Value-Based Treatment of Common Pediatric Fractures by Primary Care

MacNeille, Rhett; Hennrikus, William L.

doi:10.1177/0009922818775743

Cited by 3 publications

(10 citation statements)

References 31 publications

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“…Two additional approaches to reducing treatment costs for pediatric closed distal radius fractures also deserve consideration. First, there is evidence that closed, nondisplaced pediatric distal radius fractures can be safely managed by pediatricians rather than orthopaedic surgeons in some contexts 31,32 . If pediatricians could provide services at a lower cost than orthopaedic surgeons, this could reduce treatment costs and increase value for patients 32,33 .…”

Section: Discussionmentioning

confidence: 99%

“…First, there is evidence that closed, nondisplaced pediatric distal radius fractures can be safely managed by pediatricians rather than orthopaedic surgeons in some contexts 31,32 . If pediatricians could provide services at a lower cost than orthopaedic surgeons, this could reduce treatment costs and increase value for patients 32,33 . Second, there is evidence to suggest that many displaced distal radius fractures do not require a reduction to heal adequately, particularly in children with several additional years of forearm growth remaining 14,34,35 .…”

Section: Discussionmentioning

confidence: 99%

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A Bundled Payment Model for Pediatric Distal Radius Fractures: Defining an Episode of Care

Godfrey

Little

Cornwall

et al. 2019

Journal of Pediatric Orthopaedics

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Background: Distal radius fractures are the most common fracture of childhood, occurring in approximately 1 per 100 children annually. Given the high incidence of these fractures, we explored feasibility of a bundled payment model. We determined the total treatment costs for each child and identified components of fracture management that contributed to variations in cost. Methods:We retrospectively reviewed all hospital and physician costs related to the treatment of closed distal radius fractures at a large academic children's hospital. We included all children age 2-15 years treated by an orthopaedic surgeon for an isolated closed distal radius fracture between 2013 and 2015. We compared total treatment costs by fracture management approach. We then estimated the contribution of each component of fracture management to total treatment costs using linear regression. Results:We identified 5,640 children meeting the inclusion criteria, of which 4,602 (81.6%) received closed treatment without manipulation, 922 (16.3%) underwent closed reduction in the clinic, emergency department, or radiology procedure suite, and 116 (2.1%) underwent treatment in the operating room. The median cost for closed treatment without manipulation was $1,390 (IQR 1,029-1,801), compared to $4,263 (IQR 3,832) for closed reduction and $9,389 (IQR 8,119) for closed reduction and percutaneous pinning (p<0.001). In multivariable regression analysis, fracture management approach and use of the operating room environment were the largest cost drivers (p<0.001, R 2 =0.88).

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

A Bundled Payment Model for Pediatric Distal Radius Fractures: Defining an Episode of Care

Godfrey

Little

Cornwall

et al. 2019

Journal of Pediatric Orthopaedics

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“…For example, the cost of a removable CAM boot applied by a pediatrician for a patient with a grade 2 ankle sprain is less than the costs associated with casting and a subsequent visit for cast removal by an orthopedic surgeon. Furthermore, the cost of caring for a distal radius buckle fracture by a pediatrician is approximately $670 when using a forearm splint compared with $768 in a short-arm cast applied by an orthopedic surgeon [24]. In total 63% of graduating pediatric residents will enter primary care [8].…”

Section: Discussionmentioning

confidence: 99%

“…In total 63% of graduating pediatric residents will enter primary care [8]. PCPs who understand basic musculoskeletal conditions can economically benefit from billing for those conditions [24,25].…”

Section: Discussionmentioning

confidence: 99%

“…Nondisplaced Salter-Harris I ankle fractures, nondisplaced clavicle fractures and Toddler fractures do not require surgical intervention, advanced imaging or orthopedic follow-up [7,24,28,29]. Similarly, buckle and clavicle fractures can be treated in the primary care setting with a removable splint and sling and no orthopedic referral [24]. Displaced fractures, growth plate fractures and fractures demonstrating delayed healing should be referred to orthopedic surgery [24].…”

Section: Discussionmentioning

confidence: 99%

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Referral patterns to a pediatric orthopedic clinic: pediatric orthopedic surgeons are primary care musculoskeletal medicine physicians

Pan

Kish

Hennrikus

2022

Journal of Pediatric Orthopaedics B

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In 2004, Reeder and in 2012, Schwend reported that inappropriate nonsurgical referrals to pediatric orthopedic clinics create a misuse of resources. Additional authors have called for re-emphasis and additional training in musculoskeletal medicine for primary care physicians (PCP) to improve the confidence, knowledge and performance when managing musculoskeletal conditions. The current study compares the diagnoses referred to a pediatric orthopedic clinic with diagnoses recommended for referral by the American Academy of Pediatrics (AAP) guidelines to determine if any improvement in the quality of referrals has occurred since Reeder and Schwend’s article. A chart review of new referrals to a pediatric orthopedic clinic during a 3-month-period was performed. Data were collected on age, sex, referring diagnosis, referral source, final diagnosis and treatment. In total 230 new consults were evaluated. The referral source was a PCP in 169 (73.5%) cases, 30 (13%) self-referrals by a parent, 19 (8.3%) from another orthopedic surgeon, 9 (3.9%) from a neurologist and 3 (1.3%) from another specialist. Fifty percent of referrals met the criteria outlined in the AAP guidelines for referral to a pediatric orthopedic specialist and 48% were classified as primary care musculoskeletal conditions. During the 15 years since the publication of Reeder’s study and despite a limited re-emphasis on musculoskeletal education, the percent of inappropriate referrals to a pediatric orthopedic clinic remains unchanged at 50%. We support an expanded musculoskeletal educational effort aimed at the medical, resident and pediatrician level, online decision-making aids, and implementation of a standardized referral form with the specific criteria of the AAP included.

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The Slipper Fracture: Revisited

Álvarez¹,

Chen²,

Pilla³

et al. 2023

Cureus

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Objectives The term “slipper fracture” is used to describe a fracture of the radius at the junction of the metaphysis and diaphysis. This fracture has an “evil” reputation because it often angulates in the cast. Historically, there have been differing opinions on the optimal way to cast slipper fractures either with a long arm cast in pronation or a long arm cast in supination to prevent angulation. The purpose of this study is to report the outcomes of “slipper fractures” treated with casting. Methods Sixteen slipper fractures were retrospectively reviewed. Electronic medical records (EMRs) and radiographs were analyzed to gather data on body weight, cast type, cast position, cast index, loss of reduction, cast wedging, repeat reduction, surgery, and amount of remodeling. Results The average age of the patients was eight years old. The average body weight was 30.4 kg. Initial casting included 14 long arm casts in neutral, one short arm cast, and one sugar tong splint. The average cast index was 0.87. Only one cast had a cast index of less than 0.8. This fracture was treated with a long arm cast and did not displace. Of the fractures, 94% lost reduction in the cast and angulated an average of 26 degrees. Two cases were treated with a cast wedge; 13 were observed. Remodeling occurred at an average rate of 2.7 degrees/month. The average remodeling measured at the last follow-up was 15 degrees. Conclusion Slipper fractures are difficult to treat due to the angulation of the fracture in the cast. The current study indicates that a long arm cast, appropriate cast index, and cast position are key to preventing the loss of reduction or angulation of a slipper fracture.

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Value-Based Treatment of Common Pediatric Fractures by Primary Care

Cited by 3 publications

References 31 publications

A Bundled Payment Model for Pediatric Distal Radius Fractures: Defining an Episode of Care

A Bundled Payment Model for Pediatric Distal Radius Fractures: Defining an Episode of Care

Referral patterns to a pediatric orthopedic clinic: pediatric orthopedic surgeons are primary care musculoskeletal medicine physicians

The Slipper Fracture: Revisited

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