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Invited Commentary
March 26, 2020

Rib Fractures, the Evidence Supporting Their Management, and Adherence to That Evidence Base

Author Affiliations
  • 1Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, University of California Davis Medical Center, Sacramento
  • 2Outcomes Research Group, Department of Surgery, University of California Davis Medical Center, Sacramento
  • 3Department of Surgery, University of California Davis Medical Center, Sacramento
JAMA Netw Open. 2020;3(3):e201591. doi:10.1001/jamanetworkopen.2020.1591

The octogenarian who fell into the side of his bathtub; the restrained driver in a motor vehicle collision at 40 mph with side impact; the retiree who slipped from her ladder while cleaning out her gutters. Invariably, it seems, an initial chest radiograph shows some fractured ribs, and the injury list in the electronic health record is populated with an S22 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code. However, from this juncture, given that trauma surgeons are wont to form strong but divergent opinions regarding management, the treatment courses vary. Is a chest computed tomographic scan necessary? Should the patient be admitted to an intensive care unit? Which form of analgesia is most appropriate? Should a thoracostomy tube be placed for a modest associated pneumothorax or hemothorax? Does noninvasive ventilation have a role? If there are multiple adjacent rib fractures, should the fractures be operatively stabilized?

In their cohort study evaluating more than 625 000 patients with rib fractures at 777 US trauma centers in the National Trauma Data Bank (NTDB) from 2007 to 2014, Tignanelli et al1 waded into the complex but fundamentally central topics of how, from an empirical perspective, trauma surgeons actually manage these patients and how aligned this care is with the available evidence from comparative effectiveness studies. They identified that among 6 so-called evidence-based practices (EBPs)—ie, neuraxial blockade, intensive care unit admission, pneumatic stabilization (ie, noninvasive ventilation to help stabilize the chest wall but to avoid the risks of endotracheal intubation), chest computed tomographic scans for elderly patients with at least 3 fractured ribs, operative fixation of what is known as flail chest, and tube thoracostomy for pneumothorax or hemothorax—3 were associated with decreased inpatient mortality (although 2 were associated with increased mortality), and adherence across all centers to all 6 EBPs was modest at best (ie, 42%) and negligible at worst (ie, 1%). Readers could easily conclude that trauma surgeons disregard available evidence of comparative effectiveness and are not optimally managing patients with chest wall injuries, possibly at significant detriment to the outcomes of those patients.

With the development and ongoing evolution of the NTDB and the American College of Surgeons Trauma Quality Improvement Program (TQIP), measurement of the quality of trauma care in the US is arguably both relatively new and well underway. A 2019 effort by the National Quality Forum, with input from a diverse assortment of stakeholders, outlined a conceptual framework to aid in identifying key gaps in the measurement of population-based trauma outcomes.2 Although the committee highlighted the need for new measures on a variety of underacknowledged aspects of trauma care (eg, injury prevention, access to care, and cost and resource use), they also recognized the ongoing need for traditional measures of quality during the acute hospitalization phase, not unlike those that Tignanelli et al1 conceived for rib fracture management.

However, before we rush headlong into measuring adherence to rib fracture EBPs, we must first ask ourselves, how certain are we that we know what optimal practice is for these injuries? Is it possible to measure such practices in a valid, reliable, feasible, and useful manner?

An appraisal of the quality of evidence cited by Tignanelli et al1 suggests that studies of far higher quality are needed to justify EBPs for rib fracture management. For example, the evidence for intensive care unit admission for elderly patients with 3 or more fractured ribs consists primarily of an expert panel recommendation3 and 1 obliquely relevant single-center observational study involving a historical control group.4 Even for topics evaluated by some randomized clinical trials, such as neuraxial blockade and operative rib fixation for flail chest, the quality of evidence on systematic review was considered very low with a high risk of bias. Except for 1 trial involving 50 patients,5 the cited evidence for pneumatic stabilization consisted of studies that were not randomized, involved only a minor fraction of participants with rib fractures, or focused on a different comparison (ie, noninvasive ventilation vs invasive ventilation as opposed to noninvasive ventilation vs no positive-pressure ventilation).

There has long been debate in the quality measurement field regarding the primacy of processes vs outcomes as the focus of measurement.6 Because they are under the direct control of clinicians, processes such as the 6 EBPs Tignanelli et al1 evaluated make for actionable measures, but what patients and clinicians care most about is the ultimate outcome of that care. As quality measures, processes are only as convincing as they are strongly associated with outcomes, and an undue focus on process can create perverse incentives and distract from the true goal of improving outcomes.

Another consideration is whether NTDB/TQIP is a suitable platform for measuring many aspects of the quality of acute care for rib fractures. The Trauma Quality Improvement Program has mainly focused on inpatient mortality and selected complications as outcomes, although it has also measured some processes (eg, transfusion ratios, time to procedural intervention for hemorrhage) based mostly on data that trauma registrars have to manually abstract. The program does not currently report any patient-reported outcomes or outcomes occurring after hospitalization, and information on processes of care is limited, all because accurate data collection is expensive. Novel efforts to extend measurement beyond the traditional TQIP outcomes could leverage nuances of the administrative data elements within the NTDB (eg, reported International Classification of Diseases, 10th Revision, Procedure Coding System codes), but the validity of these elements for specific topics (eg, radiographic or noninvasive procedures) remains highly questionable. Thus, the measurement of the quality of acute trauma care involves an uncertainty principle. It is possible to collect a relatively small number of simple outcomes from most centers or a larger variety or complexity of outcomes from a few centers, but it is not possible to collect a larger variety or complexity of outcomes from most centers.

Perhaps unintentionally, what the report by Tignanelli et al1 highlights most is the indisputable paucity of high-quality evidence regarding rib fracture management. After all, it is far easier to convene an expert panel or conduct an observational study using an existing data set than it is to conduct a high-quality randomized clinical trial. Numerous barriers impede the conduct of randomized clinical trials in acute injury care,7 and calling for more such studies has been criticized as hackneyed, but those truths do not make such studies any less relevant or necessary. Although adequately powered and rigorously designed pragmatic trials are ideal, funding from public or private sources for trials examining existing interventions, such as those involved in rib fracture management, is virtually nonexistent—except perhaps for industry funding of small trials evaluating rib fixation. Perhaps consideration should be given to encouraging and guiding junior investigators—whose greatest asset might be so-called sweat equity—to conduct smaller, simpler, and lower-cost single-center trials that could be aggregated in meta-analyses. Perhaps investigators should receive more academic recognition for enrolling and collecting data from a few patients who contribute to a multicenter randomized clinical trial than they do for authoring an observational study with obvious design flaws and risk of bias. Even if the effort requires unconventional approaches, our patients would stand to benefit if we were to dedicate more resources to, and truly align academic incentives with, producing the highest-quality evidence.

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Article Information

Published: March 26, 2020. doi:10.1001/jamanetworkopen.2020.1591

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Utter GH et al. JAMA Network Open.

Corresponding Author: Garth H. Utter, MD, MSc, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5027, North Addition Office Building, Sacramento, CA 95817 (ghutter@ucdavis.edu).

Conflict of Interest Disclosures: Dr Utter reported receiving contract funding from the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services and serving on the Trauma Outcomes Committee of the National Quality Forum outside the submitted work. No other disclosures were reported.

Tignanelli  CJ, Rix  A, Napolitano  LM, Hemmila  MR, Ma  S, Kummerfeld  E.  Association between adherence to evidence-based practices for treatment of patients with traumatic rib fractures and mortality rates among US trauma centers.  JAMA Netw Open. 2020;3(3):e201316. doi:10.1001/jamanetworkopen.2020.1316Google Scholar
National Quality Forum. Trauma outcomes final report. Published May 2019. Accessed February 14, 2020. https://www.qualityforum.org/Publications/2019/05/Trauma_Outcomes_Final_Report.aspx
Brasel  KJ, Moore  EE, Albrecht  RA,  et al.  Western Trauma Association critical decisions in trauma: management of rib fractures.  J Trauma Acute Care Surg. 2017;82(1):200-203. doi:10.1097/TA.0000000000001301PubMedGoogle ScholarCrossref
Todd  SR, McNally  MM, Holcomb  JB,  et al.  A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients.  Am J Surg. 2006;192(6):806-811. doi:10.1016/j.amjsurg.2006.08.048PubMedGoogle ScholarCrossref
Hernandez  G, Fernandez  R, Lopez-Reina  P,  et al.  Noninvasive ventilation reduces intubation in chest trauma-related hypoxemia: a randomized clinical trial.  Chest. 2010;137(1):74-80. doi:10.1378/chest.09-1114PubMedGoogle ScholarCrossref
Mant  J.  Process versus outcome indicators in the assessment of quality of health care.  Int J Qual Health Care. 2001;13(6):475-480. doi:10.1093/intqhc/13.6.475PubMedGoogle ScholarCrossref
Miskimins  R, Pati  S, Schreiber  M.  Barriers to clinical research in trauma.  Transfusion. 2019;59(S1):846-853. doi:10.1111/trf.15097PubMedGoogle ScholarCrossref
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