Rehabilitation After Total Knee Arthroplasty: Do Racial Disparities Exist?

BACKGROUND: Racial disparities in functional outcomes after total knee arthroplasty (TKA) exist. Whether differences in rehabilitation utilization contribute to these disparities remains to be investigated. METHODS: Among 8349 women enrolled in the prospective Women's Health Initiative cohort who underwent primary TKA between 2006 and 2013, rehabilitation utilization was determined through linked Medicare claims data. Postacute discharge destination (home, skilled nursing facility, and inpatient rehabilitation facility), facility length of stay, and number of home health physical therapy (HHPT) and outpatient physical therapy (OPPT) sessions were compared between racial groups. RESULTS: Non-Hispanic black women had worse physical function (median score, 65 vs 70) and higher likelihood of disability (13.2% vs 6.9%) than non-Hispanic white women before surgery. After TKA, black women were more likely to be discharged postacutely to an institutional facility (64.3% vs 54.5%) than white women, were more likely to receive HHPT services (52.6% vs 47.8%), and received more HHPT and OPPT sessions. After stratification by postacute discharge setting, the likelihood of receipt of HHPT or OPPT services was similar between racial groups. No significant difference in receipt of HHPT or OPPT services was found after use of propensity score weighting to balance health and medical characteristics indicating severity of need for physical therapy services. CONCLUSION: Rehabilitation utilization was generally comparable between black and white women who received TKA when accounting for need. There was no evidence of underutilization of post-TKA rehabilitation services, and thus disparities in post-TKA functional outcomes do not appear to be a result of inequitable receipt of rehabilitation care.

Antipsychotic polypharmacy trends among Medicaid beneficiaries with schizophrenia in San Diego County, 1999-2004.

OBJECTIVE: This study examined trends and costs of second-generation antipsychotic polypharmacy among Medicaid beneficiaries with schizophrenia in San Diego County. METHODS: Medicaid data were used to identify 15,962 persons with schizophrenia receiving antipsychotic medications between 1999 and 2004. The yearly proportion of beneficiaries receiving second-generation antipsychotic polypharmacy, duration of polypharmacy, inpatient admissions, and pharmaceutical costs were examined. RESULTS: The proportion of clients receiving second-generation antipsychotic polypharmacy increased from 3.3% in 1999 to 13.7% in 2004, whereas annual antipsychotic medication costs increased from $4,128 to $5,231 (2004 dollars). Among those receiving second-generation polypharmacy, the percentage receiving second-generation polypharmacy for 12 months increased from 5.1% to 14.4%, and the percentage hospitalized increased from 7.2% to 9.0%. CONCLUSIONS: The prevalence of long-term second-generation antipsychotic polypharmacy and its associated costs increased substantially between 1999 and 2004. Prescribing antipsychotic polypharmacy is an unproven and costly strategy that if left unchanged could lead to administrative efforts to cut costs and dictate practice.

Tobacco industry price-subsidizing promotions may overcome the downward pressure of higher prices on initiation of regular smoking.

Real cigarette prices in the US increased from the early 1980s to early 1990s. Holding all else equal, adolescent initiation of regular smoking should have declined during this period. Using national population-based surveys (n = 336 343) conducted in the 1990s, we present trends (early 1960s to mid-1990s) in the initiation of regular smoking among 14-17-year-old adolescents and 18-21-year-old young adults. We also present trends in consumer-price-index-adjusted cigarette price and tobacco-industry expenditures for price-subsidizing promotions. We relate price and price-subsidizing tobacco industry expenditures to trends in initiation in the two age groups, using autoregressive integrated moving average models (ARIMA). From the model results, we conclude that price-subsidizing promotions may provide the tobacco industry with an effective way to segment the market. That is, they effectively offer lower prices to population subgroups that are more price-sensitive (e.g. young smokers not yet addicted), countering the depressing effect of general price increases on smoking. Thus, we find that the relationship of cigarette price to smoking behavior is more complex than previously described.