The economic and resource burden of e-scooter-related orthopaedic injuries: A district general hospital's experience.

PURPOSE: Electric scooters (e-scooters) are an increasingly popular method of transportation worldwide. However, there are concerns regarding their safety, specifically with regards to orthopaedic injuries. We aimed to investigate the overall burden and financial impact on orthopaedic services as a result of e-scooter-related orthopaedic injuries. METHODS: We retrospectively identified all e-scooter-related injuries requiring orthopaedic admission or surgical intervention in a large District General Hospital in England over a 16-month period between September 2020 and December 2021. Injuries sustained, surgical management, inpatient stay and resources used were calculated. RESULTS: Seventy-nine patients presented with orthopaedic injuries as a result of e-scooter transportation with a mean age of 30.1 years (SD 11.6), of which 62 were males and 17 were females. A total of 86 individual orthopaedic injuries were sustained, with fractures being the most common type of injury. Of these, 23 patients required 28 individual surgical procedures. The combined theatre and recovery time of these procedures was 5500 min, while isolated operating time was 2088 min. The total cost of theatre running time for these patients was estimated at £77,000. A total of 17 patients required hospital admission under Trauma and Orthopaedics, which accounted for total combined stay of 99 days with a mean length of stay of 5.8 days. CONCLUSION: While there are potential environmental benefits to e-scooters, we demonstrate the risks of injury associated with their use and the associated increased burden to the healthcare system through additional emergency attendances, frequent outpatient clinic appointments, surgical procedures, and hospital inpatient admissions.

Racial Disparities in the Operative Management of Orthopedic Trauma: A Systematic Review and Meta-Analysis.

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.

Charges, length of stay, and complication associations with trauma center ownership in adult patients with mild to moderate trauma.

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.

Annual epidemiological and health insurance disease burden of pertrochanteric fractures in Hungary / A pertrochanter törés okozta éves epidemiológiai és egészségbiztosítási betegségteher elemzése Magyarországon.

Összefoglaló. Bevezetés: A pertrochanter töréssel kapcsolatos szolgáltatások igénybevétele jelentos terhet jelent a társadalom és az egészségügyi rendszerek számára. Célkituzés: Elemzésünk célja volt a pertrochanter törés okozta éves epidemiológiai és egészségbiztosítási betegségteher meghatározása Magyarországon. Adatok és módszerek: A felhasznált adatok a Nemzeti Egészségbiztosítási Alapkezelo (NEAK) finanszírozási adatbázisából származnak 2018. évre vonatkozóan. A betegszámok alapján meghatároztuk a 100 000 lakosra jutó prevalenciát, az éves egészségbiztosítási kiadásokat korcsoportos és nemenkénti bontásban. Az elemzésbe az érintett egészségbiztosítási ellátások teljes körét bevontuk. A pertrochanter töréseket a Betegségek Nemzetközi Osztályozása (BNO, 10. revízió) szerinti S7210-es kóddal azonosítottuk. Eredmények: A legnagyobb országos betegszámot a járóbeteg-szakellátás esetében találtuk: 2845 férfi, 6312 no, együtt 9157 fo. Ezt követte az aktívfekvobeteg-szakellátás (2388 férfi és 5858 no, együtt 8246 fo). A valamennyi életkorra számított, 100 000 lakosra vetített prevalencia a férfiaknál 51,1 beteg, a noknél 114,7 beteg, együtt 84,3 beteg volt az aktívfekvobeteg-szakellátásban. A pertrochanter törés kezelésére 7,329 milliárd Ft-ot költöttek 2018-ban (27,12 millió USD, illetve 22,98 millió EUR). A kiadások 28,0%-a férfiaknál, 72,0%-a noknél jelent meg. Az egészségbiztosítási kiadások 90,7%-a az aktívfekvobeteg-szakellátásban jelentkezett. Az egy betegre jutó átlagos éves összesített egészségbiztosítási kiadás 858 710 Ft (3177 USD/2693 EUR) volt a férfiak és 901 047 Ft (3334 USD/2826 EUR) a nok esetében. Következtetés: A pertrochanter törés elofordulási gyakorisága 2,5-szer magasabb a nok esetében, mint a férfiaknál. Az aktívfekvobeteg-szakellátás igénybevétele bizonyult a legfobb költségtényezonek. Orv Hetil. 2021; 162(Suppl 1): 46-53. INTRODUCTION: Health services utilization related to pertrochanteric fractures represents a significant burden for the society and health care systems. OBJECTIVE: Our aim was to analyse the epidemiological and health insurance burden of pertrochanteric fractures in Hungary. DATA AND METHODS: Data were derived from the financial database of the National Health Insurance Fund Administration (NHIFA) of Hungary for the year 2018. The data analysed included annual patient numbers, prevalence per 100 000 population in acute inpatient care, health insurance costs calculated for age groups and sex for all types of care. Patients with pertrochanteric fracture were identified with the code S7210 of the International Classification of Diseases, 10th revision. RESULTS: We found a significant patient turnover in outpatient care: 2845 men, 6312 women, in total 9157 patients, followed by acute inpatient care (2388 men, 5858 women, together: 8246 patients). Based on patient numbers in acute inpatient care, the prevalence per 100 000 among men was 51.1, among women 114.7, together 84.3 patients. In 2018, NHIFA spent 7.329 billion HUF (27.12 million USD, 22.98 million EUR) on the treatment of pertrochanteric fractures. 28.0% of the costs was spent on the treatment of male, 72.0% on female patients. Reimbursement of acute inpatient care was the main cost driver (90.7% of the total expenditure). The average annual treatment cost per patient was 858 710 HUF (3177 USD/2693 EUR) for men and 901 047 HUF (3334 USD/2826 EUR) for women. CONCLUSION: The prevalence of pertrochanteric fracture was 2.5 times higher in women compared to men. Acute inpatient care was the major cost driver in the treatment of pertrochanteric fracture. Orv Hetil. 2021; 162(Suppl 1): 46-53.

A Novel Instant 3-Dimensional Printing System for Postoperative Fracture Patients: A Comparative Cohort Study.

BACKGROUND Traditional plaster (TP) is a widely used auxiliary fixation (AF) approach for postoperative fracture patients. However, patient discomfort and inconvenience to clinicians has limited its application. We introduce a novel instant 3-dimensional printing appliance system (3D-AS) to address such issues. MATERIAL AND METHODS Twenty-seven postoperative fracture patients were divided randomly between a TP group and a 3D-AS group, and analyzed retrospectively. Radiographic images during follow-up were evaluated for fracture healing and fracture reduction quality. The range of motion (ROM) was recorded to assess motor performance. Patient pain was assessed using the Visual Analogue Scale (VAS). Complications were also compared between the 2 groups. RESULTS The patients comprised 17 men and 10 women with ages ranging from 21 to 69 years (mean age: 47.35). All patients completed a follow-up visit (range: 14-19 months, mean: 13.59 months). Although no significant difference was found between general characteristics (P>0.05) and the time of fracture union (P>0.05), significant differences between groups were seen in complications (P<0.05), VAS (P<0.01), patient satisfaction (P<0.05), and ROM for the upper joints (P<0.05). CONCLUSIONS Our study suggests that 3D-AS provides better upper-limb ROM and more comfortable healing for postoperative fracture patients, indicating that it can be recommended for use in such patients.

The Cost of a Fall Among Older Adults Requiring Emergency Services.

BACKGROUND/OBJECTIVE: The cost of a fall among older adults requiring emergency services is unclear, especially beyond the acute care period. We evaluated medical expenditures (costs) to 1 year among community-dwelling older adults who fell and required ambulance transport, including acute versus post-acute periods, the primary drivers of cost, and comparison to baseline expenditures. DESIGN: Retrospective cohort analysis. SETTING: Forty-four emergency medical services agencies transporting to 51 emergency department in seven northwest counties from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012. PARTICIPANTS: We included 2,494 community-dwelling adults, 65 years and older, transported by ambulance after a fall with continuous fee-for-service Medicare coverage. MEASUREMENTS: The primary outcome was total Medicare expenditures to 1 year (2019 U.S. dollars), with separation by acute versus post-acute periods and by cost category. We included 48 variables in a standardized risk-adjustment model to generate adjusted cost estimates. RESULTS: The median age was 83 years, with 74% female, and 41.9% requiring admission during the index visit. The median total cost of a fall to 1 year was $26,143 (interquartile range (IQR) = $9,634-$68,086), including acute care median $1,957 (IQR = $1,298-$12,924) and post-acute median $20,560 (IQR = $5,673-$58,074). Baseline costs for the previous year were median $8,642 (IQR = $479-$10,948). Costs increased across all categories except outpatient, with the largest increase for inpatient costs (baseline median $0 vs postfall median $9,477). In multivariable analysis, the following were associated with higher costs: high baseline costs, older age, comorbidities, extremity fractures (lower extremity, pelvis, and humerus), noninjury diagnoses, and surgical interventions. Compared with baseline, costs increased for 74.6% of patients, with a median increase of $12,682 (IQR = -$185 to $51,189). CONCLUSION: Older adults who fall and require emergency services have increased healthcare expenditures compared with baseline, particularly during the post-acute period. Comorbidities, noninjury medical conditions, fracture type, and surgical interventions were independently associated with increased costs.

Clinical outcome and operative cost comparison: Locked compression plate versus reconstruction plate in midshaft clavicle fractures.

OBJECTIVE: The aim of this study was to compare the clinical outcomes and operative cost of a locked compression plate (LCP) and a nonlocked reconstruction plate in the treatment of displaced midshaft clavicle fracture. METHODS: From January 2013 till March 2018, a total of 55 patients with acute unilateral closed midshaft clavicle fracture were treated with either a 3.5-mm pre-contoured LCP [32 patients; 25 men and 7 women; mean age: 35 years (range: 19-63 years)] or a 3.5-mm nonlocked reconstruction plate [23 patients; 20 men and 3 women; mean age: 31.4 years (range: 17-61 years)]. The clinical outcomes in terms of fracture union, Quick Disability of Arm, Shoulder and Hand (DASH) score, implant irritation, failure rate, and reoperation rate were evaluated retrospectively. The patient billing records were reviewed to obtain primary operation, reoperation, and total operative cost for midshaft clavicle fracture. These values were analyzed and converted from Malaysia Ringgit (RM) to United States Dollar (USD) at the exchange rate of RM 1 to USD 0.24. All patients were followed up for at least one-year duration. RESULTS: The mean time to fracture union, implant irritation, implant failure, and reoperation rate showed no significant difference between the two groups of patients. The mean Quick DASH score was significantly better in the reconstruction plate group with 13 points compared with 28 points in the LCP group (p=0.003). In terms of total operative cost, the LCP group recorded a cost of USD 391 higher than the reconstruction plate group (p<0.001). CONCLUSION: The 3.5-mm reconstruction plate achieved not only satisfactory clinical outcomes but was also more cost-effective than the LCP in the treatment of displaced midshaft clavicle fractures. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Step-downs reduce workers' compensation payments to encourage return to work: are they effective?

OBJECTIVE: To determine whether step-downs, which cut the rate of compensation paid to injured workers after they have been on benefits for several months, are effective as a return to work incentive. METHODS: We aggregated administrative claims data from seven Australian workers' compensation systems to calculate weekly scheme exit rates, a proxy for return to work. Jurisdictions were further subdivided into four injury subgroups: fractures, musculoskeletal, mental health and other trauma. The effect of step-downs on scheme exit was tested using a regression discontinuity design. Results were pooled into meta-analyses to calculate combined effects and the proportion of variance attributable to heterogeneity. RESULTS: The combined effect of step-downs was a 0.86 percentage point (95% CI -1.45 to -0.27) reduction in the exit rate, with significant heterogeneity between jurisdictions (I2=68%, p=0.003). Neither timing nor magnitude of step-downs was a significant moderator of effects. Within injury subgroups, only fractures had a significant combined effect (-0.84, 95% CI -1.61 to -0.07). Sensitivity analysis indicated potential effects within mental health and musculoskeletal conditions as well. CONCLUSIONS: The results suggest some workers' compensation recipients anticipate step-downs and exit the system early to avoid the reduction in income. However, the effects were small and suggest step-downs have marginal practical significance. We conclude that step-downs are generally ineffective as a return to work policy initiative.Postprint link: https://www.medrxiv.org/content/10.1101/19012286.

The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis.

The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization.

Cost-benefit analysis, cost-effectiveness analysis, and impact of antiepileptic drugs on the risk of fracture in patients with epilepsy: A nationwide cohort study.

PURPOSE: Although nonenzyme-inducing antiepileptic drugs (nEIAEDs) are accepted for the treatment of epilepsy, few studies have examined the costs, benefits, and cost-effectiveness of nEIAEDs in relation to the incidence of fracture among patients with epilepsy. In the present study, we performed cost-benefit and cost-effectiveness analyses comparing the influence of enzyme-inducing AEDs (EIAEDs) and nEIAEDs on the risk of fracture in this population. METHODS: A total of 4864 patients with epilepsy were classified into EIAED and nEIAED groups. Propensity score matching was applied to reduce the influence of selection bias. Clinical outcomes were measured in relation to AED fee, medical expenses associated with epilepsy and fracture, and the total number of fractures. Cost-benefit and cost-effectiveness analyses were performed for all patients. RESULTS: Patients in the unmatched EIAED cohort (n = 3686) were older and had more comorbidities. After matching, the cohorts exhibited similar features (n = 2432 each). Fracture risk was lower in the nEIAED group than in the EIAED group (HR = 0.70). The additional medical expense of nEIAEDs in fractures and epilepsy for 2 years per person was 107,731 New Taiwan dollars (NT$). The additional cost for nEIAEDs to reduce one event of fracture was $14,789,421 NT$. CONCLUSIONS: Patients with epilepsy using nEIAEDs had a lower risk of fracture than those using EIAEDs. However, the cost-benefit ratio and cost-effectiveness of such treatment were lower in the nEIAED group than in the EIAED group.

Variations in Revenue Generation for the Care of Orthopaedic Trauma Patients.

BACKGROUND: In the background of increasing competition between trauma centers, this study investigated the relative reimbursement of trauma care provided in an urban trauma setting, comparing patients previously unknown (new) to the system, representing potential sources of new revenue, and those who were known (established), having received medical care previously in the same system. METHODS: A retrospective review of 440 patients with high-energy fractures at a single level 1 trauma center was conducted. Payment to charge (P/C) ratios for professional and facilities services within 6 months of injury were calculated. RESULTS: Mean professional charges per patient were $35,522 and $30,639 (P = 0.11), between new and established patients, respectively, whereas mean professional payments were statistically different, $7,894 and $4,365 (P < 0.001). Mean differences in P/C for facilities payments for new and established patients were not statistically significant, but professional P/C was higher in new patients (P < 0.001), consistent with better insured patients. DISCUSSION: Insurance companies reimburse for professional or facilities services with statistically different P/C ratios. Treating new patients at our institution likely benefits our institution by offering exposure to a more favorable payer mix and more complex patients. LEVEL OF EVIDENCE: Retrospective level III.

Neer Type-II Distal Clavicle Fractures: A Cost-Effectiveness Analysis of Fixation Techniques.

BACKGROUND: Neer type-II distal clavicle fractures are unstable and are generally appropriately managed with operative fixation. Fixation options include locking plates, hook plates, and suture button devices. No consensus on optimal technique exists. METHODS: A decision tree model was created describing fixation of Neer type-II fractures using hook plates, locking plates, or suture buttons. Outcomes included uneventful healing, symptomatic implant removal, deep infection requiring debridement, and nonunion requiring revision. Weighted averages derived from a systematic review were used for probabilities. Cost-effectiveness was evaluated by calculating incremental cost-effectiveness ratios (ICERs). The ICER is defined as the ratio of the difference in cost and difference in effectiveness of each strategy, and is measured in cost per quality-adjusted life year (QALY). The model was evaluated using thresholds of $50,000/QALY and $100,000/QALY. Sensitivity analysis was performed on all outcome probabilities for each fixation strategy to assess cost-effectiveness across a range of values. RESULTS: Forty-three papers met final inclusion criteria. Using suture buttons as the reference case in the health-care cost model, suture button repair was dominant (both less expensive and clinically superior). Hook plates cost substantially more ($5,360.52) compared with suture buttons and locking plates ($3,713.50 and $4,007.44, respectively). Suture buttons and locking plates yielded similar clinical outcomes (0.92 and 0.91 QALY, respectively). Suture button dominance persisted in the societal perspective model. Sensitivity analysis on outcome probabilities showed that locking plates became the most cost-effective strategy if the revision rate after their use was lowered to 2.2%, from the overall average in the sources of >19%. No other changes in outcome probabilities for any of the 3 techniques allowed suture buttons to be surpassed as the most cost-effective. CONCLUSIONS: The cost-effectiveness of suture buttons is driven by low revision rates and high uneventful healing rates. Similar QALY values for locking plate and suture button fixation were observed, which is consistent with existing literature that has failed to identify either as the clinically superior technique. Cost-effectiveness should fit prominently into the decision-making rubric for these injuries. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Operative treatment of displaced midshaft clavicular fractures is not cost-effective.

BACKGROUND: Conventional treatment of displaced midshaft clavicular fractures is nonoperative. Recent studies have implied that operative treatment might result in a faster return to work, resulting in a decreased productivity loss for society. The cost utility of plate fixation vs. nonoperative treatment of displaced midshaft clavicular fractures has not previously been investigated using a societal perspective. METHODS: Decision analytical modeling of incremental costs and quality-adjusted life-years (QALYs) was performed. Data on utility, hospitalization, and productivity costs were retrieved from a Danish randomized controlled trial. Supplementary data were taken from randomized controlled trials identified in the literature. A 1-year time horizon was applied, and all prices were reported with respect to a 2016 level. RESULTS: Operative treatment was associated with a larger QALY gain in patients and a higher cost compared with nonoperative treatment. The incremental cost-effectiveness ratio (ICER) was estimated in Danish currency (Danish krone [kr]) at kr1,360,000 (€182,306) per QALY from a health-sector perspective and kr1,388,738 (€186,158) per QALY from a societal perspective. Considering a subgroup analysis of patients with a high-load shoulder profession, operative treatment was dominated by nonoperative treatment from a health-sector perspective. Considering a societal perspective, the ICER was estimated at -kr889,091 (-€119,181) per reduction of 1 QALY. One-way and probabilistic sensitivity analyses showed that the results were subject to uncertainty. CONCLUSION: Operative treatment is not cost-effective when considering a threshold of €34,000/QALY. However, for a subgroup of patients with a high-load shoulder profession, operative treatment might be cost-effective compared with nonoperative treatment.

Health Care Costs of Post-traumatic Osteomyelitis in China: Current Situation and Influencing Factors.

BACKGROUND: Currently, very limited information is available regarding the economic burdens of patients with extremity post-traumatic osteomyelitis (OM). This study aimed to investigate direct health care costs and utilization for inpatients with extremity post-traumatic OM and analyze its constituent ratios and influencing factors in Southern China. METHODS: We searched in the electronic medical record system for inpatients who had received surgical interventions at our department between 2013 and 2016 for extremity post-traumatic OM. Data of direct health care costs incurred during their hospitalizations were collected in six main categories (service, diagnosis, treatment, materials, pharmaceuticals, and miscellaneous expenses). In addition, data of total medical costs for contemporaneous inpatients with non-post-traumatic OM were also collected as controls. RESULTS: A total of 278 post-traumatic OM and 10,420 controls were included. The median cost for the post-traumatic OM inpatients was $10,504 US dollars, 4.8-fold higher than that for those with non-post-traumatic OM ($2189, P < 0.001). The direct cost in the category of materials accounted for the largest proportion (61%), followed by that in pharmaceuticals (12%) and treatment (11%). The median number of hospital admissions for post-traumatic OM patients was 1 time, with a median length-of-stay of 22 d. The most influencing factors for the health care costs of the post-traumatic OM inpatients were use of an external fixator ($16,016 for those who used versus $4956 for those who did not, P < 0.001), external fixator type ($19,563 for ring fixator versus $14,966 for rail fixator, P < 0.001), infection site ($13,755 for tibia, $14,216 for femur and $5673 for calcaneus, P < 0.001), and infection-associated injury type ($12,890 for infection after open fracture versus $8087 for infection after closed fracture, P = 0.001). CONCLUSIONS: An unexpectedly large proportion of the direct health care costs for inpatients with extremity post-traumatic OM went to cover an external fixator, with expenses for pharmaceuticals and treatment accounting for only a little more than the tenth of the total health care costs. Use of external fixator, external fixator type, infection site, and infection-associated injury type directly influenced the health care costs.

Impact of sports participation on incidence of bone traumatic fractures and health-care costs among adolescents: ABCD - Growth Study.

Objective: To analyze the risk of bone traumatic fractures according to the engagement in sports, as well as to identify the potential impact of sports participation and traumatic fractures on health-care costs among adolescents. Methods: This is a longitudinal 12-month study of 285 adolescents of both sexes in Brazil. We assessed the occurrence of traumatic fractures and health-care services (hospitalizations, medicine use, medical consultations, and exams) by phone contact every month for 12 months. Adolescents were divided into four groups according to sport characteristics: non-sport (n = 104), non-impact sport (swimming [n = 34]), martial arts (n = 49 [judo, karate, kung-Fu]) and impact sports (n = 98 [track-and-field, basketball, gymnastics, tennis, and baseball]). Results: The incidence of new fractures was 2.1%. The overall costs accounted during the 12-month follow-up were U$ 3,259.66. Swimmers (US$ 13.86) had higher health-care costs than non-sport (US$ 1.82), martial arts (US$ 2.23), and impact sports (US$ 2.32). Conclusion: swimming seems to be related to higher health-care costs among adolescents.

The cost-effectiveness of extended-release calcifediol versus paricalcitol for the treatment of secondary hyperparathyroidism in stage 3-4 CKD.

Aims: Patients with chronic kidney disease (CKD) not on dialysis frequently have vitamin D insufficiency (VDI) and secondary hyperparathyroidism (SHPT), which are associated with an increased risk of cardiovascular (CV) disease, fracture, CKD progression, and death. This study estimated the cost-effectiveness of extended-release calcifediol (ERC) vs paricalcitol for the treatment of patients with CKD stages 3-4 that have SHPT and VDI.Materials and methods: An economic analysis of SHPT treatments among a hypothetical cohort of 1,000 patients with CKD Stage 3 and 4 with SHPT and VDI was developed to estimate differences in the rates and costs of CV events, fractures, CKD stage progression, and mortality in patients treated with ERC and paricalcitol. A Markov model was developed with 1-year cycles and a 5-year time horizon from a US Medicare payer perspective with costs valued in 2017 US dollars.Results: The outcomes of the model were rates of clinical events, total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). Across a 1,000-person cohort, ERC was the dominant (less costly, more effective) treatment strategy when compared with paricalcitol. Treatment with ERC resulted in cost savings of $14.8 M (95% CI = -$10.0 M-$45.2 M) and an incremental gain of 340 QALYs (95% CI = 200-496) compared to treatment with paricalcitol.Limitations: Bridging biochemical levels to clinical outcomes may not represent real-world risk of the clinical events modeled. Future real-world outcomes of patients treated with ERC and paricalcitol may be used to evaluate the model results.Conclusions: This model demonstrated favorable short- and long-term clinical benefits associated with the use of ERC in patients with CKD Stage 3 and 4 with SHPT and VDI, suggesting ERC may be cost-effective from the Medicare perspective compared to paricalcitol.

Socioeconomic factors and lifestyles influencing the incidence of calcaneal fractures, a national population-based survey in China.

BACKGROUND: We aimed to do a national survey on the population-based incidence of calcaneal fracture in China. METHODS: All the data on calcaneal fractures were available from the China National Fracture Survey (CNFS) between January and May in 2015. And in the CNFS, all eligible household members were sampled from 8 provinces, 24 urban cities and 24 rural counties in China, using stratified random sampling and the probability proportional to size method. Questionnaires were sent to every participant for data collection and quality control was accomplished by our research team members. RESULTS: A total of 512187 valid questionnaires were collected and relevant data were abstracted and analyzed. There were 59 patients with 62 calcaneal fractures occurring in 2014, indicating that the incidence was 11.5/100,000 person-years, 17.3/100,000 in males, and 5.5/100,000 in females. BMI ≥ 28.0 kg/m2, scarce meat consumption, smoking, alcohol consumption, average sleep time < 7 h/day, and previous history of fracture were identified as independent risk factors for calcaneal fracture. CONCLUSIONS: Specific public health policies focusing on quitting smoking, decreasing alcohol consumption, and encouraging individuals to obtain sufficient sleep should be implemented. Reasonable meat consumption and maintaining a normal body weight should be emphasized in individuals, especially in those with previous fracture.

Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?

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.