Article Figures & Data
Figures
- Figure 1
Timeline depicting patient inclusion and assessments of outcomes. DD, direct discharge; EPR, electronic patient record; PREM, patient-reported experience measure; PROM, patient-reported outcome measure.
- Figure 2
Flow chart depicting the inclusion of patients. In the DD cohort, patients in the emergency department with SSI were used to assess implementation. Patients who provided informed consent were used to assess healthcare utilization, and patients who completed the survey were used to assess patient-reported outcomes and experiences. DD, direct discharge; PREM, patient-reported experience measure; PROM, patient-reported outcome measure; SSI, simple stable injury.
- Figure 3
Depiction of differences in satisfaction with treatment, functional outcome, and healthcare utilization before and after direct discharge. DD, direct discharge; LEFS, Lower Extremity Functional Scale; PROMIS, Patient-Reported Outcomes Measurement Information System; QuickDASH, Shortened Version of the Disabilities of the Arm, Shoulder and Hand.
Tables
- Table 1
Simple and stable injuries, criteria and immobilization
Injury Pediatric/adult Criteria Immobilization after DD Pediatric clavicle Fx Pediatric Age ≤14.
No indication for surgical treatment.
Sling.
Radial head/neck Fx Adult Head: Mason type 1; neck: undisplaced.
Or positive fat pad sign.
Pressure bandage, sling.
Greenstick or torus/buckle-type Fx of the distal radius Pediatric Acceptable angulation-based residual growth.
Torus/buckle type: isolated ulna Fx, isolated radius Fx, or both.
Greenstick type: isolated ulna Fx or isolated radius Fx.
Removable wrist brace.
Fifth metacarpal neck Fx Adult Volar angulation <70°.
No rotational deviation.
Buddy strap and pressure bandage.
Mallet finger Adult Either bony or tendinous.
Treated conservatively.
Mallet splint.
Weber A-type ankle Fx Adult Dislocation <2 mm.
No signs of stage 2 supination-adduction-type injury.
Tubigrip and ankle brace.
Avulsion-type ankle Fx Adult Either lateral or medial malleolus or tarsal bones.
Tubigrip and ankle brace.
Fx of fifth metatarsal base Adult Fx located in either zone 1 or zone 2.
Dislocation ≤4 mm.
Walker boot.
Fx of greater toe Both Either proximal or distal phalanx Fx.
Undisplaced.
Spica pressure bandage and bandage shoe.
Fx of lesser toe Both Any isolated Fx.
No indication for surgical treatment.
Buddy strap.
Bicycle spoke injury Pediatric No Fx based on radiograph.
Superficial wound.
Pressure bandage.
DD, direct discharge; Fx, fracture.;
- Table 2
Different questionnaires used to assess satisfaction, functional outcome, and quality of life
Outcome Extremity Age category Number of items Summary score Non-inferiority margin (MCID) Satisfaction with treatment Either All participants 1 item; 0–100 VAS Rating scale (0–10*) −0.7 points Functional outcome No questionnaire Either 0–3 PROMIS UE SF Upper 4–17 8 items; 5P Likert T-score Not available PROMIS Mobility SF Lower 4–17 8 items; 5P Likert T-score −3.0 points QuickDASH Upper ≥18 11 items; 5P Likert Total (100–0*) +15.91 points LEFS Lower ≥18 20 items; 5P Likert Total (0–80*) −9.0 points Health-related QoL No questionnaire Either 0–3 EQ-5D-Youth Either 4–11, and 12–17 (if proxy) 5 items; 3 levels,
1 item; 0–100 VASIndex (0–1*)
VAS score (0–100*)EQ-5D-5L Either ≥18, and 12–17 (self-complete) 5 items; 3 levels,
1 item; 0–100 VASIndex (0–1*)
VAS score (0–100*)Summary scores were calculated using the guideline of each corresponding questionnaire. Normative Dutch values of the EQ-5D-5L were used to calculate the EQ-5D-5L index scores, and normative values of the EQ-5D-3L were used to calculate the EQ-5D-Youth index scores.
T-score: 50 points equal to mean score of the reference population and −10 equal to the mean score of −1 SD compared with reference.
*Indicates best outcome score.
EQ-5D-3L, EuroQol-5-dimension 3-level questionnaire; EQ-5D-5L, EuroQol-5-dimension 5-level questionnaire; 5L, 5-level; LEFS, Lower Extremity Functional Scale; MCID, minimal clinically important difference; 5P, 5-point; PROMIS, Patient-Reported Outcomes Measurement Information System; QoL, quality of life; QuickDASH, Shortened Version of the Disabilities of the Arm, Shoulder and Hand; SF, Short Form; UE, upper extremity; VAS, Visual Analog Scale.
- Table 3
Baseline characteristics of participating patients
Characteristics Provided informed consent (n=719) Completed the survey (n=297) Pre-DD (n=348) DD (n=371) Pre-DD (n=144) DD (n=153) Age, median (IQR) 24 (10–45) 28 (10–48) 26 (11–55) 36 (13–54) Age <18 years, n (%) 142 (40.8) 135 (36.4) 59 (41.0) 48 (31.4) Gender male, n (%) 194 (55.7) 197 (53.1) 76 (52.8) 68 (44.4) Type of injury, n (%) Pediatric clavicle Fx 13 (3.7) 17 (4.6) 8 (5.6) 8 (5.2) Radial head/neck Fx 61 (17.5) 56 (15.1) 24 (16.7) 28 (18.3) Pediatric Fx distal radius Greenstick 47 (13.5) 25 (6.7) 15 (10.4) 9 (5.9) Torus 58 (16.7) 48 (12.9) 21 (14.6) 18 (11.8) Fifth metacarpal neck Fx 25 (7.2) 11 (3.0) 6 (4.2) 1 (0.7) Mallet finger 19 (5.5) 8 (2.2) 6 (4.2) 4 (2.6) Weber A-type ankle Fx 20 (5.7) 21 (5.7) 11 (7.6) 14 (9.2) Avulsion-type ankle Fx 10 (2.9) 32 (8.6) 8 (5.6) 12 (7.8) Fx of fifth metatarsal base 46 (13.2) 51 (13.7) 17 (11.8) 20 (13.1) Fx of greater toe 19 (5.5) 36 (9.7) 10 (6.9) 11 (7.2) Fx of lesser toe 16 (4.6) 34 (9.2) 10 (6.9) 18 (11.8) Bicycle spoke injury 14 (4.0) 32 (8.6) 8 (5.6) 10 (6.5) Region, age category, functional outcome questionnaire, n (%) UE, age 0–3, none 7 (2.0) 11 (3.0) 3 (2.1) 4 (2.6) LE, age 0–3, none 2 (0.6) 4 (1.1) 0 (0.0) 1 (0.7) UE, pediatric, PROMIS UE 112 (32.2) 81 (21.8) 41 (28.5) 31 (20.3) LE, pediatric, PROMIS Mobility 21 (6.0) 39 (10.5) 15 (10.4) 12 (7.8) UE, adult, QuickDASH 104 (29.9) 73 (19.7) 36 (25.0) 33 (21.6) LE, adult, LEFS 102 (29.3) 163 (43.9) 49 (34.0) 72 (47.1) Employment status, n (%) Going to work – – 58 (40.3) 73 (47.7) Going to school – – 59 (41.0) 44 (28.8) No work/school – – 27 (18.8) 36 (23.5) DD, direct discharge; Fx, fracture; LE, lower extremity; LEFS, Lower Extremity Functional Scale; PROMIS, Patient-Reported Outcomes Measurement Information System; QuickDASH, Shortened Version of the Disabilities of the Arm, Shoulder and Hand; UE, upper extremity.
- Table 4
Patient-reported outcomes and experiences at 3 months
Outcome Response, n Descriptive outcome Effect (regression DD vs. pre-DD) Non-inferior Pre-DD DD Pre-DD DD Difference, mean (95% CI) Significance, p value Continuous data, mean (SD) Satisfaction (VAS 0–100) 144 153 8.13 (1.5) 7.95 (1.7) −0.16 (−0.53 to 0.21) 0.408 Yes Pain (VAS 0–100) 144 153 1.40 (2.1) 1.52 (1.9) 0.078 (−0.37 to 0.53) 0.727 – Functional outcome 141 148 77.4 (26.4) 81.0 (21.9) 3.98 (−1.56 to 9.37) 0.166 – QuickDASH 36 33 10.5 (12.2) 13.2 (14.8) 4.15 (−2.00 to 10.50) 0.231 Yes LEFS 49 72 63.1 (16.4) 64.0 (15.4) 1.06 (−4.56 to 6.81) 0.716 Yes PROMIS UE 41 31 35.3 (14.7) 38.7 (13.6) 3.79 (−3.40 to 10.88) 0.270 NA PROMIS Mobility 15 12 44.0 (12.5) 54.1 (7.4) 10.79 (2.78 to 19.67) 0.019 Yes Health-related QoL EQ-5D-5L index 85 105 0.839 (0.189) 0.852 (0.139) 0.014 (−0.032 to 0.062) 0.553 – EQ-5D-5L VAS 85 105 80.2 (16.7) 80.3 (13.1) 0.19 (−4.1 to 4.4) 0.932 – EQ-5D-Youth index 56 43 0.874 (0.242) 0.949 (0.148) 0.076 (0.003 to 0.156) 0.052 – EQ-5D-Youth VAS 56 43 92.3 (9.6) 94.7 (7.5) 2.4 (−1.0 to 5.8) 0.169 – Dichotomous data, n (%) OR (95% CI) Dissatisfied with treatment (Likert) 144 153 5 (3.5) 11 (7.2) 2.05 (0.69 to 6.09) 0.197 – Treatment preference DD 144 153 57 (39.6) 125 (81.7) 6.72 (3.95 to 11.41) <0.001 – Propensity score-adjusted linear regression was performed to analyze continuous data with bootstrapping for non-normal distribution and binary logistic to analyze dichotomous data.
Non-inferiority margins: satisfaction −0.7; QuickDASH +15.91; LEFS −9.0; PROMIS Mobility −3.0.
A p value <0.05 was considered statistically significant.
DD, direct discharge; EQ-5D-5L, EuroQol-5-dimension 5-level questionnaire; LEFS, Lower Extremity Functional Scale; NA, not available; PROMIS, Patient-Reported Outcomes Measurement Information System; QoL, quality of life; QuickDASH, Shortened Version of the Disabilities of the Arm, Shoulder and Hand; UE, upper extremity; VAS, Visual Analog Scale.
- Table 5
Resource utilization
Outcome Patients, n Descriptive outcome Effect (regression DD vs. pre-DD) Pre-DD DD Pre-DD DD Difference, mean (95% CI) Significance, p value Survey at 3 months Return-to-sports (days), mean (SD) 90 80 29.2 (24.7) 26.6 (25.3) −3.49 (−10.61 to 3.97) 0.372 Return-to-work (days), mean (SD) 58 73 13.3 (21.0) 9.1 (14.8) −0.165 (−4.91 to 1.44) 0.313 Return-to-school (days), mean (SD) 59 44 2.3 (3.4) 1.9 (2.1) −0.43 (−0.17 to 0.59) 0.456 OR (95% CI) Visited general practitioner, n (%) 144 153 34 (23.6) 40 (26.1) 1.08 (0.63 to 1.85) 0.784 Visited physiotherapist, n (%) 144 153 38 (26.4) 32 (20.9) 0.70 (0.41 to 1.21) 0.197 Missed school for follow-up, n (%) 59 44 34 (57.6) 5 (11.4) 0.084 (0.028 to 0.253) <0.001 Missed work for follow-up, n (%) 58 73 26 (44.8) 6 (8.2) 0.110 (0.041 to 0.296) <0.001 EPR evaluation (range 14–26 months) Difference, mean (95% CI) Number of hospital visits, mean (SD) 348 371 1.80 (1.13) 0.14 (0.47) −1.68 (−1.81 to −1.55) <0.001 With physician 1.62 (0.94) 0.11 (0.44) −1.53 (−1.65 to −1.42) <0.001 With plaster technician 0.18 (0.51) 0.05 (0.26) −0.13 (−0.19 to −0.07) <0.001 Imaging during follow-up, mean (SD) 348 371 X-ray 0.30 (0.65) 0.05 (0.32) −0.26 (−0.33 to 0.18) <0.001 CT scan 0.0 0.01 (0.07) NP – MRI scan 0.0 0.0 NP – No-shows, n (%) 348 371 9 (2.6) 0.0 NP – Propensity score-adjusted linear regression performed to analyze continuous data with bootstrapping for non-normal distribution and binary logistic to analyze dichotomous data.
A p value <0.05 was considered statistically significant.
DD, direct discharge; EPR, electronic patient record; NP, not performed (as the number of observations was too small to perform bootstrapping (if applicable) and subsequent regression).
