and Treatment Variation of Common Fractures of Elderly Patients Abstract Fractures of the hip, wrist, proximal humerus, and ankle frequently are observed among the elderly patient popula
Trang 1and Treatment Variation of Common Fractures of
Elderly Patients
Abstract
Fractures of the hip, wrist, proximal humerus, and ankle frequently are observed among the elderly patient population in the United States The Medicare patient population has shown dramatic geographic variation in the rates of these common fractures, with
an increased incidence observed throughout the Southeast
Treatment (surgical versus nonsurgical) is also highly variable and dependent on the geographic location but not necessarily on the type of injury Whereas regional variation in medical treatment may be attributed to variations in practice patterns, the etiology behind the dramatic variations in fractures is less well-defined and
is likely multifactorial, related to environmental, occupational, genetic, or nutritional factors
Older patients (>65 years) are known to be at risk for fracture because of their increased incidence
of osteoporotic bone, poor balance, compromised vision, and
delay-ed reaction times.1-4 Additionally, many older patients have atrophic soft tissues, such that forces may be more easily transmitted to the un-derlying bony structures.4 As a re-sult, this elderly group represents a substantial proportion of the pa-tients with fractures of the hip, wrist, proximal humerus, and an-kle.5 Despite the well-known fre-quency of fractures in older individ-uals, little is known about the geographic differences between frac-ture rates and the geographic varia-tion in treatment of these common injuries
Authors have shown varying fracture patterns among elderly in-dividuals throughout the United States In these limited patient
pop-ulations, patients residing in the South were more likely than those
in the Northeast to sustain a hip fracture.6-10 However, researchers know little about the underlying eti-ology of this discrepancy and whether the discrepancy persists when patients change geographic lo-cation.11 Additionally, the regional variation in treatment of these frac-tures is not well understood Using Medicare data, Weinstein
in the Dartmouth Atlas of Muscu-loskeletal Health Care (DAMHC)
showed large geographic variations among the rates of the four most common orthopaedic fractures in the elderly (ie, hip, wrist, proximal humerus, ankle) despite similar ac-cess to medical care.5Additionally, geographic residence among patients sustaining these injuries strongly correlates with the type of fracture management (ie, surgical versus nonsurgical).12
Scott M Sporer, MD, MS
James N Weinstein, DO, MS
Kenneth J Koval, MD
Dr Sporer is Assistant Professor,
Department of Orthopaedic Surgery,
Rush Medical College, Winfield, IL Dr.
Weinstein is Chairman and Professor,
Department of Orthopaedic Surgery,
Dartmouth-Hitchcock Medical Center,
Lebanon, NH, and Professor, Dartmouth
Medical School and the Center for the
Evaluative Clinical Sciences, Dartmouth
College, Hanover, NH Dr Koval is
Professor, Department of Orthopaedic
Surgery, Dartmouth-Hitchcock Medical
Center.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr Sporer, Dr Weinstein, and Dr Koval.
Supported in part by NIAMS
#U01-AR45444-01A1, the Robert Wood
Johnson Foundation, the American
Academy of Orthopaedic Surgeons, and
the American Hospital Association.
Reprint requests: Dr Sporer, Rush
Medical College, 25 N Winfield Road,
Winfield, IL 60190.
J Am Acad Orthop Surg
2006;14:246-255
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
Trang 2Variation in the Rates of
Fracture
The entire methodology of the
DAMHCmay be found in its
Appen-dix on Methods Briefly, Medicare
data from 1996 and 1997 were used
to evaluate regional variation in the
rates of fracture and surgical
treat-ment for fractures involving the hip,
wrist, proximal humerus, and ankle
Databases provided through the
Health Care Financing
Administra-tion were analyzed to determine the
number of possible Medicare
benefi-ciaries in a designated region, as well
as demographic data for these
indi-viduals (age, sex, and race) The
Medicare Provider Analysis and
Re-view (MEDPAR) File (hospital
claims data) and Medicare Part B
data were analyzed to determine the
rates of utilization for fracture care
of the hip, wrist, proximal humerus,
and ankle Hospital referral regions
were defined according to the 1996
to 1999 DAMHC guidelines.12These
hospital referral regions represent
tertiary care facilities in which there
is delivery of specific cardiovascular
and neurosurgical procedures
The incidence of fracture of the
hip, wrist, proximal humerus, and
ankle among Medicare enrollees was
determined from the Medicare Part
B file utilizing physician-generated
Current Procedural Terminology
(CPT) codes (Table 1) These codes
allowed all patients to be categorized
into surgical and nonsurgical
treat-ment groups Procedures and
diag-nostic tests were adjusted for patient
age, race, and sex The regional rates
of fracture for the wrist, proximal
humerus, hip, and ankle were then
calculated, and maps of the ratio
be-tween observed versus expected
re-sults were generated The expected
number of fractures was calculated
by multiplying the average fracture
rate with the number of people in
each Health Services
Administra-tion populaAdministra-tion
In 1996 and 1997, Medicare
enroll-ees sustained >450,000 fractures The
hip, wrist, ankle, and proximal hu-merus account for >400,000 of these fractures and represent approxi-mately 85% of all injuries observed
in this patient population12(Figure 1)
Fractures about the hip (intertro-chanteric and femoral neck) ac-counted for >213,000 injuries and were the most commonly observed types of fracture within the Medi-care population for that period The incidence of hip fractures varied by a factor of 2, from 4.9 (Honolulu, HI)
to 10.7 (Rome, GA) per 1,000 Medi-care enrollees (Figure 2) Four hospi-tal referral regions had rates of hip fracture at least 30% greater than the national average, whereas 6 re-gions had rates at least 25% below the national average.12
Wrist fractures were the second most common fracture observed in the Medicare patient population, ac-counting for >96,000 injuries, 85%
of them observed in women The in-cidence of wrist fractures varied by a factor of 4, from 1.5 (Everett, WA) to 5.7 (Huntsville, AL) per 1,000 Medi-care enrollees (Figure 3) Twenty-nine referral regions had rates of wrist fracture at least 30% greater than the national average, whereas
61 regions had rates at least 25% be-low the national average.12
Ankle fractures accounted for
>46,000 injuries that occurred in the Medicare patient population in 1996 and 1997 The incidence of ankle fracture was far more varied throughout the United States, with certain regions of the country show-ing a more than sixfold variation in incidence, from 0.5 per 1,000 (Hono-lulu, HI) to 3.1 per 1,000 (Danville, PA) (Figure 4) Forty-six hospital re-ferral regions had rates of ankle frac-ture of at least 30% greater than the national average, whereas 79 regions had rates at least 25% below the na-tional average
Proximal humerus fractures ac-counted for 43,500 injuries in the Medicare patient population Simi-lar to ankle fractures, the incidence
of these injuries showed dramatic
re-gional variation, from 0.3 per 1,000 enrollees (Jackson, TN) to 3.4 per 1,000 enrollees (Covington, KY) Fifty-six hospital referral regions had rates of proximal humerus fracture
at least 30% greater than the
nation-al average, whereas 111 regions had rates at least 25% below the
nation-al average.12
Treatment Variation
Fractures can be treated either surgi-cally or nonsurgisurgi-cally The decision
to proceed with surgery is highly de-pendent on a number of factors, in-cluding the anatomic location, asso-ciated soft-tissue injuries, and the number of associated fractures The great majority of patients with frac-tures of the hip undergo surgical in-tervention Conversely, the majority
of patients with fractures of the proximal humerus undergo nonsur-gical management Other fractures, such as those of the ankle and wrist, often are treatable with either surgi-cal stabilization or cast immobiliza-tion, depending on the severity of in-jury (Figure 5)
More than 98% of the Medicare patients who sustained a hip fracture
in 1996 and 1997 were treated with surgical stabilization Mobilization is difficult without surgery; therefore, nonsurgical treatment is generally re-served for patients with multiple co-morbidities and for injuries that pose
a substantial surgical risk Weinstein reported that the mortality rates for patients undergoing surgery were 7%
at 30 days and 25% at 1 year.5In con-trast, patients treated nonsurgically had a 17% mortality rate at 30 days and a 39% rate at 1 year
Wrist fractures were most com-monly managed with closed reduc-tion and cast immobilizareduc-tion De-spite this trend, different regions of the United States were far more likely to incorporate surgical inter-vention in their treatment with ei-ther pins, screws, or external fixa-tion The proportion of wrist fractures treated surgically varied by
Trang 3a factor of 10 from 5.1% (Greenville,
NC) to 50.7% (Olympia, WA) In
gen-eral, patients in the Northwest were
more likely than patients in the
Southeast to have surgical
interven-tion (Figure 6) In seven regions, 40%
of wrist fractures received surgical treatment; in 30 regions, only 10% of them received surgical treatment.5 Similar to wrist fractures, most
ankle fractures sustained by the Medicare population were treated nonsurgically Again, patients in cer-tain regions of the country were more likely than others to undergo
Table 1
CPT Codes for the Four Most Common Orthopaedic Fractures in the Elderly
Hip Fracture CPT Codes
27235 Percutaneous skeletal fixation, femoral fracture, proximal, neck
27236 Open treatment, femoral fracture, proximal, neck, internal fixation/prosthetic
27244 Open treatment, inter/per/subtrochanteric femoral fracture, with plate/screw type implant
27245 Open treatment, inter/per/subtrochanteric femoral fracture; with intramedullary implant
27230 Closed treatment, femoral fracture, proximal end, neck; without manipulation
27232 Closed treatment, femoral fracture, proximal end, neck; with manipulation
27238 Closed treatment, inter/per/subtrochanteric femoral fracture; without manipulation
27240 Closed treatment, inter/per/subtrochanteric femoral fracture; with manipulation
Ankle Fracture CPT Codes
27766 Open treatment, medial malleolus fracture, with/without internal/external fixation
27792 Open treatment, distal fibular fracture, with/without internal/external fixation
27814 Open treatment, bimalleolar ankle fracture, with/without internal/external fixation
27822 Open treatment, trimalleolar ankle fracture, medial/lateral malleolus; without fixation
27823 Open treatment, trimalleolar ankle fracture, medial/lateral malleolus with fixation
27826 Open treatment, fracture, weight bearing articular surface, distal tibia, with fixation; fibula
27827 Open treatment, fracture, weight bearing articular surface/portion, distal tibia, with fixation; tibia
27828 Open treatment, fracture, weight bearing articular surface, distal tibia, with fixation; fibula and tibia
27829 Open treatment, distal tibiofibular joint disruption, with/without internal/external fixation
27760 Closed treatment, medial malleolus fracture; without manipulation
27762 Closed treatment, medial malleolus fracture; with manipulation, with/without skin/skeletal traction
27786 Closed treatment, distal fibular fracture (lateral malleolus); with/without manipulation
27788 Closed treatment, distal fibular fracture (lateral malleolus); with manipulation
27808 Closed treatment, bimalleolar ankle fracture, without manipulation
27810 Closed treatment, bimalleolar ankle fracture, with manipulation
27816 Closed treatment, trimalleolar ankle fracture, without manipulation
27818 Closed treatment, trimalleolar ankle fracture, with manipulation
27824 Closed treatment, fracture, weight bearing articular portion, distal tibia without manipulation
27825 Closed treatment, fracture, weight bearing articular portion, distal tibia with skeletal traction
Proximal Humerus Fracture CPT Codes
23615 Open treatment, proximal humeral fracture, with/without internal/external fixation/tuberosity repair
23630 Open treatment, greater humeral tuberosity fracture with/without internal/external fixation
23670 Open treatment, shoulder dislocation w/fracture, greater tuberosity, with/without external rotation
23680 Open treatment, shoulder dislocation, w/surgical/anatomical neck fixator
23600 Closed treatment, proximal humeral fracture; without manipulation
23605 Closed treatment, proximal humeral fracture; with manipulation
23620 Closed treatment, greater humeral tuberosity fracture; without manipulation
23625 Closed treatment, greater humeral tuberosity fracture; with manipulation
23665 Closed treatment, shoulder dislocation with fracture, greater tuberosity, with manipulation
23675 Closed treatment, shoulder dislocation, with humoral neck fracture, with manipulation
Wrist Fracture CPT Codes
25611 Percutaneous skeletal fixation, distal radial fracture/epiphyseal separation, with manipulation
25620 Open treatment, distal radial fracture/epiphyseal separation
25600 Closed treatment, distal radial fracture; without manipulation
25605 Closed treatment, distal radial fracture; with manipulation
Trang 4surgical fixation The percentage of ankle fractures treated surgically varied by a factor of nearly 4 from 20.8% (Altoona, PA) to 77.1%
(Chi-co, CA) On average, patients in the Northwest were more likely than patients in the Southeast to receive surgical intervention In 32 regions,
at least 60% of ankle fractures were surgically treated, whereas in 50 re-gions, 30% of such fractures were surgically treated.5
Most proximal humerus fractures represent low-energy injuries and can be treated nonsurgically with a sling and swath for immobilization Surgical intervention was initiated,
on average, 14.3% of the time in the United States.5 Large variations in the percentages of surgical interven-tion were observed, from 6.4% (Takoma Park, MD) of all proximal humerus fractures to 60.0%
(Taco-ma, WA) (Figure 7) In 8 regions, at least 40% of proximal humerus frac-tures were treated surgically; in 35 regions, less than 10% were treated surgically.5
Figure 1
Fractures among Medicare enrollees during 1996 Fractures of the hip, wrist, ankle,
and proximal humerus were the most common fractures observed (Reproduced
with permission from Weinstein JN, Birkmeyer JD [eds]: The Dartmouth Atlas of
Musculoskeletal Health Care Chicago, IL: American Hospital Publishing, 2000,
p 96.)
Figure 2
The geographic variation of hip fracture rates within the United States in 1996 and 1997, adjusting for age, race, and sex No-tice the increased prevalence of hip fractures throughout the southern states (Reproduced with permission from Weinstein JN,
Birkmeyer JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care Chicago, IL: American Hospital Publishing, 2000,
p 101.)
Trang 5Figure 3
The geographic variation of wrist fracture rates within the United States in 1996 and 1997, adjusting for age, race, and sex Notice the increased prevalence of fractures throughout the eastern states (Reproduced with permission from Weinstein JN,
Birkmeyer JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care Chicago, IL: American Hospital Publishing, 2000,
p 123.)
Figure 4
The geographic variation of ankle fracture rates within the United States between 1996 and 1997, adjusting for age, race and sex Notice the increased prevalence of fractures throughout the eastern states (Reproduced with permission from Weinstein
JN, Birkmeyer JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care Chicago, IL: American Hospital Publishing,
2000, p 109.)
Trang 6Geographic Variation of Fracture Rates
Hip
As the population ages, the prev-alence of fracture in the United States unquestionably will increase The population aged≥80 years is the fastest growing cohort in the United States.13More than 450,000 fractures
of the hip, wrist, ankle, and proximal humerus were identified in the Medicare patient population aged
>65 years in 1996 and 1997.5 Numer-ous authors have demonstrated that increased age, female gender, smok-ing, and osteoporosis are risk factors for sustaining these injuries.14 Addi-tionally, poor vision, decreased reac-tion times, nutrireac-tional status, and a smaller soft-tissue envelope pose other risks for fracture.2-4,15-17 Although studies have shown dra-matic differences in regional variation
of certain surgical procedures, such as radical prostatectomy and coronary artery bypass, little information was
Figure 5
The proportion of fractures treated surgically among Medicare enrollees in 1996
and 1997 Notice that nearly all hip fractures are treated surgically, whereas most
proximal humerus fractures are treated nonsurgically Other fracture patterns
demonstrate marked regional variability in their preferred method of treatment
(Reproduced with permission from Weinstein JN, Birkmeyer JD [eds]: The
Dartmouth Atlas of Musculoskeletal Health Care Chicago, IL: American Hospital
Publishing, 2000, p 97.)
Figure 6
The proportion of wrist fractures treated surgically in 1996 and 1997 Note that most fractures are treated nonsurgically However, several areas treat>40% of wrist fractures with surgery (Reproduced with permission from Weinstein JN, Birkmeyer
JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care Chicago, IL: American Hospital Publishing, 2000, p 125.)
Trang 7known about the regional variation
of common fractures in the Medicare
population.12Our results suggest that,
despite adjustment for age, sex, and
race, specific populations in various
regions of the country are at increased
risk of fracture.5Fractures of the
prox-imal humerus, ankle, wrist, and hip
showed a tenfold, sixfold, fourfold,
and twofold variation in fracture rate,
respectively.5
The southeastern states, on
aver-age, had greater risk of fracture,
whereas northern states were
rela-tively protected The underlying
eti-ology for these dramatic differences
has yet to be determined It is
un-likely that the differences observed in
these multiple studies5are a result of
chance alone Although there may be
a systemic sampling bias secondary
to variable physician coding, the
ob-served differences are too large to be
related to this variable alone These
trends also have been observed over
very large geographic regions rather
than specific locations Additionally,
other authors have reached similar
conclusions with regard to the geo-graphic variation of hip fractures.9 One potential hypothesis is that peo-ple living in the southern regions are exposed to environmental factors that place them at an increased risk
of fracture.11 Potential environmental risk fac-tors may be directly related to the re-gion, such as air quality, degree of sunlight, or the water quality Alter-natively, environmental risk factors may be associated with specific ar-eas of the country related to diet, poverty, or medical practice pat-terns Another hypothesis is that pa-tients with different genetic suscep-tibility to fractures live in the southern regions.14,18
Geographic variation in the rate of hip fractures was initially described
by Bacon et al19during a review of the 1979 to 1985 National Hospital Discharge Survey.20The rates of hos-pitalization for fracture of the hip were 45% higher in the Northeast compared with the South This study was limited in its ability to
provide only regional hospitalization rates because of the sampling from the National Hospital Discharge Sur-vey Additionally, this survey exam-ined only procedures that were per-formed within a specific region, and
it did not provide any patient demo-graphic information The authors hy-pothesized that the increased risk of hip fracture within the northern re-gion may be secondary to a relatively high proportion of residents of Scan-dinavian ancestry in this area Previ-ous studies that evaluated national hospital discharge data demonstrated higher fracture rates throughout northern European countries.14,18 The increased risk for fracture is con-sidered to be secondary to a higher prevalence of osteoporosis through-out this region
Stroup et al6used data from the
1985 Medicare Provider Analysis and Review file (MEDPAR) to deter-mine the relative rate of hip fracture within the United States The inci-dence of hip fractures was shown to follow a north-to-south gradient,
Figure 7
The proportion of proximal humerus fractures treated surgically in 1996 and 1997 Note that most fractures are treated
nonsurgically However, several areas treat>40% of proximal humerus fractures with surgery (Reproduced with permission
from Weinstein JN, Birkmeyer JD [eds]: The Dartmouth Atlas of Musculoskeletal Health Care Chicago, IL: American Hospital
Publishing, 2000, p 115.)
Trang 8with higher fracture rates among the
southern states The geographic
vari-ation in fracture rates was consistent
among both men and women and
among both “white” and “other
than white” age groups The authors
did not think that the delivery of
health care or practice patterns
could account for these differences
because the trend was consistent
among both men and women
Several authors have
demonstrat-ed an increasdemonstrat-ed relative risk of
frac-ture among patients living in the
southeastern and Appalachian
re-gions Hinton et al7reviewed
Medi-care date from 1984 to 1987 (687,850
hip fractures) They concluded that
rates of hip fracture were greater for
women than men and were higher in
the southern region of the United
States There was an approximate
twofold variation throughout the
United States, from 0.88 (New
Jer-sey) to 1.25 (Mississippi) per 100,000
Medicare enrollees This study also
examined the location of the hip
fracture as either cervical,
trochan-teric, or subtrochanteric The rates
of both cervical and trochanteric
fractures remained higher in the
southern regions for white women
than in the northern regions
How-ever, this variation was
dispropor-tionate because of the higher rates of
cervical fractures The significance
of this finding is unclear, yet the
au-thors concluded that the cervical
re-gion of the hip may be more
sensi-tive to the effects of nutritional,
socioeconomic, or environmental
factors This study also
demonstrat-ed that the risk of a hip fracture
dou-bles each successive 5 years and
that, among women, the relative
risk of cervical to trochanteric
frac-tures varies inversely by age.21
Karagas et al9 reviewed 39,599
Medicare hip fractures between 1986
and 1990 and found results similar
to those of Hinton et al.7The overall
rate of both femoral neck and
tro-chanteric fractures was highest
among white women, whereas the
ratio of trochanteric to femoral neck
fractures increased with advancing age However, these trends were not observed among men or among black patients The authors hypoth-esized that the observed hip fracture rates could be related to localized differences in bone density at
specif-ic sites of the proximal femur Mel-ton et al21had previously shown that once a patient’s bone mineral
densi-ty drops below 0.60 g/cm2, that pa-tient had an increased incidence of trochanteric fracture
Jacobsen et al22reported similar north-to-south regional variation among hip fractures using data from the HCFA and the Department of Veterans Affairs Additionally, data from the Bureau of Health Profes-sions Area Resource File was used to examine potential environmental risk factors A regression analysis was performed that confirmed “a positive association between hip fracture incidence and the percent of the 65-year and older population be-low the poverty level and the per-cent of land in farms.”22The authors also found a weak association be-tween soft and fluoridated water and reduced sunlight exposure with an increased risk of hip fracture
The effect of fluoridated water also has been evaluated by Karagas et
al.8Using a 5% sample of the Medi-care population, a correlation be-tween fluoridated drinking water and the risk of hip or ankle fracture was not observed However, within the study population, a north-to-south geographic gradient for increased in-cidence of hip fracture persisted
The potential of reduced sunlight
as a risk factor for hip fracture was in-directly examined by Jacobsen et al10 when they reported on the seasonal variation in the incidence of hip frac-ture Using HCFA data from 1984 to
1987, the seasonal variation among 621,387 hip fractures demonstrated a definite seasonal pattern among both male and female patients, with a peak in December and February and
a nadir between July and August
This seasonal trend persisted among
all five latitude groups The authors hypothesized that, given that the for-mation of vitamin D is dependent on sunlight, and given that there are fewer hours of sunlight during the winter months, the degree of osteo-malacia may increase in elderly pa-tients during this time and can place them at a higher risk for fracture Lauderdale et al11 examined the impact of former residence on the rate of hip fracture in the Medicare patient population The authors con-cluded that the risk for fracture was dependent on region of residence early in life rather than later in life.11 These results suggest that strategies designed to improve peak bone mass during early childhood would be more effective than mini-mizing risk factors later in life The etiology of the variable rates
of hip fracture throughout the
Unit-ed States is unknown However, it is unlikely that these large variations are the result of chance alone
Rath-er, the fracture variability probably
is multifactorial and includes exter-nal factors related to environmental exposure and internal factors related
to genetic predisposition
Shoulder, Wrist, and Ankle Fractures
Whereas the geographic variation among hip fractures has been gener-ally well-described, a paucity of in-formation is available about the re-gional variation among other common fractures (ie, proximal hu-merus, distal forearm, ankle) in the elderly population Karagas et al8 were the first to describe geographic trends among fractures of the proxi-mal humerus, distal forearm, and ankle Using Medicare data, they showed that fractures of the proxi-mal humerus and distal forearm oc-cur in a geographic pattern that is distinct from that observed with hip fractures The risk of fracture in-creased from west to east rather than from north to south (a trend also ob-served with hip fractures) The data
presented from the DAMHC
Trang 9sup-port the finding of an increased risk
of proximal humerus, distal forearm,
and ankle fractures among eastern
regions of the United States.5 One
hypothesis for these observations is
that the risk factors for hip fractures
are different from the risk factors for
proximal humerus, distal forearm,
and wrist and ankle fractures
The exact etiology of the
geo-graphic variation among fracture rates
within the United States remains
un-clear It is likely multifactorial, a
re-sult of varying degrees of certain
en-vironmental, occupational, genetic,
and nutritional risk factors that exist
between regions of the country One
of our hypotheses is that fractures of
the hip are related to relatively
sed-entary individuals, whereas fractures
of the ankle, distal forearm, or
prox-imal humerus are related to
individ-uals actively participating in the
workforce or in recreational activities
A second hypothesis of ours is that
nutritional factors preferentially
af-fect the bone metabolism of the
fem-oral neck We think that further
ep-idemiologic research should be
performed in this area to help reduce
the cost, societal burden, and loss of
independence related to these
debil-itating fractures within the elderly
pa-tient population
Geographic Variation in
Treatment
There also are dramatic differences in
the treatment strategies used for the
most common fractures in Medicare
patients Some fractures, such as
those of the hip, have been shown to
be treated best with surgical
inter-vention; thus they show little
geo-graphic variation in the proportion of
fractures treated surgically This was
observed in the DAMHC data, with
more than 98% of patients receiving
surgical intervention for a hip
frac-ture.5 Conversely, certain fractures
can be treated either surgically or
nonsurgically In general,
nondis-placed fractures can be treated with
cast immobilization, whereas
dis-placed fractures require surgical re-duction and fixation We observed large variations in the proportion of wrist, ankle, proximal humerus, and distal forearm fractures treated sur-gically throughout the United States.5In general, the northwestern regions were more likely to initiate surgical treatment despite their rel-ative lower incidence of fracture
There are several possible expla-nations for the observed differences
in the proportion of patients receiv-ing surgical treatment It is possible that the fractures encountered in the Northwest are more displaced or open or have associated injuries; the severity of injury is unable to be de-termined from the Medicare data
However, to our knowledge, no data support the concept that more se-vere injuries are more likely to occur
in these regions
Diagnostic intensity also has been shown to influence the rates of surgical intervention Regions with more aggressive diagnostic imaging tend to have higher surgical rates for specific conditions.23 However, pa-tients who sustain fractures of the hip, wrist, ankle, and proximal hu-merus are in significant discomfort, and plain radiographs are sufficient
to make a diagnosis Therefore, in-creased diagnostic testing is
unlike-ly a plausible explanation
The varying incidence of surgical intervention also may be related to the population density of practicing orthopaedic surgeons in a particular area of the country Keller at el24 de-scribed regional variation in the pro-cedural rate among several major or-thopaedic conditions, a variation that may be partially attributed to the number of practicing ortho-paedic surgeons in an area However, other authors have failed to show a similar relationship between the uti-lization of certain orthopaedic proce-dures and the population density of orthopaedic surgeons in an area.25,26
It has been shown that surgeons possess varying thresholds to recom-mend and initiate surgical
interven-tion, referred to as the local aggres-siveness phenomena.12As a result, regions throughout the country tend
to have so-called surgical
signa-tures, reflecting the practices
regard-ing surgical treatment of the ortho-paedic surgeons in that area A region’s surgical signature may be a result of variability in orthopaedic training in different parts of the country or a result of a paucity of data regarding the optimal treatment
of a particular fracture Weinstein27 has shown that the rate of surgical intervention depends on the vari-ability in clinical decision making as well as patient-perceived risks and benefits For low variability proce-dures, such as hip fractures, the sur-gical rate is relatively constant throughout the United States In contrast, disk herniations have nu-merous treatment options, less sci-entific uniformity, and greater po-tential risks Consequently, regional variability is far greater than that seen with hip fractures
Patient expectations also may contribute to the geographic vari-ability among surgical rates It is possible that the perceived benefit of surgery is regionally dependent, and that patients in the northwestern portion of the United States think that the likelihood of returning to their preinjury status is greater with surgery Consequently, patients and surgeons may be more likely to ini-tiate surgical intervention for a par-ticular fracture
Patients are the ones ultimately affected by the decision to proceed with surgical intervention Thus, pa-tients need to be actively involved in the decision-making process in order
to make an informed choice.7When patients are properly educated about surgical alternatives, they make choices that are most appropriate for their specific situations
Summary
The United States’ population is ag-ing As a result, orthopaedic
Trang 10sur-geons are likely to experience a
greater number of fractures in the
elderly population Throughout the
country, the variability in the
inci-dence of the most common fractures
is marked The underlying etiology
is unclear but likely is
multifactori-al, including socimultifactori-al, environmentmultifactori-al,
nutritional, and genetic
characteris-tics There also is a wide range of
hy-potheses; one possibility is that the
risk factors for fractures in different
locations vary, another that certain
fractures are related to the activity
level of the individual, and another
that nutrient factors preferentially
affects bone metabolism in different
regions There also is marked
vari-ability in treatment among these
common fractures This surgical
variability likely represents the
sur-geon’s preference and his or her
threshold for initiating surgical
treatment Hypothetically, this
vari-ability also may exist because some
fractures encountered in one region
are different from those in another or
it may be a result of the population
density of orthopaedic surgeons
practicing in a region Additional
studies are needed to elucidate
un-derlying patient preferences and
whether the decision to proceed
with surgery is driven by the
physi-cian, the patient, or both jointly
References
Citation numbers printed in bold
type indicate references published
within the past 5 years
1 Baron JA, Barrett JA, Karagas MR: The
epidemiology of peripheral fractures.
Bone1996;18(suppl 3):209S-213S.
2 Felson DT, Anderson JJ, Hannan MT,
Milton RC, Wilson PW, Kiel DP:
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