Factors affecting management of children’s low-risk distal radius fractures in the emergency department: a population-based retrospective cohort study

Tara Baxter; Teresa To; Maria Chiu; Mark Camp; Andrew Howard

doi:10.9778/cmajo.20200116

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Figure 1:
Exclusion flow diagram.
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Figure 2:
Yearly variation in type of follow-up visit for low-risk pediatric distal radius fractures.

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Table 1:

ICES databases and data elements accessed

Database	Description	Data obtained
National Ambulatory Care Reporting System	Outpatient data: Same-day surgery, emergency department and clinic visits in hospital and community settings in Ontario	Main diagnosis code Intervention codes Visit disposition Date of service
Ontario Health Insurance Plan	Billing data: Records of all claims for insured services made to the health plan	Fee codes Diagnosis codes Date of service
ICES Physician Database	Physician data: Demographic characteristics, training, practice location, and specialty.	Physician type/specialty Year of medical graduation
Ontario Health Care Institution Database	Hospital data	Hospital type
Registered Persons Database	Identification data: Demographic characteristics, ability to link other data and ongoing eligibility to receive insurance coverage	Patient age Patient sex Rurality of residence Insurance eligibility
Census	General data: Demographic characteristics, ethnicity, income, housing conditions, family structure and spoken languages from households across Canada	Deprivation quintile
Canadian Institute for Health Information Discharge Abstract Database	Inpatient data: Admissions, diagnoses and interventions	Intervention codes Comorbidities Hospital admission
Ontario Cancer Registry	Cancer data: Cancer diagnoses in Ontario residents	Comorbidities

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Table 2:

Description of low-risk pediatric distal radius fracture cohort, stratified by outcome of interest, no follow-up

Predictor of interest	No. (%)^*
Predictor of interest	No follow-up n = 14 742 (20.8%)	Other treatment n = 56 059 (79.2%)	Total n = 70 801 (100.0%)
Patient sex
Male	8775 (20.2)	34 713 (79.8)	43 488 (61.4)
Female	5967 (21.8)	21 346 (78.2)	27 313 (38.6)
Patient age at diagnosis, mean ± SD	9.22 ± 3.2	9.25 ± 3.2	9.24 ± 3.2
Patient deprivation quintile
1 (least marginalized)	3733 (19.5)	15 408 (80.5)	19 141 (27.0)
2	3162 (20.5)	12 228 (79.5)	15 390 (21.7)
3	2856 (21.8)	10 258 (78.2)	13 114 (18.5)
4	2578 (22.3)	8974 (77.7)	11 552 (16.3)
5 (most marginalized)	2413 (20.8)	9191 (79.2)	11 604 (16.4)
Rural patient residence
Yes	2689 (34.4)	5135 (65.6)	7824 (11.1)
No	12 053 (19.1)	50 924 (80.9)	62 977 (88.9)
Rural emergency department
Yes	2135 (38.2)	3458 (61.8)	5593 (7.9)
No	12 607 (19.3)	52 601 (80.7)	65 208 (92.1)
Hospital type
Pediatric	1362 (24.1)	4298 (75.9)	5660 (8.0)
Teaching	1274 (17.8)	5880 (82.2)	7154 (10.1)
Community	10 394 (19.3)	43 495 (80.7)	53 889 (76.1)
Small	1712 (41.8)	2386 (58.2)	4098 (5.8)
Physician year of medical graduation
Before 2002	12 012 (21.2)	44 637 (78.8)	56 649 (80.0)
After 2002	2730 (19.3)	11 422 (80.7)	14 152 (20.0)
Physician specialty
Emergency medicine residency trained	1103 (18.0)	5022 (82.0)	6125 (8.7)
Family medicine + emergency medicine certification	5894 (18.9)	25 276 (81.1)	31 170 (44.0)
Family or general practitioner	6130 (23.1)	20 450 (76.9)	26 580 (37.5)
Pediatrician	984 (21.7)	3559 (78.3)	4543 (6.4)
Pediatric emergency medicine subspecialty	522 (32.4)	1090 (67.6)	1612 (2.3)
Orthopedic surgery	109 (14.1)	662 (85.9)	771 (1.1)
Fiscal year
2003	429 (18.1)	1939 (81.9)	2368 (3.3)
2004	1187 (18.9)	5089 (81.1)	6276 (8.9)
2005	1174 (19.5)	4854 (80.5)	6028 (8.5)
2006	1222 (21.2)	4552 (78.8)	5774 (8.2)
2007	1167 (20.4)	4561 (79.6)	5728 (8.1)
2008	1136 (20.4)	4439 (79.6)	5575 (7.9)
2009	1160 (20.6)	4464 (79.4)	5624 (7.9)
2010	1208 (21.7)	4352 (78.3)	5560 (7.9)
2011	1263 (22.2)	4414 (77.8)	5677 (8.0)
2012	1238 (23.0)	4152 (77.0)	5390 (7.6)
2013	1262 (22.2)	4412 (77.8)	5674 (8.0)
2014	1261 (21.8)	4522 (78.2)	5783 (8.2)
2015	1035 (19.4)	4309 (80.6)	5344 (7.5)

Note: SD = standard deviation.
↵* Unless stated otherwise.

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Table 3:

Multivariable log-binomial regression analysis of factors predictive of receiving no follow-up after a low-risk pediatric distal radius fracture (n = 70 801)

Predictor of interest	Adjusted RR (95% CI) for receiving no follow-up
Patient sex
Male	1.00 (Ref.)
Female	1.08 (1.05–1.11)
Patient age	1.00 (0.99–1.01)
Patient deprivation quintile
1 (least marginalized)	1.00 (Ref.)
2	1.01 (0.97–1.05)
3	1.04 (0.99–1.09)
4	1.06 (1.01–1.10)
5 (most marginalized)	1.03 (0.99–1.08)
Rural patient residence
Yes	1.44 (1.38–1.50)
No	1.00 (Ref.)
Hospital type
Pediatric	1.16 (1.07–1.26)
Teaching	1.00 (Ref.)
Community	1.13 (1.06–1.20)
Small	1.86 (1.72–2.01)
Physician specialty
Emergency medicine residency trained	1.00 (Ref.)
Family medicine + emergency medicine certification	1.00 (0.94–1.06)
Family or general practitioner	1.09 (1.02–1.16)
Pediatrician	1.22 (1.11–1.34)
Pediatric emergency medicine subspecialty	1.73 (1.56–1.92)
Orthopedic surgery	0.76 (0.63–0.91)
Fiscal year
2003	1.00 (Ref.)
2004	1.05 (0.95–1.16)
2005	1.09 (0.99–1.21)
2006	1.18 (1.07–1.31)
2007	1.13 (1.03–1.25)
2008	1.16 (1.05–1.28)
2009	1.14 (1.04–1.26)
2010	1.19 (1.08–1.32)
2011	1.20 (1.09–1.33)
2012	1.24 (1.12–1.37)
2013	1.21 (1.09–1.33)
2014	1.19 (1.08–1.31)
2015	1.06 (0.95–1.17)