Section of Plastic Surgery Department of Surgery University of Michigan Health System, and Veterans Administration Health System Ann Arbor, Mich.
Section of Plastic Surgery Department of Surgery University of Michigan Health System Ann Arbor, Mich.
Correspondence to Dr. Sears, Section of Plastic Surgery, University of Michigan Health System, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, Mich. 48109-5340, firstname.lastname@example.org
We thank the authors for their comments on our study entitled “The Influence of Procedure Delay on Resource Use: A National Study of Patients with Open Tibial Fracture.”1 Indeed, Marko Godina should be commended on his 1986 study of 532 patients at a single center undergoing microsurgical reconstruction for posttraumatic defects of the extremities.2 Godina’s study evaluated the impact of timing of microsurgical reconstruction on outcomes of infection, time to union, and hospital length of stay, among other outcomes. This study was not limited to patients with lower extremity injuries but included patients with injuries involving all extremities.
A closer evaluation of the patient sample in Godina’s study highlights the critical need to account for the impact of individual variation on outcomes of interest. Individual variation in bodily injury in conjunction with extremity trauma will influence the timing of surgical interventions a great deal. There is no mention of associated injuries that likely influenced the timing of reconstruction, overall length of stay, and resource use. In order to relate resource use to timing of a single procedure, one must attempt to mitigate the influence of other injuries these patients often have, whether by limiting the study to patients with an isolated injury type or quantifying injury severity as a control variable by an accepted method.
We attempted to minimize the influence of associated injuries and individual variation in our study by limiting our sample to patients with a primary diagnosis of open tibial fracture, by calculating an injury severity score for each patient, and by making the main predictor of our study a characteristic at the hospital level. We studied practice patterns in which surgical care of any kind was initiated, rather than focusing on the timing of any one particular surgical intervention, such as operative fixation or soft-tissue coverage. The impact of timing of definitive coverage of complex lower extremity injuries on complications and additional outcomes is a complex topic and was not the intervention of focus in our study.
The aim of our study was to better understand the impact of health systems’ delays, or hospital behavior, on resource use in our sample of patients with open tibial fracture. To further curtail the influence of individual variation, we looked at the behavior of the hospital in initiating surgical care, measured in quartiles of the best- and worst-performing hospitals. We evaluated whether the hospital’s probability of delay influenced length of stay and cost, regardless of the timing of the patient’s own initial surgical intervention. While controlling for injury severity and other risk factors, patients treated at the worst-performing hospitals with delayed initiation of surgical intervention had an estimated 11 percent longer stay and 12 percent higher cost compared with patients at the best performing hospitals.
It is important not only to evaluate the impact of individual variation on patient outcomes but also to examine system practices for quality improvement. Our study sought to better understand the impact that hospital-level delays may have on individual resource use. With a better understanding of practices at the hospital level, we may initiate a better evaluation of potential inefficiencies at the systems level rather than merely attributing all outcome differences to individual practice variation.
The authors have no conflicts of interest to declare.
Erika Davis Sears, M.D., M.S.
Section of Plastic Surgery
Department of Surgery
University of Michigan Health System, and
Veterans Administration Health System
Ann Arbor, Mich.
Kevin C. Chung, M.D., M.S.
Section of Plastic Surgery
Department of Surgery
University of Michigan Health System
Ann Arbor, Mich.
1. Sears ED, Burke JF, Davis MM, Chung KC. The influence of procedure delay on resource use: A national study of patients with open tibial fracture. Plast Reconstr Surg. 2013;131:553–563
2. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78:285–292
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