Analysis of factors influencing hospitalization cost of patients with distal radius fractures: an empirical study based on public traditional Chinese medicine hospitals in two cities, China.

BACKGROUND: Distal radius fractures (DRFs) have become a public health problem for all countries, bringing a heavier economic burden of disease globally, with China's disease economic burden being even more acute due to the trend of an aging population. This study aimed to explore the influencing factors of hospitalization cost of patients with DRFs in traditional Chinese medicine (TCMa) hospitals to provide a scientific basis for controlling hospitalization cost. METHODS: With 1306 cases of DRFs patients hospitalized in 15 public TCMa hospitals in two cities of Gansu Province in China from January 2017 to 2022 as the study object, the influencing factors of hospitalization cost were studied in depth gradually through univariate analysis, multiple linear regression, and path model. RESULTS: Hospitalization cost of patients with DRFs is mainly affected by the length of stay, surgery and operation, hospital levels, payment methods of medical insurance, use of TCMa preparations, complications and comorbidities, and clinical pathways. The length of stay is the most critical factor influencing the hospitalization cost, and the longer the length of stay, the higher the hospitalization cost. CONCLUSIONS: TCMa hospitals should actively take advantage of TCMb diagnostic modalities and therapeutic methods to ensure the efficacy of treatment and effectively reduce the length of stay at the same time, to lower hospitalization cost. It is also necessary to further deepen the reform of the medical insurance payment methods and strengthen the construction of the hierarchical diagnosis and treatment system, to make the patients receive reasonable reimbursement for medical expenses, thus effectively alleviating the economic burden of the disease in the patients with DRFs.

Cost Analysis of Volar Plate Fixation Versus Plaster Cast Immobilization for Intra-Articular Distal Radial Fractures.

BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial.

BACKGROUND: This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures. METHODS: This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio. RESULTS: Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year. CONCLUSIONS: Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Cost-Effectiveness of Volar Locking Plate Compared with Augmented External Fixation for Displaced Intra-Articular Wrist Fractures.

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

Institutional Variation in Surgical Rates and Costs for Pediatric Distal Radius Fractures: Analysis of the Pediatric Health Information System (PHIS) Database.

Background: Reduction of variations may streamline healthcare delivery, improve patient outcomes, and minimize cost. The purpose of this study was to characterize variations in surgical rates and hospital costs for treatment of pediatric distal radius fractures (DRFs) using Pediatric Health Information System (PHIS) database. Methods: The PHIS database was queried from 2009-2013 for DRFs in patients 4-18 years of age. Patients who underwent surgical treatment with internal fixation were identified using surgical CPT codes and/or ICD-9 procedure codes. 25 children's hospitals were included. Surgical rates and hospital costs were modeled. Rates were adjusted and standardized for gender, age, presence of other diagnoses, and year. Results: The aggregate rate of surgery for treatment of DRF was 2.65% and for open surgery was 0.81%. The standardized surgical rates for the 25 hospitals ranged widely, from 1.45% to 13.8% and for open surgical treatment from 0.51% to 4.27%. Six of the 25 hospitals had rates significantly higher than the aggregate for surgical treatment. Standardized hospital costs per patient ranged from $361 to $1,088 (2013 US dollars) across the hospitals with fairly uniform distribution. Conclusions: In the United States, there is great variability in practice and hospital costs of treatment of distal radius fractures. Further characterization of the root causes of these variations, and the effect, if any, on patient outcomes, is needed to improve value delivery in pediatric orthopaedic care.Level of Evidence: II.

Effect of Global Fracture Care Billing on Distal Radius Fractures.

Nonoperative distal radius fracture treatment without manipulation can be coded and billed in a global fee or itemized structure. Little is known regarding the association between these coding/billing structures and subsequent clinical care. The MarketScan Research Database (IBM, Armonk, New York) was retrospectively queried for patients with a distal radius fracture diagnosis code from 2003 to 2014. Patients with a Current Procedural Terminology code for surgical treatment or closed treatment with manipulation were excluded. The remaining nonoperatively treated patients were separated based on billing structure. Results were analyzed for provider initiating global fracture care, as well as the likelihood and frequency of follow-up visits related to the injury for each group. A total of 381,561 patients were identified based on inclusion criteria. Global fracture care billing was initiated for 177,153 (46%) patients, whereas itemized billing was performed for 204,408 (54%) patients. Orthopedic surgeons were the most likely provider (69%) to initiate global fracture care after diagnosis of distal radius fracture. Emergency physicians were the second most common specialty (6%). Patients for whom global fracture care was initiated were more likely to not receive any follow-up office visits compared with patients for whom itemized billing was performed (39.2% vs 25.4%). Additionally, patients with global billing had significantly fewer office visits during the 90-day global period (1.3 vs 2.3). This study demonstrates that patients billed via global fracture care have less frequent follow-up and fewer office visits during the 90-day global period than patients billed in itemized fashion. [Orthopedics. 2020;43(5);e471-e475.].

Volar Plate Fixation in Adults with a Displaced Extra-Articular Distal Radial Fracture Is Cost-Effective.

BACKGROUND: To our knowledge, a health economic evaluation of volar plate fixation compared with plaster immobilization in patients with a displaced extra-articular distal radial fracture has not been previously conducted. METHODS: A cost-effectiveness analysis of a multicenter randomized controlled trial was performed. Ninety patients were randomly assigned to volar plate fixation or plaster immobilization. The use of resources per patient was documented prospectively for up to 12 months after randomization and included direct medical, direct non-medical, and indirect non-medical costs due to the distal radial fracture and the received treatment. RESULTS: The mean quality-adjusted life-years (QALYs) at 12 months were higher in patients treated with volar plate fixation (mean QALY difference, 0.16 [bias-corrected and accelerated 95% confidence interval (CI), 0.07 to 0.27]). (The 95% CIs throughout are bias-corrected and accelerated.) In addition, the mean total costs per patient were lower in patients treated with volar plate fixation (mean difference, -$299 [95% CI, -$1,880 to $1,024]). The difference in costs per QALY was -$1,838 (95% CI, -$12,604 to $9,787), in favor of volar plate fixation. In a subgroup analysis of patients who had paid employment, the difference in costs per QALY favored volar plate fixation by -$7,459 (95% CI, -$23,919 to $3,233). CONCLUSIONS: In adults with a displaced extra-articular distal radial fracture, volar plate fixation is a cost-effective intervention, especially in patients who had paid employment. Besides its better functional results, volar plate fixation is less expensive and provides a better quality of life than plaster immobilization. LEVEL OF EVIDENCE: Economic Level I. See Instructions for Authors for a complete description of levels of evidence.

Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department.

Importance: Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed. Objective: To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures. Design, Setting, and Participants: This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019. Main Outcomes and Measures: Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care. Results: Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03). Conclusions and Relevance: The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial.

Importance: The value of precise anatomic restoration for distal radius fractures (DRFs) in older adults has been debated for many decades, with conflicting results in the literature. In light of the growing population of adults aged 60 years and older, both fracture incidence and associated treatment costs are expected to increase. Objective: To determine the association between radiographic measures of reduction and patient outcomes after DRF in older patients. Design, Setting, and Participants: Data were collected from the Wrist and Radius Injury Surgical Trial (WRIST), a multicenter randomized clinical trial of DRF treatments for adults aged 60 years and older (enrollment from April 10, 2012, to December 31, 2016, with a 2-year follow-up). Data analysis was performed from January 3, 2019, to August 19, 2019. WRIST participants who completed 12-month assessments were included in the study. According to the biomechanical principle of alignment, 2-phase multivariable regression models were adopted to assess the association between radiographic measures of reduction and functional and patient-reported outcomes 12 months following treatment. Interventions: Participants were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Those who opted for nonoperative treatment received casts. Main Outcomes and Measures: Hand grip strength, wrist arc of motion, radial deviation, ulnar deviation, the Michigan Hand Outcomes Questionnaire (MHQ) total score, MHQ function score, and MHQ activities of daily living score were measured at 12 months following treatment. Results: Data from 166 WRIST participants (144 [86.7%] women; mean [SD] age, 70.9 [8.9] years) found that only 2 of the 84 correlation coefficients calculated were statistically significant. For patients aged 70 years or older, every degree increase in radial inclination away from normal (22°) grip strength in the injured hand was 1.1 kg weaker than the uninjured hand (95% CI, 0.38-1.76; P = .004) and each millimeter increase toward normal (0 mm) in ulnar variance was associated with a 10.4-point improvement in MHQ ADL score (95% CI, -16.84 to -3.86; P = .003). However, neither of these radiographic parameters appeared to be associated with MHQ total or function scores. Conclusions and Relevance: The study results suggest that precise restoration of wrist anatomy is not associated with better patient outcomes for older adults with DRF 12 months following treatment. Surgeons can consider this evidence to improve quality of care by prioritizing patient preferences and efficient use of resources over achieving exact realignment. Trial Registration: ClinicalTrials.gov identifier: NCT01589692.

Adhering to Radiographic Clinical Practice Guidelines for Distal Radial Fracture Management Is Associated with Improved Outcomes and Lower Costs.

BACKGROUND: The American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Treatment of Distal Radius Fractures has not been evaluated in clinical practice. We hypothesized that adhering to the distal radial fracture radiographic clinical practice guideline (CPG) improves outcomes and reduces costs. METHODS: We reviewed 266 patients with distal radial fractures treated at 1 institution. Based on CPG radiographic parameters (Recommendation 3), care was rated as "appropriate" or "inappropriate." QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) scores were collected. The direct costs of distal radial fracture care were determined. Descriptive statistics and nonparametric tests were used to evaluate demographic characteristics and outcomes across groups. QuickDASH scores, grouped by postoperative time interval, were analyzed using linear mixed effect models to predict outcome trends. RESULTS: In this study, 145 patients in the operative treatment group and 121 patients in the nonoperative treatment group were included. Of the 145 patients in the operative treatment group, 6 underwent an inappropriate surgical procedure, limiting any analyses of that group. Of the 121 patients in the nonoperative treatment group, 68 were treated inappropriately. For the patients in the nonoperative treatment group, appropriate care provided a significant outcome benefit by 1 year; the median QuickDASH score was 10.1 points for the appropriate treatment group and 19.5 points for the inappropriate treatment group (p = 0.05). The total direct costs for inappropriate nonoperative treatment were, on average, 60% higher than appropriate nonoperative treatment. In predictive models, patients with appropriate care in the operative treatment group and the nonoperative treatment group had better outcomes than patients with inappropriate nonoperative treatment at all time points after 29 days. CONCLUSIONS: When nonoperative distal radial fracture management was aligned with radiographic CPG criteria, patients in our cohort had improved patient-reported outcomes with lower costs. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The efficacy, safety, and cost benefits of splints for fractures of the distal radius in children: A systematic review and meta-analysis protocol.

BACKGROUND: Distal radius fractures (DRFs) is one of the most common bone injuries in children, which may lead to deformity and other complications if the treatment is not prompt or appropriate. Splints external fixation is a common conservative treatment for such fractures. Therefore, we conducted a systematic review and meta-analysis to explore the efficacy, safety and cost benefits of splints in the treatment of DRFs in children. METHODS: PubMed, Web of Science, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov, Chinese National Knowledge Infrastructure Database (CNKI), Wanfang Database, and VIP Database were searched for eligible randomized controlled trials (RCTs). The methodological quality of the included studies and the level of evidence for results were assessed, respectively, using the risk bias assessment tool of Cochrane and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Statistical analysis was conducted with Revman 5.3. RESULTS: This study will analyze and integrate the existing evidence for effectiveness, safety and cost benefits of splints on DRFs in children. CONCLUSION: The conclusion of this study will provide evidence to effectiveness, safety and cost benefits of splints on DRFs in children, which can further guide the selection of appropriate interventions. PROSPERO REGISTRATION NUMBER: CRD42019123429.

Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-based Medicine.

BACKGROUND: Multiple randomized trials have showed equivalent outcomes and improved patient/family satisfaction using a removable brace to treat pediatric distal radius buckle fractures (DRBF). We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at 2 tertiary care orthopaedic clinics from a baseline of 34.8% to 80%. METHODS: Clinic billing records were reviewed monthly to determine treatment (brace vs. cast) of DRBF and tracked using control charts (p-chart). Balance measures including correct application of the diagnostic criteria and algorithm were monitored. Process measures including the number of follow-up visits, radiographs obtained, and total cost of treatment were collected. Baseline data were obtained over a 3-month period, followed by a 12-month period of interventions using Plan-Do-Study-Act cycles targeting both individuals and groups of providers. RESULTS: The proportion of DRBF treated in a brace increased from a combined baseline of 34.8% to a combined 84% at the end of the study period. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as >67%), with only 1 provider continuing to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at 1 of 2 institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 following intervention. CONCLUSIONS: Implementation of brace treatment for pediatric DRBF using QI methodology resulted in a shift toward brace treatment in the majority of patients, leading to substantial medical and nonmedical cost savings. Although patient preference was cited as the most common reason for persistent cast treatment, the data show the use of cast treatment to be more dependent upon individual provider preference. LEVEL OF EVIDENCE: Level II-therapeutic.

Business Modeling of Orthopaedic Trauma in the Emergency Department: An Untapped Revenue Stream.

INTRODUCTION: Emergency departments (EDs) and emergency medicine and orthopaedic residencies can be faced with financial challenges while caring for patients. Procedures performed by residents are a potentially viable source of revenue that may make orthopaedic coverage of the ED a financially viable service line. METHODS: A custom text-mining program was created and validated, which allowed evaluation of all orthopaedic resident notes. Procedures performed in the ED were quantified, allowing for the calculation of professional fee billing data. The patients with distal radius fractures were followed after fracture reduction through final outpatient clinic follow-up to identify additional professional fee billing. RESULTS: Over a 1-year period, more than $445,000 in uncaptured professional fees charged was identified in the 12 most common Current Procedural Terminology codes for splint application and fracture reduction in the ED. More than $395,000 of outpatient professional revenue was received for patients who had reduction of distal radius fractures in the ED. CONCLUSION: A notable, previously unrecognized and uncaptured source of revenue was identified and quantified. Professional fee billing for distal radius fracture reduction in the ED did not have a negative effect on outpatient professional fee revenue received for these patients.

A Dedicated Fracture Reduction Room: A Cost-Effective Alternative to the Operating Room.

INTRODUCTION: Charges, procedural efficiency, return to activity, and complications after closed treatment of fractures performed in an operating room (OR) versus closed reduction in a dedicated fracture reduction room (FRR) were compared. METHODS: Patients with closed fractures of the forearm who underwent closed reduction in the year before (OR), and after implementation of the FRR, were retrospectively reviewed. Charges, American Society of Anesthesiologists class, sex, age, length of follow-up, prior reduction, fracture location/displacement, time from injury to procedure, procedural time, time to return to activity, and complications were recorded. RESULTS: Eighteen patients met the inclusion criteria in the FRR group (13 men, 5 women), and 22 in the OR group (18 men, 4 women). No notable differences in age, sex, follow-up, American Society of Anesthesiologists class, fracture location/displacement, incidence of prior reduction, or time to return to activity were observed. Two (9.5%) complications occurred in the FRR group versus 7 (32%) in the OR group, P > 0.05. No anesthesia complications were present. Patients treated in the FRR incurred charges of $5,299 ± $1,289 versus $10,455 ± $2,290 in the OR, P < 0.001. Total time of visit in the FRR was ∼30% less than the OR, P < 0.001. No notable delay in treatment was observed. DISCUSSION: In the era of finite resources and value-based care, implementation of a FRR resulted in safe, cost-effective, and increased procedural efficiency.

A Bundled Payment Model for Pediatric Distal Radius Fractures: Defining an Episode of Care.

BACKGROUND: Distal radius fractures are the most common fracture of childhood, occurring in ∼1 per 100 children annually. Given the high incidence of these fractures, we explored feasibility of a bundled payment model. We determined the total treatment costs for each child and identified components of fracture management that contributed to variations in cost. METHODS: We retrospectively reviewed all hospital and physician costs related to the treatment of closed distal radius fractures at a large academic children's hospital. We included all children age 2 to 15 years treated by an orthopaedic surgeon for an isolated closed distal radius fracture between 2013 and 2015. We compared total treatment costs by fracture management approach. We then estimated the contribution of each component of fracture management to total treatment costs using linear regression. RESULTS: We identified 5640 children meeting the inclusion criteria, of which 4602 (81.6%) received closed treatment without manipulation, 922 (16.3%) underwent closed reduction in the clinic, emergency department, or radiology procedure suite, and 116 (2.1%) underwent treatment in the operating room. The median cost for closed treatment without manipulation was $1390 [interquartile range (IQR) 1029 to 1801], compared with $4263 (IQR, 3740 to 4832) for closed reduction and $9389 (IQR, 8272 to 11,119) for closed reduction and percutaneous pinning (P<0.001). In multivariable regression analysis, fracture management approach and use of the operating room environment were the largest cost drivers (P<0.001, R=0.88). Closed reduction in the clinic or emergency department added $894 (95% confidence interval, 819-969) to treatment costs, while closed reduction in the operating room added $5568 (95% confidence interval, 5224-6297). Location of the initial clinical evaluation, number of radiographic imaging series obtained, and number of orthopaedic clinic visits also contributed to total costs. CONCLUSIONS: Closed pediatric distal radius fractures treated without manipulation show small variations in treatment costs, making them well suited for bundled payment. Bundled payments for these fractures could reduce costs by encouraging adoption of existing evidence-based practices. LEVEL OF EVIDENCE: Level III-therapeutic.

Evaluation of Factors Driving Cost Variation for Distal Radius Fracture Open Reduction Internal Fixation.

PURPOSE: Distal radius fracture open reduction and internal fixation (ORIF) represents a considerable cost burden to the health care system. We aimed to elucidate demographic-, injury-, and treatment-specific factors influencing surgical encounter costs for distal radius ORIF. METHODS: We retrospectively reviewed adult patients treated with isolated distal radius ORIF between November 2014 and October 2016 at a single tertiary academic medical center. Using our institution's information technology value tools-which allow for comprehensive payment and cost data collection and analysis on an item-level basis-we determined relative costs (RC) for each factor potentially influencing total direct costs (TDC) for distal radius ORIF using univariate and multivariable gamma regression analyses. RESULTS: Of the included 108 patients, implants and facility utilization costs were responsible for 48.3% and 37.9% of TDC, respectively. Factors associated with increased TDC include plate manufacturer (RC 1.52 for the most vs least expensive manufacturer), number of screws (RC 1.03 per screw) and distal radius plates used (RC 1.67 per additional plate), surgery setting (RC 1.32 for main hospital vs ambulatory surgery center), treating service (RC 1.40 for trauma vs hand surgeons), and surgical time (RC 1.04 for every 10 min of additional surgical time). Open fracture was associated with increased costs (RC 1.55 vs closed fracture), whereas other estimates of fracture severity were nonsignificant. In the multivariable model controlling for injury-specific factors, variables including implant manufacturer, and number of distal radius plates and screws used, remained as significant drivers of TDC. CONCLUSIONS: Substantial variations in surgical direct costs for distal radius ORIF exist, and implant choice is the predominant driver. Cost reductions may be expected through judicious use of additional plates and screws, if hospital systems use bargaining power to reduce implant costs, and by efficiently completing surgeries. CLINICAL RELEVANCE: This study identifies modifiable factors that may lead to cost reduction for distal radius ORIF.

Cost of Surgical Treatment for Distal Radius Fractures and the Implications of Episode-Based Bundled Payments.

PURPOSE: To examine the cost of care of surgical treatment for a distal radius fracture (DRF) and develop episodes that may be used to develop future bundled payment programs. METHODS: Using 2009 to 2015 claims data from the Truven MarketScan Databases, we examined the cost of care for surgical treatment of DRFs among adult patients in the United States. We excluded patients with concurrent fractures, patients who required complex care, and patients in assisted living facilities. We extracted data on cost and type of services provided to eligible patients, tracking patients from 3 days prior to operation to 90 days after operation. From these data, we developed 4 episode-of-care scenarios to develop an estimated bundled payment. We computed the variation in cost between surgery types, time periods, and type of service provided. RESULTS: Our final sample included 23,453 DRF operations, of which 15% were performed on patients 65 years of age or older. The majority (88%) underwent open fixation, the option associated with the highest cost. The average cost of care for a DRF patient ranged from $6,577 to $8,181 depending on the definition of an episode-of-care. Regardless of definition, the variation in cost was high. The cost of surgery itself composed 61% to 91% of the total cost of an episode. Of claims not directly related to the surgery, anesthesia and drugs, imaging, and therapy costs composed the next greatest proportions of the total cost of care. CONCLUSIONS: Many DRF surgical episodes incur substantially higher costs than the average. To maximize cost reduction, bundled payments for DRFs are best designed with a clinically narrow definition that is limited to services related to the fracture and long enough to capture relevant postoperative therapy and imaging costs. CLINICAL RELEVANCE: This study provides insight on spending to lay the foundation for shifting reimbursement strategies.

Intramedullary nails in the treatment of the distal radius fractures.

The distal radius fracture is a common injury in old persons. Its treatment remains a critical challenge because of number of cases, the final cost of the procedure, the level of X-ray irradiation, and the demand of technique of fixation in osteoporotic bone. The entire closed procedure requires a strict percutaneous nailing. This offers advantages in terms of postoperative pain, per-operative irradiation, and cost. The main problem was so far the ability to insure a stable reduction in time. This point is discussed with the introduction of the "Nail-o-Flex®" nail. A continuous series of 83 patients is introduced.

How Much Will My Child's Operation Cost? Availability of Consumer Prices From US Hospitals for a Common Pediatric Orthopaedic Surgical Procedure.

BACKGROUND: Price transparency allows patients to make value-based health care decisions and is particularly important for individuals who are uninsured or enrolled in high-deductible health care plans. The availability of consumer prices for children undergoing orthopaedic surgery has not been previously investigated. We aimed to determine the availability of price estimates from hospitals in the United States for an archetypal pediatric orthopaedic surgical procedure (closed reduction and percutaneous pinning of a distal radius fracture) and identify variations in price estimates across hospitals. METHODS: This prospective investigation utilized a scripted telephone call to obtain price estimates from 50 "top-ranked hospitals" for pediatric orthopaedics and 1 "non-top-ranked hospital" from each state and the District of Columbia. Price estimates were requested using a standardized script, in which an investigator posed as the mother of a child with a displaced distal radius fracture that needed closed reduction and pinning. Price estimates (complete or partial) were recorded for each hospital. The number of calls and the duration of time required to obtain the pricing information was also recorded. Variation was assessed, and hospitals were compared on the basis of ranking, teaching status, and region. RESULTS: Less than half (44%) of the 101 hospitals provided a complete price estimate. The mean price estimate for top-ranked hospitals ($17,813; range, $2742 to $49,063) was 50% higher than the price estimate for non-top-ranked hospitals ($11,866; range, $3623 to $22,967) (P=0.020). Differences in price estimates were attributable to differences in hospital fees (P=0.003), not surgeon fees. Top-ranked hospitals required more calls than non-top-ranked hospitals (4.4±2.9 vs. 2.8±2.3 calls, P=0.003). A longer duration of time was required to obtain price estimates from top-ranked hospitals than from non-top-ranked hospitals (8.2±9.4 vs. 4.1±5.1 d, P=0.024). CONCLUSIONS: Price estimates for pediatric orthopaedic procedures are difficult to obtain. Top-ranked hospitals are more expensive and less likely to provide price information than non-top-ranked hospitals, with price differences primarily caused by variation in hospital fees, not surgeon fees. LEVEL OF EVIDENCE: Level II-economic and decision analyses.

Outcomes and financial implications of intra-articular distal radius fractures: a comparative study of open reduction internal fixation (ORIF) with volar locking plates versus nonoperative management.

BACKGROUND: To evaluate the functional and radiographic outcomes, as well as the treatment costs, of closed displaced intra-articular distal radius fractures treated with either open reduction internal fixation (ORIF) with volar locking plates or nonoperative treatment with plaster cast immobilisation. MATERIALS AND METHODS: A total of 60 patients (32 receiving ORIF, 28 receiving nonoperative treatment) with closed intra-articular distal radius fractures were included. The mean age was 52.1 and 57.4, respectively. Functional and radiographic assessments were carried out at 12 months post-injury. Patients' treatment costs, median salaries and lengths of medical leave were obtained. RESULTS: DASH and MAYO wrist score in the ORIF group did not differ significantly from those in the nonoperative group. Apart from superior ulnar deviation in the ORIF group (p = 0.0096), differences in the range of motion of the injured wrists were not significant. Similarly, there were no significant differences in grip strength and visual analog scale for pain. Volar tilt (p = 0.0399), radial height (p = 0.0087), radial inclination (p = 0.0051) and articular step-off (p = 0.0002) were all significantly superior in the ORIF group. There was a 37-fold difference in mean treatment costs between ORIF (SGD 7951.23) and nonoperative treatment (SGD 230.52). CONCLUSION: Our study shows no difference in overall functional outcomes at 12 months for closed displaced intra-articular distal radius fractures treated with either ORIF with volar locking plates or plaster cast immobilisation, and this is independent of radiographic outcome. A longer follow-up, nevertheless, is needed to determine whether the development of post-traumatic arthritis will have an effect on function. The vast difference in treatment costs should be taken into consideration when deciding on the treatment option. LEVEL OF EVIDENCE: Level 3.