Research

Original Investigation

Cost-Based Decision Analysis of Postreduction Imaging

in the Management of Mandibular Fractures
Dane Michael Barrett, MD; Travis W. Halbert, BS; Caitlin E. Fiorillo, MD;
Stephen S. Park, MD; J. Jared Christophel, MD, MPH

IMPORTANCE Immediate postreduction imaging is a standard practice in the management of

mandibular fractures at many hospitals. However, the literature suggests that postreduction
imaging in maxillofacial fractures fails to influence clinical decision making significantly.

OBJECTIVES To determine the cost-effectiveness of different clinical decision pathways

regarding postreduction imaging as it relates to the experience of the surgeon, and to
demonstrate that baseline postreduction imaging has utility based on the complication rate
of the surgeon.

DESIGN, SETTING, AND PARTICIPANTS We developed a decision tree model using commercially
available software. The model accounted for cost of imaging modalities, adequacy of
reduction, complication rate, cost of initial operating room time, and, if applicable, operative
charges for revision surgery in the event of a complication. A review of the University of
Virginia clinical data repository of 100 patients with recent mandible fractures was used to
estimate the cost associated with running an operating suite for mandibular fracture repair.
The University of Virginia billing system also provided costs associated with a single
computed tomogram, panoramic radiography, and intraoperative 3-dimensional computed
tomography. A sensitivity analysis determined how variation in complication rate affects the
cost of the decision pathways.

INTERVENTION Intraoperative imaging, postreduction imaging, or no imaging.

MAIN OUTCOMES AND MEASURES Sensitivity of the decision tree model to variation in
complication rate.

RESULTS Using current hospital charges, the model is sensitive to variability in the
complication rate with a breakpoint of 17.7%. It is most cost-effective to obtain a
post-reduction panorex if the surgeon’s complication rate is above 17.7% and most
cost-effective not to obtain any postreduction imaging if the complication rate is below 17.7%.
Intraoperative computed tomography is not cost-effective at any complication rate. Two-way
sensitivity analysis allowed the model to be generalizable to varied institutional costs and
surgical complication rates.

CONCLUSIONS AND RELEVANCE The utility of postreduction imaging from the standpoint of
Author Affiliations: Department of
cost analysis depends on the complication rate of the facial traumatologist and institutional
Otolaryngology–Head and Neck
charge data. Based on this model, the facial traumatologist at our institution should obtain Surgery, University of Virginia Health
postreduction panorex imaging for patients with mandible fractures until their complication System, Charlottesville (Barrett, Park,
rate drops below 17.7%. The 2-way sensitivity analysis in this study allows the facial Christophel); currently in medical
school at University of Virginia School
traumatologist to apply his or her complication rate and institutional cost data to determine
of Medicine, Charlottesville (Halbert);
whether routine postreduction imaging is necessary. Department of Otolaryngology–Head
and Neck Surgery, University of
LEVEL OF EVIDENCE NA. Kentucky Health System, Lexington
(Fiorillo).
Corresponding Author: J. Jared
Christophel, MD, MPH, Department
of Otolaryngology–Head and Neck
Surgery, University of Virginia Health
System, PO Box 800713,
JAMA Facial Plast Surg. 2015;17(1):28-32. doi:10.1001/jamafacial.2014.782 Charlottesville, VA 22908
Published online October 30, 2014. (jjc3y@hscmail.mcc.virginia.edu).

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 Postreduction Imaging of Mandibular Fractures
M
anagement of facial fractures places a considerable
burden on the health care system. During 2007 alone,
407 167 visits to US emergency departments for fa-
cial fractures led to a total hospitalization time in the United
States of 534 322 days.1 Mandibular fractures constitute 36%
to 54% of all facial fractures and represent a significant pro-
portion of the financial burden due to facial trauma.2
With the ever increasing cost of health care, the develop-
ment of practice patterns that efficiently and effectively re-
sult in a complication-free repair is paramount. Cost-
effectiveness and the utility of different aspects regarding
management of facial fractures have already been studied thor-
oughly in the literature. Past reports have compared the cost-
effectiveness of different reduction and fixation techniques for
facial fractures.3-6 Others have evaluated the utility of post-
operative imaging, citing that routine postoperative radiogra-
phy does not significantly influence clinical decision making
in the treatment of maxillofacial trauma. 2,7-11 Jain and
Alexander,10 for example, concluded that intraoperative re-
duction and immediate postoperative occlusion in maxillofa-
cial fractures were better indicators of clinical outcome.
Nonetheless, postoperative evaluation of facial fracture re-
pair often includes a panoramic radiograph (panorex) as a stan-
dard practice.12 Despite the cost, the provider and patient may
benefit from these images in the event of a complication. The
imaging provides a baseline of the repaired fracture’s align-
ment and hardware positioning.9 Should a complication de-
velop, a simple panorex radiograph can be obtained and com-
Figure 1. Decision Tree Model
Reduction adequate
0.99
IOCT
Redo
#
Cost of AORT = $620
Cost of COR = $29 047 Reduction adequate
Cost of CT = $2046 0.99
Cost of IOCT = $250
Cost of OR = $30 205
PR
Cost of PR = $313
CR = 0.15
CR2 = 0.16
Return to OR
# No complication
Complication
[Cost of OR + Cost of CT + Cost of COR]\1
No imaging CR+ 0.01
No complication
Cost of OR\1
#
0.99 indicates the proportion of the time that the reduction is adequate
immediately after surgery (ie, no immediate realignment if using intraoperative
computed tomography [IOCT] and no immediate return to the operating room
[OR] after postoperative panorex radiography [PR]).9 The complication rate
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Original Investigation Research
pared with the baseline radiograph to guide further clinical
decision making. A baseline study provides useful informa-
tion in deciding whether a return trip to the operating room
(OR) is necessary. If no postoperative baseline radiograph is
available and a possible complication arises, the practitioner
will often order more expensive computed tomography (CT)
to provide useful information.
The other option would be the use of intraoperative CT to
confirm radiologic alignment. This method does not require
a separate operation should alignment be inadequate. How-
ever, intraoperative CT adds to operative time at the initial sur-
gery. Overall treatment cost thus depends highly on the pro-
vider’s choice of imaging modality and complication rate. In
the literature, complication rates requiring return to the OR at
any time in the postoperative period range from 9% to 25%.13-18
Methods
A model decision tree was developed to mirror clinical decision-
making pathways that are most often used to assess ad-
equacy of fracture reduction (Figure 1). The model has the fol-
lowing 3 pathways for the surgeon: intraoperative CT,
immediate postoperative panorex radiography, and no imaging.
After choosing 1 of the 3 pathways, the model simulates the
costs of clinical care from that point onward. Costs are set in
US dollars. The possibility exists that the initial reduction is
inadequate and must be immediately redone. Once the reduc-
Complication
[Cost of OR + Cost of IOCT + Cost of AORT + Cost of CT + Cost of COR]\1
CR
No complication
[Cost of OR + Cost of IOCT + Cost of AORT]\1
#
Complication
[Cost of OR + Cost of IOCT + Cost of AORT + Cost of CT + Cost of COR]\1
CR
No complication
[Cost of OR + Cost of IOCT + Cost of AORT]\1
#
Complication
[Cost of OR + Cost of PR + Cost of PR + Cost of COR]\1
CR
No complication
[Cost of OR + Cost of PR]\1
#
Complication
[Cost of OR + Cost of PR + Cost of OR + Cost of PR + Cost of PR + Cost of COR]\1
CR
[Cost of OR + Cost of PR + Cost of OR + Cost of PR]\1
#
(CR) +0.1 is the aforementioned proportion plus 0.01 because no intervention
(IOCT or postoperative PR) was performed and assuming that no immediate
return to OR occurs in this setting. AORT indicates cost of additional OR time;
COR, cost of OR.
JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1 29
 Research Original Investigation Postreduction Imaging of Mandibular Fractures

tion is adequate, a postoperative complication may occur in erature where available. Cost data were obtained from the Uni-
the future. Postoperative complication was defined as the need versity of Virginia clinical data repository (Table). A clinical data
to return to the OR for any reason. The need for further imaging repository review of 100 recent deidentified patients treated
and further OR costs subsequently emerge as possibilities. Af- for mandible fracture was used to estimate the charges asso-
ter the initial decision node (1 of 3 pathways), the model en- ciated with running an operating suite for mandibular frac-
counters chance nodes where variables, such as chance of ad- ture repair. The mean charge of a return to the OR for a com-
equate reduction and chance of complication, determine the plication was determined from the 6 most recent patient
proportion of cases that follow different pathways. Costs are complications. The University of Virginia billing system also
then incurred based on the operation and imaging choice. provided costs associated with single CT, panorex radiogra-
The study was approved by the University of Virginia In- phy, and intraoperative 3-dimensional CT. Finally, we per-
stitutional Review Board for Health Sciences Research (HSR# formed a sensitivity analysis on the model using commer-
16217). The variables for the model were obtained from the lit- cially available software (TreeAge Pro 2012, R2.3; TreeAge
Software, Inc) to determine whether the total cost depended
Table. Decision Tree Model OR and Imaging Costs on the complication rate and to determine which route on the
decision tree was most cost-effective (Figure 2).
Item Costa Source
Charge, $
CT 2046 UVA billing
Panorex radiography 313 UVA billing Results
Intraoperative 620 UVA billing Sensitivity analysis was applied demonstrating that the deci-
3-dimensional
fluoroscopy/CT sion tree model was sensitive to a complication rate of 17.7%
OR (Figure 2). In our decision tree model, regardless of the com-
Initial 30 205 UVA CDR (review of last plication rate, intraoperative CT was always the more expen-
100 patients)
sive option secondary to the increased OR time added by the
Complication 29 047 UVA CDR (review of last
6 complications) use of intraoperative imaging. When we compared the deci-
Variable rates sion to obtain postreduction imaging with no imaging, the
Adequate reduction, 0.99 Bali and Lopes,9 2004 breakpoint was 17.7%. At a complication rate requiring return
proportion to the OR of greater than 17.7%, obtaining postoperative pan-
Complication NA Literature rates vary orex radiography is the more cost-effective option. At lower
(9%-25%)
complication rates, no postoperative imaging is the more cost-
Abbreviations: CDR, clinical data repository; CT, computed tomography; NA, not
effective choice.
applicable; OR, operating room; UVA, University of Virginia.
a
Assuming the mean OR charge to fix a mandibular frac-
Unless otherwise indicated, data are expressed as US dollars.
ture is rather constant at a given institution, the model is sen-

Figure 2. Sensitivity Analysis of Cost vs Complication Rate

38 848.25
17.7
38 170.48

37 492.72

36 814.95

36 137.18
Cost, $

35 459.42

34 781.65

34 103.88

33 426.11

IOCT
32 748.35 No imaging
Panorex radiography

32 070.58 The decision tree model was sensitive

5 7 9 11 13 15 17 19 21 23 25 to a complication rate of 17.7%.
Complication Rate, % IOCT indicates intraoperative
computed tomography.

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 Postreduction Imaging of Mandibular Fractures
sitive to small differences in imaging modality costs. How-
ever, the OR charges overwhelm the small incremental charges
associated with each imaging modality, and varying the OR
charge changes the breakpoint for imaging choice signifi-
cantly. To account for different OR charges at different insti-
tutions, a 2-way sensitivity analysis was performed (Figure 3).
This analysis generalizes the model and allows surgeons at dif-
ferent institutions to determine when they should choose pan-
orex radiography and when they should choose no imaging
based on their OR costs and complication rates. Plotting the
institutional cost and individual complication rate in Figure 3
indicates the cost-effective modality.
Discussion
In clinical decision-making algorithms, decision points often
become standard practice with little evidence. As the evi-
dence for or against the decision point builds, that standard
of practice shifts. In many institutions, postreduction imaging
is still the standard of care. Recent evidence, however, has sug-
gested that postreduction imaging is unnecessary because it
rarely alters clinical decision making. The added negative as-
pects of imaging associated with radiation exposure, delayed
discharge, and perceived increased cost have resulted in a call
to abandon this practice.9 However, most of these studies have
not fully taken into account the issues of cost as it relates to
the experience of the surgeon.
In our decision tree analysis using local cost data, we found
that the complication rate significantly affects the cost-
effectiveness with a breakpoint at 17.7%. A complication con-
sisted of any event that would prompt the surgeon to con-
sider returning to the OR. Such examples include infection,
nonunion, malunion, delayed union, objective malocclu-
sion, or hardware extrusion. Surgeons with historical compli-
cation rates of 17.7% or more would be best advised to obtain
routine postreduction imaging, whereas those with rates less
than 17.7% should not.
The specific rate for our institution, however, is not im-
portant. Rather, this model’s demonstration that cost-
effective decision making depends on the individual sur-
geon’s complication rate matters. This guideline is more helpful
than a generalized prescription that postreduction imaging is
necessary or unnecessary.
This knowledge prompts the surgeon to analyze his or her
operative data to determine his or her specific complication
rate and the charges to fix a mandibular fracture at his or her
institution. From these data, the surgeon can use the 2-way
sensitivity analysis in Figure 3 to determine whether routine
postoperative imaging as part of his or her individual practice
will apply cost savings to the health system. Practice improve-
ment studies of this type can be performed on an ongoing ba-
sis well after residency and may represent the type of data col-
lection and reflection for which the Maintenance of
Certification is striving.
As the surgeon gains experience, a reduction in postop-
erative complications should follow. The utility of postreduc-
tion imaging as part of routine practice at that point could no
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Original Investigation Research
Figure 3. Two-Way Sensitivity Analysis of Different Operating Room (OR)
Costs vs Complication Rate
40 000
32 500
Cost of OR, $
25 000
17 500
No imaging
Panorex radiography
10 000
5 7 9 11 13 15 17 19 21 23 25
Complication Rate, %
Plotting the institutional cost and individual complication rate indicates the
cost-effective modality.
longer be necessary. In addition, obtaining a postoperative pan-
orex radiograph can be very useful for immediate feedback and
learning because fractures that seemed perfectly aligned in the
OR may have some radiologic inadequacy. A postoperative ra-
diograph allows the surgeon to assess the adequacy of the re-
duction and to determine whether the surgical procedure per-
formed went as planned. This type of immediate feedback
allows the surgeon to implement the appropriate changes to
avoid the same mistakes in subsequent patients. A break-
point such as that proposed by the present study can be used
as a benchmark as one ascends the learning curve.
The major limitation of this study is that cost was deter-
mined using OR charges. Charges do not reflect the real cost
to the system, but they are the only consistent financial num-
ber associated with a surgical procedure; collections and re-
imbursement vary widely based on the payer and patient. A
lower, more realistic cost would make the model more sensi-
tive to the choice of imaging modality and make obtaining rou-
tine panorex radiography more efficient most of the time
(Figure 3).
Conclusions
The utility of postreduction imaging from the standpoint of
cost-effectiveness depends on the complication rate of the fa-
cial traumatologist. Therefore, a generic dictum regarding rou-
tine postreduction imaging is not helpful. Rather, the facial
traumatologist should use his or her prior experience and in-
dividualized complication rate to determine whether routine
postreduction imaging is necessary. This practiced-based learn-
ing approach encourages the facial traumatologist to navi-
gate the health care system responsibly while caring for his or
her patient effectively.
JAMA Facial Plastic Surgery January/February 2015 Volume 17, Number 1 31
 Research Original Investigation
ARTICLE INFORMATION
Accepted for Publication: July 1, 2014.
Published Online: October 30, 2014.
doi:10.1001/jamafacial.2014.782.
Author Contributions: Drs Barrett and Christophel
had full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Park, Christophel.
Acquisition, analysis, or interpretation of data:
Barrett, Halbert, Fiorillo, Christophel.
Drafting of the manuscript: Barrett, Halbert, Fiorillo,
Christophel.
Critical revision of the manuscript for important
intellectual content: Barrett, Park, Christophel.
Statistical analysis: Fiorillo, Park, Christophel.
Administrative, technical, or material support:
Barrett, Christophel.
Study supervision: Christophel.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This paper was presented
at the annual meeting of the Virginia Society of
Otolaryngology; March 29, 2014; Williamsburg,
Virginia.
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