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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 2  |  Page : 104-110

Cost-based analysis of operative maxillofacial fracture managements


1 Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Muğla Sıtkı Koçman University, Muğla, South Korea
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Muğla Sıtkı Koçman University, Muğla, Turkey
3 Department of Biostatistics, Faculty of Medicine, Muğla Sıtkı Koçman University, Muğla, Turkey

Date of Submission19-Jun-2019
Date of Acceptance20-Jul-2019
Date of Web Publication18-Mar-2020

Correspondence Address:
Dr. Mehmet Altiparmak
Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul
South Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_54_19

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  Abstract 


Aims: There is no current study presenting a descriptive cost-based analysis of operative maxillofacial fracture managements in Turkey. Therefore, this study attempted to investigate the overall treatment costs of maxillofacial traumas. Materials and Methods: Maxillofacial trauma patients treated between January 2012 and December 2016 with at least 12 months of follow-up were included in this study. Parameters including age, gender, etiology of injury, site of trauma, additional traumas, comorbidities, length of hospitalization, treatment technique and material used in surgery, duration of surgery, complication rates, and hospital costs for treatments were analyzed retrospectively. The costs were converted into USD ($) according to the currency exchange rate. Results: The most cost-effective (351$) was the teenage group (10–17 years) and the most expensive (793$) was the group over 61 years of age with significant differences. Etiologically, assaults were statistically significantly (P = 0.047) cheaper than motorbike accidents. The most expensive treatments were tetrad site fractures, and the most cost-effective treatments were maxillary fractures. The total costs of tetrad site fractures (1088$) was statistically significantly expensive than that of maxillary fractures (245$) (P = 0.006). Additional injuries caused statistically significantly higher costs to maxillofacial trauma treatments (P = 0.002). Closed techniques or plate fixations with six holes or less were statistically significantly cheaper than plate fixations with more than six holes (P < 0.001). Maxillofacial treatments had a complication rate of 8.6%. Complications caused statistically significantly higher treatment costs (P = 0.038). Conclusions: The results of this study suggest that maxillofacial surgeons should use the resources in the most effective way to maintain low complication rates and treatment costs in managing maxillofacial traumas.

Keywords: Cost analysis, facial fracture, maxillofacial trauma


How to cite this article:
Altiparmak M, Pektas ML, Kasap S, Tosun K, Nisanci M. Cost-based analysis of operative maxillofacial fracture managements. Turk J Plast Surg 2020;28:104-10

How to cite this URL:
Altiparmak M, Pektas ML, Kasap S, Tosun K, Nisanci M. Cost-based analysis of operative maxillofacial fracture managements. Turk J Plast Surg [serial online] 2020 [cited 2020 May 27];28:104-10. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/2/104/280992




  Introduction Top


According to the Turkish Statistical Institute, it is estimated that the medical expenses in the year 2016 incurred $26,193,873.1 which comprises 4.6% of the gross domestic product, similar to other middle-income countries.[1],[2] Maxillofacial traumas occur as a result of various traumatic insults such as motor vehicle accidents, falls, and assaults, which are not uncommon. Maxillofacial trauma rates are increasing dramatically and cause high economic burden.[3] According to a literature review, there are twenty economic studies based on oral and maxillofacial traumas up to the year 2016.[4] Most authors have compared the costs of several treatment methods,[5],[6] whereas some authors compared different disciplines,[7] and some others investigated the admission types of maxillofacial traumas.[8] To date, there is no current study presenting a descriptive cost-based analysis of operative maxillofacial fracture managements in Turkey. Therefore, this study attempted to focus on the structural damage to the facial skeleton and the concomitant economic burden of treating such fractures to the health-care system. The present study is also a review and comparison of treatment costs of maxillofacial traumas throughout the world.


  Materials and Methods Top


The ethical approval for this study was obtained from the Ethical Committee of Muǧla Sıtkı Koçman University. This study was performed under the guidelines of Helsinki Declaration. Maxillofacial trauma patients treated at a Level 1 trauma center (a center where all trauma patients are referred, a reference hospital) between January 2012 and December 2016 with at least 12 months of follow-up were included in this study. The term maxillofacialtrauma in this study refers to bony injury of the face with or without facial soft-tissue injury, alone or in combination with various traumas. Patients who had maxillofacial traumas but treated conservatively, patients who died before any operation or died after a treatment before discharge, and patients with unavailable data were excluded from the study. Parameters including age, gender, etiology of injury, site of trauma, additional traumas, comorbidities, length of hospitalization, treatment technique and material used in surgery, duration of surgery, complication rates, and hospital costs for treatments were analyzed retrospectively. A total of 312 maxillofacial traumas fit the inclusion criteria and were operated in this period of time. Of these patients, a total of 183 patients could be extracted from the database and analyzed. Some parameters such as additional traumas, complications, and chronic diseases have not been recorded in some patients. Thus, the number of patients in some parameters is fewer than that of the total. Interventions under anesthesia (or at least sedation) were included. Operative time was calculated according to the anesthesia record forms.

Total costs included preoperative diagnostic tests, emergency room costs, operating room charges, hospital accommodation, medication, surgical instruments, anesthesia, and facility care charges. Intermaxillary fixations (IMFs) were only estimated as the initial presentation charges, and arch-bar removals were not added to the cost as they were performed under local anesthesia. However, any complications which needed additional expense such as hardware removal, postoperative infection, neurosensory disturbance, and unfavorable scarring were added to the original treatment costs.

The statistical comparison between groups was performed with Wilcoxon–Mann–Whitney test. Correlations between parameters were assessed with Pearson's correlation analysis. P < 0.05 was considered statistically significant. All statistical analyses were performed with software R (version 3.4.2, R Foundation for Statistical Computing, Vienna, Austria). The costs were calculated as Turkish Liras (₺) and converted into USD ($) according to the currency exchange rate on June 29, 2018 (1 ₺ =4.57 $)


  Results Top


A total of 183 patients (32 women and 151 men) were scanned retrospectively. The mean age of the patients was 32.81 ± 15.33 years (minimum = 5 years and maximum = 77 years). The results are summarized in [Table 1].
Table 1: Demographics of maxillofacial treatment total costs

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In terms of cost-based analysis:

  1. There was no difference between male and female patients (P = 0.655, Wilcoxon–Mann–Whitney test)
  2. There was no correlation between age and total cost analysis (r = 0.08, P = 0.294, Pearson's correlation). Only the “10–17” years' age group had statistically significantly lower cost compared with the “over 61” years' age group (P = 0.038, Wilcoxon–Mann–Whitney test)
  3. Etiologically, the only statistically significant difference of costs was seen between assaults and motorcycle accidents in which assaults incurred the lowest and motorcycle accidents incurred the highest cost (P = 0.047, Wilcoxon–Mann–Whitney test). Other etiologies were not statistically significant among each other in terms of costs
  4. Statistically significant differences between fracturesites in terms of total cost analysis are summarized in [Table 2] and depicted in [Graph 1]:


    • Mandibular treatments were significantly costly than maxillary fracture treatments
    • Maxillary fracture treatments were significantly cost-effective than orbital and frontal fractures
    • Double-site fractures were significantly expensive than maxillary and orbital fractures and were significantly cheaper than triple-site fractures
    • Triple- and tetrad-site fractures were significantly costly than single-site fractures (mandibular, maxillary, zygomatic, and orbital fractures).


    Daily hospital costs per patient are detailed in [Table 3].
    Table 2: Fracture sites and total costs per patient

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    Table 3: Daily costs of maxillofacial fracture treatments per patient

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  5. Additional traumas caused statistically significantly higher costs to maxillofacial traumas (P = 0.002, Wilcoxon–Mann–Whitney test)





    • Patients with maxillofacial traumas with orthopedic interventions received statistically significantly higher overall costs than patients without additional traumas (P = 0.013, Wilcoxon–Mann–Whitney test)
    • Patients with thoracic, general, and neurosurgical interventions received statistically significantly higher costs than patients without additional traumas (P < 0.001, Wilcoxon–Mann–Whitney test)
    • There was no significant difference between orthopedic and thoracic–general–neurosurgical interventions (P = 0.452, Wilcoxon–Mann–Whitney test)
    • Patients with two additional traumas received statistically significantly higher costs than patients with no additional traumas (P < 0.001, Wilcoxon–Mann–Whitney test)
    • Maxillofacial traumas with skin defects and dermal and nerve injuries have no statistically significant impact on treatment costs (P = 0.646, Wilcoxon–Mann–Whitney test).




  6. The mean hospital length of stay (LOS) was 6.66 ± 5.53 days (minimum = 1 day and maximum = 54 days)


    • Hospital LOS was found to have a positive correlation with hospital charges (r = 0.59, P < 0.001, Pearson's correlation analysis).


  7. The mean operational time of reconstruction was 112.9 ± 102.74 min (minimum = 20 min and maximum = 630 min)


    • Operational time had a statistically significant impact on hospital charges (r = 0.70, P < 0.001, Pearson's correlation analysis)


  8. On comparing treatment techniques and material usage:


    • Holes ≤6 (six holes or less) had no statistically significant difference between open reduction and internal fixation (ORIF) (open reduction / repositioning) (P = 260, Wilcoxon–Mann–Whitney test) and holes ≤6+ ORIF (P = 0.548, Wilcoxon–Mann–Whitney test)
    • Holes ≤6 had statistically significantly higher expenses than maxillomandibular fixation (MMF) (closed reduction / IMF) techniques only (P < 0.001, Wilcoxon–Mann–Whitney test)
    • Holes ≤6 had statistically significantly lower costs than holes >6 (more than six holes) and holes >6+ ORIF (P < 0.001, Wilcoxon–Mann–Whitney test)
    • No statistically significant difference was observed between holes ≤6+ ORIF and ORIF (P = 0.173, Wilcoxon–Mann–Whitney test)
    • Holes ≤6+ ORIF costs were only statistically significantly higher than MMF techniques (P < 0.001, Wilcoxon–Mann–Whitney test).
    • Holes ≤6+ ORIF costs were statistically significantly cost-effective than holes > 6 (P = 0.009) and holes > 6+ ORIF costs (P < 0.001)
    • ORIF was statistically significantly expensive than MMF (P < 0.001) and statistically significantly cost-effective than holes >6 and hole >6 + ORIF (P < 0.001)
    • Holes >6 were statistically significantly cost-effective than holes >6+ ORIF (P < 0.001, Wilcoxon–Mann–Whitney test).


    The treatment techniques and material usage are compared on [Graph 2].



  9. Chronic diseases and nicotine and alcohol consumption had no statistically significant effect on treatment costs (P = 0.967, Wilcoxon–Mann–Whitney test)
  10. Complications were found to increase the overall costs statistically significantly (P = 0.038, Wilcoxon–Mann–Whitney test). The total complication rate was 8.6%.


The total costs per patient in the literature are presented in [Table 4].
Table 4: Total maxillofacial trauma treatment costs per patient throughout the world

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  Discussion Top


The main objective of this study is to describe the financial burden of maxillofacial trauma patients to the health-care system of Turkey. Maxillofacial traumas were not isolated from additional injuries as they mostly are in an interlaced fashion of complex traumas. Oral and maxillofacial traumas cannot be separated from other injuries because it would cause systematic errors such as low costs of management and underestimation of maxillofacial trauma incidences and their relations between other traumas and treatment costs. This study aims to gain a general opinion on the economic impact of maxillofacial traumas and provide the basis for further analyzing and comparing various treatment methods in this particular zone of injury.

There was a male predominance in this study, which is similar with the literature.[3],[7],[9],[10] In general, male population has higher economic and social interactions than woman, which may be the cause of this finding. There were no differences between genders in terms of financial burden of maxillofacial traumas. Male and female maxillofacial trauma forms seem to be similar.

Various trauma patterns are associated with different age groups.[11] Literature reveals young- to middle-aged groups as the most injured population.[10],[12] In contrast with studies which excluded young and older age groups of trauma,[13],[14],[15] all ages of maxillofacial traumas were included in the current study. The most injured age group was 18–30 years. The most expensive group was the elderlies (>61 years) and the least costly group was the teenagers (10–17 years). The treatment costs of elderlies were significantly expensive than that of the teenagers. Fragility increases with age which results in increased bony fragments and additional injuries.

Maxillofacial trauma etiologies vary in literature due to socioeconomic impacts. In most studies, motor vehicle accidents are the main etiological factor of maxillofacial traumas.[7],[10],[16] Assaults and interpersonal violence are the leading factors in various studies.[8],[14],[15] Assaults are mainly reported in developed countries,[14] and they commonly cause isolated fractures, whereas traffic accidents mainly cause combined facial fractures.[7] Motor vehicle accidents and assaults are the common causes of maxillofacial fractures. Assaults brought out the lowest costs, whereas motorcycle accidents resulted with significantly highest costs. Assaults are common in young patients resulting in arcus zygoma fractures in common and are mainly treated with closed reduction. This maintains lower treatment costs. However, motorcycle accidents mainly cause combined facial traumas with additional injuries resulting in higher financial burden.

Some studies have shown zygoma to be the most injured bone in maxillofacial traumas.[10],[12] Mandible is the most common fractured bone in the present study. Maxilla and alveolar fractures incurred the lowest cost of treatment. Combined maxillofacial traumas are naturally more expensive than isolated fractures.[7] A combination of three and four regions of facial bone fractures incurred the most expensive rates of treatments in our study. Mandible, zygoma, and frontal bones have the highest treatment expenses in isolated maxillofacial traumas. Increase rate of fractured bony regions results in higher financial burden. Furthermore, multiple fractures are more expensive than single fractures in the same region of trauma.[17] This is mainly caused by increase in hardware utilization, intensive care unit hospitalization, and complication rates.

Additional injuries and traumas cannot be excluded from maxillofacial injuries. Isolated maxillofacial traumas are rare compared to multiple traumas, especially in motor vehicle accidents. Maxillofacial trauma treatments with additional injuries in general are found to be significantly expensive than treatments of other injuries. In detail, the most frequent additional injuries are dental injuries, soft-tissue defects, and nerve injuries. However, these types of traumas have no impact on the financial burden. On the other hand, the second-most seen additional injuries were extremity traumas. Maxillofacial traumas including orthopedic, neurosurgical, general, and thoracic surgery interventions have statistically significant high expenses compared with traumas without additional injuries. This is mainly due to additional hardware usage, long hospitalization time, and high complication rates. A study from Australia revealed an average of 2.9 number of other injuries, especially orthopedic and neurosurgical, combined with maxillofacial traumas.[7] Nine patients who received two other specialty interventions costed higher than single type of additional injuries. Some studies have not included additional injuries to the total charges,[14],[15],[16] whereas additional traumas have been shown to increase the costs and hospital stays significantly.[1] Our findings also support that adding the costs of other injuries increases the overall treatment costs.

Hospitalization time is shown to have a positive correlation with treatment costs in our study, as seen in the literature.[1] The average LOS of maxillofacial traumas in our study was 6.66 days. The mean LOS varies largely (0.83–11 days) in literature.[12],[15] This variance has multifactorial reasons such as types of fractures and inclusion of additional traumas. Daily hospitalization costs of mandibular fractures have been estimated as $1690 in the USA.[18] These are the raw costs of hospitalization with hardware usage and operation room (OR) utilization, with additional trauma prices excluded.

The estimated average operational time includes not only the maxillofacial treatment duration, but also the total anesthesia times, interventions of other specialties, and complication management times in the OR. General anesthesia times have been shown to double the costs compared to treatments under local anesthesia.[1] The average costs of OR occupation (excluding hardware usage) differ between countries and vary from 213£/15 min to $33/min in maxillofacial treatments.[18],[19] We found a positive correlation between the duration of operation and overall treatment costs of maxillofacial fractures. This finding correlates with the existing literature.[15]

In terms of hardware materials and techniques, we found that they have significant financial impact on overall treatment costs of maxillofacial traumas. An Australian study[7] has shown no contribution of prosthesis to overall costs, whereas in the USA,[14] usage of plates has shown significant impact on the financial burden of maxillofacial treatments as in most countries.[5] Most studies have stressed the higher efficacy of open reduction techniques and rigid methods (ORIF) over closed (MMF) or nonrigid methods of maxillofacial fracture treatment.[5],[7],[9],[12],[13],[15],[18] Exceptional studies have shown that ORIF has no clear advantage over MMF in mandibular fractures.[20]

Treating complications and lost productivity could be estimated as indirect charges and should be added to the costs.[5],[18] Most studies have not estimated the complication rates and indirect costs, which affects the overall financial burden.[5],[7],[9],[12] Malocclusion and infections are the most common complications according to a study from Turkey.[10] Even though ORIF costs higher than closed techniques, when complications and postoperative visits are added, ORIF seems to be more cost-effective.[9] The complication rates vary between 6.6% and 16.4% in the literature.[8],[14],[15],[21] Our complication rate of 8.6% is on the lower limit of this interval. According to our study, handling complications has significant effects on overall treatment costs.

Mandibular fracture treatments are said to be more expensive than major illnesses such as Type 2 diabetes and hypertension.[22] On the other hand, it seems that systemic diseases (hypertension, diabetes, etc.) and nicotine and alcohol consumption have no significant effects on treatment costs.

There are numerous types of variables affecting the financial burden of maxillofacial trauma treatments. David et al.[14] supported the fact that only pre- and post-operative managements could be modified financially. However, our study shows that operative variables, such as duration of surgery and hardware material usage, are also effective in reducing the financial burden.

Studies concerning treatment costs provide insight into the hospital charges of maxillofacial traumas throughout the world. According to this, hospital charges in Turkey appear to be <1/10 compared with costs in most of the other countries. The daily or overall costs of maxillofacial fracture treatments are low in all countries to the best of our knowledge. Besides, the complication rates are low despite the minimum charges.

A prospective cohort study with an additional injury severity score evaluation could be more precise in estimating maxillofacial trauma costs. Furthermore, adding life quality index scores to the indirect costs could maintain more accurate estimation of costs. Absence of labor loss and retrospective design are some of the limitations of this study.


  Conclusions Top


Maxillofacial traumas cover the bigger proportion of traumatic health-care financial burden. Treatment costs are higher in older ages and motorcycle accidents, with additional injuries and exceeding number of osteo-synthetic materials and complications. Maxillofacial surgeons must use the resources in the most effective and responsible ways in order to maintain the lowest financial burden with the highest quality of treatment.

Acknowledgements

The authors want to thank Soner Akgül and Hatice Parlatıcı for their great efforts on helping collecting data for this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Full text]  
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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