Safe Zones for Cerclage Wiring of the Humeral Diaphysis.

Cerclage wiring of the humeral diaphysis entails particular danger to the radial nerve and the deep brachial artery. We sought to delineate safe zones for minimally invasive cerclage wiring of the humeral diaphysis, specifically in relation to the radial nerve and accompanying vasculature. Cerclage wires were percutaneously inserted into three groups of fresh-frozen cadaveric humeri. Group 1-proximal midshaft humerus at 30% of humeral height (n = 4); Group 2-midshaft spiral groove at 45% of humeral height (n = 4); and Group 3-distal midshaft humerus at 60% of humeral height (n = 4). Subsequently, an extensive surgical exploration of the arteries and nerves around the humerus was performed, noting any disturbance to the vessels or nerves and measuring the distance from the cerclage wire to the radial nerve. Neurovascular structures were injured in 75% of specimens when the cerclage wire was inserted at the level of the spiral groove. Both posterior structures, e.g. the radial nerve and the deep brachial artery, and medial structures, e.g., the median nerve and brachial artery, were incarcerated. Application of the cerclage at 30% or 60% of humeral height did not cause neurovascular injury. Minimally invasive application of the cerclage wire at the spiral groove, which is at 45% of humeral height, is likely to cause injury to neurovascular structures. Application of the cerclage at the proximal or distal midshaft humeral areas is associated with less risk of such injury. Clin. Anat. 33:552-557, 2020. © 2019 Wiley Periodicals, Inc.

Complexities of Perioperative Pain Management in Orthopedic Trauma.

PURPOSE OF REVIEW: This review discusses both obvious and hidden barriers in trauma patient access to pain management specialists and provides some suggestions focusing on outcome optimization in the perioperative period. RECENT FINDINGS: Orthopedic trauma surgeons strive to provide patients the best possible perioperative pain management, while balancing against potential risks of opioid abuse and addiction. Surgeons often find they are ill-prepared to effectively manage postoperative pain in patients returning several months following trauma surgery, many times still dependent on opioids for pain control. Some individuals from this trauma patient population may also require the care of pain management specialists and/or consultation with drug addiction specialists. As the US opioid epidemic continues to worsen, orthopedic trauma surgeons can find it difficult to obtain access to pain management specialists for those patients requiring complex pain medication management and substance abuse counseling. The current state of perioperative pain management for orthopedic trauma patients remains troubling due to reliance on only opioid analgesics, society-associated risks of opioid medication addiction, an "underground" prescription drug marketplace, and an uncertain legal atmosphere related to opioid pain medication management that can deter pain management physicians from accepting narcotic-addicted patients and discourage future physicians from pursuing advanced training in the specialty of pain management. Additionally, barriers continue to exist among Medicaid patients that deter this patient population from access to pain medicine subspecialty care, diminishing medication management reimbursement rates make it increasingly difficult for trauma patients to receive proper opioid analgesic pain medication management, and a lack of proper opioid analgesic medication management training among PCPs and orthopedic trauma surgeons further contributes to an environment ill-prepared to provide effective perioperative pain management for orthopedic trauma patients.

Motorcycle Helmets: The Economic Burden of an Incomplete Helmet Law to Medical Care in the State of Connecticut.

The lack of a mandatory motorcycle helmet law leads to increased injury severity and increased health care costs. This study presents a financial model to estimate how the lack of a mandatory helmet law impacts the cost of health care in the state of Connecticut. The average cost to treat a helmeted rider and a nonhelmeted rider was $3,112 and $5,746 respectively (cost adjusted for year 2014). The total hospital treatment cost in the state of Connecticut from 2003 through 2012 was $73,106,197, with $51,508,804 attributed to nonhelmeted riders and $21,597,393 attributed to helmeted riders. The total Medicaid cost to the state of Connecticut for treating nonhelmeted patients was $18,277,317. This model demonstrates that the lack of a mandatory helmet law increases overall health care costs to the state of Connecticut, and provides a framework by which hospital costs can be reduced to contribute to the economic stability of health care economics in the state.

The feasibility of a novel 3D-Printed patient specific cutting guide for extended trochanteric osteotomies.

BACKGROUND: The extended trochanteric osteotomy (ETO) is a surgical technique utilized to expose the intramedullary canal of the proximal femur, protect the soft tissues and promote reliable healing. However, imprecise execution of the osteotomy can lead to fracture, soft tissue injury, non-union, and unnecessary morbidity. We developed a technique to create patient specific, 3D-printed cutting guides to aid in accurate positioning of the ETO and improve osteotomy quality and outcomes. METHODS: Patient specific cutting guides were created based on CT scans using Synopysis Simpleware ScanIP and Solidworks. Custom 3D printed cutting guides were tested on synthetic femurs with foam cortical shells and on cadaveric femurs. To confirm accuracy of the osteotomies, dimensions of the performed osteotomies were compared to the virtually planned osteotomies. RESULTS: Use of the patient specific ETO cutting guides resulted in successful osteotomies, exposing the femoral canal and the femoral stem both in synthetic sawbone and cadaveric testing. In cadaveric testing, the guides allowed for osteotomies without fracture and cuts made using the guide were accurate within 6 percent error from the virtually planned osteotomy. CONCLUSION: The 3D-printed patient specific cutting guides used to aid in ETOs proved to be accurate. Through the iterative development of cutting guides, we found that a simple design was key to a reliable and accurate guide. While future clinical trials in human subjects are needed, we believe our custom 3D printed cutting guide design to be effective at aiding in performing ETOs for revision total hip arthroplasty surgeries.

Outcomes of Distal Third Femur Fractures in Patients 18 Years and Older: A Pilot Study.

INTRODUCTION: The selection of the most optimal fixation method for fractures of the distal femur, whether intramedullary nail (NL), lateral locking plate (PL), or nail/plate (NP) is not always clear. This study retrospectively evaluates surgical patients with distal femur fractures and introduces a pilot study using cluster analysis to identify the most optimal fracture fixation method for a given fracture type. METHODS: This is a retrospective cohort study of patients 18 years and older with an isolated distal femur fracture who presented to our Level-1 trauma center between January 1, 2012, and December 31, 2022, and obtained NL, PL, or NP implants. Patients with polytrauma and those without at least six months of follow-up were excluded. A chart review was used to obtain demographics, fracture classification, fixation method, and postoperative complications. A cluster analysis was performed. The following factors were used to determine a successful outcome: ambulatory status pre-injury and 6-12 months postoperatively, infection, non-union, mortality, and implant failure. RESULTS: A total of 169 patients met inclusion criteria. No statistically significant association between the fracture classification and fixation type with overall outcome was found. However, patients treated with an NP (n = 14) had a success rate of 92.9% vs only a 68.1% success rate in those treated with a PL (n = 116) (p = 0.106). The most notable findings in the cluster analysis (15 total clusters) included transverse extraarticular fractures demonstrating 100% success if treated with NP (n = 6), 50% success with NL (n=2), and 78.57% success with PL fixation (n=14). NP constructs in complete articular fractures demonstrated success in 100% of patients (n = 5), whereas 77.78% of patients treated with NL (n = 9) and 61.36% of those treated with PL (n = 44). CONCLUSIONS: Plate fixation was the predominant fixation method used for distal third femur fractures regardless of fracture classification. However, NP constructs trended towards improved success rates, especially in complete intraarticular and transverse extraarticular fractures, suggesting the potential benefit of additional fixation with these fractures. Cluster analysis provided a heuristic way of creating patient profiles in patients with distal third femur fractures. However, a larger cohort study is needed to corroborate these findings to ultimately develop a clinical decision-making tool that also accounts for patient specific characteristics.

Periarticular Injection Versus Peripheral Nerve Blockade in Bilateral Total Hip Arthroplasty.

Pain control after total hip arthroplasty is associated with patient satisfaction, early discharge, and improved surgical outcomes. Two commonly utilized opioid-reducing analgesic modalities are periarticular injection (PAI) by surgeons and motor-sparing peripheral nerve block (PNB) by anesthesiologists. We present a case contrasting PAI and PNB in a single patient undergoing bilateral total hip arthroplasty. For the left hip, the patient received preoperative transmuscular quadratus lumborum, femoral nerve, and lateral femoral cutaneous nerve blocks using a combination of low-concentration local anesthetic and glucocorticoids. For the right hip, the patient received an intraoperative PAI with liposomal bupivacaine. The patient's pain scores and recovery were evaluated for three months postoperatively. The patient's pain scores on postoperative day (POD) zero to five were consistently lower in the left hip than in the right hip. For this patient undergoing bilateral hip replacement, preoperative PNBs were superior to PAI for postoperative pain control.

An analytical model of lateral condylar plate working length.

BACKGROUND: The locking plate is a common device to treat distal femur fractures. Healing is affected by construct stiffness, thus many surgeon-controlled variables such as working length have been examined for their effects on strain at the fracture. No convenient analytical model which aids surgeons in determining working length has yet been described. We propose an analytical model and compare it to finite element analysis and cadaveric biomechanical testing. METHODS: First, an analytical model based on a cantilever beam equation was derived. Next, a finite element model was developed based on a CT scan of a "fresh-frozen" cadaveric femur. Third, biomechanical testing in single-leg stance loading was performed on the cadaver. In all methods, strain at the fracture was recorded. An ANCOVA test was conducted to compare the strains. FINDINGS: In all models, as the working length increased so did strain. For strain at the fracture, the shortest working length (35 mm) had a strain of 8% in the analytical model, 9% in the finite element model, and 7% for the cadaver. The longest working length (140 mm) demonstrated strain of 15% in the analytical model, and the finite element and biomechanical tests both demonstrated strain of 14%. INTERPRETATION: The strain predicted by the analytical model was consistent with the strain observed in both the finite element and biomechanical models. As demonstrated in existing literature, increasing the working length increases strain at the fracture site. Additional work is required to refine and establish validity and reliability of the analytical model.

Current advances in training orthopaedic patients to comply with partial weight-bearing instructions.

Partial weight-bearing instructions are commonly given to orthopaedic patients and are an important part of post-injury and/or post-operative care. However, the ability of patients to comply with these instructions is poorly defined. Training methods for instructing these patients vary widely among institutions. Traditional methods of training include verbal instruction and use of a bathroom scale. Recent technological advances have created biofeedback devices capable of offering feedback to partial weight-bearing patients. Biofeedback devices have shown great promise in training patients to better comply with partial weight-bearing instructions. This review examines the background and significance of partial weight bearing and offers insights into current advances in training methods for partial weight-bearing patients.

Accuracy of guide wire placement for femoral neck stabilization using 3D printed drill guides.

BACKGROUND: The goal of stabilization of the femoral neck is to limit morbidity and mortality from fracture. Of three potential methods of fixation, (three percutaneous screws, the Synthes Femoral Neck System, and a dynamic hip screw), each requires guide wire positioning of the implant(s) in the femoral neck and head. Consistent and accurate positioning of these systems is paramount to reduce surgical times, stabilize fractures effectively, and reduce complications. To help expedite surgery and achieve ideal implant positioning in the geriatric population, we have developed and validated a surgical planning methodology using 3D modelling and printing technology. METHODS: Using image processing software, 3D surgical models were generated placing guide wires in a virtual model of an osteoporotic proximal femur sawbone. Three unique drill guides were created to achieve the optimal position for implant placement for each of the three different implant systems, and the guides were 3D printed. Subsequently, a trauma fellowship trained orthopedic surgeon used the 3D printed guides to position 2.8 mm diameter drill bit tipped guide wires into five osteoporotic sawbones for each of the three systems (fifteen sawbones total). Computed Tomography (CT) scans were then taken of each of the sawbones with the implants in place. 3D model renderings of the CT scans were created using image processing techniques and the displacement and angular deviations at guide wire entry to the optimal sawbone model were measured. RESULTS: Across all three percutaneous screw guide wires, the average displacement was 3.19 ± 0.12 mm and the average angular deviation was 4.10 ± 0.17o. The Femoral Neck System guide wires had an average displacement of 1.59 ± 0.18 mm and average angular deviation of 2.81 ± 0.64o. The Dynamic Hip Screw had an average displacement of 1.03 ± 0.19 mm and average angular deviation of 2.59 ± 0.39o. CONCLUSION: The use of custom 3D printed drill guides to assist with the positioning of guide wires proved to be accurate for each of the three types of surgical strategies. Guides which are used to place more than 1 guide wire may have lower positional accuracy, as the guide may shift during multiple wire insertions. We believe that personalized point of care drill guides provide an accurate intraoperative method for positioning implants into the femoral neck.

Simulating Prophylactic Fixation Methods for Osteoporotic Femoral Neck Fracture Prevention.

Introduction: Geriatric patients who suffer femoral neck fractures have high morbidity and mortality. Prophylactic fixation of the femoral neck is a potential avenue to reduce the incidence of femoral neck fractures. We studied 3 different implants traditionally used to stabilize the femoral neck: 6.5 mm cannulated screws (CANN), the femoral neck system (FNS) (Depuy Synthes), and the dynamic hip screw (DHS) (Depuy Synthes). Materials and Methods: Five osteoporotic Sawbone femurs were used for each model and a control group. Two scenarios were investigated: single leg stance to measure construct stiffness and lateral impact to measure construct stiffness, energy to fracture, and qualitative examination of fracture patterns. Stiffness for each femur and energy to fracture for the lateral impact scenario were calculated and compared between groups using one-way ANOVA. Results: DHS showed significantly higher stiffness than the other 2 implants and the control in single leg stance. In the lateral impact scenario, the DHS and CANN were significantly stiffer FNS and the control. Femurs implanted with CANN tended to fracture at the greater trochanter while FNS fractured in a transverse subtrochanteric pattern, and DHS fractured obliquely in the subtrochanteric region. Discussion: FNS and DHS experienced fracture patterns less amenable to surgical correction. CANN and DHS proved better able to resist external forces in the lateral fall scenario. CANN also proved better able to resist external forces in the single leg stance scenario and experienced a more amenable fracture pattern in the lateral fall scenario. Conclusions: FNS was less able to resist external forces compared with the other implants. This work informs the potential implications between the choice of implants that, although historically have not been used prophylactically, may be considered in the future for prophylactic stabilization of the femoral neck. Cadaveric study and clinical trials are recommended for further study.

Medium-term outcome and classification of traumatic anterior hip dislocations.

INTRODUCTION: Traumatic anterior hip dislocations are subdivided to obturator (inferior) and pubic (superior) dislocations by Epstein's descriptive classification. This rare injury is thought to have favourable clinical outcomes. The incidence of associated femoral head and acetabular injuries has been low in past case series. We sought to revisit this injury and classification in the era of advanced imaging and contemporary surgical techniques. MATERIALS AND METHODS: A retrospective study of 15 patients treated for anterior hip dislocation was performed. Medical records were reviewed for demographic and surgical data. Imaging studies were revisited to determine direction of dislocation and associated fractures. Patients were assessed for pain, hip function using the modified Harris Hip Score (mHHS), hip range of motion and radiographic changes. Mean follow-up time was 3 years. RESULTS: Anterior dislocation occurred in an obturator (inferior), pubic (superior) or central direction. 9 patients had concomitant femoral head impaction and 7 patients suffered from acetabular fractures. 8 patients with an anterior hip dislocation underwent surgical treatment. This therapy, along with early range of motion and weight bearing, produced favourable clinical outcomes with 9 patients reporting no pain and an average mHHS of 83.8. 6 patients had heterotopic ossification at latest follow-up. CONCLUSIONS: Traumatic anterior hip dislocation is commonly associated with femoral head impaction and acetabular injuries which should be addressed operatively when appropriate to produce favourable results. In this paper, we propose a revision to the commonly used descriptive classification system.

Clusters of Injuries From Motorcycle Collisions: Exploratory Factor Analysis of a Single Institution Trauma Registry.

Objective With the goal of guiding acute management of associated injuries motorcycle trauma patients, this study aims to identify patterns of associated injuries after motorcycle collisions using exploratory factor analysis. Methods We conducted a retrospective review at a Level 1 trauma center of all patients who presented after motorcycle collisions resulting in trauma system activations between July 2, 2002 and December 31, 2013. We performed exploratory factor analysis on this dataset to identify sets of injuries that cluster together. Results We identified 1,050 patients who presented for trauma after a motorcycle collision. These patients had 3,101 injuries, including 1,694 fractures. Using exploratory factor analysis, we developed a model with four latent factors that explained approximately half of the variance in injuries. These factors were defined by: head and cervical spine injuries; extremity injuries; abdomen, pelvis and upper extremity injuries; and shoulder girdle and thorax injuries. We also found a novel injury pattern relationship between forearm shaft/wrist and lower extremity injuries. Conclusions Motorcycle trauma results in distinct clusters of associated injuries likely due to common motorcycle collision patterns, most notably a novel relationship between forearm shaft/wrist and lower extremity injuries that merits further exploration, and could play a role during secondary survey.

High-risk motor vehicle drivers engage in more risk behaviors than motorcyclists.

OBJECTIVE: The purpose of this study was to characterize and compare risk behaviors between motorcyclists and motor vehicle drivers who were involved in accidents and required hospitalization. The study focused on patients who were recently involved in motorcycle collisions (MCCs) and motor vehicle collisions (MVCs). METHODS: We identified 63 patients involved in MCCs and 39 patients involved in MVCs who were admitted to our level-1 trauma center from April 2014 to September 2015. These 102 patients completed a questionnaire designed to evaluate risky driving behaviors. Pearson's chi-squared tests and unpaired two-tailed t-tests were used to evaluate categorical and normally distributed continuous variables, respectively. Multivariable linear regression was used to analyze predictors of risk behavior. Significance was set at p < 0.05. RESULTS: When compared to patients involved in an MCC, patients involved in MVCs were more likely to be female (p = 0.007), drive more frequently (p < 0.001), and never perceive the risk of an accident (p = 0.036). MVC patients were more likely to have admitted to substance use on the day of the accident (p = 0.030), historically drive under the influence of drugs (p = 0.031), drive while tired (p < 0.001), drive while text messaging (p < 0.001), and speed while overtaking vehicles (p = 0.011). Overall, MVC patients engaged in more risk behaviors (3.3 ± 1.3 vs. 2.0 ± 1.5; p < 0.001) and were more likely to engage in multiple risk behaviors (p < 0.001). MVCs were associated with increased risk behavior, even after controlling for protective behaviors, driving history, and demographics (p = 0.045). CONCLUSIONS: Within our cohort of trauma patients at our institution, motor vehicle drivers were more likely than motorcyclists to engage in any one risk behavior and engage in a higher number of risk behaviors. In addition, motor vehicle drivers perceived their risk of a potential accident as lower than riding a motorcycle. Education initiatives should focus on motor vehicle driver safety interventions that reduce risk behaviors.

A review of common motorcycle collision mechanisms of injury.

Injuries sustained in motorcycle collisions can be organized into distinct patterns to improve recognition and treatment.Lowside, highside, topside, and collision are the four main categories of motorcycle crash types.Within those four crash types, mechanisms of injury include head-leading collisions, direct vertical impact, motorcycle radius, motorcycle thumb, fuel tank injures, limb entrapment, tyre-spoke injury, and crash modifying manoeuvre. Cite this article: EFORT Open Rev 2020;5:544-548. DOI: 10.1302/2058-5241.5.190090.

Negative Pressure Incisional Therapy and Infection After Direct Anterior Approach Primary Total Hip Arthroplasty.

With the aging of the US population, total hip arthroplasty (THA) is becoming an increasingly common procedure. A major concern after THA is reducing infection rates, as infections can cause devastating complications. Improved sterile technique, standardized infection control protocols, and novel dressings have been used to reduce postoperative surgical site infections (SSIs). The use of either silver-impregnated dry dressings or easily applied incisional negative pressure dressings is aimed at reducing the rates of SSIs after primary anterior THA. The authors retrospectively reviewed the medical records of 275 patients who underwent anterior THA at their institution during a 1-year period. Patients were separated into groups based on their surgical dressing. Rates of SSI were documented, and the effects of various factors, including age, sex, body mass index, and comorbidities, were compared between the 2 cohorts. The authors also analyzed high-risk patients to determine whether easily applied incisional negative pressure dressings reduced infections. The use of easily applied incisional negative pressure dressings after primary anterior THA did not have a statistically significant impact on SSI rate (P=.42). There was also no difference in SSI, readmission, or reoperation in the high-risk group. The goal of using an incisional negative pressure wound therapy device is to help further decrease the risk of SSI. This study's findings suggest that the SSI rate in this group did not differ from that in the standard dressing group, such that the prophylactic use of a negative pressure wound therapy device is not indicated for either standard or high-risk patients undergoing primary anterior approach THA. [Orthopedics. 2019; 42(6):e539-e544.].

Medicaid Patients Have Greater Difficulty Scheduling Health Care Appointments Compared With Private Insurance Patients: A Meta-Analysis.

Medicaid patients are known to have reduced access to care compared with privately insured patients; however, quantifying this disparity with large controlled studies remains a challenge. This meta-analysis evaluates the disparity in health services accessibility of appointments between Medicaid and privately insured patients through audit studies of health care appointments and schedules. Audit studies evaluating different types of outpatient physician practices were selected. Studies were categorized based on the characteristics of the simulated patient scenario. The relative risk of appointment availability was calculated for all different types of audit scenario characteristics. As a secondary analysis, appointment availability was compared pre- versus post-Medicaid expansion. Overall, 34 audit studies were identified, which demonstrated that Medicaid insurance is associated with a 1.6-fold lower likelihood in successfully scheduling a primary care appointment and a 3.3-fold lower likelihood in successfully scheduling a specialty appointment when compared with private insurance. In this first meta-analysis comparing appointment availability between Medicaid and privately insured patients, we demonstrate Medicaid patients have greater difficulty obtaining appointments compared with privately insured patients across a variety of medical scenarios.

The Effect of Insurance Type on Patient Access to Ankle Fracture Care Under the Affordable Care Act.

The purpose of this study is to assess the effect of insurance type (Medicaid, Medicare, private insurance) on the ability for patients with operative ankle fractures to access orthopedic traumatologists. The research team called 245 board-certified orthopedic surgeons specializing in orthopedic trauma within 8 representative states. The caller requested an appointment for their fictitious mother in order to be evaluated for an ankle fracture which was previously evaluated by her primary care physician and believed to require surgery. Each office was called 3 times to assess the response for each insurance type. For each call, information was documented regarding whether the patient was able to receive an appointment and the barriers the patient confronted to receive an appointment. Overall, 35.7% of offices scheduled an appointment for a patient with Medicaid, in comparison to 81.4%and 88.6% for Medicare and BlueCross, respectively (P < .0001). Medicaid patients confronted more barriers for receiving appointments. There was no statistically significant difference in access for Medicaid patients in states that had expanded Medicaid eligibility vs states that had not expanded Medicaid. Medicaid reimbursement for open reduction and internal fixation of an ankle fracture did not significantly correlate with appointment success rates or wait times. Despite the passage of the Affordable Care Act, patients with Medicaid have reduced access to orthopedic surgeons and more complex barriers to receiving appointments. A more robust strategy for increasing care-access for patients with Medicaid would be more equitable.

The effect of insurance type on trauma patient access to psychiatric care under the Affordable Care Act.

OBJECTIVE: The objective of the study was to assess the effect of insurance type (Medicaid, Medicare, private insurance or cash pay) on patients' access to psychiatrists for a new patient consultation. METHOD: 240 psychiatrists identified as interested in treating patients with PTSD were called across 8 states. The caller requested an appointment for her fictitious boyfriend who had been in a car accident to be evaluated for PTSD. Each office was called four times to assess the responses for each payment type. From each call, whether an appointment was offered and barriers to an appointment were recorded. RESULTS: 21% of psychiatrists would see new patients. 15% of offices scheduled an appointment for a patient with Medicaid, compared to 34% for Medicare, 54% for BlueCross and 93% for cash pay (p<0.001). Medicaid patients confronted more barriers to receiving appointments and had more trouble scheduling appointments in states with expanded Medicaid eligibility. The overall number of Medicaid patients who would be able to theoretically schedule an appointment in states with versus states without expanded Medicaid eligibility was approximately equivalent. Psychiatry practice characteristics, such as whether the practice was academic, were not significantly associated with acceptance of Medicaid. CONCLUSIONS: Access to a psychiatrist for a new patient consultation is challenging. Despite expansion of the Affordable Care Act, substantial barriers remain for Medicaid patients in accessing psychiatric care compared to patients with Medicare, private insurance or those who pay cash.

The Effect of Insurance Type on Fragility Fracture Patient Access to Endocrinology Under the Affordable Care Act.

OBJECTIVES: To assess the effect of insurance type (Medicaid, Medicare, and private insurance) on fragility fracture patients' access to endocrinology specialists in the postoperative period. MATERIALS AND METHODS: The research team called 247 board-certified endocrinologists in 8 representative states. The caller requested an appointment for her fictitious mother to be evaluated for osteoporosis after suffering a hip fracture that required surgery. The caller stated that her mother had an abnormal level of parathyroid hormone and her mother's orthopedic surgeon believed she needed to see an endocrinologist. Each office was called 3 times to assess the responses for each insurance type. For each call, we documented whether the patient was able to receive an appointment and the barriers the patient confronted to receiving an appointment. RESULTS: About 15.8% of offices scheduled an appointment for a patient with Medicaid, compared to 48.6% for Medicare and 54.3% for BlueCross (P < .0001). Medicaid patients confronted more barriers to receiving appointments. There was no statistically significant difference in access for Medicaid patients in states that had expanded Medicaid versus states that had not expanded Medicaid. Medicaid reimbursement for a new level 3 patient visit did not significantly correlate with appointment success rates or wait times. CONCLUSION: Despite the passage of the Affordable Care Act, Medicaid patients have reduced access to endocrinologists and more complex barriers to receiving appointments. A more robust strategy for increasing access to care for Medicaid patients would be more equitable.

Influence of Medical Insurance Under the Affordable Care Act on Access to Pain Management of the Trauma Patient.

BACKGROUND AND OBJECTIVES: The Affordable Care Act intended to "extend affordable coverage" and "ensure access" for vulnerable patient populations. This investigation examined whether the type of insurance (Medicaid, Medicare, Blue Cross, cash pay) carried by trauma patients influences access to pain management specialty care. METHODS: Investigators phoned 443 board-certified pain specialists, securing office visits with 235 pain physicians from 8 different states. Appointments for pain management were for a patient who sustained an ankle fracture requiring surgery and experiencing difficulty weaning off opioids. Offices were phoned 4 times assessing responses to the 4 different payment methodologies. RESULTS: Fifty-three percent of pain specialists contacted (235 of 443) were willing to see new patients to manage pain medication. Within the 53% of positive responses, 7.2% of physicians scheduled appointments for Medicaid patients, compared with 26.8% for cash-paying patients, 39.6% for those with Medicare, and 41.3% with Blue Cross (P < 0.0001). There were no differences in appointment access between states that had expanded Medicaid eligibility for low-income adults versus states that had not expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement levels for new patient visits correlated with ability to schedule an appointment or influenced wait times. CONCLUSIONS: Access to pain specialists for management of pain medication in the postoperative trauma patient proved challenging. Despite the Affordable Care Act, Medicaid patients still experienced curtailed access to pain specialists and confronted the highest incidence of barriers to receiving appointments.