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Facial Fracture Management: Accountable Care and Value for the New Healthcare Paradigm?
Joshua M. Adkinson, M.D., Ramon Garza, III, M.D., Jarom N. Gilstrap, M.D., Sherrine M. Eid, M.P.H., Robert X. Murphy, Jr., M.D., M.S..
Lehigh Valley Health Network, Allentown, PA, USA.

Controversy exists in the literature regarding management of facial fractures. While early repair was historically advocated, recent data suggests that such repair can be detrimental. In addition, indications for operative intervention can be subjective and may not actually reflect the clinical severity of the fracture. Since facial fracture repair is a significant cost for society, the value of fracture management must be evaluated. The objective of this study is to examine management of facial fractures as well as the financial impact at our Level 1 Trauma Center.
An IRB-approved review of the Trauma Registry from 2000-2010 was performed: facial fractures, repair (inpatient/outpatient), age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), and length of stay were documented. Gross and net revenue were obtained from the network database. A multivariate linear regression and ANOVA were performed using SPSS 15.0 (SPSS Inc, Chicago, IL).
The database identified 44,900 patients; 3,116 sustained 4,285 fractures. There were 1009 malar/maxillary, 664 mandible, 1769 nasal, and 843 orbital fractures. A trend towards both older patients and higher ISS scores was observed. Patients undergoing inpatient repair of facial fractures had the highest average ISS and lowest average GCS. 21.8% of fractures were repaired: 814 (87.1%) as an inpatient (mean 4.18 days to surgery), and 121 (12.9%) as an outpatient (mean 14.61 days to surgery). 17.9% of single fractures were repaired, while multiple fractures were repaired at a rate of 39.5%. The rate of fracture repair increased as the number of fractures sustained increased (Figure 1).

Trends in non-operative versus operative management have remained stable (Figure 2).

Mandible fractures comprised the highest percentage of those undergoing inpatient surgical intervention (Figure 3).

Only 1 of 3358 fractures treated non-operatively later required delayed fixation (>90 days from discharge). Revenue for the total care of patients undergoing inpatient repair of facial fractures significantly exceeded revenue for inpatients that did not undergo surgery as well as those who underwent outpatient surgery (Table 1).
At our Level 1 Trauma Center, most patients with facial fractures are managed non-operatively. Patients who have sustained multiple facial fractures, particularly involving the mandible, are most likely to undergo surgical repair. Revenue for the total care of patients requiring inpatient surgery significantly exceeds revenue for patients undergoing outpatient repair. However, there may be greater value to society in conservative management of patients with synarthrodial facial bone fractures, unless repair is clinically indicated.

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