“Throwing the Flag”: Patient Behavior Reporting Affects Outcomes Following Orthopedic Trauma Surgery

Objectives: To evaluate the association between electronic health record (EHR)–based behavioral flag designation and postoperative outcomes in orthopedic trauma patients undergoing surgical fixation for acute fractures. Design: Retrospective cohort study with 1:1 propensity score matching. Setting: Level I trauma center Patients Selection Criteria: Adult orthopedic trauma patients who underwent operative fixation for an acute fracture and received a long-term behavioral flag issued for documented disruptive, threatening, or violent behavior toward healthcare staff following institutional review either before surgery or within 1 year postoperatively were included. Those with pathologic fractures and those with inadequate follow-up were excluded. Each flagged patient was matched to an unflagged control based on age, sex, BMI, smoking status, comorbidity burden, and fracture type. Outcome Measures and Comparisons: Primary outcomes included 1-year rates of major postoperative complications (e.g., fracture-related infection, nonunion, painful hardware) and reoperation. Subgroup analyses examined outcomes by timing of flag assignment. Results: A total of 116 patients were included (58 flagged patients, 58 unflagged). Flagged patients had a mean age of 53.4 ± 18.1 years (range, 19–74) and were 55.2% male; unflagged controls had a mean age of 49.0 ± 13.6 years (range, 21–71) and were 55.2% male. Adequate covariate balance was achieved after 1:1 propensity score matching. Median follow-up was 12 months (range, 6 months to 9 years). Major postoperative complications occurred in 10 flagged patients (17.2%) and 2 controls (3.4%). Reoperations occurred in 9 flagged patients (15.5%) and 2 controls (3.4%). Compared with controls, patients with a behavioral flag assigned either before surgery or within 1 year postoperatively had higher odds of major complications (OR 5.57; 95% CI 1.99–18.30; p=0.002) and reoperation (OR 4.06; 95% CI 1.31–15.40; p=0.022). Among flagged patients, those with a preoperative behavioral flag had the highest odds of major complications (OR 14.74; 95% CI 2.52–282.0; p=0.014). Conclusions: EHR behavioral flag designation was associated with higher odds of major postoperative complications and reoperation after operative fixation of acute fractures. Preoperative behavioral flags demonstrated the strongest association with adverse outcomes. Behavioral flag status may serve as a useful marker of elevated perioperative risk in orthopedic trauma patients. Level of Evidence: Level III, Therapeutic