Journal of Agromedicine, 20:140–148, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1059-924X print/1545-0813 online DOI: 10.1080/1059924X.2015.1010066
Orthopaedic Trauma in the Anabaptist Community: Epidemiology and Hospital Charges Louis C. Grandizio, Benjamin R. Wagner, Jove Graham, Joel C. Klena, and Michael Suk Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, Pennsylvania, USA
ABSTRACT. This study aims to define the epidemiology of orthopaedic trauma in the rural Anabaptist community and analyze the hospital charges associated with their treatment. The authors performed a retrospective review of 79 Amish and 40 Mennonite patients who had been seen in their rural level I trauma center emergency department for an orthopaedic injury from January 2006 to May 2013. Data collection included baseline demographics, injury mechanism and severity, injury complex, operative interventions, outcomes, and hospital charges. Amish and Mennonite groups were similar except for a higher percentage of males in the Mennonite group. For Amish patients, occupational injuries (52%) and buggy accidents (16%) accounted for the highest percentage of admissions. Eighty-seven percent sustained at least one fracture, most commonly of the hand (11%). Amish patients were statistically more likely to sustain fractures of the spine, and Mennonite patients were more likely to sustain fractures of the foot and femur. Over half of patients required surgery (58%). Total hospital charges did not differ based between the groups. Amish patients completed outpatient follow-up less frequently than Mennonite patients. Anabaptist patients are at risk for a variety of orthopaedic injuries related to their unique lifestyle and vocations. Socioreligious beliefs must be taken into consideration when educating these patients regarding postinjury care, as attendance at outpatient follow-up is low. Understanding the types of injuries that these patients sustain can help create strategies to prevent costly transportation and agricultural accidents within the Anabaptist community.
KEYWORDS. Amish, epidemiology, orthopaedics, trauma
INTRODUCTION As part of the Anabaptist community, the Amish are a conservative religious group who reside primarily in rural regions of Ohio, Indiana, Iowa, and central Pennsylvania. They live an agrarian lifestyle and the use of electricity and modern automobiles are not permitted within the scope of their religious beliefs.1 Amish patients will utilize the services of a physician, but this is often limited to medical emergencies and severe trauma. They have strong familial and social
support systems and will often care for members of their community at home. There is a perception among clinicians that Amish patients do not routinely attend outpatient follow-up appointments. It is unknown whether compliance is related to socioreligious beliefs regarding health care, financial concerns, transportation issues, or simply a misconception among clinicians who routinely treat this population. Geisinger Medical Center, which is a rural level I trauma center located in central Pennsylvania, treats a large number of Amish patients.
Address correspondence to: Louis C. Grandizio, Department of Orthopaedic Surgery, Geisinger Medical Center, 21-30, 100 N Academy Avenue, Danville, PA 17822, USA (E-mail: [email protected]).
140
Grandizio et al.
There are inherent risks associated with farming and agriculture. Musculoskeletal injuries are common within the Anabaptist community; however, little is known about the specific types of musculoskeletal injuries that these patients sustain.2,3 Lifestyle and vocational factors unique to the Anabaptist community can be a significant cause of morbidity and mortality within their community and can result in an increased financial burden for patients. The Amish are exempt from the federal Social Security program and are uninsured.4 Amish patients, with the support of their community, will “self-pay” for medical services. Patients without insurance face significant financial challenges with respect to their health care, and it is difficult to predict the final cost of care when a patient is initially admitted to the hospital after a traumatic event. There is a paucity of literature that has examined the financial impact of health care costs for Amish patients, especially as it pertains to orthopaedic injuries. The purpose of this retrospective study was to describe epidemiology of orthopaedic trauma in both Amish and Mennonite patients and to analyze the hospital charges associated with their treatment. As with any patient population with unique religious beliefs, cultural practices, language, or insurance barriers, it is important to analyze their treatment and outcomes to improve patient care while remaining sensitive to socioreligious considerations.
MATERIALS AND METHODS Geisinger Medical Center, a level I trauma center in rural central Pennsylvania, provides tertiary care for a catchment area of approximately 25,000 square miles. All Amish patients who had been seen in our emergency department by the orthopaedic surgery staff with a traumatic injury from January 2006 through May 2013 were retrospectively identified through our electronic medical records (EMR) and were included in the study. A total of 79 Amish patients were identified that met inclusion criteria. Data collection included age, gender, admission date, length of hospital and intensive
141
care unit (ICU) stay, types of imaging studies obtained, Glasgow Coma Score (GCS), injury severity score (ISS), and trauma-related injury severity score (TRISS). The orthopaedic injury complex was recorded for each patient. For each patient that required orthopaedic operative intervention, additional information was recorded, including type of procedure, number of procedures performed, total number of trips to the operating room, and whether the patient required readmission for operative intervention. We recorded discharge and outcome data, including mortality, functional independence measure (FIM) score, disposition at time of discharge, and total hospital charges. Furthermore, we recorded compliance with and duration of outpatient follow-up. Mechanism of injury was recorded for each patient and categorized as injuries related to occupational incidents, animal injuries, recreational injuries, and transportation injuries, which included buggy accidents. Injury mechanisms related to farming were analyzed and reported separately, as some patients who sustained animal-, occupational, or transportationrelated injuries did so while performing farm work. To determine whether injury mechanisms were truly unique among Amish patients and to better compare hospital charges, we examined a comparison cohort of Old Order Anabaptist (Mennonite) patients as well. The Mennonites are another conservative religious group that reside in rural central Pennsylvania; however; their beliefs permit the use of electricity, automobiles, and other modern conveniences. Although they also often engage in farm-related activities, they often have either private or government health insurance. Using the same inclusion criteria, a total of 40 Mennonite patients were retrospectively identified from January 2006 through May 2013, all of whom had health insurance. Similar data were recorded for each Mennonite patient. Each variable of interest was compared between the Amish and Mennonite cohorts, either using Student t testing (for comparison of means) or chi-square testing (for percentages). All statistical analysis was performed using SAS software (SAS 9.3; Cary, NC) with
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ORTHOPAEDIC TRAUMA IN THE ANABAPTIST COMMUNITY
differences of P < .05 considered statistically significant. This study was approved by the institutional review board at Geisinger Medical Center in Danville, Pennsylvania.
RESULTS The baseline characteristics of all patients meeting inclusion criteria are presented in Table 1. Amish and Mennonite patients were similar with the exception of a higher percentage of males in the Mennonite group (75% vs. 93%, P = .02). The mean age of Amish patients was 24 years old. Nine percent required ICU admission, and the average length of stay was 3.8 days. Baseline injury information is also presented in Table 1. Occupational injuries accounted for the highest percentage of admissions for both Amish and Mennonite patients (52% and 50%, respectively). Buggy accidents accounted for 16% of admissions for Amish patients, whereas there were no buggy accidents among Mennonite patients (P < .01). Injuries sustained as a result of farming incidents accounted for 63% of all injuries for all patients in our series. For Amish patients, 68% sustained injuries as a result of faming compared with 53% of Mennonite patients (P = .09). Although Amish patients were not statistically more likely to sustain injuries as a result of farming incidents, traumatic agricultural events constituted the largest injury mechanism in our series. Upon presentation to our institution, 44% of Amish patients and 45% of Mennonite patients underwent computed tomography (CT) scan as part of the initial trauma evaluation (P = .94). After transfer from an outside institution, 10% of both Amish and Mennonite had their CT scan repeated if the study was deemed inadequate or if the imaging study was not transferred with the patient (P = .99). Table 2 defines the types of orthopaedic injuries sustained by Anabaptist patients. Figure 1 illustrates the breakdown of the fractures by body region in Amish patients. Amish patients were statistically more likely to sustain
fractures of the spine compared with Mennonite patients (P = .0004). Mennonite patients were more likely to sustain fractures of the foot and femur compared with Amish patients, and these results were statically significant (P = .01 and .003, respectively) Tables 3 and 4 illustrate the orthopaedic operative procedures performed. For Amish patients, 56% underwent orthopaedic operative intervention and a mean of 2.8 procedures were performed per patient that required surgery. Nineteen percent of Amish patients required readmission for an operative procedure (Table 1), and readmission was associated with an average of $24,573 in additional hospital charges (Table 5). Débridement and irrigation of open fractures or traumatic arthrotomies of joints were the most common procedures performed (31%), followed by open reduction and internal fixation of fractures (26%) for Amish patients. Table 5 outlines patient outcomes. There were no deaths in our series. No Amish patients were discharged to a rehabilitation facility. Although 82% of Amish patients attended their initial outpatient follow-up appointment, only 20% completed outpatient follow-up and were discharged from care. In comparison, 85% of patients in the Mennonite cohort attended their initial outpatient follow-up appointment and 45% completed outpatient follow-up. These results were statistically significant (P < .01). Additionally, 11% Amish patients had final recommendations from physical therapy, occupational therapy, or care management that advised either continued hospitalization or an inpatient rehab stay after discharge. All Amish patients in our series went home after discharge, and one patient left against medical advice. Total hospital charges averaged $58,031 per Amish patient, and although their mean charges were lower, the results were not statically significant compared to Mennonite patients. Length of stay and number of operative procedures were associated with higher hospital charges. For patients that had any operative procedure done, each additional trip to the operation room (OR) was associated with a cost ratio (multiplying the inpatient charges in log-dollars) by 1.55 per OR trip (95% confidence interval [CI] = 1.18–2.03,
Grandizio et al.
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TABLE 1. Baseline Characteristics and Baseline Injury Information for Amish and Mennonite Patients Characteristic
Amish
Mennonite
P value
Total patients, N Male, n (%) Age in years, Mean (range) Transfer from OSH, n (%) Trauma alert, n (%) Length of stay in days per patient, Mean (range)
79 59 (75%) 24 (1–82) 30 (38%) 38 (48%) 3.8 (1–20)
40 37 (93%) 27 (1–77) 16 (40%) 18 (45%) 4.0 (1–21)
— .02 .31 .83 .75 .82
Season of Admission, n (%) Winter Spring Summer Fall ICU admission, n (%) Length of ICU stay (in days per patient admitted to ICU), Mean (range) Intubated, n (%) Readmitted for OR, n (%) Length of readmission stay (in days per patient readmitted), Mean (range)
15 (19%) 19 (24%) 21 (27%) 24 (30%) 7 (9%) 5.9 (1–14) 5 (6%) 15 (19%) 1.7 (0–8)
6 (15%) 10 (25%) 10 (25%) 14 (35%) 5 (13%) 6.2 (2–13) 5 (13%) 8 (20%) 1.3 (1–2)
.53 .90 .25 .40 .89
Amish
Mennonite
P value
79 14.6 (3–15) 10.6 (1–50) 97.3 (38.7–99.7)
40 14.5 (3–15) 12.3 (1–50) 96.0 (32.5–99.7)
— .78 .42 .54
Mechanism of injury category Animal, n (%) Occupational, n (%) Recreational, n (%) Transportation, n (%) Other, n (%)
4 (5%) 41 (52%) 10 (13%) 21 (27%) 3 (4%)
2 (5%) 20 (50%) 6 (15%) 11 (28%) 1 (3%)
.99 .99 .84 .72 .92 .99
Mechanism of injury description Buggy accident, n (%) Logging accident, n (%) MVA, n (%) Table-saw injury, n (%) Other, n (%)
13 (16%) 3 (4%) 8 (10%) 5 (6%) 50 (63%)
0 (0%) 2 (5%) 6 (15%) 1 (3%) 31 (78%)
.03
Orthopaedic Trauma in the Anabaptist Community: Epidemiology and Hospital Charges Louis C. Grandizio, Benjamin R. Wagner, Jove Graham, Joel C. Klena, and Michael Suk Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, Pennsylvania, USA
ABSTRACT. This study aims to define the epidemiology of orthopaedic trauma in the rural Anabaptist community and analyze the hospital charges associated with their treatment. The authors performed a retrospective review of 79 Amish and 40 Mennonite patients who had been seen in their rural level I trauma center emergency department for an orthopaedic injury from January 2006 to May 2013. Data collection included baseline demographics, injury mechanism and severity, injury complex, operative interventions, outcomes, and hospital charges. Amish and Mennonite groups were similar except for a higher percentage of males in the Mennonite group. For Amish patients, occupational injuries (52%) and buggy accidents (16%) accounted for the highest percentage of admissions. Eighty-seven percent sustained at least one fracture, most commonly of the hand (11%). Amish patients were statistically more likely to sustain fractures of the spine, and Mennonite patients were more likely to sustain fractures of the foot and femur. Over half of patients required surgery (58%). Total hospital charges did not differ based between the groups. Amish patients completed outpatient follow-up less frequently than Mennonite patients. Anabaptist patients are at risk for a variety of orthopaedic injuries related to their unique lifestyle and vocations. Socioreligious beliefs must be taken into consideration when educating these patients regarding postinjury care, as attendance at outpatient follow-up is low. Understanding the types of injuries that these patients sustain can help create strategies to prevent costly transportation and agricultural accidents within the Anabaptist community.
KEYWORDS. Amish, epidemiology, orthopaedics, trauma
INTRODUCTION As part of the Anabaptist community, the Amish are a conservative religious group who reside primarily in rural regions of Ohio, Indiana, Iowa, and central Pennsylvania. They live an agrarian lifestyle and the use of electricity and modern automobiles are not permitted within the scope of their religious beliefs.1 Amish patients will utilize the services of a physician, but this is often limited to medical emergencies and severe trauma. They have strong familial and social
support systems and will often care for members of their community at home. There is a perception among clinicians that Amish patients do not routinely attend outpatient follow-up appointments. It is unknown whether compliance is related to socioreligious beliefs regarding health care, financial concerns, transportation issues, or simply a misconception among clinicians who routinely treat this population. Geisinger Medical Center, which is a rural level I trauma center located in central Pennsylvania, treats a large number of Amish patients.
Address correspondence to: Louis C. Grandizio, Department of Orthopaedic Surgery, Geisinger Medical Center, 21-30, 100 N Academy Avenue, Danville, PA 17822, USA (E-mail: [email protected]).
140
Grandizio et al.
There are inherent risks associated with farming and agriculture. Musculoskeletal injuries are common within the Anabaptist community; however, little is known about the specific types of musculoskeletal injuries that these patients sustain.2,3 Lifestyle and vocational factors unique to the Anabaptist community can be a significant cause of morbidity and mortality within their community and can result in an increased financial burden for patients. The Amish are exempt from the federal Social Security program and are uninsured.4 Amish patients, with the support of their community, will “self-pay” for medical services. Patients without insurance face significant financial challenges with respect to their health care, and it is difficult to predict the final cost of care when a patient is initially admitted to the hospital after a traumatic event. There is a paucity of literature that has examined the financial impact of health care costs for Amish patients, especially as it pertains to orthopaedic injuries. The purpose of this retrospective study was to describe epidemiology of orthopaedic trauma in both Amish and Mennonite patients and to analyze the hospital charges associated with their treatment. As with any patient population with unique religious beliefs, cultural practices, language, or insurance barriers, it is important to analyze their treatment and outcomes to improve patient care while remaining sensitive to socioreligious considerations.
MATERIALS AND METHODS Geisinger Medical Center, a level I trauma center in rural central Pennsylvania, provides tertiary care for a catchment area of approximately 25,000 square miles. All Amish patients who had been seen in our emergency department by the orthopaedic surgery staff with a traumatic injury from January 2006 through May 2013 were retrospectively identified through our electronic medical records (EMR) and were included in the study. A total of 79 Amish patients were identified that met inclusion criteria. Data collection included age, gender, admission date, length of hospital and intensive
141
care unit (ICU) stay, types of imaging studies obtained, Glasgow Coma Score (GCS), injury severity score (ISS), and trauma-related injury severity score (TRISS). The orthopaedic injury complex was recorded for each patient. For each patient that required orthopaedic operative intervention, additional information was recorded, including type of procedure, number of procedures performed, total number of trips to the operating room, and whether the patient required readmission for operative intervention. We recorded discharge and outcome data, including mortality, functional independence measure (FIM) score, disposition at time of discharge, and total hospital charges. Furthermore, we recorded compliance with and duration of outpatient follow-up. Mechanism of injury was recorded for each patient and categorized as injuries related to occupational incidents, animal injuries, recreational injuries, and transportation injuries, which included buggy accidents. Injury mechanisms related to farming were analyzed and reported separately, as some patients who sustained animal-, occupational, or transportationrelated injuries did so while performing farm work. To determine whether injury mechanisms were truly unique among Amish patients and to better compare hospital charges, we examined a comparison cohort of Old Order Anabaptist (Mennonite) patients as well. The Mennonites are another conservative religious group that reside in rural central Pennsylvania; however; their beliefs permit the use of electricity, automobiles, and other modern conveniences. Although they also often engage in farm-related activities, they often have either private or government health insurance. Using the same inclusion criteria, a total of 40 Mennonite patients were retrospectively identified from January 2006 through May 2013, all of whom had health insurance. Similar data were recorded for each Mennonite patient. Each variable of interest was compared between the Amish and Mennonite cohorts, either using Student t testing (for comparison of means) or chi-square testing (for percentages). All statistical analysis was performed using SAS software (SAS 9.3; Cary, NC) with
142
ORTHOPAEDIC TRAUMA IN THE ANABAPTIST COMMUNITY
differences of P < .05 considered statistically significant. This study was approved by the institutional review board at Geisinger Medical Center in Danville, Pennsylvania.
RESULTS The baseline characteristics of all patients meeting inclusion criteria are presented in Table 1. Amish and Mennonite patients were similar with the exception of a higher percentage of males in the Mennonite group (75% vs. 93%, P = .02). The mean age of Amish patients was 24 years old. Nine percent required ICU admission, and the average length of stay was 3.8 days. Baseline injury information is also presented in Table 1. Occupational injuries accounted for the highest percentage of admissions for both Amish and Mennonite patients (52% and 50%, respectively). Buggy accidents accounted for 16% of admissions for Amish patients, whereas there were no buggy accidents among Mennonite patients (P < .01). Injuries sustained as a result of farming incidents accounted for 63% of all injuries for all patients in our series. For Amish patients, 68% sustained injuries as a result of faming compared with 53% of Mennonite patients (P = .09). Although Amish patients were not statistically more likely to sustain injuries as a result of farming incidents, traumatic agricultural events constituted the largest injury mechanism in our series. Upon presentation to our institution, 44% of Amish patients and 45% of Mennonite patients underwent computed tomography (CT) scan as part of the initial trauma evaluation (P = .94). After transfer from an outside institution, 10% of both Amish and Mennonite had their CT scan repeated if the study was deemed inadequate or if the imaging study was not transferred with the patient (P = .99). Table 2 defines the types of orthopaedic injuries sustained by Anabaptist patients. Figure 1 illustrates the breakdown of the fractures by body region in Amish patients. Amish patients were statistically more likely to sustain
fractures of the spine compared with Mennonite patients (P = .0004). Mennonite patients were more likely to sustain fractures of the foot and femur compared with Amish patients, and these results were statically significant (P = .01 and .003, respectively) Tables 3 and 4 illustrate the orthopaedic operative procedures performed. For Amish patients, 56% underwent orthopaedic operative intervention and a mean of 2.8 procedures were performed per patient that required surgery. Nineteen percent of Amish patients required readmission for an operative procedure (Table 1), and readmission was associated with an average of $24,573 in additional hospital charges (Table 5). Débridement and irrigation of open fractures or traumatic arthrotomies of joints were the most common procedures performed (31%), followed by open reduction and internal fixation of fractures (26%) for Amish patients. Table 5 outlines patient outcomes. There were no deaths in our series. No Amish patients were discharged to a rehabilitation facility. Although 82% of Amish patients attended their initial outpatient follow-up appointment, only 20% completed outpatient follow-up and were discharged from care. In comparison, 85% of patients in the Mennonite cohort attended their initial outpatient follow-up appointment and 45% completed outpatient follow-up. These results were statistically significant (P < .01). Additionally, 11% Amish patients had final recommendations from physical therapy, occupational therapy, or care management that advised either continued hospitalization or an inpatient rehab stay after discharge. All Amish patients in our series went home after discharge, and one patient left against medical advice. Total hospital charges averaged $58,031 per Amish patient, and although their mean charges were lower, the results were not statically significant compared to Mennonite patients. Length of stay and number of operative procedures were associated with higher hospital charges. For patients that had any operative procedure done, each additional trip to the operation room (OR) was associated with a cost ratio (multiplying the inpatient charges in log-dollars) by 1.55 per OR trip (95% confidence interval [CI] = 1.18–2.03,
Grandizio et al.
143
TABLE 1. Baseline Characteristics and Baseline Injury Information for Amish and Mennonite Patients Characteristic
Amish
Mennonite
P value
Total patients, N Male, n (%) Age in years, Mean (range) Transfer from OSH, n (%) Trauma alert, n (%) Length of stay in days per patient, Mean (range)
79 59 (75%) 24 (1–82) 30 (38%) 38 (48%) 3.8 (1–20)
40 37 (93%) 27 (1–77) 16 (40%) 18 (45%) 4.0 (1–21)
— .02 .31 .83 .75 .82
Season of Admission, n (%) Winter Spring Summer Fall ICU admission, n (%) Length of ICU stay (in days per patient admitted to ICU), Mean (range) Intubated, n (%) Readmitted for OR, n (%) Length of readmission stay (in days per patient readmitted), Mean (range)
15 (19%) 19 (24%) 21 (27%) 24 (30%) 7 (9%) 5.9 (1–14) 5 (6%) 15 (19%) 1.7 (0–8)
6 (15%) 10 (25%) 10 (25%) 14 (35%) 5 (13%) 6.2 (2–13) 5 (13%) 8 (20%) 1.3 (1–2)
.53 .90 .25 .40 .89
Amish
Mennonite
P value
79 14.6 (3–15) 10.6 (1–50) 97.3 (38.7–99.7)
40 14.5 (3–15) 12.3 (1–50) 96.0 (32.5–99.7)
— .78 .42 .54
Mechanism of injury category Animal, n (%) Occupational, n (%) Recreational, n (%) Transportation, n (%) Other, n (%)
4 (5%) 41 (52%) 10 (13%) 21 (27%) 3 (4%)
2 (5%) 20 (50%) 6 (15%) 11 (28%) 1 (3%)
.99 .99 .84 .72 .92 .99
Mechanism of injury description Buggy accident, n (%) Logging accident, n (%) MVA, n (%) Table-saw injury, n (%) Other, n (%)
13 (16%) 3 (4%) 8 (10%) 5 (6%) 50 (63%)
0 (0%) 2 (5%) 6 (15%) 1 (3%) 31 (78%)
.03
