Little Kevin J, Godfrey Jenna, Cornwall Roger, Carr Preston, Dolan Kevin, Balch Samora Julie
Division of Pediatric Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati.
Department of Orthopaedic Surgery, Nationwide Children's Hospital, Columbus, OH.
J Pediatr Orthop. 2019 Sep;39(8):e586-e591. doi: 10.1097/BPO.0000000000001239.
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%.
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.
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.
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 II-therapeutic.
多项随机试验表明，使用可摘除支具治疗小儿桡骨远端青枝骨折（DRBF）可取得同等疗效，并提高患者/家属满意度。我们检验了这样一个假设，即我们可以运用质量改进（QI）方法，将两家三级护理骨科诊所中接受可摘除支具治疗的DRBF患者比例从34.8%的基线水平提高到80%。
每月审查诊所计费记录，以确定DRBF的治疗方式（支具与石膏），并使用控制图（p图）进行跟踪。监测包括诊断标准和算法正确应用在内的平衡指标。收集包括随访次数、所拍X光片数量和治疗总成本在内的过程指标。在3个月期间获取基线数据，随后使用针对个体和医疗服务提供者群体的计划-执行-研究-行动循环进行为期12个月的干预。
在研究期结束时，接受支具治疗的DRBF患者比例从综合基线水平的34.8%提高到了综合的84%。干预后，83%（15/18）的医疗服务提供者开始对大多数患者（定义为>67%）使用支具，只有1名医疗服务提供者继续100%使用石膏。患者偏好被列为使用石膏治疗的最常见原因。两家机构中的一家所拍X光片数量显著减少。支具治疗的费用平均每位患者比石膏治疗少630美元，干预后估计节省医疗成本205,000美元。
运用QI方法对小儿DRBF实施支具治疗，使大多数患者转向支具治疗，从而大幅节省了医疗和非医疗成本。尽管患者偏好被列为持续使用石膏治疗的最常见原因，但数据表明石膏治疗的使用更依赖于个体医疗服务提供者的偏好。
二级治疗性。
