BACKGROUND:Facial fractures represent a common source of emergency department (ED) utilization, but the national economic burden of isolated injuries remains poorly defined. PURPOSE:The purpose was to estimate the national cost of managing isolated facial fractures and identify factors associated with expenditure. STUDY DESIGN, SETTING, SAMPLE:This was a retrospective cohort study using the 2022 Nationwide Emergency Department Sample. Adults with an isolated facial fracture based on International Classification of Diseases, tenth revision codes were included. Patients younger than 18 years were excluded. PREDICTOR VARIABLE:The predictor variable was a set of factors categorized as demogIaphic (age, sex), clinical (Charlson Comorbidity Index), care process (ED disposition, no operative intervention), and hospital-level (trauma center designation). MAIN OUTCOME VARIABLE:The primary outcome was economic burden measured as total encounter cost, derived by applying hospital-specific cost-to-charge ratios to reported charges. COVARIATES:None. ANALYSES:Survey-weighted descriptive statistics estimated national case volume and expenditure. Survey-weighted bivariate analyses and generalized linear models with log-link evaluated associations between study variables and total encounter cost. Regression coefficients were exponentiated and reported as cost ratios (CRs), representing differences in expected cost compared to the reference group. CRs greater than 1.00 indicated higher expected cost, whereas CRs less than 1.00 indicated lower expected cost. Statistical significance was defined as P < .001. RESULTS:There were 135,763 weighted ED encounters involving subjects with a mean age of 48.6 ± 21.9 years and 77,360 (57.0%) were male. The mean and median cost per encounter were $2,065 ± 3,915 and $1,151 [interquartile range, $690 to $1,941], respectively. Total national cost in 2022 was $280.3 million. In the fully adjusted multivariable model, higher expected total encounter cost was associated with hospital admission (CR, 3.26; 95% CI, 3.00 to 3.55), level I trauma centers (CR, 1.86; 95% CI, 1.63 to 2.12), operative intervention (CR, 1.75; 95% CI, 1.57 to 1.95), and mandible fractures (CR, 1.52; 95% CI, 1.37 to 1.69) (all P < .001). Encounters resulting in admission represented 6.14% of encounters but accounted for 31.9% of total national expenditures. CONCLUSIONS AND RELEVANCE:Isolated facial fractures impose substantial annual costs in the United States. Expenditures were largely driven by injury pattern and downstream care processes, particularly hospital admission.

BACKGROUND:Odontogenic infections represent a significant yet preventable cause of health care expenditure in the United States. However, their economic burden is not well defined. PURPOSE:The purpose of this study was to estimate the per-admission hospital costs of managing odontogenic infections and identify factors associated with increased cost. STUDY DESIGN, SETTING, AND SAMPLE:This was a retrospective cohort study using the National Inpatient Sample database from years 2017 to 2019. Adults admitted for management of an odontogenic infection based on ICD-10 coding were included. Patients under 18 years or missing outcomes data were excluded. PREDICTOR VARIABLE:The predictors were variables categorized into demographic (age, sex), clinical (Charlson comorbidity index), procedural (incision and drainage), and hospital characteristics (teaching status) groups. MAIN OUTCOME VARIABLE:The outcome was economic burden measured as the total hospital cost of admission, derived by applying hospital-specific cost to charge ratios to reported charges and adjusting for inflation to 2019 dollars. COVARIATES:None. ANALYSES:Survey-weighted descriptive, bivariate, and generalized linear model statistics were used to evaluate the association between cost and study variables. Costs were log-transformed in analyses to address for right skew. Effects are reported as cost ratios (CRs) or the multiplicative change in expected cost versus the reference group; for continuous variables, the CR reflects the change per one-unit increase. RESULTS:There were 52,250 weighted admissions (∼17,417/year) with a mean age of 41.8 ± 20.5 years and 24,655 males (47.2%). The mean and median costs per admission were $8,162 ± 10,282 and $5,863 [IQR $3,744 to 9,013], respectively. The total annual national cost was $142 million. In adjusted analysis, higher costs were primarily driven by disease severity with airway intervention (CR 3.04, 95% CI 2.83 to 3.27), mediastinitis (CR 2.50, 95% CI 1.73 to 3.62), necrotizing fasciitis (CR 1.79, 95% CI 1.34 to 2.38), sepsis (CR 1.30, 95% CI 1.25 to 1.35), and incision and drainage (CR 1.20, 95% CI 1.17 to 1.24) having the highest CRs (all P < .001). Time to drainage in days (CR 1.13, 95% CI 1.11 to 1.15) was the only modifiable driver. CONCLUSIONS AND RELEVANCE:Inpatient management of odontogenic infections imposes substantial national costs, driven largely by markers of disease severity.

BACKGROUND:Secondary overtriage, defined as transfer to a higher level of care without subsequent need for admission, operative intervention, or other advanced inpatient resources, is common among patients with isolated facial fractures and contributes to avoidable health care costs. PURPOSE:The study purpose was to measure temporal trends and identify risk factors for secondary overtriage among adults transferred for isolated facial fractures. STUDY DESIGN, SETTING SAMPLE:This was a retrospective cohort study using the American College of Surgeons National Trauma Data Bank (2007-2023). Adults transferred for management of isolated facial fractures were included. Patients with missing data were excluded. PREDICTOR VARIABLE:The predictor variable was calendar year of transfer, modeled as a categorical variable for descriptive analyses (2007-2015, 2016-2023) and a continuous variable for regression analyses. MAIN OUTCOME VARIABLE:The outcome variable was secondary overtriage, defined as transfer to a receiving emergency department followed by discharge home without surgical intervention for facial fractures or hospital admission. COVARIATES:Covariates included demographic (age, race), clinical (Charlson Comorbidity Index), injury-related (fracture site), and hospital characteristics (teaching status, bed size). ANALYSES:Descriptive, bivariate, and multivariable logistic regression statistics were performed to measure the association between calendar year and secondary overtriage. Statistical significance was set at P < .001. RESULTS:The sample was composed of 110,157 subjects with a mean age of 44.6 (19.8) years, and 79,690 (72.3%) were male. Overall, 30,583 (27.8%) subjects met criteria for secondary overtriage. Overtriage increased from 11% in 2007 to 38% in 2023. Subjects treated in 2016-2023 were 1.65 times more likely to be overtriaged than those treated in 2007-2015 (95% CI: 1.61 to 1.70, P < .001). After adjustment for study covariates, each additional calendar year was associated with 12% increased odds of overtriage (odds ratio (OR) 1.12, 95% CI: 1.11 to 1.12, P < .001). Overtriage was also independently associated with self-pay status (OR: 1.74, 95% CI: 1.67 to 1.82) and university hospitals (OR: 1.65, 95% CI: 1.55 to 1.76) (all P < .001). Mandibular fractures were associated with lower odds of overtriage (OR: 0.22, 95% CI: 0.19 to 0.26, P < .001). CONCLUSIONS AND RELEVANCE:Secondary overtriage increased substantially over time and remains common, affecting over one-third of transferred subjects in recent years.

BACKGROUND:Duplication of computed tomography (CT) imaging following interfacility transfer for trauma is a well-established systems level inefficiency. However, the incidence and drivers of repeat imaging have not been examined within the maxillofacial trauma demographic. PURPOSE:The purpose was to estimate the frequency and factors associated with redundant maxillofacial CT imaging among adults transferred for isolated facial fractures. STUDY DESIGN, SETTING SAMPLE:This was a retrospective cohort study using the American College of Surgeons National Trauma Data Bank from 2017 to 2024. Patients at least 18 years of age, transferred for management of isolated facial fractures, were included. Patients with missing data were excluded. PREDICTOR VARIABLE:The predictor variable was a set of factors categorized as demographic (age, sex), clinical (Charlson comorbidity index), injury-related (fracture location), and hospital-level characteristics (bed size, teaching status). MAIN OUTCOME VARIABLE:The primary outcome was duplicated imaging, defined as the receipt of a dedicated maxillofacial CT scan at the receiving trauma center within 24 hours of arrival. COVARIATES:None. ANALYSES:Descriptive, bivariate, and multivariable logistic regression statistics were computed to measure the associations between study variables and duplicated imaging. An alpha threshold of P < .001 was considered statistically significant. RESULTS:The cohort consisted of 72,766 subjects with a mean age of 47.0 ± 20.2 years and was 69.8% male (n = 50,817). Redundant imaging occurred in 16.8% (n = 12,206) of the cohort over the study period. In the fully adjusted model, the strongest predictor of redundancy was the receipt of a trauma pan-scan (odds ratio [OR] = 11.0, 95% CI 10.2 to 11.9, P < .001). Other predictors included for-profit status (OR = 1.65, 95% CI, 1.55 to 1.76), university hospitals (OR = 1.27, 95% CI, 1.16 to 1.40), and mandibular fractures (OR = 1.28, 95% CI, 1.19 to 1.37) (all P < .001). Conversely, hospitals with >600 beds were less likely to duplicate scans (OR = 0.59, 95% CI, 0.52 to 0.67, P < .001). Repeated imaging was associated with a 2 to 3% increase in operative intervention for fractures of the mandible, maxilla, and orbit (all P < .001). CONCLUSIONS AND RELEVANCE:Imaging redundancy affects approximately one in 6 transferred facial trauma patients and is driven primarily by trauma imaging protocols and hospital characteristics.

BACKGROUND:Patients with facial fractures are disproportionately uninsured or underinsured, creating a substantial economic burden for trauma systems. Although the Affordable Care Act (ACA) significantly expanded Medicaid eligibility, its effect on insurance coverage among adults with facial trauma remains poorly defined. PURPOSE:The purpose of the study was to evaluate the association between ACA implementation and Medicaid coverage among adults presenting with isolated facial fractures. STUDY DESIGN, SETTING SAMPLE:This was a retrospective cohort study using the American College of Surgeons National Trauma Data Bank from 2008 to 2019. Adults with isolated facial fractures were included. Patients with polytrauma or missing data were excluded. PREDICTOR VARIABLE:The primary predictor was time period relative to ACA implementation, defined as pre-ACA (2008 to 2013) or post-ACA (2014 to 2019). MAIN OUTCOME VARIABLE:The primary outcome was insurance payor at the time of encounter (Medicaid vs non-Medicaid). COVARIATES:Covariates included demographic (age, sex), clinical (Charlson comorbidity index), injury-related (injury severity score, fracture location), and hospital characteristics (teaching status, bed size). ANALYSES:Descriptive, bivariate, and multivariable logistic regression statistics were performed to evaluate the association between ACA implementation and Medicaid coverage. A threshold of P < .001 was considered significant for all analyses. RESULTS:A total of 187,803 subjects were included of which 47,315 (25%) were treated pre-ACA and 140,488 (75%) were treated post-ACA. The cohort had a mean age of 44.8 ± 20.2 years, was 73% male (n = 137,408), and 64% White (n = 119,674). Medicaid coverage increased from 16% pre-ACA to 24% post-ACA, with a corresponding decrease in self-pay from 30 to 20% (P < .001). After adjustment for demographic, clinical, injury-related, and hospital covariates, post-ACA treatment was associated with significantly higher odds of Medicaid coverage (odds ratio [OR]: 1.93, 95% CI: 1.88 to 1.99, P < .001). The relative increase in Medicaid coverage was greater at non-level 1 centers (OR: 1.93, 95% CI: 1.82 to 2.04, P < .001) compared to level 1 centers (OR: 1.34, 95% CI: 1.29 to 1.40, P < .001). CONCLUSIONS AND RELEVANCE:ACA implementation was associated with increased Medicaid coverage and reduced uninsured status. Medicaid expansion improved access to care; similar efforts may enhance the sustainability of facial trauma services within modern trauma systems.

BACKGROUND:Postoperative loss to follow-up in facial trauma patients is a persistent challenge potentially linked to adverse outcomes. However, factors associated with loss to follow-up remain poorly characterized. PURPOSE:The purpose of this study was to measure the association between socioeconomic deprivation, as defined by the Area Deprivation Index (ADI), and postoperative loss to follow-up within 90 days of discharge after operative management of facial trauma. STUDY DESIGN, SETTING SAMPLE:This was a retrospective cohort study of all adults undergoing operative treatment for facial injuries at the University of Maryland Shock Trauma Center from 2021 to 2024. Patients who died within 90 days of discharge were excluded. PREDICTOR VARIABLE:The predictor was neighborhood socioeconomic deprivation measured using ADI national percentile rankings, categorized into quartiles. MAIN OUTCOME VARIABLE:The primary outcome was loss to follow-up, defined as failure to attend any postoperative clinic visit within 90 days of discharge. COVARIATES:Covariates included demographic (race, distance to hospital), social (marital status, employment), and clinical characteristics (etiology, concomitant injuries). ANALYSES:Descriptive and bivariate analyses evaluated associations between ADI and loss to follow-up. Multivariable logistic regression assessed factors independently associated with loss to follow-up. RESULTS:A total of 881 subjects were included, of which 663 (75.3%) attended follow-up and 218 (24.7%) did not. The cohort had a mean age of 40.8 ± 17.1 years, was 80% male (n = 704), and 47% White (n = 410). In bivariate analysis, higher ADI was associated with loss to follow-up, with subjects in the third (relative risk: 2.14; 95% CI: 1.31 to 3.50) and fourth quartiles (relative risk: 2.21; 95% CI: 1.31 to 3.73) having greater likelihood of missed follow-up compared to those in the first quartile. In adjusted analysis, ADI in the third (OR: 2.13; 95% CI: 1.13 to 4.03) or fourth quartile (odds ratio: 2.21; 95% CI: 1.09 to 4.45) remained independently associated with loss to follow-up. Emergency department utilization occurred in 59 subjects (6.70%); one-quarter received all postoperative care in the emergency department. CONCLUSIONS AND RELEVANCE:Neighborhood socioeconomic deprivation is independently associated with loss to follow-up after facial trauma surgery. Targeted interventions addressing structural barriers may improve continuity of care and reduce avoidable health care utilization in this demographic.

STUDY OBJECTIVES:Opioid medications are routinely used for short-term pain management after surgery. However, data on the effects of postsurgical opioid use on sleep is limited. The goal of this pilot study was to examine differences in objective sleep metrics between those on opioid versus non-opioid therapy for pain management in the immediate postsurgical period using participants in the pilot study from the Opioid Analgesic Reduction Study (OARS) and to determine if sex modifies the association. METHODS:The OARS study is a randomized, multisite study designed for people undergoing surgical removal of impacted third molars. Adult participants were stratified by sex and randomized to a treatment group. Participants wore an actigraph monitor for three days post-surgery. Actigraph-derived outcomes included total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE). Subjective survey data, including the Brief Pain Inventory (BPI) and Pain and Sleep Questionnaire (PSQ-3), were collected. RESULTS:Data from 41 of the 50 pilot study participants who had full actigraphy data was included. The opioid group (n = 19) experienced more WASO on nights 1 and 3 than the nonopioid group (n = 22). The difference between the nonopioid and opioid groups was -22.3 min [90%CI:-42.8,-1.9] and -21.5 min [90%CI -41.9,-1.0], respectively. The noted difference was driven by men in the opioid group. In contrast, differences between treatment groups with regards to subjective surveys was driven by women. Women in the opioid group had worse mean PSQ-3 scores (p = 0.09): mean difference = -1.3 [90%CI:-2.4,-0.2] and -1.3 [90%CI:-2.3,-0.3] after nights 1 and 2, respectively. CONCLUSION:Postsurgical opioid therapy is associated with worse objective and subjective sleep compared to non-opioid therapy. The associations are modified by sex.

BACKGROUND:The trauma literature suggests that treatment at a level 1 trauma center is associated with improved outcomes for a diversity of injuries. However, differences in outcomes with respect to trauma center designation are poorly studied in the facial trauma demographic. PURPOSE:The purpose of this study was to measure the association between trauma center designation and clinical outcomes in patients undergoing management of isolated mandible fractures. STUDY DESIGN, SETTING, SAMPLE:This was a retrospective cohort study using the 2018 to 2022 American College of Surgeons National Trauma Data Bank. Adult patients with an isolated mandibular fracture undergoing open reduction internal fixation or closed reduction were included. Patients missing demographic or outcomes data were excluded. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE:The primary predictor was trauma center designation (level 1 or nonlevel 1). MAIN OUTCOME VARIABLE:The primary outcome was any complication. Secondary outcomes were return to the operating room, length of stay, adverse discharge disposition, and specific complications. COVARIATES:Covariates were categorized into demographic (age, sex), medical (Elixhauser Comorbidity Index), injury severity, operative intervention (open reduction internal fixation or closed reduction), and hospital characteristics (teaching status, bed size). ANALYSES:Descriptive, bivariate, and multiple regression statistics were performed to evaluate the association between trauma center designation and outcomes. RESULTS:The cohort was composed of 28,897 subjects with a mean age of 35.1 ± 14.0 years, and 23,718 were male (82.1%). There were 16,788 (58.1%) and 12,109 (41.9%) subjects treated at level 1 and nonlevel 1 trauma centers, respectively. Complication rates were 1.10% (188) and 1.00% (120) at level 1 and nonlevel 1 trauma centers, respectively (relative risk: 0.88; 95% confidence interval: 0.70 to 1.11; P = .3). After adjusting for demographic, medical, injury severity, operative intervention, and hospital characteristic covariates, treatment at a level 1 trauma center was not independently associated with complications, nor was it associated with return to the operating room, length of stay, or adverse discharge disposition. CONCLUSIONS AND RELEVANCE:Trauma center designation was not an independent predictor of adverse outcomes. Additional studies are needed to identify which patients will benefit most from treatment at a level 1 trauma center in this demographic.

Background. Opioids are still being prescribed to manage acute postsurgical pain. Unnecessary opioid prescriptions can lead to addiction and death, as unused tablets are easily diverted. Methods. To determine whether combination nonopioid analgesics are at least as good as opioid analgesics, a multisite, double-blind, randomized, stratified, noninferiority comparative effectiveness trial was conducted, which examined patient-centered outcomes after impacted mandibular third- molar extraction surgery. Participants were randomized to receive 5 mg of hydrocodone with 300 mg of acetaminophen (opioid) or 400 mg of ibuprofen and 500 mg of acetaminophen (nonopioid). After an initial dose, analgesic was taken every 4 through 6 hours as needed for pain. Results. In this randomized multisite clinical trial (n = 1,815 adults), those not taking opioids experienced significantly less pain (numeric rating scale ranging from 0 [no pain] through 10 [worst pain imaginable]) for first day and night (mean difference, -0.70; 95% CI, -0.94 to -0.45; P < .001) and second day and night (mean difference, -0.28; 95% CI, -0.52 to -0.04; P = .015), and experienced no more pain than participants taking opioids over the entire postoperative period (mean difference, -0.20; 98.75% CI, -0.45 to 0.05; P = .172). Participants not taking opioids had higher overall satisfaction at the postoperative visit (85.3% extremely satisfied or satisfied vs 78.9%; 95% CI, 1.21 to 1.98; P = .006). Conclusions. The ibuprofen and acetaminophen combination managed pain better for the first 2 days and led to greater satisfaction over the entire postoperative period than hydrocodone with acetaminophen. At no time did hydrocodone outperform the nonopioid.

This prespecified subgroup analysis of a randomized clinical trial investigates noninferiority for pain relief, treatment effects, and patient satisfaction for nonopioids vs opioids in male and female patients after impacted mandibular third molar extraction.

BACKGROUND:Resident participation in surgery has been associated with longer operative times, but its impact on clinical outcomes is mixed. While this relationship has been explored in other surgical subspecialties, it remains understudied in maxillofacial trauma--a core component of oral and maxillofacial surgery training. PURPOSE:The purpose of this study was to measure the association between resident participation and perioperative outcomes in patients undergoing open reduction and internal fixation of a single maxillofacial fracture. STUDY DESIGN, SETTING, SAMPLE:This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database, 2005-2012. Patients undergoing open reduction and internal fixation of a single maxillofacial fracture were included. Patients under 18 years old or with missing data were excluded. PREDICTOR VARIABLE:The predictor was resident participation in the surgical case (yes/no). MAIN OUTCOME VARIABLE:The primary outcome was the presence of any complication within 30 days postoperatively. Secondary outcomes included operative time (minutes), return to the operating room, and presence of any surgical complication. COVARIATES:Covariates were categorized as demographic (age, sex), medical (body mass index, comorbidities) and operative (wound classification, fracture location). ANALYSES:Descriptive and bivariate statistics were calculated. Relative risks and 95% CIs were computed to measure the association between resident participation and complications. RESULTS:There were 746 subjects with a mean age of 38.5 ± 16.7 years (79.2% male, n = 591). Of these subjects, 454 (60.9%) underwent surgery with resident participation and 292 (39.1%) without. The overall complication rate was 3.6% (n = 27), with no significant difference between cases with (4.4%, n = 20) and without (2.4%, n = 7) residents (relative risk 1.84; 95% CI 0.82-4.64; P = .1). Resident involvement was not associated with increased surgical complications or return to the operating room. Mean operative time was 45% longer with resident participation (136 vs 94 minutes, P < .001). CONCLUSION AND RELEVANCE:Resident participation was not associated with higher complication rates, but was associated with longer operative time. These findings support the continued role of surgical trainees while identifying opportunities to improve operative efficiency in academic settings.

BACKGROUND:Same day discharge pathways have the potential to reduce health care expenditures and improve access to care for patients undergoing orthognathic surgery. However, the effect of same day discharge on safety and postoperative outcomes is poorly understood. PURPOSE:The purpose of this study was to measure the association between discharge pathway and 30-day hospital readmission, as well as evaluate trends in same day discharge over time in patients undergoing orthognathic surgery. STUDY DESIGN, SETTING SAMPLE:This was a retrospective cohort study using the 2011 to 2023 American College of Surgeons National Surgical Quality Improvement Program databases. Patients undergoing orthognathic surgery were included. Patients with missing data or undergoing concurrent temporomandibular joint or facial cosmetic procedures were excluded. PREDICTOR VARIABLE:The predictor was discharge pathway, categorized as either same day discharge from the hospital or inpatient admission. MAIN OUTCOME VARIABLE:The primary outcome was hospital readmission within 30 days of surgery. COVARIATES:Covariates were categorized into demographic (age, sex), medical (hypertension, diabetes), and perioperative (type of surgery, operative time). ANALYSES:Descriptive and bivariate statistics were performed to evaluate the association between discharge pathway and readmission. Linear regression was utilized to analyze trends in discharge pathway over time. RESULTS:The cohort was composed of 2,056 subjects with a mean age of 28.8 ± 10.8 years, and 1,035 were male (50.3%). Of these, 468 (22.8%) were discharged the same day and 1,588 (77.2%) were admitted. Readmission rates were 0.40% (n = 2) for same day discharge and 1.10% (n = 17) for inpatient admission (relative risk 0.4, 95% CI 0.09 to 1.72, P = .3). In bivariate analysis, no study covariates including discharge pathway were associated with readmission. The mean time between discharge and readmission for the same day discharge and inpatient admission groups were 7.5 ± 6.4 days and 12.2 ± 9.0 days, respectively (P = .4). The frequency of same day discharge increased during the study period from 10.7% in 2011 to 23.1% in 2023 (P = .03). CONCLUSIONS AND RELEVANCE:Same day discharge was not associated with an increased risk of 30-day readmission in appropriately selected patients.