8) and 214 males aged (48 ± 17.3). A total of 74(17.5 %) abnormal findings were noted, out of which only 1(0.23 %) underwent management change. The mean turnaround time for patients undergoing rib series had a value of 133.5 (±129.8) min as opposed to a single chest PA of 61.8(± 64) min. Average effective radiation dose for a rib series was 0.105 (±0.04) mSv, whereas average effective radiation dose of a single chest PA was 0.02 mSv. Dedicated rib series has a low-yield diagnostic value as it pertains to management change. The overall impact on patient care based on our findings is small when compared to the risks associated with prolonged TAT, repeated exposure to radiation, and extensive medical costs.

Rib fracture fixation for flail chest: what is the benefit?

BACKGROUND: Recently, rib fracture fixation for flail chest has been used increasingly at both academic and nonacademic trauma centers. Although a few small non-US studies have demonstrated a clinical benefit, it is unclear whether this benefit outweighs the added expense and potential perioperative complications related to the procedure. We therefore sought to determine if open reduction and internal fixation of ribs for flail chest (ORIF-FC) represents a cost-effective means for managing these patients. STUDY DESIGN: A Markov transition state analysis was performed modeling the outcomes of the standard of care or ORIF-FC for flail chest. The incidences of ventilator-associated pneumonia, tracheostomy, sepsis, prolonged ventilation, deep vein thrombosis, pulmonary embolism, wound infection, and postoperative hemorrhage were obtained based on literature review. Medicare 2010 reimbursement costs were used for diagnoses and procedures. A quality of life improvement factor ranging from 0 to 15% improvement was used to estimate the improvement in pain and functional outcomes related to ORIF-FC. The most cost-effective treatment was then determined, ranging the incidences of ventilator-associated pneumonia and quality of life improvement factor. RESULTS: Cost effectiveness was $15,269 for ORIF-FC compared with $16,810 for standard of care. Even when the quality of life improvement factor was set to 0%, ORIF-FC remained the most cost-effective strategy. Similarly, ORIF-FC remained the most cost-effective strategy by $8,400 when the incidence of ventilator-associated pneumonia after ORIF was as high as 22%. CONCLUSIONS: Despite the additional cost of surgery, rib fracture fixation dominates the standard of care and should be considered in the management of appropriate flail chest patients.

[Direct and indirect costs of fractures due to osteoporosis in Austria]. / Direkte und indirekte Kosten von osteoporotisch bedingten Frakturen in Österreich.

OBJECTIVES: We examined the financial burden of osteoporosis in Austria. METHODS: We took both direct and indirect costs into consideration. Direct costs encompass medical costs such as expenses for pharmaceuticals, inpatient and outpatient medical care costs, as well as other medical services (e.g., occupational therapies). Non-medical direct costs include transportation costs and medical devices (e.g., wheel chairs or crutches). Indirect costs refer to costs of productivity losses due to absence of work. Moreover, we included costs for early retirement and opportunity costs of informal care provided by family members. While there exist similar studies for other countries, this is the first comprehensive study for Austria. For our analysis, we combined data of official statistics, expert estimates as well as unique patient surveys that are currently conducted in the course of an international osteoporotic fracture study in Austria. RESULTS: Our estimation of the total annual costs in the year 2008 imposed by osteoporosis in Austria is 707.4 million €. The largest fraction of this amount is incurred by acute hospital treatment. Another significant figure, accounting for 29% of total costs, is the opportunity cost of informal care. CONCLUSIONS: The financial burden of osteoporosis in Austria is substantial. Economic evaluations of preventive and therapeutic interventions for the specific context of Austria are needed to inform health policy decision makers.