Delay in Knee MRI Scan Completion Since Implementation of the Affordable Care Act:: A Retrospective Cohort Study.

INTRODUCTION: The most impactful resolutions of the Patient Protection and Affordable Care Act (ACA) took effect on January 1, 2014. The clinical and economic effects are widely experienced by orthopaedic surgeons, but are not well quantified. We proposed to evaluate the effect of the ACA on the timing of MRI for knee pathology before and after implementation of the legislation. METHODS: We conducted a retrospective analysis of all knee MRIs done at our institution from 2011 to 2016 (3 years before and after ACA implementation). The MRI completion time was calculated by comparing the dates of initial clinical evaluation and MRI completion. The groups were subdivided based on insurance payer status (Medicare, Medicaid, and commercial payers). The cohorts were compared to determine differences in average completion time and completion rates at time intervals from initial clinic visit before and after ACA implementation. RESULTS: MRI scans of 5,543 knees were included, 3,157 (57%) before ACA implementation and 2,386 (43%) after. There was a 5.6% increase in Medicaid cohort representation after ACA implementation. Patients waited 14 days longer for MRIs after ACA implementation (116 versus 102 days). There were increased completion times for patients in the commercial payer (113 versus 100 days) and Medicaid (131 versus 96 days) groups. Fewer patients had received MRI after ACA implementation within 2, 6, and 12 weeks of their initial clinic visits. DISCUSSION: The time between initial clinical evaluation and MRI scan completion for knee pathology markedly increased after ACA implementation, particularly in the commercial payer and Medicaid cohorts. Additional studies are needed to determine the effect of longer wait times on patient satisfaction, delayed treatment, and increased morbidity. As healthcare policy changes continue, their effects on orthopaedic patients and providers should be closely scrutinized. LEVEL OF EVIDENCE: Level III-Retrospective cohort study.

Utility of the Merchant View Radiograph for Assessment of Tibial Tubercle-Trochlear Groove Distance: A Comparison to MRI in Pediatric and Adolescent Patients.

BACKGROUND: Plain radiographic evaluation remains the standard initial assessment of patellar instability, while 3-dimensional imaging is obtained in some patients. Merchant radiographs can demonstrate the tibial tubercle relative to the trochlear groove (TT-TG), but the determination of the TT-TG from these radiographs has been abandoned since its original description. The purpose of this study is to evaluate the utility of the TT-TG measured on Merchant radiographs for the assessment of patellar instability. METHODS: A prospective cohort study was performed of pediatric and adolescent patients aged 10 to 18 who underwent standardized Merchant radiographs, including a total of 98 knees (in 57 patients). Merchant TT-TG was measured as the distance between the center of the trochlear groove and the tibial tubercle, with both lines perpendicular to the anterior femoral condylar axis. In Part 1, the Merchant TT-TG measured by the tibial tubercle radiographic appearance was compared with the measurement utilizing a radiographic marker. In Part 2, the Merchant TT-TG was compared with the magnetic resonance imaging (MRI) TT-TG distance using bivariate linear regression analysis. TT-TG measurements were compared in patients with and without patellar instability with receiver operating characteristic curve analysis. RESULTS: The tibial tubercle was identified on Merchant radiograph in 81.7% (67/82) of knees, and there was an excellent correlation (Pearson correlation coefficient=0.85) between the Merchant TT-TG and the measurement based on marker placement. Merchant TT-TG was on average 4.5 mm less than MRI TT-TG (12.8±4.4 vs. 8.4±7.7 mm, P<0.001) and was moderately correlated (Pearson correlation coefficient=0.58, P<0.01). TT-TG distance was increased in patients with patellar instability compared with those without patellar instability on the Merchant view (10.5±6.9 vs. 2.0±5.5 mm, P<0.001) and MRI (13.9±4.4 vs. 10.5±2.9 mm, P=0.012). Merchant TT-TG also demonstrated a higher area under the curve than MRI TT-TG (0.872 vs. 0.775) in differentiating patients with and without patellar instability. CONCLUSIONS: Standardized Merchant radiographs allow for reliable assessment of the Merchant TT-TG distance when the tibial tubercle is visualized and moderately correlate with MRI TT-TG (with Merchant TT-TG on average 4.5 mm less than MRI). LEVEL OF EVIDENCE: Level III.