A Claims Based Natural History of the Post-Treatment Period after a Unilateral Elbow
Fracture
Fernando Pena Molina MD, FEBOT1,Maha Karim BS2, Samantha J Beckley PhD2, Shaun K
Stinton PhD2, Thomas P Branch MD3
1 Orthopaedics and Trauma Surgery Unit, Hospital de Denia, Denia, Alicante, Spain
2 ArthroResearch LLC, 441 Armour Place NE, Atlanta, GA, 30324, United States
3 Ermi LLC, 2872 Woodcock Blvd. Suite 100, Atlanta, GA, 30341, United States
Address for correspondence:
Samantha Beckley, 441 Armour Place NE, Atlanta, GA, 30324, USA
Phone: +1 404-579-1546
Email: s.beckley@arthroresearch.com.
| Abstract: 250 words Objective: The aim of this paper was to determine a claims-based timeline of unilateral elbow fracture recovery including the effect of comorbidities and post-treatment complications on recovery. Methods: Healthcare claims data were analyzed to assess costs and recovery timelines after unilateral elbow fracture treatment. Costs examined included: i) index surgery/treatment, ii) complication surgery, iii) revision or salvage surgeries, iv) non-operative hospitalization, v) motion restoring surgery and vi) elbow-related outpatient surgery were reported. The impact of comorbidities–diabetes, obesity, peripheral vascular disease, and cardiovascular disease–was evaluated. Additionally, data on re-hospitalizations, with or without further surgery, were analyzed to understand complications after the initial treatment. Perioperative complications including joint fibrosis/contracture, infection, and pulmonary embolus were also reported. Results: Index surgery/treatment median cost and length of post-treatment recovery (from index surgery/treatment to last physical therapy claim) was $4,494 ($872 to $10,444) and 102.5 days (36-480 days), respectively.A total of 59% of patients completed their posttreatment period in six months with 41% of patients taking longer. Patients that required a complication surgery had recovery times three times longer and added seven times the cost, in comparison to those without complication surgeries. Conclusion: Comorbidities and complications following elbow fracture treatment lead to substantial increases in both costs and recovery durations. Understanding the typical recovery timeline after elbow fracture treatment, as well as the variations in outlier patients, can assist in optimizing recovery management and guiding appropriate interventions. |
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| 2500 word limit for Orthopedics Introduction: The elbow is a critical joint in the body for daily functions and independent living [1]. Elbow fractures are among the most common fractures in orthopedics representing 7% of all adult fractures [2]. Fractures around the elbow are particularly complex as they are often associated with a dislocation of the joint [3, 4, 5]. Despite the increasing sophistication in the operative treatment of elbow fractures severe fractures have been reported to experience significant motion loss [6]. Even elbow fractures treated non-operatively in the elderly had a complication rate as high as 26% [7]. Understanding and defining the current common recovery period following treatment is a crucial first step toward improving outcomes. With most treatments reported as a case series with a minimum of two year follow-up, the immediate treatment recovery period has not been given sufficient attention. Meanwhile, a substantial portion of healthcare spending occurs in this period. Defining a “Natural History” of the immediate recovery period requires a substantially larger dataset than standard case series typically provide, ensuring all potential recovery pathways are represented. One valuable resource for studying elbow fracture recovery patterns is the IBM MarketScan Commercial Claims and Encounters Database. This database contains de-identified health data from reimbursed healthcare claims for over 250 employers and health plans [8], covering clinical |
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| utilization, expenses, insurance details, and care services for a large, insured population in the United States, which included an estimated 30 million individuals each year [8]. The aim of this study was to perform a claims-based timeline analysis of unilateral elbow fracture, from the initial treatment to the final physical therapy session, to outline a natural recovery timeline. Additionally, we sought to quantify the impact of comorbidities and post-treatment complications on this recovery trajectory. Methods: Study Population This study utilized data from the IBM MarketScan database (2015–2018), which include records for 11 million patients and 1 billion claims, were used for this study. Patients were included if they had at least two years of consecutive years of coverage. Elbow fracture CPT codes (Addendum #1) to identify eligible patients. Patients with simultaneous or staged bilateral elbow fractures were excluded to prevent skewed costs and recovery times. The post-treatment period was defined as the timeline from the index elbow fracture surgery/treatment to the last Healthcare Common Procedure Coding System (HCPCS CPT) charge for physical therapy (PT). Only patients with at least one PT CPT charge (codes >=97000 & <98000) post-treatment were included. Cost Analysis |
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| The costs associated with the index treatment include all healthcare expenses incurred during inpatient hospitalization or within eight days of outpatient surgery. Subsequent procedures were categorized into four groups: i) complication-related surgery, ii) revision surgery after elbow fracture (salvage) iii) non-operative hospitalization, and iv) motion-restoring surgery. Total costs in each category represent all healthcare expenditures, encompassing the cited index treatment and any additional post-index treatment events. These costs provide a comprehensive view of the financial impact and the risk of related subsequent events. Standard CPT codes for post-treatment expenses, such as PT/Occupational therapy (>=97000 & <98000), physician visits (>=99200 and <99300, with injection CPT codes, 20610/20611), and radiology, were also analyzed (see Addendum #1). Expenses unrelated to elbow fractures were excluded from the analysis if there were no elbow-related ICD 9/10 codes on the HCPCS form. All reported costs reflect amounts paid by insurance. Comorbidities The study analyzed the impact of comorbidities on recovery timelines. Therefore, patients subsets were created and analyzed for individuals with i) diabetes (codes 25.0 & E11.9), ii) obesity (codes 278., E66., & Z68.4), iii) peripheral vascular disease (PVD, codes 440.:444., 785., & I73.9), iv) joint infection (codes 711., 996., M00., M01, & M02), and v) cardiovascular disease (CVD, codes 390.:459., I11, I20, I21, & I25). Index Surgery All costs related to the index treatment were included as identified by the case identifier (CaseID) for inpatient surgery. For index treatments performed in the outpatient setting (without a CaseID), all costs over an eight day period were included in the total index costs, as submitted |
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| claims were spread out over time. If elbow fracture treatment started in an outpatient setting and then was transferred to a hospital, creating a new CaseID within eight days, these costs were included in the outpatient index treatment costs. If a patient started treatment in an inpatient setting and were subsequently transferred to an inpatient rehabilitation hospital, these were counted as two separate hospitalizations. The inpatient rehabilitation hospitalization was considered a nonoperative hospitalization. Additional Post-Treatment Surgeries The impact of post-treatment complications on recovery was analyzed, focusing on rehospitalizations with and without additional surgeries, including elbow fracture revisions (Addendum #2), motion-restoring surgeries (MRS, Addendum #3), and other complication-related surgeries (Addendum #4). Hospitalizations were identified by a new CaseID linked to or following the index treatment. Perioperative complications such as joint contracture (Addendum #5), infection (Addendum #6), and pulmonary embolus (Addendum #7) were also analyzed. Presentation of Recovery Pathway A best-case recovery pathway assumes an uncomplicated post-treatment course, where the patient undergoes the index treatment, is discharged, attends PT, and recovers within six months. It is well documented that a disability such as an injury or surgery changes from acute to chronic at the six month mark [9,10], and most states and insurance providers cap temporary or short-term disability insurance at six months. To illustrate complicated recoveries, a multiple-pathway chart (Figure 1) shows the aggregate impact of multiple postoperative events. |
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| This chart does not represent a timeline but highlights the cumulative risk impact of successive complications during the postoperative period. Data Analysis Data were analyzed using the R statistical programming language (version 4.3.3). Given the large sample size, results are presented as medians with an interquartile range (IQR). Results: Study Group Demographics The study group was composed of 2,680 patients comprising 57% females. The median age was 30 years with a range from 1 to 62 years; however, the distribution of age appears bimodal with a concentration younger than 20 and over 40 years of age (Figure 2). No data was available for the height or weights of patients. Index Surgery/Treatment Costs Of the 2,680 patients, 194 were treated as inpatient only, 2466 were outpatient and 14 started as outpatient, but ended as inpatient. The distribution of inpatient and outpatient treatments of elbow fractures is shown in Table 1 and 2. The index treatment median cost was $4,494 (IQR:$872-$10,444). Inpatient surgery median cost was $6,297 (IQR:$2,577-$21,381). Outpatient treatments had a median cost of $4,372 (IQR:$792-$9,85. In the case of patients starting as an outpatient but ended as an inpatient the median cost was $23,600 (IQR:$10,003$41,276). Recovery Period |
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| The median length of post-treatment recovery was 102.5 days (IQR:36-480 days). Only 59% of patients completed their postoperative period within six months (Figure 3). Patients who completed their recovery in less than six months, spent a median of 43 days in structured outpatient PT whereas patients who took over six months to complete their recovery, spent a median of 604 days in structured outpatient PT. The additional post-treatment costs occurring after the six months period for patients requiring continued PT had a median value of $3,295 (IQR: $1,154–$8,740). Complicating Events After MRS, the median number of days in structured PT and the costs of post-treatment care both nearly tripled (Table 3). The median recovery period and cost for patients that required a complication surgery following a unilateral elbow fracture were three times longer and added seven times the cost in comparison to patients that did not require any complication surgeries (Table 3). Revision surgery had a similar impact (Table 3). No patients were hospitalized for infection or pulmonary embolism attributable to the elbow fracture were identified (Table 3). The cumulative effect on medical care costs and recovery time as a result of multiple events in the post-treatment period are shown in Figure 4 and Table 4. In particular, the decision to perform a MRS substantially increased the risk of requiring revision or salvage surgery. Patients undergoing MRS were 1.7 times more likely to need a revision compared to those without a MRS (19% vs. 11%). A single elbow fracture with no complications, no revisions and no MRS had a median post-treatment cost of $2,099 (Figure 4). We found that 20.6% of patients with a unilateral elbow |
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| fracture required a secondary surgery (Figure 4). The median post-treatment cost surged dramatically to $56,673 when a MRS, revision surgery as well as a complication surgery was performed. Out of the 2,680 patients t with a unilateral elbow fracture, 2,605 patients did not undergo a MRS and required a median of 97 PT days (IQR:35-475 days)with a median cost of $2,714 (IQR:$1236-$6757). The median cost for patients requiring a MRS was $20,383 (IQR:$10,288-$33,765) with a median of 333 PT days (IQR:141-677 days) for recovery. Joint Contracture The presence of joint contracture at the time of index treatment had no impact on recovery costs or time to recover whereas the development of joint contracture after the index treatment had a major impact (Table 5). The median cost and recovery time for the subset of patients that developed a joint contracture post operatively was much larger than the subset of patients with who did not develop a contracture (Table 5). Impact of Comorbidities on Recovery The effect of the presence of diabetes, PVD, obesity and CVD is shown in Table 6. The clinical impact of these conditions on recovery was small. Discussion: The primary outcome of this study was the establishment of a benchmark for the recovery period following the treatment of unilateral elbow fractures. This benchmark serves as a standardized tool for tracking and managing the progress of a patient over the early recovery phase. The median recovery time after the treatment for an elbow fracture was 102.5 days. Over 40% of patients’ recovery duration extended over six months (Figure 3). The large variations in recovery |
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| timelines noted in this study, underscore the complexity of the immediate recovery phase after the treatment of an elbow fracture. A second key finding is that critical post-treatment secondary surgeries and events, including MRS, complication surgery, revision surgery, and non-operative hospitalizations, substantially affected both recovery duration and healthcare costs following unilateral elbow fracture. Common causes for complication surgery include non-unions, infection, limited range of motion and instability. An earlier study reported that 22% of secondary surgeries were for the treatment of motion loss [12]. Treatment of elbow fractures by open reduction and internal fixation (ORIF) has shown an average complication rate of 24.8% [12]. Therefore, multiple studies have suggested elbow arthroplasty may be a viable initial solution to the complex ORIF of elbow fractures associated with high complication rates [13, 14, 15]. Additionally, Li et al. has suggested that the need for ulnar nerve transposition following an elbow fracture should be considered a significant complication [16]. The third important finding in this study was the considerable increase in cost and recovery time associated with the presence of an elbow contracture (M24.52) following the treatment of a unilateral elbow fracture (Table 5). Notably, only one patient out of 2680 had an elbow contracture before treatment and that patient required a three year recovery. While the acceptable range of motion for the elbow is 30 to 130 degrees of motion, full motion from 0 to 150 degrees is needed for sports activities [1, 17]. Open fractures, terrible triads, fracture-dislocations and intra-articular fractures all lead to poorer outcomes and restricted range of motion [3, 13, 14, 18, 19, 20, 21, 22, 23, 24, 25, 26]. |
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| The fourth key finding in this study highlights the impact of comorbidities on the cost and recovery time following unilateral elbow fracture treatment. Very little has been published about the impact of comorbidities on recovery after elbow fractures. One study cited an incidence of 0.26% for a venous thromboembolism in patients undergoing an elbow arthroplasty [27]. The presence of any comorbidity added 66 to 113 days to the time of recovery. Both PVD and CVD added large post-treatment costs. Only CVD increased the risk of infection or pulmonary embolism. While further studies are needed to corroborate these findings, to the best of our knowledge, this study is the first to identify their impact. There are multiple limitations with a HCPCS Claims Based analysis. There is the presence of standard coding inconsistencies, particularly since this study spans the change from ICD 9 to ICD 10 codes. One of the limitations of this study was that the database claims did not include the cost of prescribed drugs which would add healthcare dollars to the total costs. In this claims based study the period of PT use was used to determine the postoperative period. Density of PT visits was not chosen as it did not reflect the need for PT, only the personal preference of the provider/patient. Conclusion: The benchmark defined in this study offers a critical framework for assessing and improving recovery outcomes in unilateral elbow fracture patients. By establishing a standardized recovery timeline, this study enables the evaluation of new interventions aimed at enhancing recovery processes. Without such a benchmark, the effectiveness of novel approaches would require reliance on randomized controlled trials. Furthermore, the observed delays in recovery—with nearly half of patients requiring more than six months to recuperate—highlight the pressing need |
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