A total of 21,638 of 252,109 patients (9%) with clavicle fractures underwent open fixation. Most fractures occurred in unspecified sites of the clavicle. Among fractures in specified sites, most were in the midshaft and at the distal end, and most patients had private insurance. A total of 27,395 of the 252,109 patients (11%) did not have any insurance (Table 2).
Exemption from institutional review board approval was obtained. There were no sources of funding for this study.
The primary outcome of interest was the presence of open surgical fixation of closed clavicle fractures. The NIS database records insurance as the “primary expected payer” and has specific codes for six categories: private insurance, Medicare, Medicaid, self-pay, no charge, and other. Patients with a payment designation of “self-pay” or “no charge” were grouped into the “patients without insurance” category.
We also included age, race, gender, household income, and location of the fracture in our analysis. The median value and interquartile range of household income was reported (see Appendix, Supplemental Digital Content 1, http://links.lww.com/CORR/A193), and the location of the fracture was obtained using specific ICD-9 codes (Table 1). Data on the incidence of clavicular surgery during the study period were also obtained.
All analyses were performed using the weighted NIS data. A univariable analysis was conducted with Pearson’s chi-square test to identify variables to be included in a multivariable analysis. The univariable analysis showed that all analyzed variables, including age, race, gender, location of the fracture, median household income, and insurance status were associated with whether a patient would choose to undergo operative fixation of the clavicle. A binary logistic regression analysis was then performed to account for these variables. To identify changes in the rate of surgery before and after the landmark 2007 Canadian Orthopaedic Trauma Society study , we performed a paired t-test. Trends in the rate of operative treatment over time per 100,000 discharges were analyzed with Poisson’s regression. The results of the logistic regression analysis were recorded as odds ratios (ORs) with 95% CIs, and the results of the Poisson regression are reported as incidence rate ratios with 95% CIs. Data were analyzed using the Statistical Package for the Social Sciences, version 23 (IBM Corp., Armonk, NY, USA).
Association Between the Likelihood of Fracture Fixation and Insurance Type
After controlling for demographic and potentially relevant variables, such as median income and location of the fracture, we found that patients with no insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by patients with Medicaid (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and patients with Medicare (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). These data show that patients with clavicle fractures and those with Medicare or Medicaid had a lower likelihood of undergoing surgery than did patients with private insurance, but were not statistically different from one another. Patients without insurance had a lower likelihood of undergoing surgery than those with private, Medicare, and Medicaid insurance.
Association Between the Likelihood of Fracture Fixation and Demographic and Socioeconomic Factors
The likelihood of patients undergoing surgery decreased as their age increased. The lowest likelihood of surgery was seen in patients aged 75 years or older (OR, 0.11; 95% CI, 0.10-0.12; p < 0.001) compared with patients aged 19 to 34 years (Table 3). Black and Hispanic patients were also less likely to undergo surgery (OR, 0.67; 95% CI, 0.62-0.72; p < 0.001 and OR, 0.82; 95% CI, 0.78-0.86; p < 0.001, respectively) than patients of other races. Patients with fractures of the midshaft were more likely to undergo surgery than those with fractures in other locations (OR, 1.90; 95% CI, 1.85-1.96; p < 0.001).
Changes in Surgical Use Over Time and Association Between Surgical Use and Insurance Type
As measured by the incidence rate ratio (that is, the ratio of incidences of operative fixation by year), there was an increase in surgically managed clavicle fractures over time. The overall proportion of patients treated with open fixation increased from 3911 per 100,000 discharges in 2001 to 11,708 per 100,000 discharges in 2013 (incidence rate ratio, 2.99; p < 0.001) (Fig. 2). The highest proportion of operations for clavicle fractures was 12,998 per 100,000 discharges in 2011 (incidence rate ratio, 3.32; p < 0.001). There was an increase in surgery from before to after the study by the Canadian Orthopaedic Trauma Society . The annual mean proportion of open fixation from 2001 to 2007 was 5746 of 111,340 clavicle fractures (5%) while that from 2008 to 2013 was 15,892 of 140,769 clavicle fractures (11%), resulting in a mean difference of 6% (± 1.16; 95% CI, 5.24-7.68; p < 0.001) (Table 2).
The proportion of closed clavicle fractures treated with open fixation has increased nationally. Recent evidence suggests that treating clavicle fractures operatively may have superior results to nonoperative management, including a lower incidence of nonunion or malunion, but the preferred management option is still debatable [4, 29, 35]. Differences in treatment may be a function of medical factors, such as location of the fracture, and socioeconomic factors, such as the type of insurance. Our data show that nonprivate insurance, no insurance, older age, and black or Hispanic race were associated with a decreased likelihood that a patient would choose to undergo operative fixation. These results highlight socioeconomic disparities in the management of a common orthopaedic condition, which may demonstrate a need for more precise treatment guidelines.
The limitations of our study are those inherent in large-database analyses, notably the lack of detailed, granular information. Certain characteristics of the fracture, such as displacement, comminution, classification, and degree of shortening were not specified in the ICD-9 coding system or the NIS database. These variables may have affected the decision-making process because the indications for surgery vary among surgeons and may explain why there were differences in care. However, there is unlikely to be a systematic difference in the presence of those variables by payer status. Additionally, variables typically associated with outpatient treatment, such as the presence of less severe injuries and fewer comorbidities, may have influenced the results if they had been included in the study . Therefore, the presented data may not be applicable to patients presenting for care at surgery centers, where the likelihood of operation may differ. While this may limit generalizability, outpatient facilities and surgery centers generally prefer insured patients, and if that is the case, it would suggest that the actual differences in surgery based on insurance status may be larger than what we observed. There is also a potential for selection bias because a large number of patients were excluded, which may have led to certain characteristics being misrepresented in our final analysis. Although some hospitals were possibly overrepresented, this was mitigated by the use of the Healthcare Cost and Utilization Project-provided trend weights. Furthermore, there is unlikely to be a clinically relevant, systematic difference in reporting of clavicle fractures.
There may have been a difference in disease burden between insurance groups because factors such as polytrauma and unmeasured disease severity may also vary. Although the NIS does not report data on the severity of each fracture, the severity of disease and debilitating trauma is often worse in patients with a low socioeconomic status than in patients with a higher socioeconomic status [9, 12, 20]. It is possible that more severe trauma among patients with nonprivate insurance may play a role in differences in surgical management. However, more severe disease would presumably result in a higher likelihood of surgical fixation of clavicle fractures, rather than the lower likelihood we observed. Therefore, the difference between the likelihoods of operation for fractures with similar severity may be even larger than reported.
Our analysis of a nationally representative database using unique, code-specific definitions suggests that differences reported in previous, more limited studies exist on a national scale. As mentioned, these studies examined data from two states that may not be nationally representative or may use nonspecific procedural codes [2, 35].
After controlling for demographic variables, fracture location, and income levels, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation than those with private insurance. These findings indicate a possible disparity in health care use, in which surgery may be overused by those with private insurance and underused by those without private insurance. As the indications for surgical management of clavicle fractures continue to be debated, surgeons must be aware of potential sources of differential treatment, such as unconscious bias, different reimbursement rates, and increasing workloads that influence management, although these have yet to be investigated among patients with clavicle fractures [1, 5, 6, 24, 34].
In addition to insurance status, race, gender, and age were patient factors associated with different likelihoods of surgery being performed. Black and Hispanic patients had a lower likelihood of undergoing operative fixation after accounting for other demographic variables, location of fracture, insurance, and income. While the cause is uncertain, studies suggest that the physician’s mode of treatment may be influenced by a patient’s race [32, 36]. Consistent with the work of others, these disparities may identify a vulnerable population [27, 43]. We also found that women were less likely to undergo surgery; however, the size of the observed effect on this finding may not be clinically relevant (OR, 0.95; 95% CI, 0.92-0.98). The likelihood of surgery notably decreased with increasing age, with the lowest likelihood in patients at least 75 years old, which corroborates the work of others . We therefore propose that educating physicians on the existence of differences in resource use based on insurance status and race may help improve outcomes for all patient groups. Greater attention to these differences among patients may reduce the gap in care.
Lastly, we found that the proportion of patients undergoing operative fixation of clavicle fractures increased from 2001 to 2013. Recent data show that operative fixation may be the preferable treatment option for adult patients with displaced clavicular shaft fractures , and our findings suggest that surgeons may be changing their practice. Specifically, there was an increase in the mean percentage of patients undergoing operative fixation from 2001 to 2007 and from 2008 to 2013, but the cause of this change is unclear. Although the peak number of surgeries occurred in 2011, we suspect that the overall trend in the increasing rate of surgical fixation will continue as more current data become available.
Patients with no insurance and nonprivate insurance are less likely to undergo operative fixation of clavicle fractures than those with private insurance, after accounting for social and demographic factors. Surgeons should be aware of these potential sources of bias that influence management. We therefore suggest that future research should query orthopaedic surgeons and their patients for factors that influence the surgical decision-making process to help ensure equal access to care for all patient groups. Furthermore, this variability in treatment suggests a need for more precise treatment guidelines for clavicle fractures.
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© 2019 by the Association of Bone and Joint Surgeons