Introduction

A study by Grauberger and colleagues at Mayo clinic in Rochester, Minnesota challenged the importance of surgery for children with femur fractures within 18 hours of hospital admission as a quality indicator for ranking pediatric orthopedic programs.[1] The authors noted that "hospitals able to provide at least 80% of pediatric patients with an operating room start time within 18 hours of admission to the emergency department score better as part of the overall pediatric orthopaedic ranking" by US News and World Report.  They challenged whether this appraisal is "arbitrary and may not be based on evidence-based clinical care" and sought to evaluate "whether the 18 hour treatment time for pediatric femur shaft fractures is a clinically meaningful metric."

Methodology and Findings

The authors retrospectively reviewed clinical outcomes of 174  children under age 16 with femoral shaft fractures treated at Mayo between 1997 and 2017, including 87 patients who underwent fracture reduction within 18 hours of admission and 87 patients who were treated after this time. The authors found "no statistically significant differences in any outcomes" including infection, return to walking, time to radiographic healing, or limb deformity. However, they acknowledge that patients who were not treated within the first 18 hours had an increased hospital stay by one day (2 vs. 3 days mean hospitalization for <18 hour and >18 hours to treatment).

The authors conclude:

• "Treatment of pediatric femur shaft fractures within 18 hours does not impact clinical outcomes. National quality measures should therefore use evidence-based metrics to help improve the standard of care."

Perspective

While attempting to demonstrate why increased time to treatment is not an important quality indicator, the authors have actually demonstrated the opposite.  Delay in treatment of femoral shaft fractures >18 hours from hospital admission increased  average hospital stay by one full day, from two to three days.  In the era of cost containment and limited resources, extended stay is far from insignificant. Their definition of quality as only reflecting the avoidance of catastrophic clinical outcomes or complications is contrary to the broader literature on healthcare quality, accessibility, and cost containment.

Time to care is indeed an important quality indicator.  Research has demonstrated that accessibility is an important dimension of healthcare quality.[2] Increased length of stay also increases costs.  Increasingly, payors require that providers treat fractures requiring surgery within the first 18-24 hours of admission (with exceptions for patients requiring medical stabilization and optimization first) or else deny payment for the extended stay as not medically necessary.

The economic and social costs of unnecessarily prolonged hospitalization are considerable. In 2020, the average cost of hospitalization in the US was reported at $2,873 per day.  A child's missed schooling[3] and parental time off work[4] have also been studied as important outcome indicators. Patient and parent satisfaction and preference are also key quality metrics.[5] As a parent, would you prefer to take your injured child to a facility where he or she would likely undergo prompt treatment, or one where as likely as not the treatment would be delayed a day?

The authors do not show that delays are inconsequential. Children treated after 18 hours took an average of 4.4 days longer to walk than patients treated within this period (52.4 vs. 48.1 days). Yet rather than calling for further study of this substantive difference, the authors dismiss it as not statistically significant despite limited patient numbers.

The authors' recommendation for dropping time to surgery for pediatric femur fractures as a quality metric does not follow from the data presented.  The increased hospitalization time due to lack of operating room availability or other institutional inefficiencies adds little value to patient care. For 50% of children (87/184) at their facility not to receive treatment for a femoral shaft fracture within 18 hours is a high number that arguably should be reflected in national rankings.  These delays are consequential in cost and care, even if not in complications, and therefore are legitimate metrics to consider in evaluating quality.

Timing of surgery is an individual decision made by the provider based on patient condition, urgency, and resource availability.  Some urgent surgeries are typically done the following day rather than at night, whereas some less urgent conditions (such as uncomplicated wrist and forearm shaft fractures) can often be treated with good results several days later.  Some research has reported better results for daytime surgeries for certain conditions in children, such as uncomplicated supracondylar humerus fractures.  Urgent or emergent factors are assessed individually for each patient by the on-call orthopedic surgeon.  

This essay does not argue that all pediatric femur fractures requiring surgery should undergo the procedure the same day, nor does it argue that delays increase complication risk for this condition. The study authors have found that not to be the case.  Rather, complications are not the only relevant outcome measure of care quality.

References

[1] Grauberger J, O'Byrne M, Stans AA, Shaughnessy WJ, Larson AN, Milbrandt TA. Does Shorter Time to Treatment of Pediatric Femur Shaft Fractures Impact Clinical Outcomes?. J Pediatr Orthop. 2020;40(6):e435-e439. doi:10.1097/BPO.0000000000001544
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283976/

[2] Cabrera-Barona P, Blaschke T, Kienberger S. Explaining Accessibility and Satisfaction Related to Healthcare: A Mixed-Methods Approach. Soc Indic Res. 2017;133(2):719-739. doi:10.1007/s11205-016-1371-9

[3] Time to Return to School After 10 Common Orthopaedic Surgeries Among Children and Adolescents
Willimon SC, Johnson MM, Herzog MM, Busch MT. Time to Return to School After 10 Common Orthopaedic Surgeries Among Children and Adolescents. J Pediatr Orthop. 2019;39(6):322-327. doi:10.1097/BPO.0000000000000947

[4] Leu D, Sargent MC, Ain MC, Leet AI, Tis JE, Sponseller PD. Spica casting for pediatric femoral fractures: a prospective, randomized controlled study of single-leg versus double-leg spica casts. J Bone Joint Surg Am. 2012;94(14):1259-1264. doi:10.2106/JBJS.K.00966

[5] Shirley ED, Sanders JO. Measuring Quality of Care with Patient Satisfaction Scores. J Bone Joint Surg Am. 2016;98(19):e83. doi:10.2106/JBJS.15.01216

Any opinions expressed are solely those of the author and not those of Cure 4 The Kids Foundation.