Outpatient Operative Management of Pediatric Supracondylar Humerus Fractures: An Analysis of Frequency, Complications, and Cost From 2009 to 2018

Abstract

Background: In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care. Methods: Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery. Results: A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P < 0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P = 0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P < 0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management.Conclusions: This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges. Level of Evidence: Level III-retrospective cohort.

Risk Factors for 30-Day Unplanned Re-Operation in Pediatric Upper Extremity Surgery: A National Surgical Quality Improvement Program (NSQIP)-Pediatric Analysis

“…In the pediatric population, Makarewich et al demonstrated that the shift to outpatient surgery in type II supracondylar humerus fractures has the potential to reduce cost, with no change in outcomes [ 30 ]. Modest et al subsequently generated similar findings after retrospectively analyzing over 8,000 pediatric patients who underwent operative management of supracondylar humerus fractures [ 29 ]. However, it is difficult to discern whether the association between unplanned re-operation and outpatient procedures is due to differences in case selection, patient co-morbidities, or other factors.…”

“…Further research may investigate the causes of unplanned re-operation in emergent/urgent procedures. Regarding the inpatient vs. outpatient setting, there has been a recent trend toward outpatient surgery in many orthopedic subspecialties [ 27 - 29 ]. In the pediatric population, Makarewich et al demonstrated that the shift to outpatient surgery in type II supracondylar humerus fractures has the potential to reduce cost, with no change in outcomes [ 30 ].…”

Predictors Associated with the Need for Open Reduction of Pediatric Supracondylar Humerus Fractures

“…There is an increasing trend to treat pediatric SCH fractures in an ambulatory setting [84][85][86] . It has been shown to be not only cost-effective, but also safe, with very low rates of postoperative infections and complications [84][85][86] .…”

Value-Driven Pediatric Supracondylar Humerus Fracture Care: Implementing Evidence-Based Practices

“…Outpatients had fewer return visits to the emergency department within 1 month. 19 However, outpatient care requires a caregiver at home, the absence of serious medical problems, and reasonable proximity to a surgical center. Although these are not modifiable factors, knowing these resource requirements can prompt surgeons to enlist the help of ancillary support as necessary to optimize value (eg, care coordination for transportation).…”