The Cost and Inpatient Burden of Treating Mandible Fractures: A Nationwide Inpatient Sample Database Analysis

Israel Pena Jr, MD; W. Marshall Guy, MD; Jose P. Zevallos, MD Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas.

Abstract Objective: At the conclusion of this presentation, the participants should be able to discuss the patient demographics, hospitalization characteristics, and costs associated with the treatment of mandible fractures. Methods: : A retrospective cross-sectional analysis was conducted by analyzing the 2009 Nationwide Inpatient Sample (NIS) database for patients with isolated mandible fractures. Results: 1481 patients were identified with isolated mandible fractures. The average age of patients was 32 and 85.4% were male. Thirty-nine percent were Caucasian, 25% African-American, 12% Hispanic, 7% other, and 1% Asian. Twelve percent of patients presented with a history of alcohol abuse, 10.7% drug abuse, and 5.5% mental illness. Thirty-seven percent were from the lowest median household income quartile, and 77% were uninsured or had Medicaid. Eighty-two percent of patients were treated in academic institutions and 18% in private hospitals. Seventy-two percent of patients were treated at large hospitals (>100 beds), 24% in medium size hospitals (50-99 beds), and 4% in small hospitals (< 50 beds) with the majority of patients (95%) receiving treatment in an urban hospital setting. Thirty-eight percent of patients underwent ORIF within 24 hours of admission, the average length of stay (LOS) was 2.96 days, and average cost of hospitalization was $35,804. Increased LOS was associated with alcohol abuse (3.88 vs. 2.83 days, p< 0.001), drug abuse (3.98 vs. 2.84 days, p<0.001), mental illness (3.00 vs. 2.00 days, p=0.005), age greater than 40 years (3.68 vs. 2.71 days, p<0.001), and treatment in a private rather than academic institution (3.17 vs. 2.91 days, p=0.03). Increased total cost was associated with drug abuse ($34,283 vs. $26,844, p=0.001), alcohol abuse ($43,991 vs. 34,675, p<0.001), age over 40 ($38,768 vs. $34,781, p=0.013), and undergoing surgery in the Northeast rather than the Midwest ($40,237 vs. $30,242, p<0.05). Conclusion: The reduction of mandible fractures indicates an extensive consumption of hospital resources, with uninsured African American males of low socioeconomic status comprising a disproportionately high percentage of patients treated nationally. Healthcare expenditures associated with the treatment of mandible fractures are higher for older patients and those with a history of mental illness or substance abuse. To improve outcomes and reduce hospital charges related to mandible fractures, outpatient resources and inpatient protocols should be implemented to address the factors we identified as contributing to higher costs and increased hospital stay.

Background •Facial fracture reduction in the US contributes to an inpatient hospital cost of $1.06 billion1 •Mandible fractures are the most common facial fracture in the US requiring operative repair and account for more than half of all hospitalization charges associated with facial fractures1 •Mandible fractures are most commonly due to assault, followed by MVA and accidental falls1,2,3,4,5,6,7,8 •A disproportionately high percentage of patients are African American1 •Alcohol and drug abuse are commonly reported comorbidities1,9,10

•Mandible fractures are most often treated with open reduction internal fixation (ORIF)11,12,13,14

Discussion •Mandible fractures were found to incur a significant burden in healthcare dollars with an average cost of $35,804 per hospitalization •Our results supported the hypothesis that multiple variables are associated with a significant increase in cost and length of stay •Uninsured males of low socioeconomic status comprise the greatest percentage of patients •Elderly patients (>40) accrue significantly higher costs and longer LOS, thus emphasis should be placed on treating elderly patients efficiently •Hospitals in the Northeast had a higher cost but equivalent LOS to hospitals in the Midwest, indicating a need for standardization of procedures and costs amongst hospitals nationwide •Academic institutions were found to have higher turnover but, though not significant, increased costs. Protocols to standardize hospitalization days in non-academic institutions are warranted •Recognizing patients with comorbidities such as alcohol and drug abuse and establishing interventions for these patients can help to alleviate the increased costs associated with alcohol and drug use •Strengths: large (1481), comprehensive, nationwide sample from one whole year was analyzed •Limitations: itemized billing costs were unavailable therefore only associations and not direct causal relationships could be determined; surgical complications were unable to be analyzed

Conclusion With an average hospitalization cost of $35,804 per person , the reduction of mandible fractures indicates an extensive consumption of hospital resources. Uninsured African American males of low socioeconomic status comprise a disproportionately high percentage of mandible fracture patients treated nationally. Healthcare expenditures associated with the treatment of mandible fractures are higher for patients over age 40 and those with a history of mental illness or substance abuse. To improve outcomes and reduce hospital charges related to mandible fractures, outpatient resources and inpatient protocols should be implemented to address these factors.

References 1. Nalliah RP, Allareddy V, Kim MK, Venugopalan SR, Gajendrareddy P, Allareddy V. Economics of facial fracture reductions in the United States over 12 months. Dent Traumatol. 2012 Apr 9. doi: 10.1111/j.1600-9657.2012.01137.x. 2. Dillon JK, Christensen B, McDonald T, Huang S, Gauger P, Gomez P. The financial burden of mandibular trauma. J Oral Maxillofac Surg. 2012 Sep;70(9):2124-34. doi: 10.1016/j.joms.2012.04.048. 3. Rikhotso E, Ferretti C. A prospective audit over a six month period of condylar fractures at Chris Hani Baragwanath Hospital. SADJ. 2008;63;222–5, 228–9. 4. Bormann KH, Wild S, Gellrich NC, Kokemu¨ller H, Stu ¨hmer C, Schmelzeisen R et al. Five-year retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology, treatment, and complications. J Oral Maxillofac Surg 2009;67:1251–5 5. Pechalova P. Maxillofacial fractures in Southern Bulgaria - a retrospective study of 1706 cases. J Craniomaxillofac Surg 2007;35:147–50. 6. Parker WL, Chehade A, Williams HB. Identification of mandibular fracture epidemiology in Canada: enhancing injury prevention and patient evaluation. Can J Plast Surg 2008;16:36–40. 7. Simsek S, Simsek B, Abubaker AO, Laskin DM. A comparative study of mandibular fractures in the United States and Turkey. Int J Oral Maxillofac Surg 2007;36:395–7 8. Erdmann D, Follmar KE, Debruijn M, Bruno AD, Jung SH, Edelman D et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg 2008;60:398–403. 9. Lee KH. Interpersonal violence and facial fractures. J Oral Maxillofac Surg 2009;67:1878–83. 10. Juric´ M, Novakovic J, Carapina M, Kneievic´ E. Treatment cost of patients with maxillofacial fractures at the University Hospital in Mostar 2002–2006. Coll Antropol 2010;34(Suppl 1):199–203 11. Melmed EP, Koonin AJ: Fractures of the mandible: A review of 909 cases. Plast Reconstr Surg 56:323, 1975 12. James RB, Kent JN: Prospective study of mandibular fractures. J Oral Surg 39:275, 1981 13. Maloney PL, Welch TB, Koku C: Early immobilization of man-dibular fractures: A retrospective study. J Oral Maxillofac Surg 49:698, 1991 14. Jaques B, Richter M, Arza A: Treatment of mandibular fractures with rigid osteosysnthesis: Using the AO system. J Oral Maxil-lofac Surg 55:1402, 199

Methods •Retrospective cross-sectional analysis of 2009 Nationwide Inpatient Sample Database (NIS) for mandible fractures •Inclusion criteria: mandible fracture defined by ICD-9 code 802.20-802.37 listed as diagnosis 1-10 •Exclusion criteria: patients diagnosed with concurrent poly-trauma (fracture outside the mandible), respiratory distress, or neurological injury •Variables analyzed: 1)Patient demographics (age, gender, race, income level, insurance type) 2)Hospital characteristics (bed size, location, region, academic status 3)Common co-morbidities (mental illness, substance abuse, alcohol use) 4)Fracture characteristics (number, location) •Average cost of hospitalization and length of stay were calculated for the population at whole and for each individual variable •Statistical analysis was performed by SigmaPlot v12.5 using paired 2 tailed t-tests and All Pairwise Multiple Comparison Procedures (Dunn's Method); to compare cost and length of stay for each variable evaluated

Results •1481 patients met inclusion criteria •Average overall cost of hospitalization was $35,804 •Average overall length of stay was 2.96 days •Patient demographics: average age of 32, majority Caucasian (39%) or African American (25%), 61% earned less than 48k, 77% uninsured or covered by Medicaid •Hospital characteristics: 72% treated at a large hospital (>100 beds), 95% in an urban setting, 82% at an academic institution, majority in the northeast (30%) or south (36%) •Co-morbidities: 12% with history of alcohol abuse, 10.7% with illicit drug use, 5.46% with concurrent mental illness •Fracture characteristics: Angle was most common fracture type (36%), 95% had one or two mandible fractures , 38% of fractures reduced within 24hrs •A significant increase of cost was associated with: age over 40 ($38,768 vs. $34,781, p=0.013), hospitalization in the Northeast vs. Midwest ($36,999 vs. $26,225, p=0.03), illicit drug use ($34,283 vs. $26,844, p=0.001), and a history of alcohol abuse ($43,991 vs. 34,675, p=0.001) •A significant increase in length of stay was associated with: age over 40 (3.68 vs. 2.71, p=0.03), treatment at a non-academic institution (3.17 vs. 2.91 days, p=0.03), alcohol abuse (3.98 vs. 2.84 days, p<0.001), mental illness (3.00 vs. 2.00 days, p=0.005), and drug abuse (3.98 vs. 2.84 days, p<0.001)

Table 1: Descriptive Statistics (N=1481) Table 2: Mean Cost and Length of Stay for Selected Variables

Table 1: Demonstrates the patient demographics, patient income quartile, presence of psychiatric disorders, alcohol abuse, drug abuse, insurance type, fracture location, number of fractures, and hospital characteristics

36%

17% 16%

3%

5%

10%

13%

Figure 1: Distribution of Mandible Fracture Locations

angle

body

symphysis

NOS

ramus

multiple

condylar process

Figure 1: Distribution of mandible

fractures based on location in

percentage. The most common

location for a fracture in our

patient population sample is the

angle.

Table 2: Demonstrates the average hospital cost and hospital length of stay based on specific variables. * P values based on All Pairwise Multiple Comparison Procedures (Dunn's Method) ‡1 P value based on All Pairwise Multiple Comparison Procedures (Dunn's Method); only Northwest versus Midwest were statistically significant (p<0.05) ‡2 P value based on All Pairwise Multiple Comparison Procedures (Dunn's Method); only a small hospital versus medium or large was statistically significant (p<0.05)

Study Variable Data (percent)

Demographic Variables Age (years) 32 <40 1101 (74.3) >40 380 (25.7)

Gender Male 1265 (85.4) Female 204 (13.8) Unknown 12 (0.8) Race White 573 (38.7) Black 367 (24.8) Hispanic 176 (11.9) Native American 7 (0.5) Asian 13 (0.9) Other 108 (7.3) Income <$39,000 542 (40.3) $39-49,000 362 (26.9) $48-63,000 260 (19.3) >$63,000 180 (13.4) Psychiatric Disorder Present 81 (5.5) Not Present 1400 (94.5) Alcohol abuse Present 179 (12.1) Not Present 1302 (87.9) Drug Abuse Present 159 (10.7) Not Present 1322 (89.3) Insurance Type Medicare 91 (6.1) Medicaid 362 (24.4) Private 334 (22.6) Self-pay 454 (30.7) Other 192 (13) No Charge 48 (3.2) Hospital Features Academic Teaching 1211 (82) Non-Teaching 270 (18) Region Northeast 437 (30) Midwest 267 (18) South 537 (36) West 240 (16) Bed Size Small 61 (4) Medium 335 (23) Large 1037 (72) Location Rural 80 (5) Urban 1401 (95)

Study Variable Mean Cost P Value Mean LOS P Value

Sample Size $35,804 NA 2.65 NA Age 0.013 <0.001

<40 $34,782 2.71

>40 $38,769 3.68 Gender 0.479 0.618

Male $36,003 2.96

Female $34,760 2.96 Race 0.314* 0.102*

White $34,576 2.97

Black $36,990 2.58

Hispanic $38,248 2.99 Native American $37,323 3.00

Asian $47,692 6.38 Income 0.368* 0.312*

<$39,000 $33,864 2.80

$39-48,000 $36,169 3.09

$48-63,000 $35,314 2.89

>$63,000 $37,443 3.38 Psychiatric Disorder <0.047 0.005

Present $37,422 3.00

Not Present $35,713 2.00 Alcohol abuse 0.001 <0.001

Present $43,991 3.88

Not Present $34,676 2.83 Drug Abuse <0.001 <0.001

Present $34,283 3.98

Not Present $26,844 2.84 Insurance 0.096* 0.131*

Medicare $40,165 3.41

Medicaid $37,601 2.82

Private $36,241 3.12

Self-pay $36,414 2.87

No Charge $26,922 2.27 Affiliation 0.649 0.031

Academic $36,185 2.91 Non- Academic $34,087 3.17 Region ‡1 0.963*

Northeast $40,238 2.94

Midwest $30,243 2.94

South $34,523 2.92

West $36,786 3.10 Hospital Size ‡2 0.602*

Small $26,225 2.43

Medium $34,914 2.82

Large $36,996 3.04 Location 0.220 0.542

Rural $29,257 2.78

Urban $36,181 2.97