Surgeon age may influence the decision to use intramedullary nails

Forte ML. JBJS. 2010; 92:1105-1114.

A surgeon’s decision to use intramedullary nails to treat intertrochanteric hip fractures, was often based on factors other than clinical outcomes evidence, according to research published in the Journal of Bone and Joint Surgery.

Mary L. Forte, PhD, DC, and colleagues found a strong link between intramedullary (IM) nail use and early-career surgeons and surgeon training programs.

Although IM nails provide no clear outcomes benefits in most patients with intertrochanteric hip fractures, their use in the United States has been increasing, according to the study abstract. The investigators anticipate that IM nail use will continue to rise “as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospital’s burden of their choices for higher cost devices under the Medicare payment system.”

In their study, Forte and colleagues examined, for the first time, the non-patient factors linked to IM nail use among Medicare patients.

Using Medicare files from 2000 to 2002, the investigators identified Medicare beneficiaries aged 65 and older who underwent inpatient surgery for intertrochanteric femoral fracture. The patients received either an IM nail or a plate-and-screw device.

The investigators merged surgeon and hospital characteristics from the Medicare provider enrollment files with the claims. They used generalized linear mixed models with fixed and random effects to model the link between surgeon and hospital factors and IM nail use while controlling for patient age, gender and race; subtrochanteric fracture; Charlson comorbidity score, nursing home residence; and Medicaid-administered assistance, according to the abstract.

In total, 192,365 claims for surgery for an intertrochanteric hip fracture met the inclusion criteria and matched with surgeon and hospital information. Between March 1, 2000 and December 31, 2002, 15,091 surgeons performed intertrochanteric hip fracture surgeries in Medicare patients.

Analysis showed that the surgeon factors associated with IM nail use included younger surgeon age (younger than 45 years), an osteopathy degree and operating at more than one hospital. The hospital factors included a higher volume of intertrochanteric hip fracture procedures, teaching hospital status and having resident assistance during surgery, according to the abstract.