Time to Diagnosis of Autism Spectrum Disorders in Children with Coexisting Developmental Behavioral Disorders.

OBJECTIVE: Our study evaluates whether having an alternate developmental behavioral disorder (DBDs) diagnosis before diagnosis of autism spectrum disorders (ASD) is associated with delays in diagnosis in a nationally representative sample. METHODS: Data were obtained from the 2011 National Survey of Pathways to Diagnosis and Services, a survey of children aged 6 to 17 years with ASD, developmental delay, or intellectual disability. A total of 1049 children met inclusion criteria for this study. Of these, 799 children were identified as "late" diagnosis if >12 months elapsed between the age parents reported concerns to a provider and age of ASD diagnosis and 250 as "timely" diagnosis if the gap was ≤12 months. Univariate and multivariate logistic regressions were used to look for association between having an alternate DBDs diagnosed before ASD and "timely" versus "late" ASD diagnosis. RESULTS: The mean time elapsed between the age parents reported concerns to a provider and age of ASD diagnosis was 51 months for children with an alternate DBDs diagnosis before receiving ASD diagnosis and 29 months for those diagnosed with alternate DBDs concurrently with ASD. Having alternate DBDs diagnosis before diagnosis with ASD was associated with "late" ASD diagnosis as follows: developmental delay (adjusted odds ratio [aOR,] 3.46; 95% confidence interval [CI], 1.86-6.42; p < 0.001), intellectual disability (aOR, 9.75; 95% CI, 3.0-31.60; p = 0.04), attention-deficit disorder (aOR, 11.07; 95% CI, 3.43-35.71; p < 0.001), depression (aOR, 8.05; 95% CI, 1.07-60.03; p = 0.0495), and behavioral conduct disorder (aOR, 9.9; 95% CI, 3.55-27.62; p < 0.001). CONCLUSION: These findings highlight the importance of research to improve the early diagnosis of ASD even in the presence of coexisting developmental behavioral disorders.

Healthy-Weight Kindergarten Children with Autism Spectrum Disorder May Become Overweight and Obese during the First Few Years of Elementary School.

Analysis of a population-based, nationally-representative longitudinal sample from the Early Childhood Longitudinal Study, Kindergarten Class of 2010-11 identified an increase in healthy-weight children with autism spectrum disorder becoming overweight and obese between first and second grade, thus identifying a critical period for early prevention and treatment.

Factors Associated with Resilience in Families of Children with Autism Spectrum Disorder.

OBJECTIVES: Families of children with autism spectrum disorder (ASD) report high levels of stress and poor psychological functioning. Resilience serves to buffer these challenges. Little is known about the factors associated with resilience in these families. METHODS: Data from the National Survey of Children's Health (NSCH) 2016 were used to investigate independent child, parent, and health care factors associated with resilience in families of children with ASD. We used the NSCH's family resilience composite derived from 4 survey questions focused on (1) communication, (2) working together to solve problems, (3) drawing on strengths, and (4) staying hopeful during difficult times. We defined family resilience as high or low based on the number of questions answered "all of the time" or "most of the time" versus "some of the time" or "none," respectively. Using survey weights, univariate and multivariate logistic regression analyses identified associations of child, parent, and health care factors with low family resilience. RESULTS: We analyzed data representing 1151 children with ASD. Low resilience was reported in 32% of families. Low family resilience was significantly associated with parent factors such as not having someone to turn to for support, cutting work hours, and feeling "child hard to care for"; child ASD-related factors such as moderate ASD severity; and health care factors such as lack of satisfaction in communications with providers. CONCLUSION: The findings highlight specific vulnerabilities in families of children with ASD that are associated with low family resilience. Intervention approaches that have the ability to improve overall family resilience should be carefully considered.

An Evaluation of Risk Factors for Patient "No Shows" at an Urban Joint Arthroplasty Clinic.

BACKGROUND: Patient physical health and provider financial health are both affected when patients are unable to attend scheduled clinic appointments. The purpose of this study is to identify risk factors for patients missing appointments to better target interventions to improve appointment attendance. METHODS: We reviewed scheduled arthroplasty appointments at an urban academic orthopaedic clinic over a 3-year period. We collected information including sex, race, distance to clinic, language, insurance, median income of home zip code, appointment day, time, precipitation, and temperature. Mixed-level multiple logistic regression was used to model the odds of missing appointments in Stata v14. RESULTS: Overall, 8,185 visits for 3,081 unique patients were reviewed and 90.7% of appointments were attended. After controlling for time and day of appointment, distance from the clinic, and the primary language spoken, patients with government insurance were two times as likely to miss an appointment compared with privately insured patients. White patients were two times as likely to attend scheduled appointments compared with black/Hispanic patients. Younger patients (<50 years) and older patients (>73 years) were 2.7 times and 1.8 times, respectively, more likely to miss appointments compared with those aged between 65 and 72 years. Appointments on the most temperate days were more likely to be missed, and those on the coldest days (14°F to 36°F) and warmest days (69°F to 89°F) were less likely to be missed. DISCUSSION: Appointment no shows are associated with sociodemographic and environmental factors. This information is valuable to help better delineate novel ways to better serve these patient populations.

Hospital Stays and Medical Expenses Increase Nationwide Among Patients With Septic Arthritis of the Shoulder Who Inject Drugs.

The authors determined the proportion of patients nationwide with septic arthritis of the shoulder who inject drugs, evaluated differences in hospitalization outcomes and charges between patients with and without injection drug use (IDU), and quantified demographic trends among patients with IDU from 2000 to 2013. Nationally representative data of patients with a principal discharge diagnosis of shoulder septic arthritis were obtained from the Nationwide Inpatient Sample 2000-2013. Using published algorithms, the authors classified septic arthritis of the shoulder as related or unrelated to IDU. They compared length of stay, leaving against medical advice, number of procedures, and mortality rates between the 2 groups, using regression models to control for age, sex, and race. Fifteen percent (95% confidence interval [CI], 13.6%-16.5%) of septic arthritis cases were associated with IDU. From 2000 to 2013, shoulder septic arthritis associated with IDU increased 4-fold. After controlling for age, sex, and race, individuals who inject drugs stayed in the hospital for 3.7 more days (95% CI, 2.4-5.0), incurred an average of $13,250 more charges for medical care (95% CI, $2635-$23,866), and were 5.54 times more likely (95% CI, 3.22-9.55) to leave against medical advice than those without IDU. From 2000 to 2013, there was an increase in the proportion of patients with IDU-related septic arthritis of the shoulder between 35 and 54 years old and 55 and 64 years old, and an increase in the proportion who were white. Injection drug use-related shoulder septic arthritis is linked to suboptimal inpatient outcomes and greater resource use. [Orthopedics. 2020;43(4):e270-e277.].

Factors Determining Home Versus Rehabilitation Discharge Following Primary Total Joint Arthroplasty for Patients Who Live Alone.

Patients who are discharged home following primary hip and knee arthroplasty have lower associated costs and better outcomes than patients who are discharged to skilled nursing facilities (SNFs). However, patients who live alone are more likely to be discharged to an SNF. We studied the factors that determine the discharge destination for patients who live alone after total joint arthroplasty (TJA) at an urban tertiary care academic hospital between April 2016 and April 2017. We identified 127 patients who lived alone: 79 (62.2%) were sent home, and 48 (37.8%) were sent to an SNF after surgery. Patients who went home versus to an SNF differed in age, employment status, exercise/active status, patient expectation of discharge to an SNF, ASA score, and the length of stay. After controlling for expectations of discharge to an SNF (OR: 28.98), patients who were younger (OR: 0.03) and employed (OR: 6.91) were more likely to be discharged home. In conclusion, the expectation of discharge location was the strongest predictor of discharge to an SNF even after controlling for age and employment. Future research should include a multi-hospital approach to strengthen the validity of our findings and investigate additional factors that impact discharge destination.

Injection Drug Use in Patients With Spinal Epidural Abscess: Nationwide Data, 2000 to 2013.

STUDY DESIGN: Retrospective review of the Healthcare Cost and Utilization Project National Inpatient Sample, 2000 to 2013. OBJECTIVE: To determine the proportion of spinal epidural abscess (SEA) cases that were related to injection drug use (IDU) and to compare length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between SEA cases with and without IDU. SUMMARY OF BACKGROUND DATA: The US opioid epidemic impacts all aspects of healthcare, including spinal surgeons. Although injection drug use (IDU) is a risk factor for spinal epidural abscess (SEA), IDU among SEA patients and its effect on clinical outcomes is not well understood. METHODS: Cases aged 15 to 64 with principal diagnosis of SEA were classified as IDU-related (IDU-SEA) or non-IDU-related (non-IDU-SEA) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for illicit drug use and hepatitis C. We determined the proportion of SEA patients with IDU and compared length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between IDU-SEA and non-IDU-SEA patients. RESULTS: From 2000 to 2013, there were 20,425 admissions with a principal diagnosis of SEA (95% confidence interval (CI), 19,281-21,568); 19.1% were associated with IDU (95% CI, 17.7%-20.5%). The proportion of white IDU-SEA cases increased by 2.4 percentage points annually (95% CI, 1.4-3.4). After adjusting for age, sex, and race, IDU-SEA patients stayed a mean of 6.7 more days in the hospital (95% CI, 5.1-8.2) and were 4.8 times more likely to leave against medical advice (95% CI, 2.9-8.0). Mean hospital charges for IDU-SEA patients were $31,603 higher (95% CI: $20,721-$42,485). Patients with IDU-SEA were less likely to have cauda equina syndrome (adjusted odds ratio, 0.48, 95% CI, 0.26-0.87). CONCLUSION: IDU-SEA patients stay in the hospital longer and more often leave against medical advice. Providers and hospitals may benefit from exploring how to better facilitate completion of inpatient treatment and achieve superior outcomes. LEVEL OF EVIDENCE: 3.

Comparing Reported Complication Rates in Shoulder Arthroplasty Between 2 Large Databases.

Large databases are commonly used to analyze surgical outcomes. Recent studies have suggested that there are differences in complication rates between databases across certain procedures, but the reasons for these differences are not fully understood. The goal of this study was to compare complications of shoulder arthroplasty across databases as well as to interpret the causes of any differences. The authors compared complication rates for shoulder arthroplasty as reported by the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2006 to 2010. The authors then restricted NIS data solely to hospitals that also contributed to NSQIP to provide a more direct comparison of the patient populations. The authors identified 48,287 discharges reported in NIS and 1679 discharges reported in NSQIP for patients who underwent shoulder arthroplasty. The complication rate for shoulder arthroplasty was significantly higher in the NIS population (12.6%; 95% confidence interval, 12.0%-13.2%) than in the NSQIP population (5.60%; 95% confidence interval, 4.59%-6.81%). When NIS data were restricted solely to hospitals that also participated in NSQIP, the rate of complications remained higher, at 13.4% (95% confidence interval, 11.2%-15.8%), and the rate increased relative to the nonrestricted data. The databases compared in this study had statistically significant differences in reported complication rates for shoulder arthroplasty. This difference persisted when NIS data were restricted to hospitals that also participated in NSQIP, suggesting that differences in database design contribute to important differences in data. Orthopedic surgeons and administrators must use caution when using complication rates derived from large database studies. [Orthopedics. 2020;43(2):113-118.].

Risk Factors for Tibial Component Oversizing in Total Knee Arthroplasty among African Americans.

Incidences and risk factors for tibial component oversizing in total knee arthroplasty (TKA) have been well described, predominantly in Caucasian samples. Component oversizing has been linked to variations in proximal tibial shape and morphology, which has been found to be objectively different in African Americans compared with Caucasians. These anthropometric differences may affect the conformity of modern TKA systems to the anatomy of African Americans undergoing TKA. We sought to investigate the incidence and risk factors for tibial baseplate oversizing in an exclusively African American population undergoing TKA with a symmetric tibial baseplate. We reviewed the records of self-reported African American patients who had undergone a primary TKA at a single academic institution between 2005 and 2016. The primary outcome was incidence of tibial baseplate oversizing in the coronal and sagittal planes as determined by a single set of appropriately rotated postoperative orthogonal radiographs. Logistic regression models identified trends in oversizing within the population based on age, sex, body mass index (BMI), and TKA model. Among all 525 knees being evaluated, the occurrences of medial and lateral overhang were 14.2 and 15.2%, respectively. Increase in age was associated with lower risk of medial tibial overhang (odds ratio = 0.97 for each 1-year increase in age). Simple linear regression models described a linear relationship between BMI and overhang, with every one-unit increase in BMI, medial tibial overhang is 0.031 mm higher and posterior tibial overhang is 0.062 mm higher. Mediolateral oversizing was approximately twice more likely in females than males. Among TKA models used, the Stryker Triathlon had the least risk for mediolateral oversizing and the P.F.C. SIGMA demonstrated the least propensity for anteroposterior oversizing. To conclude, incidence of mediolateral tibial oversizing in this population was common. Previously identified variables affecting proximal tibial morphology, including age, body morphotype, and gender, may be equally applicable to the conformity of tibial baseplates in this population. Surgeons must pay particular attention to avoid mediolateral tibial oversizing in this population, especially in obese and older patients.

Older age and larger cyst size in children with spontaneous rupture of periorbital dermoid cysts.

We analyzed clinical and histopathologic data of 97 pediatric patients who underwent excision of dermoid cysts. On review, 16.5% of the sample population demonstrated localized chronic inflammatory changes, including the presence of giant cells and epithelial disruption. These features were considered indicative of prior cyst rupture. Age at time of initial presentation was significantly older and cyst size was significantly larger in patients with histopathologic signs of previous rupture. Longer time to presentation and time to excision were associated with increased odds of spontaneous rupture.

Prospective Observational Study Comparing Sepsis-2 and Sepsis-3 Definitions in Predicting Mortality in Critically Ill Patients.

BACKGROUND: Sepsis definitions have evolved, but there is a lack of consensus over adoption of the most recent definition, Sepsis-3. We sought to compare Sepsis-2 and Sepsis-3 in the classification of patients with sepsis and mortality risk at 30 days. METHODS: We used the following definitions: Sepsis-2 (≥2 systemic inflammatory response syndrome criteria + infection), Sepsis-3 (prescreening by quick Sequential Organ Failure Assessment [qSOFA] of ≥2 of 3 criteria followed by the complete score change ≥2 + infection), and an amended Sepsis-3 definition, iqSOFA (qSOFA ≥2 + infection). We used χ 2 or Wilcoxon rank-sum tests, receiver-operator characteristic curves, and survival analysis. RESULTS: We enrolled 176 patients (95% in an intensive care unit, 38.6% female, median age 61.4 years). Of 105 patients classified by Sepsis-2 as having sepsis, 80 had sepsis per Sepsis-3 or iqSOFA (kappa = 0.72; 95% confidence interval [CI], 0.62-0.82). Twenty-five (14.8%) died (20 of 100 with sepsis per Sepsis-2 [20%], and 20 of 77 [26.0%] with sepsis per Sepsis-3 or iqSOFA). Results for Sepsis-3 and iqSOFA were identical. The area under the curve of receiver-operator characteristic (ROC) curves for identifying those who died were 0.54 (95% CI, 0.41-0.68) for Sepsis-2, 0.84 (95% CI, 0.74-0.93) for Sepsis-3, and 0.69 (95% CI, 0.60-0.79) for iqSOFA (P < .01). Hazard ratios for death associated with sepsis were greatest for sepsis or septic shock per Sepsis-3. CONCLUSIONS: Sepsis-3 and iqSOFA were better at predicting death than Sepsis-2. Using the SOFA score might add little advantage compared with the simpler iqSOFA score.

Chronic Prescription Opioid Use Before and After Total Hip and Knee Arthroplasty in Patients Younger Than 65 Years.

BACKGROUND: Opioids are commonly prescribed to patients with painful and symptomatic degenerative joint disease preoperatively as a nonoperative intervention to reduce patients' symptoms and pain. The goal of total joint arthroplasty (TJA) is to reduce or eliminate the painful symptoms of degenerative joint disease. Due to the addictive property of opioid medications, some patients may develop a pattern of chronic opioid use after TJA. METHODS: We used MarketScan Commercial Claims and Encounters database to identify 125,019 patients (age <65 years) who underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA) between 2009 and 2012. During the study period, opioid use was analyzed 3 months before surgery and at 12 months after surgery. We defined chronic opioid use as having 2 or more opioid prescriptions filled within any 6-week period. Multivariate logistic regression was used. RESULTS: Of the 24,127 patients who were chronic prescription opioid users before surgery, 72% were no longer chronic users 1 year after surgery. Of the 100,892 patients who were nonusers before surgery, 4% became chronic users within 1 year after surgery. TKA and hospital stay longer than 3 days were significant risk factors of persisting chronic opioid use after surgery, while age played a mixed role in predicting change of opioid use. CONCLUSION: Using our definition of chronic use, overall chronic opioid use decreased from 19% to 9% after TJA. Patients were more likely to cease chronic opioid use after TJA (72%) than to become chronic users (4%).

Parental concern regarding obesity in children with autism spectrum disorder in the United States: National Survey of Children's Health 2016.

BACKGROUND: The prevalence of obesity in children with autism spectrum disorder (ASD) exceeds that of the general population, but the level of parental concern about obesity in these children is unexplored. OBJECTIVE: We estimate the prevalence of obesity in children 10-17 years in the redesigned National Survey of Children's Health (NSCH) 2016, and compare parental concern about obesity between parents of children with and without ASD. METHODS: The nationally representative NSCH 2016 oversampled parents of children with parent-report of special health care needs, including ASD. Parents opted to complete the survey via the web or surface mail. Following report of their child's height and weight, parents were asked "Are you concerned about their weight?" Response options included: "Yes, it's too high," "Yes, it's too low," or "No, I am not concerned." Obesity (>95th percentile BMI) was defined using the 2000 CDC growth reference. We used logistic regression to compare odds of obesity, and odds of parental concern, between children with and without ASD. RESULTS: In 24,251 children, ASD (n = 699) increased obesity risk after adjusting for age, sex, and race/ethnicity (OR = 1.54, 95%CI: 1.11, 2.14). ASD medication did not significantly affect obesity. ASD increased obesity concern (OR = 2.17, 95%CI: 1.53, 4.81) among parents with obese children. Parents of boys with obesity and ASD had less obesity concern if he was taking medication for ASD (OR = 0.258, 95%CI: 0.09, 0.78). CONCLUSION: While the prevalence of obesity is elevated in children with ASD, parental obesity concern is high, suggesting opportunities for the development of parent-focused obesity prevention and treatment interventions for this population.

Three Different Databases, Three Different Complication Rates for Knee and Hip Arthroplasty: Comparing the National Inpatient Sample, National Hospital Discharge Survey, and National Surgical Quality Improvement Program, 2006 to 2010.

BACKGROUND: National databases are increasingly used to research complication rates, risk factors, and the role of comorbidities. Three commonly used databases are the Healthcare Cost and Utilization Program's National Inpatient Sample (NIS), the National Hospital Discharge Survey (NHDS), and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Despite many publications, the accuracy of results from these databases remains unclear. METHODS: We compared demographics and complication rates of primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA) across three national databases from 2006 to 2010. Using International Classification of Diseases, Ninth Revision, Clinical Modification and Current Procedural Terminology codes to identify cases, we calculated postoperative inpatient complication rates in all three databases and 30-day complication rates in the NSQIP. RESULTS: We identified a total of 607,322 TKAs and 279,428 THAs. Overall complication rates varied greatly between the databases. For TKA, the overall complication rates were the highest in the NIS (17.3% [16.6 to 18.0]), followed by the NHDS (14.9% [14.0 to 15.8]), and then the NSQIP 30 days (10.20% [9.73 to 10.70]) and the NSQIP until discharge (7.34% [6.95 to 7.75]). Similarly, for THA, the NIS was the highest (24.09% [23.05 to 25.16]), and then the NHDS (21.5% [19.8 to 23.2]), followed by the NSQIP 30 days (12.00% [11.31 to 12.72]), and the NSQIP until discharge (9.25% [8.64 to 9.90]). Breakdown and comparison of individual adverse events further revealed different complication rates. CONCLUSION: The estimated complication rates from THA and TKA depend on which data source is used because of differences in data collection and sampling methodology. Similar differences may exist in other publications that use such secondary data sources.

An Evidence Map of Research Linking Dietary Sugars to Potentially Related Health Outcomes.

BACKGROUND: Evidence mapping is an emerging tool used to systematically identify, organize, and summarize the quantity, distribution, and characteristics of published studies with the goal of identifying knowledge gaps and future research needs. OBJECTIVE: The aim of the study was to present an evidence-map database of all published studies that investigated dietary sugars and to select health outcomes for explicating research trends and gaps. METHODS: To update an evidence-map database previously published in 2013, we performed a literature search in MEDLINE to identify English-language, peer-reviewed human intervention and prospective cohort studies published from January 2013 to December 2016. Abstracts and full-text articles were dual screened on the basis of predefined eligibility criteria. We classified outcomes into 7 health outcome categories that are potentially affected by dietary sugar. Data from the updated evidence-map database were merged with those from the previous database for analysis and charting. RESULTS: There were 918 sugar and control intervention arms from a total of 298 intervention studies from 1966 to December 2016. A variety of sugar interventions were investigated across the included intervention studies, and it appears that the research interest across all outcome categories (cardiovascular disease risks, diabetes risks, body weight, body composition, appetite, dietary intake, and liver health-related outcomes) sharply increased from 2006. Bubble plots showed research gaps in long-term intervention studies and in intervention studies in patients with diabetes. In contrast, all 25 included cohort studies had long-term follow-up durations and much larger sample sizes than did intervention studies. None of the cohort studies evaluated dietary intake outcomes, and only one cohort study each examined appetite- and liver health-related outcomes. CONCLUSIONS: The research trends and research gaps have not changed since 2013 when the original evidence-map database was updated. With continuous updating, evidence mapping can facilitate the process of knowledge translation and possibly reduce research waste.

Off the Market: The Percentage of Products Available After Ten Years.

BACKGROUND: We observed that medical devices advertised in journals are often no longer available 5 to 10 years after first being advertised. In this study, we quantified the percentage of products advertised from 2003 to 2008 in the Journal of Bone and Joint Surgery, American, which were still available 5 to 10 years after first being advertised. METHODS: We created a database of 427 unique orthopaedic products advertised in the Journal of Bone and Joint Surgery. In 2013, we classified products into categories: available in advertised form, available in modified form, available under a different manufacturer, and available but temporarily recalled, discontinued voluntarily, or discontinued by forced recall. RESULTS: A total of 13.8% of products were discontinued 5 to 10 years after being advertised. Three percent were discontinued through forced recall, and 10.8% were discontinued voluntarily. Of the products still available, 60.2% were in current form, 12.9% were modified, 11.9% were available under a different company, and 1.2% were available but were temporarily recalled. CONCLUSION: Five to 10 years after the initial advertisement, nearly 40% of products were not available in their original advertised form.

The 22-Modifier in Reimbursement for Orthopedic Procedures: Hip Arthroplasty and Obesity Are Worth the Effort.

BACKGROUND: Orthopedic surgeons utilize the 22-modifier when billing for complex procedures under the American Medical Association's Current Procedural Terminology (CPT) for reasons such as excessive blood loss, anatomic abnormality, and morbid obesity, cases that would ideally be reimbursed at a higher rate to compensate for additional physician work and time. We investigated how the 22-modifier affects physician reimbursement in knee and hip arthroplasty. METHODS: We queried hospital billing data from 2009 to 2016, identifying all cases performed at our urban tertiary care orthopedic center for knee arthroplasty (CPT codes 27438, 27447, 27487, and 27488) and hip arthroplasty (CPT codes 27130, 27132, 27134, 27236). We extracted patient insurance status and reimbursement data to compare the average reimbursement between cases with and without the 22-modifier. RESULTS: We analyzed data from 2605 procedures performed by 10 providers. There were 136 cases with 22-modifiers. For knee arthroplasty (n = 1323), the 22-modifier did not significantly increase reimbursement after adjusting for insurer, provider, and fiscal year (4.2% dollars higher on average, P = .159). For hip arthroplasty (n = 1282), cases with a 22-modifier had significantly higher reimbursement than those without the 22-modifier (6.2% dollars more, P = .049). For hip arthroplasty cases with a 22-modifier, those noting morbid obesity were reimbursed 29% higher than those cases with other etiology. CONCLUSIONS: The effect of the 22-modifier on reimbursement amount is differential between knee and hip arthroplasty. Hip arthroplasty procedures coded as 22-modifier are reimbursed more than those without the 22-modifier. Providers should consider these potential returns when considering submitting a 22-modifier.

Concussion Prevalence in Competitive Ultimate Frisbee Players.

BACKGROUND: Ultimate Frisbee (ultimate) is a fast-growing, popular sport played nationally by over 4 million athletes. While several studies have examined injury rates in ultimate, no work has investigated the prevalence of concussions specifically or players' knowledge and management of those injuries. PURPOSE: To estimate the lifetime prevalence of concussions in ultimate and to assess players' knowledge of concussions as well as their concussion management behaviors. STUDY DESIGN: Descriptive epidemiology study. METHODS: From June to November 2015, we collected ultimate-related concussion data via an anonymous web-based survey, the Concussion in Ultimate Frisbee Survey, from a convenience sample of 787 male and female ultimate players across the United States. RESULTS: There were 553 male and 234 female respondents included in the analysis; 26.58% of men and 24.79% of women reported that they had sustained at least 1 concussion while playing ultimate, with 45.58% and 43.10% of those men and women, respectively, reporting multiple concussions. A total of 67.81% of men and 78.21% of women stated that they would remove themselves from play after sustaining a given concussion, although 45.99% of men and 37.62% of women indicated that they had returned to play in the same game or practice. CONCLUSION: Our preliminary data suggest that concussions do commonly occur in competitive ultimate and that better education and management of concussions in ultimate athletes are needed. This study is an important first step in deepening our understanding of these issues.

Impact of a Novel Wellness Group Visit Model on Obesity and Behavior Change.

BACKGROUND: Increasing weight-related illness in the United States has led to 120,000 preventable deaths annually and soaring medical costs. Treating patients in a group setting may be more effective than traditional care (TC) in achieving behavioral change. We studied a wellness-group (WG) model to determine whether it could generate sustained behavioral change and weight loss in a subset of patients. METHODS: 99 patients with a body mass index (BMI) >30 kg/m2 from 1 family practice volunteered to participate in a 15-visit WG co-led by a family physician and dietitian. We compared these WG patients with 190 patients who had a BMI >30 kg/m2 and who received TC in the form of an annual physical during the same time period. The patients were mostly white, highly educated, and of middle-to-high-income households. All patients were surveyed on their ability to sustain 12 wellness behaviors 3 months after completing their WG or physical. Patients were not paid to complete the survey. We reviewed medical charts for weight, BMI, blood pressure, lipids, and glycohemoglobin before and at least 1 year after the WG or physical. WG patients' weights were recorded at the beginning and end of the WG as was the weight from their most recent office visit. RESULTS: WG patients were more likely to report sustaining 12 of 12 wellness behaviors than patients who received TC with an annual physical. At 1 year, WG patients also lost more weight than TC patients (-13.21 pounds for WG vs +1.94 pounds for TC) and achieved greater reduction in their systolic blood pressure (-6.96 mm Hg for WG vs -1.13 mm Hg for TC). Average weight gained after the WG was 6.9 pounds. Among WG patients, 61% lost a clinically relevant amount of weight (>5%). Of the WG patients who lost clinically relevant weight, 71% were able to maintain at least half of their weight loss 3 years later. CONCLUSIONS: An observational study of a novel WG model showed that WG patients sustained wellness behaviors and weight loss over time when compared with patients who received TC.

Attitudes on cost-effectiveness and equity: a cross-sectional study examining the viewpoints of medical professionals.

OBJECTIVE: To determine the attitudes of physicians and trainees in regard to the roles of both cost-effectiveness and equity in clinical decision making. DESIGN: In this cross-sectional study, electronic surveys containing a hypothetical decision-making scenario were sent to medical professionals to select between two colon cancer screening tests for a population. SETTING: Three Greater Boston academic medical institutions: Tufts University School of Medicine, Tufts Medical Centre and Lahey Hospital and Medical Centre. PARTICIPANTS: 819 medical students, 497 residents-in-training and 671 practising physicians were contacted electronically using institutional and organisational directories. MAIN OUTCOMES AND MEASURES: Stratified opinions of medical providers and trainee subgroups regarding cost-effectiveness and equity. RESULTS: A total of 881 respondents comprising 512 medical students, 133 medical residents-in-training and 236 practising physicians completed the survey (total response rate 44.3%). Thirty-six per cent of medical students, 44% of residents-in-training and 53% of practising physicians favoured the less effective and more equitable screening test. Residents-in-training (OR 1.49, CI 1.01 to 2.21; p=0.044) and practising physicians (OR 2.12, CI 1.54 to 2.92; p<0.001) were more likely to favour the equitable option compared with medical students. Moreover, female responders across all three cohorts favoured the more equitable screening test to a greater degree than did male responders (OR 1.70, CI 1.29 to 2.24; p<0.001). CONCLUSIONS: Cost-effectiveness analysis does not accurately reflect the importance that medical professionals place on equity. Among medical professionals, practising physicians appear to be more egalitarian than residents-in-training, while medical students appear to be most utilitarian and cost-effective. Meanwhile, female respondents in all three cohorts favoured the more equitable option to a greater degree than their male counterparts. Healthcare policies that trade off equity in favour of cost-effectiveness may be unacceptable to many medical professionals, especially practising physicians and women.