Increasing Brace Treatment for Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-Based Medicine

Abstract

There is no financial information to disclose. Multiple randomized trials have demonstrated equivalent outcomes and improved patient/family satisfaction in the treatment of distal radius buckle fractures (DRBF) with a removable splint or brace when compared to traditional cast immobilization,1-3 although casting still remains the default treatment.4 We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at two tertiary care orthopaedic clinics from a baseline of 33% to 80%. Clinic billing records were reviewed monthly to determine treatment of DRBF (brace versus cast), which was tracked using control charts (p-chart). The number of follow up visits, radiographs obtained, and total cost of treatment was collected. Baseline data were obtained over a three month period, followed by a 12-month intervention period (1/1/16 – 12/31/16) using Plan-Do-Study-Act (PDSA) cycles targeting both individuals and groups of providers. Patients/families were given a cost survey to determine non-medical costs associated with follow-up clinic visits. The proportion of DRBF treated in a brace increased at both centers from a combined baseline of 33% to a combined 94% at the end of the study period, and 83% over the last quarter. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as > 67%), although 1 provider continued to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at one of two institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 overall following intervention. Furthermore, 98% of patients treated in a brace did not return for follow-up, saving each patient an average of $70 per visit in lost wages, travel, and childcare expenses. (Fig. 38-1) •Implementation of brace treatment for DRBF using QI methodology at two tertiary care centers resulted in a significant increase in brace treatment, leading to substantial medical and non-medical cost savings.•Although patient preference was cited as the most common reason for persistent cast treatment, the data demonstrate the use of cast treatment to be more dependent upon individual provider preference.•Quality improvement methodology can be utilized to enact and track implementation of Level-I medical evidence into practice, although barriers still exist that may be provider-dependent.