The popularity of outcome measures used in shoulder arthroplasty literature.

INTRODUCTION: Patient-reported outcomes (PROs) are frequently utilized within orthopaedics to determine the extent of patient disease and the efficacy of surgical treatments. Shoulder arthroplasty is a common treatment option for a range of pathologies; however, substantial variety exists regarding the instruments used within the published literature, limiting their quality and generalizability. The purpose of the present systematic review is to evaluate the overall number and frequency of outcome measures used in all clinical studies evaluating outcomes following shoulder arthroplasty. METHODS: This systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that assessed patient reported outcomes following total shoulder arthroplasty, reverse shoulder arthroplasty, and shoulder hemiarthroplasty were obtained from PubMed, MEDLINE, and EMBASE databases. For each manuscript, the journal, authors, region of origin, level of evidence, and subject/pathology were recorded. The frequency of each reported outcome measure and category. Associations between study characteristics and measure categories were tested using Poisson regression with robust error variance. RESULTS: A total of 682 articles were included in the analysis, reporting 42 different PROs. The most popular tools were the Constant-Murley score (49.7%), the American Shoulder and Elbow Surgeons Evaluation Form (37.7%), and the Visual Analog Scale (34.3%). A generic outcome tool was used in 287 studies (42.1%), while 645 (94.6%) utilized a shoulder-specific measure and 49 (7.2%) used a disease-specific measure. The use of generic (p<0.001) and disease specific (p<0.001) measures were associated with higher level of evidence. CONCLUSION: Studies assessing patient outcomes following shoulder arthroplasty employ a large range of PRO measuring tools, many of which are non-validated. Furthermore, only a small percentage of studies utilize a combination of tools from different categories despite current recommendations. Consensus on validated and clinically-meaningful tools from multiple categories is necessary to increase the generalizability and applicability of published studies in shoulder arthroplasty literature. LEVEL OF EVIDENCE: 1.

The Affordable Care Act: Long-Term Financial Impact on a Level I Trauma Center.

BACKGROUND: Prior studies of the impact of the Affordable Care Act on reimbursement for inpatient trauma care do not include disproportionate share hospital (DSH) funding. Because trauma centers and other safety-net hospitals are sensitive to any changes in financial support, it is essential to include DSH funding in evaluating overall reimbursement. This study analyzes the long-term financial trends, including DSH, of a level I trauma center in Ohio, a state that expanded Medicaid. METHODS: Charges, reimbursement, sources of insurance coverage, Injury Severity Scores, and DSH funding for the trauma patient population of an Ohio American College of Surgeons level 1 trauma center were studied from 2012 to 2017. Data were collected from Transition Systems, Inc. RESULTS: During 2012-2017, self-pay patient cases decreased from 15.0% to 4.1% and commercial insurance patients decreased from 34.2% to 27.6%. The percentage of Medicaid patients increased from 15.5% to 27.1%; however, Medicaid reimbursement average per case declined from $17,779 in 2012 to $10,115 in 2017 (a decline of 43.1%). Self-pay charges decreased from $22.0 million to $6.7 million. Total DSH funding, compensation given to hospitals that disproportionately treat underserved populations, decreased 17.4%. CONCLUSIONS: Self-pay charges and self-pay patients decreased dramatically; Medicaid patients and charges increased substantially in the years after the implementation of the Affordable Care Act at our trauma center. However, there was a decrease in commercial insurance, which had the highest reimbursement for our hospital, and a significant decline in DSH, a critical supplemental source of funding for safety-net hospitals.

Initial impact of the Affordable Care Act on an Ohio Level I trauma center.

BACKGROUND: Hospital financial pressures and inadequate reimbursement contribute to the closure of trauma centers. Uninsured patients contribute significantly to the burden of trauma center costs. The Affordable Care Act implemented changes in 2014 to provide health care coverage for all Americans. This study analyzes the impact of the recent health care changes on an Ohio Level I trauma center financials. METHODS: We conducted an analysis of trauma charges, reimbursement, and supplemental payments at an Ohio Level I trauma center. A 3-year trauma patient cohort (2012-2014) was selected and grouped by reimbursement source (Medicare, Medicaid, other government, commercial, and self-pay/charity). A total of 9,655 patients were reviewed. Data were collected with the Transition Systems Inc. accounting system and analyzed with IBM SPSS Statistics 22.0. RESULTS: For trauma cases, the percentage of self-pay/charity patients decreased during the 2012 to 2014 period (15.1%, 15%, to 6.4%, respectively), while the percentage of Medicaid decreased from 2012 to 2013 followed by a large increase in 2014 (15.4%, 13.9%, to 24.3%, respectively). The percentage of commercially insured patients decreased slightly from 2012 to 2014 (34.2%, 32.3%, to 30.7%, respectively). Uninsured charges decreased notably (approximately $22.5 million and $21 million for 2012-2013 to approximately $8.6 million in 2014). Medicaid charges decreased from 2012 to 2013, followed by a rebound in 2014 ($50.7 million in 2012 to $37.3 million in 2013 to $54.3 million in 2014). The percentage of total charges for self-pay/charity decreased (9.5%, 10.1%, to 4.1%). The percentage of total charges for Medicaid increased (21.4%, 18.0%, to 25.9%). Mean Medicaid reimbursement per patient decreased ($19,000, $14,000, to $13,000). Mean reimbursement per uninsured patient did not vary significantly among years. Total hospital supplemental payments (trauma and nontrauma combined) decreased ($47.6 million, $49 million, to $39.2 million). CONCLUSION: In the first year following the changes implemented by the Affordable Care Act, our hospital saw self-pay/charity charges decrease, Medicaid charges increase, and total hospital supplemental payments decrease. In addition, there was a small, yet noteworthy, downward trend in the number of commercially insured patients. Although more data collection and analysis are needed, this initial financial evaluation of a Level I trauma center following the Affordable Care Act provides insight into insurance trends.