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Incidence and Cost of Treating Axis Fractures in the United States From 2000 to 2010

Daniels, Alan H. MD*; Arthur, Melanie PhD; Esmende, Sean M. MD*; Vigneswaran, Hari BS*; Palumbo, Mark A. MD*

doi: 10.1097/BRS.0000000000000417
Health Services Research

Study Design. Retrospective database analysis.

Objective. To examine the incidence of hospitalization, treatment, and cost of caring for patients with axis (C2) fractures.

Summary of Background Data. The incidence of C2 fractures in the elderly seems to be increasing, however, a comprehensive analysis of the incidence, treatment, and cost of treating C2 fractures has not been previously reported.

Methods. The Nationwide Inpatient Sample from 2000 to 2010 was used to identify patients with C2 fracture without neurological injury (International Classification of Disease, Ninth Revision, Clinical Modification code 805.02). Examined variables included age, International Classification of Disease, Ninth Revision, Clinical Modification injury severity score, comorbidities, mortality, hospital length of stay, treatments, and total inpatient hospitalization charge. Charges were adjusted for inflation to 2010 US dollars as well as for cost-to-charge ratios.

Results. In total, 31,129 patients with C2 fracture were identified. From 2000 to 2010 the incidence of C2 fracture hospitalization increased in all age groups (P < 0.0001). The most rapid increase was in patients older than 84 years, who experienced a 3-fold increase from 3.18 to 9.77 hospitalizations per 10,000 individuals per year (P < 0.0001). From 2000 to 2010, the rate of halo vest placement decreased from 25.2% to 10.4% (P < 0.0001), whereas the rate of surgical intervention increased from 13.1% to 16.5% (P = 0.029). For nonoperatively treated patients, the mean hospitalization charge per patient increased from $39,346 in 2000 to $63,222 in 2010, and for surgically treated patients, it increased from $70,784 in 2000 to $133,064 in 2010 (P < 0.0001). During the decade, the estimated charges for annual inpatient care for patients with C2 fracture in the United States increased 4.7-fold from $334,138,919 to $1,577,254,958 (P < 0.0001).

Conclusion. The incidence of C2 fracture hospitalizations increased dramatically from 2000 to 2010, with the most rapid increase in the elderly represented by a greater than 3-fold increase for patients older than 84 years. The inpatient charges for treating C2 fractures have risen faster than the increased incidence, with a 4.7-fold increase in hospital charges resulting in estimated annual charges of more than $1.5 billion in 2010.

Level of Evidence: 3

In the United States, from 2000 to 2010, the incidence of C2 fracture hospitalization rose, most rapidly in the elderly. The rate of halo placement decreased over time, whereas the rate of surgical intervention increased. The hospital charges associated with caring for patients with C2 fracture has outpaced the rising incidence.

*Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI; and

Department of Sociology, University of Alaska Fairbanks, Fairbanks, AK.

Address correspondence and reprint requests to Alan H. Daniels, MD, Department of Orthopaedic Surgery, Rhode Island Hospital, 593 Eddy St, Providence, RI, 02903; E-mail:

Acknowledgment date: December 21, 2013. First revision date: March 25, 2014. Second revision date: April 28, 2014. Acceptance date: April 29, 2014.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, expert testimony, payment for development of educational presentations, travel/accommodations/meeting expenses.

© 2014 by Lippincott Williams & Wilkins