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The Influence of Procedure Delay on Resource Use: A National Study of Patients with Open Tibial Fracture

Sears, Erika Davis M.D., M.S.; Burke, James F. M.D., M.S.; Davis, Matthew M. M.D., M.A.P.P.; Chung, Kevin C. M.D., M.S.

Plastic and Reconstructive Surgery: March 2013 - Volume 131 - Issue 3 - p 553–563
doi: 10.1097/PRS.0b013e31827c6efc
Reconstructive: Lower Extremity: Original Articles

Background: The purpose of this study was to (1) understand national variation in delay of emergency procedures in patients with open tibial fracture at the hospital level and (2) compare length of stay and cost in patients cared for at the best- and worst-performing hospitals for delay.

Methods: The authors retrospectively analyzed the 2003 to 2009 Nationwide Inpatient Sample. Adult patients with open tibial fracture were included. Hospital probability of delay in performing emergency procedures beyond the day of admission was calculated. Multilevel linear regression random-effects models were created to evaluate the relationship between the treating hospital's tendency for delay (in quartiles) and the log-transformed outcomes of length of stay and cost.

Results: The final sample included 7029 patients from 332 hospitals. Patients treated at hospitals in the fourth (worst) quartile for delay were estimated to have 12 percent (95 percent CI, 2 to 21 percent) higher cost compared with patients treated at hospitals in the first quartile. In addition, patients treated at hospitals in the fourth quartile had an estimated 11 percent (95 percent CI, 4 to 17 percent) longer length of stay compared with patients treated at hospitals in the first quartile.

Conclusions: Patients with open tibial fracture treated at hospitals with more timely initiation of surgical care had lower cost and shorter length of stay than patients treated at hospitals with less timely initiation of care. Policies directed toward mitigating variation in care may reduce unnecessary waste.


Ann Arbor, Mich.

From the Section of Plastic Surgery, Department of Surgery, and the Departments of Neurology, Pediatrics, and Internal Medicine, University of Michigan Health System, and the Veterans Administration Health System.

Received for publication June 11, 2012; accepted September 27, 2012.

Disclosure:The authors have no conflicts of interest to declare.

Kevin C. Chung, M.D., M.S.; Section of Plastic Surgery, University of Michigan Health System, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, Mich. 48109-5340,

©2013American Society of Plastic Surgeons