title: Does Insurance Status Affect the Management of Acute Clavicle Fractures?
abstract: OBJECTIVE
  To evaluate whether insurance is an unrecognized factor that plays a role in determining whether a patient receives surgery.
  
  
  METHODS
  A retrospective cross-sectional analysis was performed using the Healthcare Cost and Utilization Project data for Florida in the year 2010. Discharge level data from emergency departments and ambulatory surgery settings were used to identify clavicle fractures by International Classification of Diseases 9 codes 81,000, 81,002, and 81,003. Internal fixation was identified using the Current Procedural Terminology code 23,515. Clavicle fractures that did not result in a Current Procedural Terminology code of 23,515 were assumed to have been managed nonoperatively. Multivariate logistic regression, allowing for intragroup correlation among surgeons, was used to determine the influence of payer source on treatment modality adjusting for race, age, number of chronic conditions, and sex.
  
  
  RESULTS
  In total, there were 7858 clavicle fractures that met criteria for inclusion. Observations were removed from the analysis if there was missing personal demographic data or if the ability to track patients from the emergency department to follow-up care was not possible. Therefore, the final sample consisted of 5185 clavicle fractures of which 233 received internal fixation (4.5%). The odds of a patient with private insurance receiving internal fixation was 7.58 times [95% confidence interval (CI) = (4.04 to -14.21), P < 0.001] greater than a self-pay patient, all else being held constant. Patients defined by "other" sources of coverage, a group that includes worker's compensation, CHAMPUS (military), CHAMPVA (veterans), or other government insurance other than Medicare and Medicaid were also associated with an increased likelihood of receiving internal fixation by a factor of 6.80 (95% CI = 3.15, 14.64, P < 0.001) relative to self-pay patients, all else being held constant. The likelihood of patients with Medicare or Medicaid receiving internal fixation did not differ statistically from self-pay patients.
  
  
  CONCLUSIONS
  Patients with any form of insurance, when compared with the self-pay, Medicare, and Medicaid populations, had a higher likelihood of operative intervention in Florida in 2010. This may represent an unintended trend in treatment.
  
  
  METHODS
  Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA; and†Department of Global Health Management and Policy, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA.
authors.forename: Ryan L
authors.initials: RL
authors.lastname: Bliss
authors.forename: Arthur M
authors.initials: AM
authors.lastname: Mora
authors.forename: Peter C
authors.initials: PC
authors.lastname: Krause
mesh_terms: D000208:Acute Disease; D000328:Adult; D002968:Clavicle / Q000293:injuries* / Q000601:surgery; D000066491:Clinical Decision-Making; D005260:Female; D005431:Florida / Q000453:epidemiology; D050723:Fractures, Bone / Q000191:economics* / Q000453:epidemiology / Q000628:therapy*; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D019458:Insurance Coverage / Q000191:economics* / Q000706:statistics & numerical data; D007348:Insurance, Health / Q000191:economics* / Q000706:statistics & numerical data; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data; D040841:Resource Allocation; D012189:Retrospective Studies