title: C2 Vertebral Fractures in the Medicare Population: Incidence, Outcomes, and Costs.
abstract: BACKGROUND
  Cervical 2 (C2) fractures in the elderly are common, and the incidence of these fractures has been increasing. Surgical and nonoperative treatments are associated with high complication and mortality rates, and these rates have not been evaluated at the population level, to our knowledge. The purpose of this study was to use the Medicare claims database to determine trends in treatment, surgical and nonoperative outcomes, and Medicare reimbursement for treatment of these fractures.
  
  
  METHODS
  We examined the Medicare claims database from 2000 to 2011 to identify patients admitted for the treatment of a C2 fracture. The incidence of fractures and the rates of nonoperative and surgical treatment were determined across the study period. We compared rates of mortality and life-threatening complications between patients treated nonoperatively and surgically. Centers for Medicare & Medicaid Services (CMS) payments for the initial admission as well as for subsequent inpatient admissions during the ninety-day post-admission period were compared between treatment groups. We used multivariate analysis to control for differences in patient characteristics between groups.
  
  
  RESULTS
  There were 81,596 admissions for C2 fracture identified, and 53,338 met inclusion criteria. The incidence of C2 fractures increased 135% from 2000 to 2011, but the rate of surgical treatment remained constant at 16%. There was significantly lower mortality at thirty days for the surgical group at 8.3% compared with the nonoperative group at 16.2% (p < 0.001) and at one year for the surgical group at 21.7% compared with the nonoperative group at 32.3% (p < 0.001). Life-threatening complications within thirty days of admission were slightly more common in the surgical group at 10.9% compared with the nonoperative group at 9.0% (p < 0.05). Medicare reimbursements for the initial inpatient admission were significantly higher (p < 0.001) in U.S. dollars for the surgical group at $21,487 compared with the nonoperative group at $8469, and this significant difference (p < 0.001) persisted in the ninety-day post-discharge period at $10,487 for the surgical group compared with $8410 for the nonoperative group.
  
  
  CONCLUSIONS
  Although the incidence of C2 fractures in the Medicare population increased from 2000 to 2011, the rate of surgery stayed relatively constant. After controlling for baseline differences, patients treated with surgery had significantly lower thirty-day and one-year mortality rates compared with patients treated nonoperatively.
  
  
  METHODS
  Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire adam.m.pearson@hitchcock.org.
authors.forename: Adam M
authors.initials: AM
authors.lastname: Pearson
authors.affiliation: Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Brook I
authors.initials: BI
authors.lastname: Martin
authors.affiliation: Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
authors.forename: Matthew
authors.initials: M
authors.lastname: Lindsey
authors.affiliation: Department of Orthopaedics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
authors.forename: Sohail K
authors.initials: SK
authors.lastname: Mirza
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002574:Cervical Vertebrae / Q000293:injuries*; D015897:Comorbidity; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D006278:Medicare / Q000191:economics*; D011183:Postoperative Complications; D016103:Spinal Fractures / Q000191:economics* / Q000453:epidemiology* / Q000401:mortality / Q000601:surgery*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology