Fri., 10/14/11 Knee, Foot & Ankle, Paper #65, 4:44 pm OTA-2011
Payer Status Negatively Influences Initial Treatment at Community Hospitals Compared to a Tertiary Care Center: A Prospective Study of 300 Operative Ankle Fractures
Michael T. Archdeacon, MD, MSE; Sudhir R. Belagaje, MD;
Theodore Toan Le, MD; John D. Wyrick, MD;
University of Cincinnati Medical Center, Cincinnati, Ohio, USA
Purpose: Ankle fractures are common injuries, and their initial and definitive management should fall within the skill set of most board-certified orthopaedic surgeons. The purpose of this study is to evaluate the association of payer status with initial treatment (attempted reduction) and transfer or referral to a tertiary care center for definitive treatment. Our null hypothesis states that no difference in initial treatment or payer status will be observed in operative ankle fracture patients who present primarily to our tertiary care center compared to patients who are transferred or referred.
Methods: We prospectively enrolled 300 consecutive operative ankle fracture patients who were definitively managed at our tertiary care center into this IRB-approved study. A power analysis demonstrated a sample size of 288 patients would be required in order to detect an odds ratio of 2.0 with a power of 0.8. Demographic, injury, initial and definitive treatment, and payer status data were obtained from the medical record and by direct patient interview. Adequacy of reduction was assessed radiographically by an independent orthopaedic surgeon not involved in the definitive care or surgery.
Results: 79% of the patients (236 of 300) presented primarily to our tertiary care center (LEV 1 group) and 21% (64 of 300) were transferred or referred (OUTSIDE group). In considering demographic and injury data, the only significant difference was noted in the distribution of race categories between groups (P = 0.04); however, there was a trend toward a higher percentage of unemployed patients in the referred group (LEV 1, 59%; OUTSIDE, 72%; P = 0.06). In terms of initial treatment, a significant difference was observed in attempted reduction (LEV 1, 73%; OUTSIDE, 42%; P <0.0001), but not in adequacy of reduction (LEV 1, 65%; OUTSIDE, 48%; P = 0.11). Definitive treatment (surgery) occurred at a median of 1 day after injury in the LEV 1 group and a median of 3 days after injury in the OUTSIDE group (P <0.0001). When considering payer status, a significant difference was observed for underinsured patients between the groups (LEV 1, 53%; OUTSIDE, 73%; P = 0.003).
Conclusions: This prospective study of 300 operative ankle fractures demonstrates the negative influence that an underinsured payer status has on both initial and definitive treatment. Underinsured patients were significantly less likely to have an attempted reduction at a community hospital compared to similar patients who presented primarily to the tertiary care center, and the interval from injury to surgery was significantly longer for the referred group. Additionally, a significantly higher proportion of patients transferred or referred to a tertiary center were underinsured compared to patients who presented primarily to the tertiary center.
Alphabetical Disclosure Listing (628K PDF)
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.