title: Cost-based decision analysis of postreduction imaging in the management of mandibular fractures.
abstract: OBJECTIVE
  Immediate postreduction imaging is a standard practice in the management of mandibular fractures at many hospitals. However, the literature suggests that postreduction imaging in maxillofacial fractures fails to influence clinical decision making significantly.
  
  
  OBJECTIVE
  To determine the cost-effectiveness of different clinical decision pathways regarding postreduction imaging as it relates to the experience of the surgeon, and to demonstrate that baseline postreduction imaging has utility based on the complication rate of the surgeon.
  
  
  METHODS
  We developed a decision tree model using commercially available software. The model accounted for cost of imaging modalities, adequacy of reduction, complication rate, cost of initial operating room time, and, if applicable, operative charges for revision surgery in the event of a complication. A review of the University of Virginia clinical data repository of 100 patients with recent mandible fractures was used to estimate the cost associated with running an operating suite for mandibular fracture repair. The University of Virginia billing system also provided costs associated with a single computed tomogram, panoramic radiography, and intraoperative 3-dimensional computed tomography. A sensitivity analysis determined how variation in complication rate affects the cost of the decision pathways.
  
  
  METHODS
  Intraoperative imaging, postreduction imaging, or no imaging.
  
  
  METHODS
  Sensitivity of the decision tree model to variation in complication rate.
  
  
  RESULTS
  Using current hospital charges, the model is sensitive to variability in the complication rate with a breakpoint of 17.7%. It is most cost-effective to obtain a post-reduction panorex if the surgeon's complication rate is above 17.7% and most cost-effective not to obtain any postreduction imaging if the complication rate is below 17.7%. Intraoperative computed tomography is not cost-effective at any complication rate. Two-way sensitivity analysis allowed the model to be generalizable to varied institutional costs and surgical complication rates.
  
  
  CONCLUSIONS
  The utility of postreduction imaging from the standpoint of cost analysis depends on the complication rate of the facial traumatologist and institutional charge data. Based on this model, the facial traumatologist at our institution should obtain postreduction panorex imaging for patients with mandible fractures until their complication rate drops below 17.7%. The 2-way sensitivity analysis in this study allows the facial traumatologist to apply his or her complication rate and institutional cost data to determine whether routine postreduction imaging is necessary.
  
  
  METHODS
  NA.
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville.
authors.forename: Dane Michael
authors.initials: DM
authors.lastname: Barrett
authors.affiliation: currently in medical school at University of Virginia School of Medicine, Charlottesville.
authors.forename: Travis W
authors.initials: TW
authors.lastname: Halbert
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Kentucky Health System, Lexington.
authors.forename: Caitlin E
authors.initials: CE
authors.lastname: Fiorillo
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville.
authors.forename: Stephen S
authors.initials: SS
authors.lastname: Park
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville.
authors.forename: J Jared
authors.initials: JJ
authors.lastname: Christophel
mesh_terms: D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods; D006785:Hospitals, University; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000191:economics / Q000706:statistics & numerical data; D015601:Injury Severity Score; D007430:Intraoperative Care / Q000191:economics; D008297:Male; D008337:Mandibular Fractures / Q000000981:diagnostic imaging* / Q000601:surgery; D015999:Multivariate Analysis; D011182:Postoperative Care / Q000191:economics* / Q000379:methods; D011862:Radiography, Panoramic / Q000191:economics / Q000706:statistics & numerical data; D012016:Reference Values; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000191:economics* / Q000706:statistics & numerical data; D014768:Virginia