Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA.
J Bone Joint Surg Am. 2010 May;92(5):1105-14. doi: 10.2106/JBJS.I.00295.
Intramedullary nails provide no clear outcomes benefit in the majority of patients with intertrochanteric hip fracture, yet their use in the United States continues to increase. Non-patient factors that are associated with intramedullary nail use among Medicare patients have not been examined. The goal of this study was to identify the surgeon and hospital characteristics that were associated with the use of intramedullary nails compared with plate-and-screw devices among elderly Medicare patients with intertrochanteric hip fractures.
Medicare beneficiaries who were sixty-five years of age or older and underwent inpatient surgery to treat an intertrochanteric femoral fracture with use of an intramedullary nail or a plate-and-screw device were identified from the United States Medicare files for 2000 to 2002. Surgeon and hospital characteristics from the Medicare provider enrollment files were merged with the claims. Generalized linear mixed models with fixed and random effects modeled the association between surgeon and hospital factors and intramedullary nail use (compared with plate and screws), controlling for patient age, sex, and race; subtrochanteric fracture; Charlson comorbidity score; nursing home residence; and Medicaid-administered assistance. The adjusted odds ratios of receiving an intramedullary nail by year, surgeon, and hospital factors are reported.
There were 192,365 claims for surgery to treat an intertrochanteric hip fracture that met the inclusion criteria and matched with surgeon and hospital information. There were 15,091 surgeons who performed intertrochanteric hip fracture surgeries in Medicare patients in 3480 hospitals between March 1, 2000, and December 31, 2002. The surgeon factors associated with intramedullary nail use include younger surgeon age (less than forty-five years old), an osteopathy degree, and operating at more than one hospital. The hospital factors associated with intramedullary nail use include a higher volume of intertrochanteric hip fracture surgeries, teaching hospital status, and having resident assistance during surgery. Surgeon factors improved the model fit more than hospital factors.
The use of intramedullary nails was strongly associated with early-career surgeons and surgeon training programs. Our findings suggest that orthopaedic faculty at teaching hospitals and younger surgeons may be selecting orthopaedic implants on the basis of factors other than clinical outcomes evidence. We expect that intramedullary nail use will continue to increase as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospital's burden of their choices for higher cost devices under the Medicare payment system.
髓内钉在大多数转子间骨折患者中并未带来明确的疗效获益，但在美国，其应用仍在不断增加。尚未对与 Medicare 患者使用髓内钉相关的非患者因素进行研究。本研究的目的是确定与老年 Medicare 患者转子间骨折的髓内钉与钢板螺钉装置使用相关的外科医生和医院特征。
从 2000 年至 2002 年的美国 Medicare 档案中，确定了年龄在 65 岁及以上并接受住院手术治疗转子间股骨骨折的 Medicare 受益人的记录，这些患者使用的是髓内钉或钢板螺钉装置。将 Medicare 提供者登记档案中的外科医生和医院特征与索赔信息合并。采用固定和随机效应的广义线性混合模型，对外科医生和医院因素与髓内钉（与钢板螺钉相比）使用之间的关系进行建模，同时控制患者的年龄、性别和种族、转子下骨折、Charlson 合并症评分、疗养院居住情况和 Medicaid 管理援助。报告了按年份、外科医生和医院因素调整后的接受髓内钉治疗的优势比。
共有 192365 例手术治疗符合纳入标准的转子间髋部骨折的索赔，并与外科医生和医院信息相匹配。在 2000 年 3 月 1 日至 2002 年 12 月 31 日期间，有 15091 名外科医生在 Medicare 患者中进行了 3480 家医院的转子间髋部骨折手术。与髓内钉使用相关的外科医生因素包括年轻的外科医生年龄（<45 岁）、整骨学位和在多个医院执业。与髓内钉使用相关的医院因素包括较高的转子间髋部骨折手术量、教学医院地位以及手术期间有住院医师协助。外科医生因素比医院因素更能提高模型拟合度。
髓内钉的使用与早期职业外科医生和外科医生培训计划密切相关。我们的研究结果表明，教学医院的骨科教员和年轻外科医生可能会根据临床结果证据以外的因素选择骨科植入物。我们预计，只要新外科医生优先接受髓内钉手术培训，并且在 Medicare 支付系统下，外科医生的报酬不受其选择高成本设备的治疗医院负担的影响，髓内钉的使用将继续增加。
