Pharmaceutical demand response to utilization management.

Prescription drug insurance increasingly imposes prior authorization (requiring providers to request coverage before claim approval) to manage utilization. Prior authorization has been criticized because of its administrative burden on providers. The primary alternative to managing utilization is imposing out-of-pocket (OOP) payment to incentivize beneficiaries to seek lower-cost care, effectively providing beneficiaries with partial insurance. Would beneficiaries prefer indirectly paying for prior authorization through higher premiums; or would they prefer prior authorization was replaced by higher OOP costs? This tradeoff depends on how much OOP costs could be displaced by prior authorization, which depends on their relative impact on demand. I estimate the effect of prior authorization and OOP costs on pharmaceutical demand in Medicare Part D, addressing endogeneity caused by unobserved drug quality and selection into plans. Despite criticism of prior authorization, I find that Medicare beneficiaries would prefer higher premiums to pay for prior authorization, over higher OOP costs.

[MALLET FINGER - DIAGNOSIS, CLASSIFICATION AND TREATMENT].

INTRODUCTION: Mallet finger is a common injury involving the extensor mechanism of the finger. It presents as an inability to extend the distal phalanx of the digit. In the right clinical setting, a thorough examination should be performed and supplemented by adequate radiographs. The mechanism of injury is usually a direct blow to an extended finger causing hyperflexion or hyperextension of the distal phalanx. Common occurrences are in young adults during sporting activities or in minor falls or trauma in osteoporotic individuals. Treatment includes use of a splint which maintains the distal phalanx in extension allowing for tendon healing or surgical intervention when indicated. In the vast majority of cases, prompt diagnosis and avid conservative treatment will result in a good outcome. Neglecting or missing this seemingly minor injury may result in a formidable functional handicap.

[Dupuytren's disease].

Dupuytren's disease is a fibromatosis affecting the hand. The disease affects the hand and fingers and may present with a contracture causing increasing disability of the hand. We can treat the symptoms but not its cause. In this article we review the background, diagnosis and methods of treatment of the disease. Although the mainstay of treatment accepted by most is surgical, use of collagenase injections aimed at chemically disintegrating pathologic cords may emerge as an important addition to the armamentarium of treatments for Dupuytren's disease.

Current practice in acute flexor tendon repair in Israel.

BACKGROUND: Various methods of core suture and suture material are used successfully in acute flexor tendon repair. OBJECTIVES: To assess the current practice in acute flexor tendon repair among Israeli hand surgeons. METHODS: A five-question survey was conducted among certified hand surgeons in Israel regarding their preferred materials and method for performing acute flexor tendon repair. RESULTS: Forty-eight hand surgeons participated in the survey. The most widely used core suture in zone 2 (58.3%), as well as in zones 3 and 4 (62.5%), was the modified Kessler type. The most widely used suture material was nylon. All surgeons incorporated epitendinous sutures to augment their core sutures. CONCLUSIONS: The modified Kessler core suture technique is the most widely used technique among Israeli hand surgeons for repairing acute flexor tendon lacerations in zones 2, 3 and 4. This finding agrees with worldwide data and with emerging data attesting to the lower risk of adhesion formation and postoperative tendon ruptures with this method. The core suture technique initially popularized by the late Prof. Isidor Kessler, who headed our department during the years 1973-92, remains the most practiced acute flexor tendon repair technique among hand surgeons in Israel.

[Ganglion cysts of the hand and wrist].

Ganglion cysts are considered the most common tumor of the wrist and hand. They are most common between the second and fourth decades of life. The most common anatomical location is the dorsal wrist. This article includes a general review of these cysts including symptoms, pathology and methods of diagnosis, as well as a review of these cysts in specific anatomic locations. The article also includes an updated review of the literature comparing open surgery vs. arthroscopic treatment. The authors believe that arthroscopic surgery of ganglion cysts will gain an important role in the treatment of these cysts.

Laser treatment of venous malformations.

Venous malformations (VM) are developmental errors comprised of enlarged dysplastic blood vessels. Clinically they manifest as either a faint blue patch or a soft blue vascular mass. Treatment options include a sclerosing agent (such as alcohol or ethiblock), surgery or laser therapy. A review of the literature concerning VM and laser treatment yielded a few sporadic reports describing series of 3 to 46 cases. In this retrospective study we reviewed the files of the relevant cases. The data included the extent of the lesion, the different anatomical sites, age of patient and the extent of clearance of the lesion as the treatment's end point. This study includes 56 cases which makes it the largest series presented. The success rate of laser treatment was 92.8%. The immediate complication rate was very low (approximately 3.57%) including minimal scarring and deformity. No long term complications were noted. Our study concludes that treatment of VM is a difficult task due to the nature of the lesions. Laser treatment of these lesions enables one to obtain good results with a very low incidence of complications. Surgery and other treatment modalities are not always satisfactory, yield similar or less efficient results and have a higher complication rate. Laser treatment can play an important role in the treatment of VM and in fact may be the treatment of choice in some settings.

Treatment of deep sternal wound infections post-open heart surgery by application of activated macrophage suspension.

Postoperative sternal wound infection remains a significant complication and generally causes considerable morbidity and mortality. Macrophages play a major role in the process of wound healing. In order to evaluate the efficacy of local injection of activated macrophage suspensions into open infected sternal wound space, a retrospective case-control study was conducted. Sixty-six patients with deep sternal wound infection treated by activated macrophages (group 1) and 64 patients with deep sternal wound infection treated by sternal reconstruction surgery with various regional flaps (group 2), were matched for gender, age, and risk index. In up to 54 months of follow-up of group 1, 60 patients (91%) achieved complete wound closure. Two (3%) late deaths occurred unrelated to the procedure. Mortality rate in group 2 was 29.7% (19/64). Duration of hospitalization was 22.6 days in group 1 vs. 56.2 days in group 2. Patients with deep sternal wound infection following open heart surgery that were treated by activated macrophages had significantly less mortality as well as significant reduction of hospitalization in comparison to the surgically treated group. These results illustrate the advantages of using a biologically based activated macrophage treatment.