Abstract
Background
Previous research has demonstrated disparities in access to care for patients with facial fractures. This study aimed to assess potential disparities in timing to nasal bone repositioning among hospitalized patients who received treatment.
Methods
Data from the 2017–2022 American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) and the International Classification of Diseases 10th revision codes (ICD-10) were used. The time to nasal bone repositioning was analyzed using multivariable Cox proportional hazards regression analysis.
Results
We analyzed data from 14,815 adult patients with traumatic nasal bone fractures who underwent repositioning during their index hospitalization. Within ten days of the initial presentation, 95 % of the patients underwent nasal repositioning. Black (HR = 0.90; CI = 0.85–0.95) and Asian (HR = 0.80; CI = 0.70–0.93) race, older age, private insurance (HR = 0.95; CI = 0.91–0.99), high Injury Severity Scores (ISS) (ISS 25+: HR = 0.33; CI = 0.31–0.35), specific injury mechanisms, facial fractures, and certain comorbidities were associated with statistically significantly longer times to repositioning. Treatment at a Level II trauma center (HR = 1.11; CI = 1.06–1.15), interfacility transfers (HR = 1.12; CI = 1.08–1.16), and open facial wounds were linked to statistically significantly shorter times to intervention.
Conclusion
In this large ACS-TQIP sample, most patients who did undergo nasal bone repositioning received it within the standard of care, with only minor timing variations based on demographic and geographic factors. In cases with higher injury severity, life-threatening injuries were prioritized before addressing nasal bone fractures. Further research should investigate initial care–access inequities in patients who experienced facial trauma but did not receive comprehensive care.
Keywords: Trauma, Healthcare disparities, Head and neck, Plastic surgery, Surgical quality, Facial fractures
Introduction
Nasal fractures are the most common facial fracture, often caused by falls, motor vehicle collisions, sports injuries, or interpersonal violence.1 Improper management can lead to long-term impairments, including nasal obstruction, septal deviation, cosmetic deformities, and psychological distress.2 Studies have highlighted disparities in facial injury care access.3,4 We aimed to elucidate the potential predictors of nasal bone repositioning delays in adult trauma patients treated for nasal bone fractures.
Methods
Using data from the 2017–2022 American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP), we identified hospitalized adult trauma patients with open or closed nasal fractures (ICD-10-CM S02.2XXA and S02.2XXB) who underwent nasal bone repositioning (ICD-10PCS 0NSB). The primary outcome measure was the time to repositioning. Potential predictors were controlled for using multivariable Cox proportional hazards regression analysis to evaluate these factors’ independent effects on the time to nasal bone repositioning. Statistical analyses were performed using STATA 18.0 (StataCorp, College Park, Texas, USA).
Results
We identified 20,330 hospitalized adult patients with trauma who underwent nasal bone repositioning between 2017 and 2022, with 14,815 patients' data included in our multivariable analysis. Overall, 25 %, 50 %, 75 %, 90 %, 95 %, and 99 % of the patients underwent nasal repositioning within one, two, four, seven, ten, and 16 days of admission, respectively.
Several characteristics demonstrated significant associations in our multivariable analysis of time to nasal bone repositioning (Table 1). Black (hazard ratio [HR] = 0.898; 95 % confidence interval [CI], 0.850–0.947) and Asian patients (HR = 0.802; 95 % CI, 0.695–0.926) had a lower hazard ratio for undergoing surgery (which implies a longer time to repositioning) than Caucasian patients. Compared with the 18–30 year age group, increased age was also associated with hazard ratios less than one. Patients with private insurance (HR = 0.949; 95 % CI, 0.913–0.987) had a lower hazard than did those with public insurance.
Table 1.
Time to Nasal Bone Repositioning Analysis Based on 14,815 Adult Trauma Patients.
| Characteristic | Hazard ratio (95 % CI) | |
|---|---|---|
| Race | ||
| Caucasian | Reference | |
| Black | 0.898 (0.850–0.947) | |
| Asian | 0.802 (0.695–0.926) | |
| Hispanic/Latino | 0.961 (0.917–1.007) | |
| Pacific Islander/American Indian | 1.039 (0.928–1.162) | |
| Other | 0.981 (0.912–1.057) | |
| Age (Years) | ||
| 18–30 | Reference | |
| 31–40 | 0.924 (0.882–0.969) | |
| 41–50 | 0.868 (0.823–0.914) | |
| 51–60 | 0.884 (0.836–0.934) | |
| 61–70 | 0.946 (0.885–1.012) | |
| 71–80 | 0.930 (0.854–1.012) | |
| 81–90 | 0.966 (0.865–1.079) | |
| Sex | ||
| Female | Reference | |
| Male | 1.035 (0.996–1.077) | |
| Insurance | ||
| Public | Reference | |
| Private | 0.949 (0.913–0.987) | |
| Self-Pay | 1.040 (0.987–1.095) | |
| Other | 1.008 (0.927–1.095) | |
| Injury Severity Score | ||
| 0–9 | Reference | |
| 10–15 | 0.687 (0.656–0.718) | |
| 16–24 | 0.509 (0.486–0.533) | |
| 25+ | 0.328 (0.309–0.349) | |
| Mechanism | ||
| Fall | Reference | |
| Penetrating Trauma | 0.860 (0.783–0.943) | |
| Motor Vehicle Collision | 0.976 (0.925–1.030) | |
| Cyclist/Pedestrian | 1.029 (0.979–1.082) | |
| Other | 1.107 (1.028–1.192) | |
| Associated Injuries | ||
| Mandibular Fracture | 0.844 (0.803–0.887) | |
| Malar/Maxillary/Zygoma Fracture | 0.721 (0.695–0.747) | |
| Orbital Fracture | 0.844 (0.814–0.875) | |
| Other Facial Fracture | 0.975 (0.848–1.122) | |
| Open Wound Nose | 1.082 (1.038–1.129) | |
| Open Wound Temporomandibular Area | 1.193 (1.117–1.273) | |
| Open Wound Lip/Oral | 1.168 (1.121–1.217) | |
| Traumatic Brain Injury | 0.916 (0.883–0.951) | |
| Epistaxis | 0.993 (0.764–1.289) | |
| Deviated Septum | 0.761 (0.304–1.904) | |
| Verification Level | ||
| Level I Trauma Center | Reference | |
| Level II Trauma Center | 1.105 (1.061–1.151) | |
| Level III Trauma Center | 1.132 (0.984–1.302) | |
| Number of Beds | ||
| ≤ 200 | Reference | |
| 201–400 | 0.970 (0.898–1.048) | |
| 401–600 | 0.908 (0.839–0.982) | |
| > 600 | 0.872 (0.806–0.944) | |
| Hospital Type | ||
| For Profit | Reference | |
| Non-Profit | 1.052 (0.997–1.110) | |
| Government | 1.127 (0.854–1.488) | |
| No Interfacility Transfer | Reference | |
| Interfacility Transfer | 1.118 (1.078–1.160) | |
| Comorbidities | ||
| Congestive Heart Failure | 0.964 (0.834–1.115) | |
| Renal Disease | 1.237 (0.978–1.565) | |
| Cerebral Vascular Attack | 0.926 (0.771–1.111) | |
| Disseminated Cancer | 0.762 (0.522–1.113) | |
| Advanced Directive Limiting Care | 0.810 (0.676–0.971) | |
| Functionally Dependent | 0.805 (0.720–0.900) | |
| Cirrhosis | 0.743 (0.620–0.890) | |
| Dementia | 0.909 (0.77–1.062) | |
| Anticoagulant Therapy | 0.856 (0.783–0.935) | |
| Mental/Personality Disorder | 0.905 (0.860–0.954) | |
| Myocardial Infarction | 0.868 (0.616–1.223) | |
| Peripheral Artery Disease | 1.105 (0.861–1.418) | |
| Prematurity | 2.389 (0.560–10.197) | |
| Pregnancy | 0.903 (0.467–1.745) | |
Hazard ratios < 1 represent delayed treatment.
CI = confidence interval.
Higher Injury Severity Scores (ISSs) were associated with progressively lower hazard ratios for repositioning. Compared with falls, penetrating trauma (HR = 0.860; 95 % CI, 0.783–0.943) and other injury mechanisms (HR = 1.107; 95 % CI, 1.028–1.192) were statistically significantly associated with differences in time to repositioning, whereas motor vehicle collision and cyclist/pedestrian did not have hazard ratios statistically significantly different than one. Several associated injuries, such as mandibular fractures (HR = 0.844; 95 % CI, 0.803–0.887), malar/maxillary/zygoma fractures (HR = 0.721; 95 % CI, 0.695–0.747), orbital fractures (HR = 0.844; 95 % CI, 0.814–0.875), and traumatic brain injuries (HR = 0.916; 95 % CI, 0.883–0.951) were associated with reduced hazards ratios, corresponding to an increased time to repositioning. Open wounds of the face, however, such as open nose wounds (HR = 1.082; 95 % CI, 1.038–1.129), cheek and temporomandibular area open wounds (HR = 1.193; 95 % CI, 1.117–1.273), and open lip or oral wounds (HR = 1.168; 95 % CI, 1.121–1.217), were associated with more timely care with hazard ratios statistically significantly greater than one.
Treatment at a Level II Trauma Center (HR = 1.105; 95 % CI, 1.061–1.151) and undergoing interfacility transfer (HR = 1.118; 95 % CI, 1.078–1.160) were associated with an increased hazard ratio. Treatment at a hospital with 401–600 beds (HR = 0.908; 95 % CI, 0.839–0.982) or >600 beds (HR = 0.872; 95 % CI, 0.806–0.944) was associated with a decreased hazard (longer time to surgery) compared to treatment at a hospital with ≤200 beds.
Discussion
This large, national, TQIP database analysis of hospitalized trauma patients with nasal bone fractures demonstrated that treatment at a Level I trauma center, high ISSs, and associated facial fractures were associated with relative delays in time to nasal bone repositioning. These findings reinforce the expectation that nasal fracture management is often postponed until critical injuries are stabilized. Level I centers may prioritize resources for patients with severe injuries and emergency conditions, potentially leading to treatment delays for non-life-threatening traumatic injuries.5
Conversely, factors such as interfacility transfer, open facial wounds, and receiving treatment at a smaller hospital were associated with shorter times to procedures, likely reflecting institutional differences in the severity of traumatically injured patients treated, patient triage, and treatment priorities.4 Considering that the significant majority of patients who underwent repositioning for their nasal fractures did so within the two-week standard, treatment timing variability may depend on surgeon or operating room availability.2
This retrospective cohort study was restricted to adult inpatients treated at trauma facilities and did not include outpatients. While nasal fractures are generally managed in a delayed but timely manner in the absence of life-threatening injuries, further research is needed to determine the optimal treatment timing within broader injury contexts, and greater attention is warranted to address inequities for those who do not receive comprehensive facial trauma care in the first place.
Conclusion
Nasal bone repositioning’s timing can vary based on injury severity, associated facial fractures, and institutional treatment protocols. For patients undergoing inpatient nasal bone repositioning, the overall impact of socioeconomic disparities on timing appears minimal, and most of these patients receive standard care in the hospital setting. Further research should explore inequities in initial treatment access to guide equitable and effective facial trauma management strategies.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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