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Disparities in the Surgical Treatment of Facial Fractures: Results from the National Trauma Data Bank
Kayla E. Leibl, BS1, Laura V. Veras, MD2,3, Elias K. Awad, BS4, Clay Kerby, HS5, Ankush Gosain, MD, PhD, FAAP, FACS2,3, Timothy W. King, MD, PhD, FAAP, FACS5,6.
1University of Wisconsin School of Medicine, Madison, WI, USA, 2University of Tennessee Health Sciences Center, Memphis, TN, USA, 3Le Bonheur Children's Hospital, Memphis, TN, USA, 4University of South Alabama, Mobile, AL, USA, 5University of Alabama at Birmingham, Birmingham, AL, USA, 6Children's of Alabama, Birmingham, AL, USA.

Purpose:
Previous studies have shown disparities in treatment and access to care exist in the United States based on race, age, and insurance coverage. The purpose of this study was to determine if disparities in surgical versus nonsurgical treatment and access to care exist for patients with facial fractures treated at trauma centers in the United States.
Methods:

Patients ranging in age from 18 to 64 years old with facial fractures treated at a trauma center between 2002-2014 were identified using the American College of Surgeons’ National Trauma Data Bank (NTDB). ICD9 diagnosis codes 802-802.9 were utilized to identify patients with facial fractures. ICD9 procedural codes were used to determine which patients with facial fractures underwent surgical repair procedures for the fractures. Patient demographic information, Injury Severity Score (ISS), and clinical data were compared by surgical repair status using the chi-square and t-test for categorical and continuous variables, respectively. Analysis of variance was used for comparison of time to surgery.
Results:
The NTDB contained 16,834 patients diagnosed with a facial fracture between 2002-2014. Within this cohort, 3,288 (19.53%) underwent reparative operative procedures for facial fractures. There was a significant difference in age between those undergoing reparative procedures when compared to those who did not undergo surgical procedures (37.9±13.3 vs. 40.2±13.8 years, p<0.0001). There were no observed differences in the surgical status of facial fractures by gender (p=0.5153). Those undergoing operative procedures had significantly higher ISS (19.9±8.8 vs. 18.6±8.6, p<0.0001). Patients in a non-teaching hospital were more likely to have non-operative treatment. (p<0.0001). Patients treated at ACS-designated trauma centers were more likely to receive surgical management when treated at a Level I center (vs. Level 2 or 3, p<0.0001). Native Americans had a significantly higher rate of operative intervention (28.4%) compared to African-Americans (20.2%) or Caucasians (19%, P<.0001). A significant difference was seen for patients receiving operative intervention based upon the type of insurance they had (p<0.0036). When comparing the time from admission to a facial surgical procedure, there were no differences seen for females compared to males (3.7±4.1 vs. 3.6±3.8 days, p=0.5664) nor for Caucasians compared to African-Americans (3.7±3.9 vs. 3.7±4.2 days, p=0.9134).
Conclusions:
Using a large national data set, we have identified disparities in surgical care for patients with facial fractures. While there was a significant difference in age of patients receiving surgical intervention, this difference is likely not clinically significant. However, we did observe significant differences in care based on race, insurance status and the type of hospital in which patients were treated. These data support the findings from a single center study previously conducted. Additional investigations utilizing prospective data should be performed to further verify and validate these results with a goal of eliminating barriers to care in patients with facial fractures.


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