The following article was published in Orthopedic Network News (ONN), Trauma Update, Volume 5, Number 2, April 1994.  To sign up for all ONN editions in print and online, plus all archives, click here:  ONN Subscription

Stan Mendenhall, Editor & Publisher Orthopedic Network News

The number of patients hospitalized for fractures has steadily decreased at a rate of 1.3% per year between 1985 and 1992, according to data published by HCIA. There are a number of reasons for this decrease including the use of non-hospital settings for the treatment of fractures, as well as improved public health initiatives such as seat belts and air bags. Although there have been decreases in the overall number, there are large variations in the frequency, distribution, and causes for different fractures.

Hospitalizations for fractures of the hip and pelvis were the most frequent in 1992, followed by fractures of the upper extremity, foot and ankle, and spine and neck. With the exception of fractures of the hip and pelvis, all other fractures have shown a steady decrease since 1985. Among those which have had the greatest decrease are fractures of the face and upper extremities including the upper arm, wrist, fingers, and hand.

Hip and pelvis fractures are predominately of women over the age of 65; in fact, 14% of all hospitalized fracture patients are patients in this category. For all other types, more men than women have fractures, with the highest male percentage for fractures of the face. The youngest patients are those with fractures of the skull and face, and foot and ankle.

According to the California Office of State Healthcare Planning, falls were responsible for 40% of all fractures in that state followed by motor vehicle accidents with 30%. Fights and brawls were responsible for only 3% of all fractures; however, 20% of fractures of the nose, jaw, and other portions of the face took place as a result of fights. Sports fractures were also relatively infrequent with 3% of all hospitalizations; however, they also were responsible for 7% of broken feet and ankles.

How fractures are treated
How a fracture is treated will depend on its location, level of severity, availability of resources, and physician experience. A simple fracture may not need a surgical procedure and may simply be casted. A more complex fracture may need pins, wires, plates, screws, or nails, which are generically called internal fixation. Internal fixation devices can improve the healing rate for the patient; however, like other implants, they also represent a hospital expense which can absorb a significant portion of a hospital’s DRG payment.

Of all the different types of fractures, internal fixation devices are most often used in fractures of ankle and foot, according to the 1991 HCIA Link study, with approximately 70% of all patients receiving internal fixation procedures. Fractures of the hip and thigh are also likely to receive internal fixation devices; however, hip fractures may also receive either a total hip or a partial hip. Total hips and partial hips accounted for the treatment of 29% of all hip fractures in 1991. On the other hand, very few of the pelvic fractures or facial fractures receive internal fixation procedures. Since 1985, there has been a gradual increase in the number of patients receiving devices for fractures. Most significantly, tibia, fibula, and ankle fractures have increased from 45% receiving internal fixation devices in 1985 to 71% in 1992. The use of internal fixation devices has actually decreased with femurs, possibly because total and partial hips may account for more of the treatment of these fractures. Humerus and radius/ulna fractures have also increased the use of internal fixation devices since 1985.

Data Limitations
Obtaining information on the cause, treatment, and type of fractures is difficult for a number of reasons. All hospitalized patients in the United States have their diagnosis and procedures recorded with the ICD-9-CM diagnosis and procedure coding system. While there are over 400 diagnoses codes for all fractures, including more than 150 for skull, the level of severity and type of fracture are not available. In recording the cause of injury, hospitals must rely on the external cause of injury codes (“E-codes”). The level of compliance in reporting E-codes varies significantly from state to state and hospital to hospital. One hospital contacted by Orthopedic Network News indicated that E-codes were generally not used because insurance companies may not reimburse cases with inappropriate E-codes. California hospitals are required to report all E-codes to the statewide hospital planning commission. Another problem with E-codes is that they are often insufficiently specific for the cause of injury. For example, sports-related injuries need to be inferred from the E-code E886.0 (”Fall in sports”), and E849.4 (”Place for recreation and sport”. The type of sport (baseball, basketball, rollerblading, etc.) cannot be determined. The lack of consistent E-coding as well as limitations in the E-code structure restricts the value of this information in public health and injury-prevention initiatives.

In the coding of procedures, there are a number of ICD-9-CM procedures which are used to differentiate internal fixation procedures from those in which no hardware is used; however, it is impossible to tell which type of device was used (nail, plates, screws, or rods). Some ICD-9-CM internalfixation procedure codes do not differentiate specific bones. For example, ankle, tibia, and fibula internal fixation procedures all have the same procedure code (79.36), which makes it difficult to differentiate internal fixation procedures of the ankle from the tibia and fibula.

Hospital Reimbursement
Reimbursement for patients with trauma or fractures consists of a number of complicated and overlapping rules for Medicare as well as non-Medicare patients. For example, the majority of hip fracture cases are Medicare patients subject to the constraints of the DRG payment system. However, if the fracture is to a Medicare beneficiary who is in an auto accident, Medicare stipulates that it is not primary payer, and that the patient’s auto insurance is responsible for the medical bills. In some states, such as Michigan, this means that the auto insurance has responsibility for all medical coverage; in other states, such as New York, there is typically a medical limit of $2,000-$10,000 on an insurance policy after which Medicare is responsible. Injuries which are work related are subject to the local workers compensation laws, which can further complicate matters.

There are at least 35 different DRGs which a fracture patient could be assigned, depending on the location of the fracture, the presence of complications or comorbid conditions, the age of the patient, and the procedure. For example, if a hip fracture patient receives a total hip, they will be assigned to DRG 209. If they receive a hip pin, they will be assigned to DRG 211. If the patient develops a complication, their DRG will be 210. If the patient is less than 17 years old (a relatively uncommon occurrence), the DRG will be 212. Several years ago Medicare created DRGs 484-487 for multiple trauma patients. Patients will be assigned to these DRGs if they have significant injuries to more than one body system, which often occurs in automobile accidents. The table at right lists the more common DRGs, procedures, DRG payments, and implant costs as a percentage of DRG payment. As can be seen, total joints for hip, ankle, and knee fractures generally consume 30-50% of a hospital’s DRG payment, whereas internal fixation devices may consume as little as 3% in the case of plates and screws, up to as much as 26% for humeral rods. External fixation (devices which attach to the outside of the bone) can absorb up to 45% of a hospital’s DRG payment.

It should also be noted that in the case of serious fractures, the hospitalization is often the first of many medical expenses for the patient. Generally not included are rehabilitation costs, braces, orthoses, and subsequent reoperations, if the first operation is not successful. It is not unusual to see medical expenses for an ankle or tibial fracture to exceed $100,000, only a portion of which is the initial hospitalization.

The Manufacturers of Trauma Products
The sales of orthopedic products to U.S. short-term acute-care hospitals were estimated to be about $2.2 billion by IMS in 1993. About 57% of these were for reconstructive devices, mostly hip and knee implants, and about 25% ($575 million) were for trauma products. Trauma products include spinal devices, plates and screws for fractures, hip fixation devices, external fixation devices, and maxillofacial products. Excluded from these estimates are bone growth stimulators, and sales of orthopedic devices to Veteran’s hospitals, and non-hospitals. U.S. company sales for the devices related to trauma (excluding spinal plates) are estimated to be about $350 million.

The companies with the greatest sales of trauma products are Synthes, followed by Smith & Nephew Richards, Howmedica, Zimmer, Biomet, ACE Medical, and DePuy. While many of these companies offer both a total joint product line as well as trauma devices, some companies, such as Synthes, have concentrated strictly in trauma products. As the total joint companies begin to discount their total joints because of pricing pressure, they may begin to include trauma products as part of their proposals to hospitals. It should be noted that trauma products, by their very nature, are handled by a different sales group, used by different surgeons and support staff, and often implanted on weekends and nights.

To illustrate the difference between the trauma patients and the elective hip and knee implant patients, Carolinas Medical Center cross-tabulated the admission times for the orthopedic trauma DRGs which had a fracture as a principal diagnosis with the day of admission and time of admission and compared this to their elective hip and knee implant procedures. They found that 89% of the elective hip and knee implants were admitted between 8am and 5pm, and 97% of these patients were admitted between Monday and Friday. Fifty six percent of the patients admitted for orthopedic trauma were admitted between 6pm and 7am, and 29% of the orthopedic trauma cases were admitted on weekends. Therefore one would expect little overlap between the surgeons, staff, or even sales forces between the users of trauma devices and hip and knee implants.

Comparing Prices
Although trauma devices are not used in the treatment of all fractures, on a national basis, the company sales per hospitalized fracture are about $200, (or about $550 per internal fixation procedure) compared to about $2,500 – $3,000 for each hip or knee implant procedure. Although that is relatively small, it is usually in the trauma products that a hospital will find a huge inventory of seldom used plates and screws, and where improved management of materials can help the hospital contain costs. According to DeNene Wood, OR Supervisor of Medical Center East in Birmingham, “Although we only spend $100,000 a year on trauma products compared to over $1,000,000 on total joints, our inventory of internal fixation devices is $226,000 out of our total operating room inventory of $1.2 million, whereas all of our total joints are on consignment.”

In comparing prices of fracture devices (pages 8-9), it is important to look at the cost of the components necessary to perform a procedure rather than each individual component. Some companies may have relatively expensive rods and nails, but inexpensive screws, so that overall, the cost of all the supplies used for a procedure may be about the same. In general, the manufacturers will charge more for more recent technology or improvements which they believe will reduce overall costs. For example, cannulated screws, are often substituted for cortical screws. Cannulated screws are hollow, so that a guide pin can be placed into a bone. This can potentially reduce the need for a separate drilling procedure; however, the cannulated screws are about $80 versus their $14 solid counterparts.

Prevention—A rational way to reduce costs
As the reimbursement systems in healthcare are targeted toward wellness and keeping people out the hospital, it is only logical that healthcare professionals begin to examine how to reduce the incidence of trauma and fractures in their communities. The cost to the United States of all accidents was estimated to be $399 billion in 1992 by the National Safety Council, the largest portion of which was for motor vehicle accidents. Wage and productivity losses were estimated to be $211 billion of the total cost of accidents, and medical expenses, $75 billion.

Motor Vehicle Crashes
Motor vehicle crashes are responsible for about 30% of all hospitalized patients with fractures. They also are responsible for 45,000 deaths each year. There is obviously a great deal of public awareness of this issue and a number of publicly available sources of data which profile the deaths and injuries. All fatal vehicular accidents are profiled in a database system called the Fatal Accident Reporting System (FARS). This is a government sponsored data collection effort sponsored through the National Highway Traffic Safety Administration. Fatal accidents have been trended by this organization since 1975 and have resulted in modifications to seat belt and helmet laws, car design and engineering changes, speed-limit modifications, and alcohol restrictions, among others.

Another data-collection effort is that of the National Accident Sampling System/General Estimates System (NASS/GES), also administered through the National Highway Traffic Safety Administration. On an annual basis, approximately 6,000 nonfatal crashes are extensively coded for analysis by interested researchers from police accident reports.

Seat belts and airbags have generally been successful in saving lives; however, the incidence of lower extremity injuries (foot, ankle, tibia, femur) has generally increased. Indeed, data from the NASS provided by the University of Michigan Transportation Research Institute indicates the increasing percentage of accidents to the lower extremity, from 30% to 33% between 1987 and 1992. Conversely, fractures of the chest and ribs have decreased from 22% to 16% in the same time frame. “Air bags are allowing people to survive what was once a fatal collision,” according to Don Huelke of UMTRI, “but they are orthopedically injured.” According to the Insurance Institute for Highway Safety, “Fractures of weight-bearing bones are the third leading cause of insurance claims with medical costs exceeding $100,000 (behind only brain damage and paralysis).” [Insurance Institute Highway Safety Status Report, vol 27, no. 13, October 31, 1992, page 5] Elaine Petrucelli, Executive Director of the Association for Advancement of Automotive Medicine, indicates that research is beginning to address this issue through the redesign of the toe pan, foot pedals and other areas which may impact the lower extremities during a motor vehicle crash.

Sports injuries are prevalent in most communities to all levels of participant—professional, occasional athlete, college, high school, and elementary-aged children. Although these injuries are quite common, there are no reliable estimates of the number of sports injuries and their related cost.

Although most hospital sports medicne programs emphasize the rehabilitation of the injured athelete, there is one organization whose aim prevention: the Institute for Preventative Sports Medicine, of Ann Arbor, Michigan, a not-for-profit research organization. They have investigated helmet and shin guard design for soccer players and, “soft” hardballs used in baseball, and other pieces of equipment. However, the research project which gave them national attention was the use of breakaway bases in softball.

The director of the institute, Dr. David Janda, relates that he often saw softball injuries as a resident at the University of Michigan emergency room in the summer months. Seventy-one percent of these injuries, he related, were caused by sliding. The injury would occur when a player would slide into the base and the base would not move since it was anchored into the ground. After some investigation, he located a company called Roger’s Sports Corporation of Elizabethtown, Pennsylvania which manufactures break-away bases. These “break away” after a player slides into it, thus reducing the trauma caused by hitting a stationary object.

In a prospective study in Ann Arbor, Michigan, Dr. Janda had a number of the recreational softball diamonds outfitted with breakaway bases, while a number retained the conventional bases. After 1260, games (633 on the break-away bases and 627 on the stationary bases) , there were two sliding injuries on the break-away bases, and 45 on the stationary ones. The cost of the injuries on the conventional bases was $55,050, and the cost of the two injuries on the break-away bases was $700. The Center for Disease Control extrapolated a national reduction of 1.7 million injuries each year for a savings $2 billion in healthcare costs if break-away bases were used instead of stationary bases nationally. Another consideration in the economics is that many of the softball participants are members of employer-sponsored leagues. An injury at an employee-sponsored league may subject the employer to workers compensation claims.

To date, Dr. Janda indicates that he has been disappointed with the receptivity of the baseball establishment to his research. Fewer than 5,000 sets of break-away bases have been sold, according to Roger Hall of Roger’s Sports Corporation, although there are more than 400,000 amateur baseball and softball fields in the country. Currently, the Toronto Blue Jays, the Los Angeles Dodgers, and the Houston Astros use these during spring training as do some professional farm teams.

With the exception of hip fractures, hospitalizations for fractures have gradually decreased since 1985. Most fracture patients are younger males with the exception of hip fractures which are older females. More fractures are using internal fixation devices to improve patient outcomes. Compared to total joints, fracture technology is less expensive and is used by an entirely different group of surgeons and support staff. Therefore purchasing arrangements which bundle total joints and trauma products may be difficult to sell to the trauma surgeons. Finally, fractures should be viewed as a medical expense which should be avoided through improved prevention.

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