Cost-Based Decision Analysis of Postreduction Imaging in the Management of Mandibular Fractures

Abstract

IMPORTANCE Immediate postreduction imaging is a standard practice in the management of mandibular fractures at many hospitals. However, the literature suggests that postreduction imaging in maxillofacial fractures fails to influence clinical decision making significantly. OBJECTIVES To determine the cost-effectiveness of different clinical decision pathways regarding postreduction imaging as it relates to the experience of the surgeon, and to demonstrate that baseline postreduction imaging has utility based on the complication rate of the surgeon. DESIGN, SETTING, AND PARTICIPANTS We developed a decision tree model using commercially available software. The model accounted for cost of imaging modalities, adequacy of reduction, complication rate, cost of initial operating room time, and, if applicable, operative charges for revision surgery in the event of a complication. A review of the University of Virginia clinical data repository of 100 patients with recent mandible fractures was used to estimate the cost associated with running an operating suite for mandibular fracture repair. The University of Virginia billing system also provided costs associated with a single computed tomogram, panoramic radiography, and intraoperative 3-dimensional computed tomography. A sensitivity analysis determined how variation in complication rate affects the cost of the decision pathways. INTERVENTION Intraoperative imaging, postreduction imaging, or no imaging. MAIN OUTCOMES AND MEASURES Sensitivity of the decision tree model to variation in complication rate. RESULTS Using current hospital charges, the model is sensitive to variability in the complication rate with a breakpoint of 17.7%. It is most cost-effective to obtain a post-reduction panorex if the surgeon's complication rate is above 17.7% and most cost-effective not to obtain any postreduction imaging if the complication rate is below 17.7%. Intraoperative computed tomography is not cost-effective at any complication rate. Two-way sensitivity analysis allowed the model to be generalizable to varied institutional costs and surgical complication rates. CONCLUSIONS AND RELEVANCE The utility of postreduction imaging from the standpoint of cost analysis depends on the complication rate of the facial traumatologist and institutional charge data. Based on this model, the facial traumatologist at our institution should obtain postreduction panorex imaging for patients with mandible fractures until their complication rate drops below 17.7%. The 2-way sensitivity analysis in this study allows the facial traumatologist to apply his or her complication rate and institutional cost data to determine whether routine postreduction imaging is necessary. LEVEL OF EVIDENCE NA.

Outpatient Surgical Management of Orbital Blowout Fractures

“…Various authors have demonstrated that reflexive postreduction imaging rarely alters clinical management. 2,20,21 Although a single postoperative CT scan is only a minor component of the entire OBF repair, it is an easily identifiable source of radiation exposure and healthcare costs that may be obviated in lieu of careful postoperative clinical examination. Further delineation of reflexive postoperative CT findings after isolated OBF repair is needed to help more clearly define its role, if any, at all.…”

Multidetector CT of Mandibular Fractures, Reductions, and Complications: A Clinically Relevant Primer for the Radiologist

“…Owing to its prominence and distinction as the only mobile bone in the face, the mandible is the second most common site of facial fracture after the nose, with assaults and motor vehicle collisions being the leading causes of these injuries (1,2). Twenty-three percent of the 400 000 emergency department visits for facial fractures in the United States in 2007 involved the mandible (3,4). In patients who undergo facial fracture reduction, the mandible is the most frequently reduced bone (5).…”

Cost‐effectiveness of routine computed tomography in the evaluation of idiopathic unilateral vocal fold paralysis

“…As a result, evidence‐based recommendations are needed, as this information can be used to enhance the physician‐patient communications process and guide appropriate test utilization. Decision‐tree based cost‐effectiveness analyses have been performed for a variety of topics relevant to the practicing otolaryngologist . The objective of this study was to perform an economic evaluation focusing on whether routine CT of the neck (from the skull base down to the thoracic inlet or aortic arch) represents a cost‐effective practice in the management of patients with UVFP with no apparent cause.…”

“…Decision-tree based cost-effectiveness analyses have been performed for a variety of topics relevant to the practicing otolaryngologist. [5][6][7][8][9][10][11][12] The objective of this study was to perform an economic evaluation focusing on whether routine CT of the neck (from the skull base down to the thoracic inlet or aortic arch) represents a cost-effective practice in the management of patients with UVFP with no apparent cause. Analysis was restricted to vocal fold paralysis and did not evaluate its cost-effectiveness in cases of paresis.…”