Treating hand fractures: Population-based study of acute health care use in British Columbia

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Research

Treating hand fractures

Population-based study of acute health care use in British Columbia

Lynne M. Feehan

PhD MSc(PT)

Samuel S. Sheps

MD FRCPC MSc

ABSTRACT

OBJECTIVE

To examine trends in use of acute health care services for hand fractures in a large diverse population across a range of medical settings.

DESIGN

Retrospective review of data from the British Columbia Linked Health Dataset on patients who had been treated for hand fractures between May 1, 1996, and April 30, 2001.

SETTING

British Columbia.

PARTICIPANTS

A total of 72 481 British Columbia residents identified from the British Columbia Linked Health Dataset as having received treatment for hand fractures.

MAIN OUTCOME MEASURES

Initial treatment for fractures (who had provided treatment and where had the treatment taken place) and hospital use (type of hospital, physician responsible, wait time, length of stay, geographic variation).

RESULTS

Almost all patients (97%) with hand fractures received initial treatment as outpatients. Just over half these patients (54%) received initial care in nonhospital settings, and more than two-thirds (70%) received initial care from primary care physicians. By far most patients (90%) were treated conservatively without surgical intervention. The few patients with more complicated hand fractures (10%) were most commonly treated in day surgery settings by specialist surgeons within 2 days of first presentation. Patients in the more rural, isolated, northern region of British Columbia had higher hospital admission rates (relative risk 2.1) for hand fractures than patients in other regions did.

CONCLUSION

In contrast to other common fracture injuries that are routinely managed by specialist surgeons, most hand fractures in BC were managed initially as nonemergency medical problems by primary care

physicians. Almost all patients were treated conservatively without surgical intervention. The few patients with more complicated hand fractures were referred to and treated quickly by specialist surgeons. Focused training and continuing education opportunities for primary care physicians on new approaches to management of acute hand fractures will ensure that patients with hand fractures in British Columbia and the whole of Canada continue to benefit from appropriate management by primary care physicians.

EDITOR’S KEY POINTS

•

This study identified trends in initial acute health care use by people in British Columbia who had received treatment for hand fractures during a 5-year period.

•

Almost all hand fracture injuries in British Columbia were treated conservatively as nonemergency med- ical problems by primary care physicians.

•

Initial conservative treatment was unsuccessful for less than 1% of patients; these patients required surgery 7 to 29 days after the injury. Only 68 of the 72 481 patients developed early complications that required surgical intervention 1 to 3 months after initial presentation; 231 developed late complica- tions that required surgical intervention 3 or more months after initial presentation.

This article has been peer reviewed.

Can Fam Physician 2008;54:1001-7

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Recherche

Cet article a fait l’objet d’une révision par des pairs.

Can Fam Physician 2008;54:1001-7

Traitement des fractures de la main

Étude stratifiée des soins actifs utilisés en Colombie-Britannique

Lynne M. Feehan

PhD MSc(PT)

Samuel S. Sheps

MD FRCPC MSc

RéSUMé

OBJECTIF

Déterminer comment on utilise les services de santé actifs dans les cas de fracture de la main chez une population large et diversifiée, et dans différents contextes médicaux.

TYPE D’éTUDE

Revue rétrospective des données du British Columbia Linked Health Dataset sur les sujets qui ont été traités pour fractures de la main entre le 1^er mai 1996 et le 30 avril 2001.

CONTEXTE

Colombie-Britannique.

PARTICIPANTS

Un total de 72 481 résidents de Colombie-Britannique qui, selon le British Columbia Linked Health Dataset, avaient été traités pour une fracture de la main.

PRINCIPAUX PARAMÈTRE éTUDIéS

Mode de traitement initial (par qui et où) et utilisation d’un hôpital (type d’hôpital, médecin responsable, temps d’attente, durée du séjour, différences régionales).

RéSULTATS

Presque tous les cas de fracture de la main (97%) ont été traités initialement en externe. Un peu plus de la moitié (54%) des patients ont été traités initialement à l’hôpital et plus des deux tiers (70%), par des médecins de première ligne. La très grande majorité (90%) ont reçu un traitement classique sans recours à la chirurgie. Les quelque 10% de patients avec des fractures plus complexes ont été le plus souvent traités en chirurgie d’un jour par des chirurgiens spécialisés et dans les 2 jours suivant la première consultation. Par rapport aux autres régions, les patients des régions rurales, reculées ou du nord de la Colombie-Britannique avaient des taux d’hospitalisation plus élevés pour les fractures de la main (risque relatif de 2,1).

CONCLUSION

Contrairement à d’autres fractures fréquentes qui sont habituellement traitées par des chirurgiens spécialistes, la plupart des fractures de la main en Colombie-Britannique ont été traitées initialement comme des problèmes non urgents et par des médecins de première ligne. Presque tous les patients ont reçu un traitement classique sans intervention chirurgicale. Les quelques cas de fractures plus compliquées ont été dirigés à des chirurgiens spécialistes pour être traités rapidement. La possibilité pour le médecin de première ligne d’avoir des séances ad hoc et de la formation continue sur les nouvelles façons de traiter les fractures de la main permettrait aux résidents de la Colombie-Britannique et de l’ensemble du Canada de bénéficier d’un traitement approprié de la part de ces médecins.

POINTS DE REPÈRE DU RéDACTEUR

•

Cette étude a permis de connaître le type de trai- tement initial offert aux résidents de la Colombie- Britannique ayant subi une fracture de la main, sur une période de 5 ans.

•

En Colombie-Britannique, presque toutes les frac- tures de la main ont été traitées de façon classique, comme des problèmes médicaux non urgents et par des médecins de première ligne.

•

Un échec du traitement classique entraînant une

chirurgie dans les 7 à 29 jours après la blessure a

été observé dans moins de 1% des cas. Seulement

68 des 72 481 patients ont développé des compli-

cations précoces requérant une chirurgie 1 à 3 mois

après la fracture; 231 ont développé des complica-

tions tardives exigeant une intervention chirurgicale

3 mois ou plus après la première consultation.

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Treating hand fractures Research

H

and fractures are the second most common type of fracture and account for up to 20% of all fractures in adults and children.^1,2 In British Columbia (BC), an estimated 14 500 hand fractures occur each year for an annual incidence of 36 fractures per 10 000 people.³ For both male and female patients, hand fractures most commonly occur during early adolescence, just after the period of most rapid bone growth.^3-8 Across the lifespan, men are twice as likely as women to sus- tain hand fractures, and most of these fractures occur between the ages of 15 and 40, during the most active and productive working years.³

Despite the fact that hand injuries are so common, an extensive review of current literature on hand fractures⁹ and related health care use,^10-13 and a search of the Canadian Institute for Health Information’s data sets¹⁴ failed to find any previous studies assessing initial management of hand fracture injuries in a large diverse population across a range of medical settings. The purpose of this study was to identify trends in initial acute health care use by all people in BC identified as having received treatment for hand fractures during a 5-year period.³

METHODS

This population-based study involved a retrospective review of 72 481 charts of BC residents previously identified from the British Columbia Linked Health Dataset (BCLHD) as having received treatment for hand fractures between May 1, 1996, and April 30, 2001.³ The BCLHD contains comprehensive linked longitudinal population health and social service data for all BC residents. The data are maintained by the Centre for Health Services and Policy Research at the University of British Columbia in Vancouver and are available for applied health service and population health research projects approved by the Ministry of Health.^3,15 This study was approved by the Ministry of Health and received institutional clinical research ethics approval.

Data were retrieved from the BCLHD Medical Service Plan (MSP), hospital separation, and the MSP Registration (Registry) data sets.¹⁵ The MSP data set contains records of payments made to medical prac- titioners for medical services provided.¹⁵ The hospital separation data set contains records of every hospital admission.¹⁵ The Registry data set includes individ- ual demographic and geographic data for registered BC residents.¹⁵ Hand fractures were identified using the International Classification of Diseases, version 9, (ICD-9)

codes for metacarpal (815), phalangeal (816), and multiple (817) hand fractures.¹⁶ British Columbia population and regional demographic data were retrieved for 1996 to 2001.¹⁷ Further details of specific data extraction and syntheses have been described previously in a study examining the population-based incidence of hand fractures in BC and the demographics of patients treated for hand fractures.³ This study examined data to define trends in initial acute health care use for hand fractures, including initial fracture treatment (who treated patients and where were they treated) and hospital use (type of hospital, physician responsible, wait time, length of stay, and geographic variations).

RESULTS

Most patients (70 092, 97%) treated for hand fractures in BC during the 5-year period of this study were initially seen as outpatients (Table 1). About 54% of those received their initial treatment in nonhospital outpatient settings, such as doctors’ offices or outpatient medical clinics. Around 45% were first treated as hospital outpatients in emergency departments, urgent care centres, or ambulatory care clinics (Table 1). Of interest was the finding that 70% received their initial outpatient care from primary care physicians; 20% were initially treated by either plastic, orthopedic, or general surgeons; and 9% were initially managed by emergency medicine specialists (Table 2).

About 10% (7482) of patients with hand fractures had associated hospital admissions: 60% (4463) of these were day surgery patients, 40% (2996) were acute admissions, and less than 1% (23) were treated while in rehabilitation or extended care hospitals. Only 3% (2389) were initially treated for hand fractures as a component of direct hospital admission (Table 1). The remaining 7% (5093) had initial outpatient care before admission. About 18%

Dr Feehan recently completed her doctorate in Interdisciplinary Studies at the University of British Columbia in Vancouver. Dr Sheps is a Professor and researcher in the Department of Health Care and Epidemiology at the University of British Columbia.

Table 1. Location of initial care for hand fractures:

N = 72 481.

LoCaTion oF CaRe no. oF PaTienTS (%)

Initial inpatient care (n = 2389)

• Acute care setting* 1589 (2)

• Day surgery 777 (1)

• Other 23 (<1)

Initial outpatient care (n = 70 092)

• Nonhospital setting 37 842 (52)

• Hospital setting 31 772 (44)

• Unknown setting 478 (< 1)

*A direct acute hospital admission was a proxy marker for more serious injury in which patients were likely to have also sustained other regional or systemic trauma in addition to hand fractures or were more likely to have had other medical complications.

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of people receiving initial treatment by specialist surgeons had subsequent hospital admissions, whereas only 5% of people initially treated by primary care physicians had subsequent hospital admissions (Table 2).

Specialist surgeons admitted 71% of acute cases; primary care physicians admitted 21%. About 96% of the day surgery patients were admitted by either orthopedic or plastic surgeons, 3% were admitted by general surgeons, and only 1% were admitted by primary care physicians (Table 3).

The overall provincial annual admission rate for hand fractures was 37 (15 for acute care and 22 for day surgery) per 100 000 people (Table 4). The Northern Health Authority had a much higher relative annual admission rate overall (relative risk [RR] 2.1) than the province did, including both relatively higher rates for day surgeries (RR 2.4) and acute admissions (RR 1.7) (Table 4).

Intervals between initial outpatient care and admission by type of admission are shown in Table 5; 67% of all admissions occurred within 48 hours of initial presentation, and 94% occurred within 30 days. Table 5 also shows the ratio for type of physician (primary care:

surgeon:emergency physician:other) providing initial outpatient care within each interval.

Of the 4% (2996) of all hand fracture patients with acute admissions, 59% were admitted and discharged within 1 day, 86% were discharged by the end of the first week, and 91% were discharged within 2 weeks (Table 6). Mean length of stay for the 1589 patients with direct acute admissions was 9.3 days compared with 2.5 days for the 1407 patients with acute admissions following initial outpatient care and less than 1 day for the 3686 people having day surgery (Table 6).

DISCUSSION

Findings from this study indicate that almost all hand fractures in BC are treated conservatively as nonemergency medical problems by primary care physicians. In part this might be the result of the primary care physician model for acute health care delivery

in Canada. It is evident that patients in BC with uncomplicated hand fractures seek first medical contact in physicians’ offices or other nonhospital settings and

Table 2. number of outpatients initially treated and sometimes admitted by various types of physicians:

N = 70 092.

TyPeS oF PhySiCianS no. TReaTeD

(%) no. aDMiTTeD (%)*

Primary care physicians 48 762 (70) 2264 (5)

Surgeons 13 800 (20) 2442 (18)^†

• Plastic surgeons 7141 (10) 1466 (21)

• Orthopedic surgeons 6153 (9) 904 (15)

• General surgeons 506 (<1) 72 (14) Emergency physicians 6146 (9) 355 (6)^‡

Other 1384 (2) 32 (2)^§

All physicians 70 092 (100) 5093 (7)

*Given the very large number of patients reviewed in this study, a sta- tistically significant difference between admission rates is likely even with very small differences in overall percentage of patients admitted by the various types of physicians. In the broader population-based sense, this significant difference might have important implications for overall health care costs and health care use planning.

†Primary care physician vs surgeon (N = 62 562):

Pearson χ²₁ = 2661.31, P < .0001.

‡Primary care physician vs emergency physician (N = 54 908):

Pearson χ²₁ = 17.61, P < .0001.

§Primary care physician vs other medical person (N = 50 146):

Pearson χ²₁ = 16.27, P < .0001.

Table 3. Type of admission by physician responsible for admission: N = 7459.

TyPe oF PhySiCian aCuTe aDMiSSion

n (%) Day SuRgeRy

aDMiSSion n (%)

Orthopedic surgeon 971 (32) 2527 (57)

Plastic surgeon 966 (32) 1721 (39)

General surgeon 134 (5) 14 (3)

Primary care physician 627 (21) 63 (1) Other medical person 277 (9) 17 (< 1) Emergency physician 21 (< 1) 1 (< 1)

All physicians 2996 (100) 4463 (100)

Table 4. hospital admission rates by region and comparisons of relative rates

heaLTh auThoRiTy aCuTe aDMiSSionS:

RaTe PeR 100 000 aCuTe aDMiSSionS:

ReLaTive RaTe

Day SuRgeRy aDMiSSionS: RaTe

PeR 100 000

Day SuRgeRy aDMiSSionS:

ReLaTive RaTe ToTaL aDMiSSionS:

RaTe PeR 100 000 ToTaL aDMiSSionS:

ReLaTive RaTe

Fraser 9 0.6 15 0.7 24 0.6

Vancouver

Coastal 15 1 14 0.6 29 0.8

Vancouver Island 13 0.9 33 1.5 46 1.2

Interior 21 1.4 22 1 43 1.2

Northern 25 1.7 52 2.4 77 2.1

Whole of British

Columbia 15 1 (reference

standard) 22 1 (reference

standard) 37 1 (reference

standard)

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Treating hand fractures Research

do not require care from specialist surgeons. Patients with more clinically severe hand fractures, including multiple trauma injuries, are more likely to receive initial care in emergency departments or to be directly admitted to hospital. Patients with more clinically complex injuries seen in any medical setting are likely to be referred to surgical specialists.^20-24

Appropriate and timely referral of patients with complex hand fractures is supported by the fact that 19% of people with hand fractures in BC received initial outpatient treatment from specialist surgeons (98%

of day surgery patients and 69% of acute admissions), and 67% of all admissions occurred within 48 hours of being seen by a surgeon. Patients in BC do not have direct access to specialist surgeons,^18,19 so it is likely

that most patients initially treated by specialist surgeons as well as those admitted to hospital were first seen by primary care physicians and then referred to specialist surgeons for timely definitive management and possible admission to hospital.

Referral to specialist surgeons for management of complex hand fractures also accounts for the difference found in rates of subsequent hospital admissions of patients treated initially by specialist surgeons (18%

admission rate) compared with those treated initially by primary care physicians (5% admission rate).¹⁰ It can be inferred that initial hand fracture management choices made by physicians in BC are appropriate.^25-27 Our study found that only 539 (< 1%) of the 72 481 patients with hand fractures had unsuccessful initial conservative treatment and went on to surgery 7 to 29 days after the injury; only 68 patients who were treated conservatively developed early complications that required surgical intervention between 30 and 100 days (1 to 3 months) after initial presentation; another 231 required surgical intervention for fracture complications after 3 months.^25-27 Interestingly, unsuccessful conservative management or early complications were not related to type of physician providing initial care, as more than 25% of these patients were managed initially by specialist surgeons. Our study did not look at whether patients with hand fractures that were initially treated surgically were admitted to hospital, so we cannot

Table 5. interval between initial outpatient treatment and first hospital admission and ratios of type of physician providing initial outpatient care within each interval: N = 5093 admissions.

DayS beTween iniTiaL TReaTMenT anD hoSPiTaL aDMiSSion

aCuTe CaRe

(LengTh oF STay > 1 Day) n = 1407 Day SuRgeRy (LengTh oF STay 0 DayS) n = 3686

TyPe oF CaRe n (%)

RaTio oF PhySiCianS PRoviDing iniTiaL CaRe (PRiMaRy CaRe PhySiCian:

SuRgeon:eMeRgenCy

PhySiCian:oTheR)* n (%)

RaTio oF PhySiCianS PRoviDing iniTiaL CaRe

(PRiMaRy CaRe PhySiCian:SuRgeon:

eMeRgenCy PhySiCian:

oTheR)*

Immediate care 0 902 (64) 30:64:4:2 1091 (30) 27:72:1:0

1 172 (12) 49:45:3:3 769 (21) 48:47:5:0

2 55 (4) 55:36:7:2 442 (12) 54:33:13:1

Timely surgery 3-6 106 (8) 50:32:17:1 718 (19) 53:35:11:1

Delayed surgery 7-14 67 (5) 54:24:16:4 341 (9) 61:24:14:1

Secondary surgery (failed

conservative management) 15-29 12 (< 1) 84:8:8:0 119 (3) 56:27:14:3

Early complications of fracture 30-100 17 (1) 59:35:6:0 51 (1) 51:35:14:0

Late complications of fracture >100 76 (5) 74:22:5:1 155 (4) 71:20:9:0

*The ratio of physicians providing all (N = 70 092) initial outpatient care was 70:20:9:1.

Table 6. Length of stay by type of acute admission: Mean length of stay was 9.3 days (range 1-871 days) for direct acute admissions, 2.5 days (range 1-165) for acute admissions after initial outpatient treatment, and 6.1 days (range 1-871) for all acute admissions (N = 2996).

LengTh oF STay in DayS

DiReCT aCuTe aDMiSSionS n = 1589

n (%)

aCuTe aDMiSSionS aFTeR ouTPaTienT CaRe

n = 1407 n (%)

aLL aCuTe aDMiSSionS n = 2996

n (%)

1 718 (45) 1046 (74) 1764 (59)

2 169 (11) 148 (11) 317 (11)

3 116 (7) 52 (4) 168 (6)

4 90 (6) 35 (2) 125 (4)

5 54 (3) 27 (2) 81 (3)

6 46 (3) 13 (< 1) 59 (2)

7 41 (3) 12 (< 1) 53 (2)

8 to 14 131 (8) 40 (3) 171 (6)

15 to 29 107 (7) 20 (1) 127 (4)

≥ 30 117 (7) 14 (< 1) 131 (4)

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comment on rates of secondary surgical complications following initial surgical interventions.^11,28-30

Our 10% hospital admission rate is higher than the 2% admission rate found in 2 large Scandinavian population-based studies using emergency department or national injury databases that included both hand and wrist injuries.^12,13 This difference can be attributed to the greater clinical complexity of hand fractures compared with the other common types of hand and wrist injuries including sprains, lacerations, and contusions included in the other studies.^10,12,13 The incidence rate of 37 hand fracture admissions per 100 000 people in BC is compa- rable to the reported incidence rates of 21 and 61 hand and wrist fracture admissions respectively, for every 100 000 women and men in Switzerland in 2000.³¹

We noted considerable regional variation in hospital admission rates in BC, with the more rural, isolated, primary industry−based, and socioeconomically deprived northern region having the highest rate for hand fracture−related admissions.¹⁷ This finding is consistent with research showing higher rates of all hospital admissions in northern regions of BC.³² The reasons for this geographic variation in hospital admission rates are not clear, although they likely result from a combination of the varying risk of sus- taining hand fractures in different regions of the province and differences in the clinical complexity of the injuries.³ Regional differences might also be the result of differences in practice patterns and access to primary care physicians and specialist surgeons, particu- larly in isolated rural communities.³³

Limitations

Potential limitations associated with a retrospective review of hand fracture data in the BCLHD administra- tive health services data set have been described previously.³ Specifically, it should be noted that data on location of outpatient treatment should be viewed with caution, as it is not monitored for accuracy.¹⁹ Some of the very isolated or socioeconomically deprived regions of BC might be underrepresented in the MSP data set, as a higher proportion of primary physician and emergency health care services in these communities are provided under salaried or sessional payment programs.^32,33 Similarly, emergency department data from the 2 Vancouver hospitals might be underrepresented, as they also used alternative payment programs during the later stages of this study.³³ Finally, given the scarcity of population-based research on hand fractures in Canada, it is unclear whether our findings can be generalized to other geographic regions in Canada.

Similar health care systems, population demographics, and diverse levels of socioeconomic development could indicate, however, that our findings likely reflect trends in initial acute health care use for hand fractures across Canada.

Conclusion

In contrast to other common fracture injuries that are routinely managed by specialist surgeons,^31,34 most hand fractures in BC receive initial care and ongoing conservative management from primary care physicians.^20-24Findings from this study emphasize the need for primary care physicians to plan for providing care for this common injury. Further prospective longitudinal cohort studies are needed to define how variables, such as clinical presentation; access to primary, emergency, and specialist surgeon care; and variations in acute health care practice models, affect primary care physicians’ practice decisions regarding acute management of hand fractures and, ultimately, clinical outcomes.^35,36 Specifically, focused training and continuing education opportunities on new approaches to management of acute hand fracture injuries will ensure that patients continue to benefit from the appropriate management choices of primary care physicians.^27,37

Acknowledgment

This study was funded in part by a grant from the WorkSafeBC Research Secretariat.

Contributors

Dr Feehan was responsible for the original idea behind the paper, design and implementation of the study, analy- sis and presentation of the findings, and writing and edit- ing the manuscript. Dr Sheps contributed advice on the implementation of the study and assisted with the interpre- tation of results and editing the manuscript.

Competing interests None declared

Correspondence to: Dr L.M. Feehan, Division of Orthopaedic Engineering Research, Department of Orthopaedics, VGH Research Pavilion, 500—828 W 10th Ave, Vancouver, BC V4Z 1L8; telephone 604 875-4111, extension 66294; fax 604 875-4851;

e-mail Feehan@interchange.ubc.ca References

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