Abstract
Research Type:
Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies
Introduction/Purpose:
Distal radius fractures, proximal femur fractures, and ankle fractures are among the most frequently encountered fractures in adult orthopedic surgery. While the work Relative Value Unit (wRVU) system aims to quantify and standardize the value of physician services based on the effort, skill, and time required for different procedures, discrepancies in wRVU allocation among different fracture types remain a topic of concerns, suggesting that it may not reflect physician compensation appropriately. This study aims to evaluate the adequacy of compensation across these three common fractures using the National Surgical Quality Improvement Program (NSQIP) database, with a particular focus on assessing potential undercompensating in ankle fracture management.
Methods:
The NSQIP database (2020–2022) was used to analyze distal radius, proximal femur, and ankle fractures identified by CPT codes. The ankle fracture group included open reduction and internal fixation (ORIF) for unimalleolar, bimalleolar, and trimalleolar fractures (CPT 27792, 27766, 27814, 27822, 27823, 27829), excluding pilon fractures. Procedures with fewer than 150 cases over three years were excluded. Proximal femur fractures included ORIF and hemiarthroplasty for femoral neck, intertrochanteric/subtrochanteric, and greater trochanter fractures (CPT 27236, 27244, 27245, 27248). All ORIF cases for distal radius fractures were included (CPT 25607, 25608, 25609).
Compensation adequacy was assessed using wRVUs, operative time (OT), wRVU/hour, and reimbursement rates ($/hour). Postoperative complications within 30 days, including mortality, readmission, reoperation, and secondary complications (wound issues, infections, thromboembolic, respiratory, renal, and cardiac events), were analyzed to compare procedural risk profiles. Additionally, covariance analysis was conducted to adjust for the effect of complication rates on compensation adequacy.
Results:
Total 79,336 cases were identified, including 15,507 ankle fractures, 51,955 proximal hip fractures, and 11,874 distal radius fractures. Compared to other fractures, ORIF for ankle fractures had a significantly longer operative time (OT) (89.16 vs. 65.32 vs. 71.21 minutes, P<.001) and lower mean wRVU (10.29 vs. 17.94 vs. 11.55, P<.001) and wRVU/hour (10.37 vs. 21.66 vs. 11.393, P<.001). These trends persisted after adjusting for the rates of complication (mortality, readmission, reoperation, wound complications, and thromboembolic events). Post-hoc analysis confirmed that ankle fractures had significantly lower wRVU and wRVU/hour, as well as longer OT, compared to proximal hip and distal radius fractures. Mortality, readmission, and reoperation rates were highest in the proximal hip fracture group, while wound complication rates were highest in the ankle fracture group.
Conclusion:
Our review indicates that the current wRVU system may not fully account for the surgical workload involved in ankle fracture management compared to proximal femur and distal radius fractures. Although ankle fracture fixation required significantly longer operative times, its wRVU/hour remained significantly lower. While variations in complication rates could contribute to differences in wRVU allocation, even after adjusting for these factors, the ankle fracture group continued to exhibit disproportionately lower wRVU/hour and extended operative duration. These findings suggest a potential need for revisions to the wRVU scale to better align compensation with surgical effort for ankle fracture fixation. Comparative Analysis of work Relative Value Units in Surgical Treatment of Common Orthopaedic Fractures: Ankle Fractures vs Distal Radius Fractures vs Proximal Hip Fractures
