HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Annals of Plastic Surgery • Volume 83, Number 1, July 2019

Sharma et al

TABLE 2. Clinical Characteristics of Patient Cohort

Patients With Change of Care Following Postoperative CT †

Entire Patient Cohort*

P

Average time to surgery, d

17 ± 44 ‡

21 ± 31 ‡

0.80

Operating department Plastic and reconstructive surgery

96 (44%) 97 (45%) 23 (11%)

3 (50%) 2 (33%) 1 (17%) 0 (0%)

0.99 0.96 0.97 1.00 1.00 0.75 1.00 0.87 0.47 0.94 0.99 1.00

Ophthalmology

Head and neck surgery

Neurosurgery

1 (<1%)

Surgical approach Transconjunctival with lateral canthotomy incision

102 (47%) 37 (17%) 35 (16%) 16 (7%) 8 (4%) 14 (6%) 4 (2%) 1 (<1%) 34 (16%)

3 (33%) 0 (0%) 1 (17%) 1 (17%) 1 (17%) 0 (0%) 0 (0%) 0 (0%) 6 (100%) 15 ± 15.3 ‡

Transconjunctival incision

Midlid incision

Subciliary incision Coronal incision

Other incision

Unknown

Fracture nonoperative

Need for reoperation

<0.001

Mean hospital length of stay,§ d

8 ± 10 ‡

0.16

*Percentage of total 217 patients. † Percentage of total 6 patients with change of treatment after postoperative CT scan. ‡ SD of sample. §Data for only 121 patients (4 patients with change of care following postoperative CT) who had length of stay documented in legacy medical records.

not a worthy use of hospital resources, and providers should maintain a higher threshold when deciding whether to order imaging for this pur- pose. Our numbers argue against the necessity of additional imaging and in favor of the head, neck, ocular, and neurological physical exam- ination as the determining factor for reoperation. The high number of scans (76) and dollars spent ($10,068.80) toward CT scans that did not influence management reveals a clear area of improvement. Never- theless, it is essential to stress the importance of individual clinical judgment when considering ordering a CT, as the potential complica- tions of an imperfect orbital floor fracture repair can be permanent. With all these considerations, the decision to order postoperative imag- ing should prioritize patient safety and clinical efficacy.

reformation, the detection of residual fracture, or the confirmation of an unremarkable physical examination. 16 Although often convenient and informative, these studies demand extensive resources of medical per- sonnel and expose patients to potentially unnecessary radiation, not to mention a 22% to 31% increase in average health care costs. 1,17 At our institution, the reason why CT, MRI, or x-ray was obtained was rarely explicitly documented in the patient's chart. Postoperative CT scans may have been ordered for any variety of reasons, including per- sistent diplopia, enophthalmos, or vertical dystopia. Additionally, given our institution is a teaching institution, postoperative imaging provides additional feedback about hardware placement that is not otherwise ob- jectively available. Specifically, x-ray was a common imaging modality as it is comparatively inexpensive and would confirm the presence of hardware placement, for medicolegal purposes. After thorough review of patients undergoing orbital floor frac- ture repairs, we find low rates of head CT scans altering postoperative management. Furthermore, the majority of reoperations performed for patients in our cohort were determined without needing postoperative imaging, emphasizing the importance of careful physical examination over confirmatory scans (82% of reoperations were not prompted by postoperative CT scans). These findings highlight an overemphasis on the clinical importance of a postoperative head CT and the presence of other factors that likely predict a change of care. This conclusion may serve as a basis for discouraging a reflex order of postoperative CT scans for the repaired orbital floor fracture patient. Our data suggest that factors other than a CT scan are more likely to predict a change in management in orbital floor fracture patients. However, given our small sample size of this population (n = 6 patients), more data from larger, possibly multicenter studies will be needed to draw meaningful conclusions about specific preoperative, periopera- tive, or postoperative factors that predict need for reoperation. Given the superfluous nature of these postoperative CT scans, our cost analysis suggests routinely ordering this type of imaging is

TABLE 3. Cost Estimates * for Orbital Fracture Repair and Associated Imaging

Procedure

CPT Code Cost

Orbit fracture repair Transantral approach Periorbital approach Combined approach With periorbital implant

21385 $4661.22 21386 $4737.06 21387 $4975.50 21390 $6668.52 Mean cost $6425.88

Imaging Orbit, face, and neck CT scan without contrast 70480 $143.84 Orbit, face, and neck MRI with and without contrast 70543 $341.54 X-ray facial bones complete 70150 $209.28

*2017 UCI Health Revenue Cycle.

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