Lewis Robert B, Hariri Omar, Elliott Marilyn E, Jo Chan-Hee, Ramo Brandon A
Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center.
Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children and Children's Medical Center of Dallas, Dallas, TX.
J Pediatr Orthop. 2019 Feb;39(2):e114-e119. doi: 10.1097/BPO.0000000000001253.
Health care in America continues to place more importance on providing value-based medicine. Medicare reimbursements are increasingly being tied to this and future policy changes are expected to reinforce these trends. Recent literature has shown pediatric femur fractures in preschool-age children have equivalent clinical and radiographic outcomes when treated with spica casting or flexible intramedullary nails (IMN). We compared hospital care statistics including charges for nonoperative versus operative treatment for closed femur fractures in 3- to 6-year-olds.
An IRB-approved retrospective chart review was performed of 73 consecutive 3- to 6-year-olds treated at a regional level 1 pediatric hospital from January 1, 2009 to December 31, 2013 with an isolated, closed femoral shaft fracture. Exclusion criteria included open fractures, bilateral injury, and polytrauma. Immediate spica casting was performed in the Emergency Department or Anesthesia Procedure Unit versus IMN in the operating room.
A total of 41 patients were treated with spica casting and 32 patients were treated operatively with flexible IMNs; 3 patients failed nonoperative care. After analysis of final treatment groups, significant differences included age at injury: 3.7 years for cast versus 5.3 years for IMN (P<0.001), time to discharge 21 versus 41 hours (P<0.001), 3.2 versus 4.4 clinic visits (P<0.001), follow-up 3.5 versus 9.4 months (P<0.001). Orthopedic surgeon charges were $1500 for casted patients versus $5500 for IMN (P<0.001). Total hospital charges were $19,200 for cast versus $59,700 for IMN (P<0.001). No difference was found between clinic charges or number of radiographs between groups. In total, 76% of cast group were discharged <24 hours from admission versus 8.6% in operative group. In the operative group, 83% had implant removal with no statistically significant charge difference between those who had implant removal versus retention.
Treatment of pediatric femur fractures in 3- to 6-year-olds with IMN is associated with longer hospital stays, significantly greater hospital charges, longer follow-up and more clinic visits compared with spica casting. These findings are at odds with previous literature showing shorter hospital stays and decreased cost with nailing compared to traction and casting. This shows a clear difference between 2 treatments that yield similar clinical and radiographic outcomes.
Level III-retrospective comparative study.
美国医疗保健越来越重视提供基于价值的医疗服务。医疗保险报销越来越多地与此挂钩，预计未来的政策变化将强化这些趋势。最近的文献表明，学龄前儿童的小儿股骨骨折采用髋人字石膏固定或弹性髓内钉（IMN）治疗时，临床和影像学结果相当。我们比较了3至6岁儿童闭合性股骨骨折非手术与手术治疗的医院护理统计数据，包括费用。
对2009年1月1日至2013年12月31日在一家地区一级儿科医院连续治疗的73例3至6岁孤立性闭合股骨干骨折患儿进行了经机构审查委员会批准的回顾性病历审查。排除标准包括开放性骨折、双侧损伤和多发伤。在急诊科或麻醉操作单元进行即刻髋人字石膏固定，而在手术室进行IMN治疗。
共41例患者采用髋人字石膏固定治疗，32例患者采用弹性IMN手术治疗；3例非手术治疗失败。对最终治疗组进行分析后，显著差异包括受伤年龄：石膏固定组为3.7岁，IMN组为5.3岁（P<0.001）；出院时间分别为21小时和41小时（P<0.001）；门诊就诊次数分别为3.2次和4.4次（P<0.001）；随访时间分别为3.5个月和9.4个月（P<0.001）。骨科医生收费方面，石膏固定患者为1500美元，IMN患者为5500美元（P<0.001）。医院总收费方面，石膏固定为19200美元，IMN为59700美元（P<0.001）。两组之间门诊收费或X光片数量无差异。总体而言，石膏固定组76%的患者入院后<24小时出院，而手术组为8.6%。在手术组中，83%的患者进行了内固定取出，取出与保留内固定的患者之间收费无统计学显著差异。
与髋人字石膏固定相比，3至6岁儿童股骨骨折采用IMN治疗与住院时间更长、医院收费显著更高、随访时间更长和门诊就诊次数更多相关。这些发现与之前的文献显示与牵引和石膏固定相比，穿钉治疗住院时间更短且成本降低相矛盾。这表明两种治疗方法在产生相似临床和影像学结果的情况下存在明显差异。
III级——回顾性比较研究。
