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Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?

Congiusta, Dominick V. MPH; Amer, Kamil M. MD; Merchant, Aziz M. MD; Vosbikian, Michael M. MD; Ahmed, Irfan H. MD

Clinical Orthopaedics and Related Research: December 2019 - Volume 477 - Issue 12 - p 2620-2628
doi: 10.1097/CORR.0000000000000836

Background Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate.

Questions/purposes (1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time?

Methods A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson’s regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios.

Results After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001).

Conclusions We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance—as well as among men and white patients compared with women and patients of color—may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient’s insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics.

Level of Evidence Level III, therapeutic study.

D.V. Congiusta, K.M. Amer, M.M. Vosbikian, I.H. Ahmed, Department of Orthopaedic Surgery, Rutgers University New Jersey Medical School, Newark, NJ

A.M. Merchant, Department of Surgery, Rutgers University New Jersey Medical School, Newark, NJ, USA

D.V. Congiusta, Rutgers University New Jersey Medical School, 140 Bergen Street, D-1610, Newark, NJ 07103, USA, Email:

Each author certifies that neither he, nor any member of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. There are no disclosures to report.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his institution waived approval for the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at Rutgers University New Jersey Medical School, Newark, NJ, USA.

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Clavicle fractures are common, accounting for 3% to 10% of all fractures in adults and up to 44% of fractures of the shoulder girdle [28, 30]. Greater than 90% of fractures are treated nonoperatively with a sling or figure-eight brace, which typically results in satisfactory proportions of union and patient-reported recovery [10, 31, 35, 44]. Recent analyses, however, reported lower risks of nonunion and symptomatic malunion in adult patients with displaced fractures undergoing operative fixation than in those undergoing nonoperative therapy [40-42]. Most notably, a 2007 study conducted by the Canadian Orthopaedic Trauma Society [4] demonstrated that operative fixation of displaced clavicular shaft fractures resulted in improved functionality and a lower risk of malunion and nonunion than did nonoperative treatment. Consequently, there has been a 337% to 705% increase in the rates of operative fixation of clavicular fractures since the early 2000s [15, 23]. The preferred modality of treatment, however, is still debated, and recent data show that socioeconomic factors such as insurance status may influence treatment plans in favor of those with a higher income and private insurance [7, 11, 17, 19, 37, 39].

Difference in access to health care is a multifaceted current challenge with major moral and economic implications that persist despite tremendous advances in health care delivery. Because the number of patients with public and private insurance continues to rise, the impact of insurance status on whether a patient will seek operative treatment has become increasingly relevant [14].

This relationship may also exist in the treatment of clavicle fractures. A recent database study [35] reported differences in the management of clavicle fractures between 2005 and 2011 in Florida and California, concluding that private insurance is associated with whether a patient will choose to undergo operative fixation for these injuries compared with patients with nonprivate insurance, despite an overall increase in the number of surgeries. Another corroborating study [2] using data from patients in Florida also concluded that private insurance was positively associated with whether patients would choose to undergo operative fixation of clavicle fractures. Notable limitations of these studies, however, were their comparatively limited sample sizes and use of data from only two states, which may not represent the national demographic. Additionally, the International Classification of Diseases, Ninth Revision (ICD-9) code 79.39, which was used in one of the aforementioned studies, is defined as “open reduction of fracture with internal fixation, other specified bone.” This code is not specific to fixation of clavicle fractures and has been used to identify fixation of fractures in other locations, such as the hip and pelvis [3, 21, 33]. This likely inflated the stated rates of surgery, questioning the foundation of the reported data. These limitations were acknowledged, and the question regarding the national applicability of these findings remains unanswered.

In response to these limitations, as well as the increasing relevance of socioeconomic factors to health care use in the US, we aimed to address several questions. (1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time?

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Patients and Methods


We retrospectively analyzed the 2001 to 2013 Nationwide Inpatient Sample (NIS) database. The NIS is a national database created by the Agency for Healthcare Research and Quality and is maintained by the Healthcare Cost and Utilization Project. The NIS approximates a 20% stratified sample of all discharges from US community hospitals, including specialty hospitals and academic medical centers, while excluding discharges from rehabilitation centers and long-term acute-care hospitals [26]. The NIS database is the largest publicly available all-payer inpatient database in the US, and its use continues to increase because of its accessibility and validated methodology [16, 18, 25]. Although many clavicle fractures are treated in the outpatient setting, studies have shown that a large proportion of orthopaedic patients seen outside hospitals have private insurance [8, 22]. To capture data on a large cohort of patients with nonprivate insurance (such as Medicare, Medicaid, and no insurance), we decided that a nationally representative inpatient sample was the most appropriate for our investigation.

The NIS database’s unique design requires specific methodological considerations that are described in online tutorials and documentation before analysis [13]. In particular, the sampling strategy changed in 2012, resulting in the need to apply trend weights for all subsequent years to permit longitudinal analyses, as per Healthcare Cost and Utilization Project guidelines. This allows for valid analyses to be conducted on data before and beginning in 2012. Specific ICD-9 codes must also be used to gather accurate estimates. Following these recommendations, we weighted data using trend and discharge weights provided by the Healthcare Cost and Utilization Project for the appropriate years, and specific ICD-9 codes were used to extract data.

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Patient Selection

We queried the NIS dataset from 2001 to 2013 for closed clavicle fractures using specific ICD-9 diagnostic codes under the designation 810.0x (Table 1). Surgical intervention was determined using specific ICD-9 procedural codes. The ICD-9 system has diagnosis codes for all bones of the upper and lower extremities, but the procedural code system groups clavicular surgery with surgery of the scapula and thorax (Table 1). Therefore, all patients with concurrent scapula and thorax fractures (ICD-9 codes 811.0x, 811.1x, and 819.x) were excluded. This eliminated the possibility that the ICD-9 procedure codes for clavicular surgery would include nonclavicular procedures. To further reduce selection bias, we additionally excluded patients with open or “unspecified” bone fractures and patients with missing data on age, gender, race, insurance status, or median income. Open fractures are absolute indications for surgery that would increase the rate of operative intervention in our analysis, and inclusion of “unspecified” bone fractures would introduce heterogeneity into the sample. A total of 410,728 patients with clavicle fractures were identified in the dataset. Owing to the sample size and in order to reduce bias, we excluded patients if there were missing data on age (n = 45,875), gender (n = 681), race (n = 68,725), insurance status (n = 1124), and income (n = 8802). Thirty-two patients with concurrent sternum and rib fractures and 33,380 patients with concurrent scapular fractures were excluded; therefore, 252,109 patients were included in our final analysis (Fig. 1).

Table 1.

Table 1.

Fig. 1

Fig. 1

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).

Table 2.

Table 2.

Exemption from institutional review board approval was obtained. There were no sources of funding for this study.

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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,, 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.

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Statistical Analysis

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 [4], 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).

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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.

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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).

Table 3.

Table 3.

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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 [4]. 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).

Fig. 2

Fig. 2

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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 [38]. 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 [15]. 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 [4], 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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