My elderly parents live in a very small town in Wyoming. We are concerned that if either one of them develops a health problem, they may not get the care they need. Last year, Mother fell and broke her wrist. She never has gotten her full motion back from that. We can't help but wonder if the care she received would have been better here where we live (close to Chicago). Is there any data on this sort of thing?
You may be asking the question: does treatment for wrist fracture vary depending on where you live? Others have asked if it makes a difference how old you are, your race, or sex? Researchers from Dartmouth Medical Center noticed that there aren't a lot of studies on the optimal treatment for distal radial (wrist) fractures. So, they used Medicare records to answer a few questions about the current state of affairs. They answered all of these questions by analyzing a sample of Medicare Part-B claims across the United States.
They found that older adults with balance problems and osteoporosis (brittle bones) seem to be the group with the largest rate of fractures in general. Wrist fractures of the distal radius occur in white women most often. In fact, women are almost five times more likely than men to break their wrists. White women are twice as likely as non-whites to fracture their wrists. Most of this was due to the higher rates of osteoporosis in white women.
But when it comes to the type of treatment provided, location seemed to make a difference, too. There are three basic types of fracture treatment including 1) putting a cast on the arm, 2) slipping a wire through the skin to hold the bones together, a procedure called percutaneous fixation, or 3) open surgery to repair the fracture with metal plates and/or screws. This last category of surgery is referred to as open reduction and internal fixation (ORIF).
Since treatment is billed by a Medicare procedural code, the Dartmouth researchers could use these codes to tell who had what kind of treatment. Patients treated by their primary care physicians in an outpatient (clinic) setting and those who were treated in a hospital or emergency department were all included. Over 300 hospital referral regions were identified by zip code and used to map out regions in the U.S.
It turns out that the rate of wrist fracture goes up with age. The oldest group (over age 80) had the highest rate of wrist fractures. Most patients (83 per cent) could be treated nonoperatively. The remainder had surgery. Older patients are less likely to have surgery. And the rate of surgery increased (doubled) during the time of this study (between 1998 and 2004).
But the most striking finding was that the kind of treatment you might receive for a wrist fracture varied greatly depending on where you lived. Nonoperative care was more common in places like Kentucky (compared to California). Open surgery varied from 0.4 per cent in Pennsylvania to 25 per cent in Great Falls, Montana. Some of the differences noted were likely due to whether patients lived in an area where there is a high density of orthopedic surgeons and the type of hospitals available (e.g., teaching hospitals versus rural hospitals).
The biggest factor on whether or not surgery was done was the presence of comorbidities (other health problems). The more compromised the patients health was, the less likely they would have surgery. Race did not seem to be a major factor in the choice of treatment. Concern about cosmetic appearance might have had an effect on the type of operation performed.
The authors of that particular study concluded that although they were able to conduct a comprehensive overview on the incidence and type of treatment for wrist fractures, they still couldnât really say why there is such a difference in how it's treated from one region to another. There could be a wide range of variables such as physician training, cultural beliefs, or even personal or even religious preferences.
More studies are needed to determine the most appropriate care for distal fractures in this age group.
Jason Fanuele, MD, et al. Distal Radial Fracture Treatment: What You Get May Depend on Your Age and Address. In The Journal of Bone and Joint Surgery. June 2009. Vol. 91A. No. 6. Pp. 1313-1319.
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