Dynamic Stress Ultrasound Assessment of Professional Baseball Players' Elbows After Ulnar Collateral Ligament Reconstruction.

BACKGROUND: There is a paucity of data analyzing dynamic stress ultrasound (SUS) findings in elite pitchers who have undergone ulnar collateral ligament (UCL) reconstruction (UCLR) and returned to sport. PURPOSE: To identify longitudinal, perioperative changes in the elbows of professional baseball pitchers who have undergone UCLR and to compare these findings with a matched cohort of healthy pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study used prospectively collected data from dynamic elbow SUS analyses of professional baseball pitchers within a single Major League Baseball organization. Pitchers were divided into 2 cohorts: a UCLR cohort and healthy cohort. The UCLR cohort eligibility included availability of (1) SUS from preseason of injury/UCLR and (2) SUS from ≥2 years after surgery. These players were 1:1 matched to players with no history of upper extremity injury to form the healthy cohort. Ligament thickness and ulnohumeral joint space at rest and under stress were directly measured. Joint laxity was calculated by subtracting joint space at rest from joint space under stress. The term "relative" was used to describe calculated differences where nondominant measurements were subtracted from dominant-side measurements. RESULTS: Eight pitchers were included in the UCLR group and matched to 8 healthy pitchers (mean age at initial SUS examination, 19.6 years). At a minimum follow-up of 2 years, there were no significant differences between groups in terms of relative or dominant arm rest space, stress space, or laxity. Longitudinally (final measurements - baseline measurements), the mean relative ulnohumeral rest space decreased in the UCLR group and increased in the healthy group (-0.36 mm vs +0.50 mm; P = .032). The finding of increased UCL thickness in the UCLR group was expected, as UCL grafts are typically thicker than native ligaments. CONCLUSION: Ulnhohumeral joint stability was achieved after UCLR as indicated by similar rest space, stress space, and joint laxity in dominant arms compared with a matched healthy cohort. A significant decrease in relative rest space after UCLR may represent the achievement of stability in surgery patients. Alternatively, the increase in ulnohumeral rest space seen in the healthy cohort may represent adaptive changes from pitching at a professional level.

Enhancing the analytic utility of clinical trial data to inform health disparities research.

Clinical trials are often conducted among younger, healthier, and less racially diverse patient populations than the population at large. Health disparities for individuals with cancer are most apparent when there are notable differences in the occurrence, frequency, burden of cancer and mortality rates among specific population groups. Enhancing the diversity of participants in clinical trials to reflect the characteristics of cancer survivors in the U.S. population is of growing interest to better insure the safety and efficacy of resultant treatments. The Project Data Sphere ® (PDS) cancer research platform is a first-of-its kind research environment that provides the research community with broad access to both de-identified patient-level clinical trial data and advanced analytic tools to enable big data-driven research. To address these analytic constraints, the data profiles in selected PDS patient-level cancer phase III clinical datasets have been augmented by linking the social, economic, and health-related characteristics of like cancer survivors from nationally representative health and health care-related survey data from the Medical Expenditure Panel Survey (MEPS). Our article shines a spotlight on this ongoing initiative to improve access to clinical trial data in support of health care disparities research initiatives.

Data Integration Innovations to Enhance Analytic Utility of Clinical Trial Content to Inform Health Disparities Research.

Project Data Sphere (PDS) is a research platform that provides the research community with broad access to both de-identified patient-level data from oncology clinical trials and related analytic tools. While these data are rich in measures that characterize the clinical trials under study, data providers are required to de-identify patient-level data by removing key demographic data. To address these analytic constraints, the data profiles in selected PDS patient-level cancer phase III clinical datasets have been augmented by linking the social, economic, and health-related characteristics of like cancer survivors from nationally representative health and health care-related survey data. Using statistical linkage and model-based techniques, patient-level records in selected PDS datasets have been linked to those of comparable cancer survivors, and are thereby augmented with survey content on social, economic, and health-related characteristics. These new analytically enhanced PDS data resources enable more targeted analyses designed to examine questions such as how disparities in cancer patients' access to health care and income impact patient outcomes in specific phase III clinical trials, and what variations in patient outcomes are associated with specific demographic, socioeconomic, and health-related factors. This study provides an overview of the methodologies used to connect patient-level clinical trial data with nationally representative health-related data on cancer survivors from the national Medical Expenditure Panel Survey (MEPS). MEPS was designed to provide national population-based health care use, expenditure, and source of payment estimates in addition to measures of health status, demographic characteristics, employment, health insurance coverage, and access to health care. Study findings include probabilistic assessments of the representation of the patients in the respective clinical trials relative to the characteristics of cancer survivors in the general population. The study also demonstrates how the augmented datasets serve to enable researchers to assess the impact of socioeconomic factors added through data integration on cancer survival and related outcomes of interest.

Postoperative radiographs after ACL reconstruction are not cost-effective.

Postoperative radiographs have become standard after anterior cruciate ligament (ACL) reconstruction, even though few findings in the literature substantiate their efficacy. The goal of this study was to determine whether routine postoperative radiographs were cost-effective in patients undergoing ACL reconstruction. In addition, the authors sought to determine whether these radiographs provided meaningful clinical information that changed postoperative management. Between January and December 2010, the authors retrospectively reviewed all patients who underwent ACL reconstruction at their institution. The clinical course of all patients was reviewed to determine whether the results of the radiograph at the time of interpretation changed the plan of care. All radiographs were then scrutinized for abnormal findings that could have changed the plan of care if noted at the time of follow-up. Of 624 patients who underwent ACL reconstruction, 340 (54.4%) had a postoperative radiograph within 30 days. No radiograph showed a complication as interpreted by the surgeon at the time the radiograph was obtained, and no changes were made in routine postoperative care. On final review of each radiograph, none showed findings that would have changed management. The cost of performing and interpreting radiographs was $42.62 per patient, with a combined cost of $14,490.80. The findings of the study showed that postoperative radiographs after ACL reconstruction should not be considered "routine" practice. In addition, because these studies provided little clinical information, they are recommended only when symptoms suggest a mechanical complication and in cases of unforeseen postoperative trauma.

Outcomes for ulnar collateral ligament reconstruction: a retrospective review using the KJOC assessment score with two-year follow-up in an overhead throwing population.

BACKGROUND: Injury to the ulnar collateral ligament (UCL) often results in valgus elbow instability requiring reconstruction. No standardized and validated outcome measure has compared outcomes between surgical techniques and institutions in the overhead throwing athlete. The aim of this study was to use the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score (KJOC score) to report functional outcomes in overhead throwing athletes undergoing UCL reconstruction. We predict that the KJOC score in our general throwing population will provide an accurate assessment of postoperative outcomes consistent with previously published reports. METHODS: A retrospective review of 33 patients undergoing UCL reconstruction was carried out during a 5-year period between 2004 and 2009. Minimum follow-up was 2.2 years with an average of 3.7 years. All surgeries were performed by fellowship-trained surgeons using either the docking (n = 12) or modified Jobe technique (n = 21). Age, sport, position, and return to play status were obtained. The KJOC score was administered to assess final functional outcome. RESULTS: A total of 33 athletes underwent UCL reconstruction-30 baseball players and 3 javelin throwers. Of these, 27 (82%) returned to their sport at their previous level in an average of 12.25 months. The overall average KJOC score was 76. Athletes who returned to their previous level of play had a mean KJOC score of 77. Those who were unable to return to play had a mean score of 69. CONCLUSION: Our study demonstrates consistent outcomes for UCL reconstruction using the KJOC shoulder and elbow score compared with previously reported data.

Outcomes after distal biceps repair in patients with workers' compensation claims.

BACKGROUND: Prior studies have suggested that patients with workers' compensation (WC) related injuries have less successful postsurgical outcomes compared to the general population. The purpose of this study was to determine the functional outcome and return to work for WC patients who have undergone distal biceps tendon repair (DBTR). A group of patients without a WC claim (non-WC) served as a control. METHODS: From July 2002 to December 2009, 60 WC patients and 63 non-WC patients who underwent unilateral, acute (<6 weeks) DBTR and had a minimum of 12 months of postoperative follow-up were contacted. Data pertaining to patient age, sex, handedness, smoking status, occupation, time to return to work, and ability to return to original occupation were obtained. Functional outcomes were primarily assessed with the DASH, DASH-Work Module, and DASH Sports/Performance Arts Module questionnaires. Outcomes in the WC group were compared to the non-WC group. RESULTS: Average length of follow-up was 3.55 years (range, 1.5-8.9) in the WC group and 3.64 years (range, 2.2-8.0) in the non-WC group. Mean DASH, DASH-Work Module, and Sports/Performance Arts Module scores were significantly greater (poorer outcome) in the WC group than in the non-WC group. Average time to return to full duty was 3.95 months in the WC group and 1.35 months in the non-WC group. CONCLUSION: WC patients who underwent distal biceps tendon repair took longer to return to work and had worse DASH scores than non-WC patients. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study, Treatment Study.

The capacity of the Medical Expenditure Panel Survey to inform the Affordable Care Act.

The Affordable Care Act (ACA) was enacted with major provisions to expand health insurance coverage, control health care costs, and improve the health care delivery system. Essential data resources will be required for effective program planning, administration, and management, in addition to facilitating evaluations of program performance. The Medical Expenditure Panel Survey (MEPS) is one of the core data resources that has been used to inform several provisions of the ACA. This paper provides a summary of the capacity of the MEPS to inform program planning, implementation, and evaluations of program performance for several components of the ACA.

Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction.

BACKGROUND: The majority of the literature on surgical outcomes of superior labral anterior posterior (SLAP) repairs has focused on short-term follow-up of 1 to 2 years, not allowing adequate time for full rehabilitation and return to maximum level of competition for all types of athletes. Also, previous studies have concentrated on using questionnaires that primarily evaluate patients' activities of daily living, which do not focus on sport-specific performance. PURPOSE: To determine the midterm results of type II SLAP repairs in overhead athletes, focusing primarily on athletic performance as well as activities of daily living. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of 30 overhead athletes, who underwent an arthroscopic superior labral repair for a symptomatic type II SLAP tear between 2002 and 2007, was performed. Our study population included 22 male and 8 female patients with a mean age at the time of surgery of 24 years. Twenty-one patients participated in baseball or softball, and the remainder of patients were involved in javelin throwing or tennis. The average follow-up was 3.5 years. The outcome of treatment was evaluated using the American Shoulder and Elbow Society (ASES) scoring system, assessing activities of daily living, and the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score, assessing sport-specific performance. In addition, the length of time to return to sport and the degree of successful performance were evaluated. RESULTS: Repairs resulted in ASES scores comparable with those from prior published studies (average ASES score, 87.9). The KJOC score averaged 73.6. The athletes' perception was that they returned to approximately 84.1% of their preinjury level of function with a mean time to return to play of 11.7 months. There was a significant drop in the ASES to KJOC score for the baseball/softball players (87.9 ± 14.94 and 72 ± 19.24, respectively; P = .006). Patients reported an overall satisfaction rate of 93.3% with the procedure, with the majority being very satisfied. CONCLUSION: Arthroscopic SLAP repairs show excellent results and a high rate of overall satisfaction; however, the outcomes are less reliable in throwers. The KJOC score provides a more stringent assessment of overhead athletes' function after SLAP repair than the ASES score. Our findings also indicate that SLAP repairs lead to improved shoulder function during routine daily activities but that consistent return to elite throwing sports may still remain somewhat problematic.

Shoulder arthroscopy positioning: lateral decubitus versus beach chair.

Since the introduction of the beach chair position for shoulder arthroscopy, orthopaedic surgeons have debated whether the beach chair or lateral decubitus is superior. Most surgeons use the same patient position to perform all of their arthroscopic shoulder procedures, regardless of the pathology. Each position has its advantages and disadvantages. The evidence regarding the efficiency, efficacy, and risks of the lateral decubitus and the beach chair positions for shoulder arthroscopy does not show one position to be superior. This review presents a comparison of these positions with regard to setup, surgical visualization, access, and patient risk.

The medical expenditure panel survey: a national information resource to support healthcare cost research and inform policy and practice.

BACKGROUND: The Medical Expenditure Panel Survey (MEPS) collects detailed information regarding the use and payment for health care services from a nationally representative sample of Americans. The survey is designed to provide analysts with the data they need to support policy-relevant research on health care expenses, utilization, insurance coverage, and access in the United States and to provide policymakers with the results and data they need to make informed decisions. OBJECTIVES: This article summarizes the capacity of this broad-based and publicly available information resource to support research efforts directed towards achieving a better understanding of the dynamics of American healthcare and to better characterize its current state. METHODS: The MEPS comprises a nationally representative sample of the civilian noninstitutionalized population in the United States, and collects comprehensive data on individuals and their health care experiences over a span of 2 years. Household survey data are collected by means of computer-assisted personal interviews, and those data are supplemented by information collected directly from the medical providers used by survey participants. Insurance data are collected both from households and through a separate state and nationally representative survey of business establishments, which collects information on health insurance provided by United States employers. RESULTS: The MEPS has been used extensively in scientific publications and published reports, as well as by the Federal and state governments to examine the delivery and financing of healthcare in the United States. CONCLUSIONS: The analytical findings generated by the MEPS are key inputs to facilitate the development, implementation, and evaluation of policies and practices addressing health care in the United States and its related costs. Recent efforts to reconcile MEPS and the National Health Expenditure Accounts have the potential to provide an even more accurate and powerful data tool for research and policy analysis.

The utility of prediction models to oversample the long-term uninsured.

OBJECTIVES: To evaluate the performance of prediction models in identifying the long-term uninsured and their utility for oversampling purposes in national health care surveys. DATA AND METHODS: Nationally representative data from the Medical Expenditure Panel Survey (MEPS) were used to examine national estimates of nonelderly adults without health insurance coverage for 2 consecutive years and to identify the factors that distinguished them from the short-term uninsured and those who are continually insured. The MEPS data were also used in the development of the prediction models to identify individuals most likely to experience long-term spells without coverage in the future. The prediction models were developed using data from the MEPS panel covering 2004-2005 and evaluated with an independent MEPS panel. RESULTS: Study findings revealed these prediction models to be markedly effective statistical tools in facilitating an efficient over-sample of individuals likely to be uninsured for long periods of duration in the future. Use of these models for oversampling purposes, to support a 50% increase in sample yield over a self-weighting design, permits the selection of the target sample of individuals who are continuously uninsured for 2 consecutive years in the most cost-efficient manner. This methodology allows for an overall sample size specification for nonelderly adults that is at least 25% lower than a design without access to the predictor variables from a screening interview or without application of oversampling techniques. CONCLUSIONS: This examination of the performance of probabilistic models, to both identify and facilitate an oversample of the long-term uninsured, demonstrates the viability of these model-based sampling methodologies for adoption in national health care surveys.

The utility of extended longitudinal profiles in predicting future health care expenditures.

BACKGROUND: Health care spending is highly concentrated. Prediction models that accurately identify the characteristics of individuals most likely to incur high levels of health expenditures in a subsequent year are important analytical and statistical tools. OBJECTIVES: This study examined the capacity of alternative models to predict the likelihood of incurring high levels of medical expenditures in a subsequent year. This effort also evaluated the utility of an additional year of longitudinal information. SUBJECTS: A nationally representative sample from the Medical Expenditure Panel Survey (MEPS). METHODS: The MEPS longitudinal data are used to examine the persistence of high expenditures during a 2-year period. With the unique linkage of the MEPS to the National Health Interview Survey, the utility of an additional year of data also was examined. Resultant models were evaluated in terms of sensitivity, specificity, and predictive capacity. RESULTS: Only modest marginal gains in discrimination capacity were realized from the use of extended longitudinal profiles from the National Health Interview Survey, relative to information on prior year characteristics. CONCLUSIONS: Our results highlight the continuing concentration of health care expenditures during the period 1996 to 2002 and reveal some attenuation in magnitude in the tail of this distribution over time. Further, our results provide evidence of the utility of probabilistic models as prediction tools to identify individuals likely to incur high levels of expenditures in future years. Predictive capacity does not suffer when restricted to a single year of prior information.

Design strategies and innovations in the medical expenditure panel survey.

BACKGROUND: Recent efforts to provide an annual profile of the health care quality of the nation's health care delivery system and to identify health care disparities in the population's access to and use of health care services have served to stimulate design innovations and content enhancements to the Medical Expenditure Panel Survey (MEPS). OBJECTIVES: To present a summary of the analytical objectives, design, and core content of the MEPS, and to provide an overview of the new and innovative design features that add capacity for health status and quality of care measurement and improve data quality. SUMMARY: The MEPS questionnaire has been expanded to include content taken from the Consumer Assessment of Health Plans Study (CAHPS) to facilitate assessments of patient experiences with health care at the national level. The survey now includes the series of questions from the SF-12 and the EuroQol 5D to improve the survey's capacity to measure health status. Additional condition-specific questions for diabetes, asthma, high blood pressure, and heart disease were added to identify the health care services received for treatment and to determine whether the care received was consistent with practice guidelines. Sample design modifications are presented, with particular emphasis given to a summary of the recent sample size increase and resultant improvements in the precision of resultant survey estimates. Attention is also given to changes in survey design, estimation, and data collection strategies that improve data quality.

Regression-based sampling for persons with high health expenditures: evaluating accuracy and yield with the 1997 MEPS.

BACKGROUND: Given the high concentration of health care expenditures among a relatively small percentage of the population, the 1997 Medical Expenditure Panel Survey was designed to learn more about these high expenditure individuals by oversampling them. OBJECTIVE: Oversampling high expenditure individuals enables more precise estimation of what the nation's health care dollar buys and who pays it. It also enhances the ability to discern the causes of high health care expenses and the characteristics of the individuals who incur them. METHOD: Using the 1987 National Medical Expenditure Survey, a probabilistic model was developed to select households from the 1996 National Health Interview Survey likely to contain individuals incurring high levels of medical expenditures in the 1997 MEPS. The accuracy of the selection model, and the degree to which the high expenditure population was oversampled, are assessed with the 1997 MEPS data. RESULTS: Over half of the persons selected by the regression model were expected to have high health expenditures. Of the 456 persons selected by the model for oversampling, 257 individuals or 56.4% did, in fact, have high expenditures. Regression-based sampling increased the proportion of MEPS individuals with high expenditures from 14.3% without oversampling to 17.2% of the total cohort with oversampling (or from 938-1,126 persons). CONCLUSION: This paper demonstrates that a model-based approach to oversampling a high expenditure population, or any population with dynamic characteristics, can be highly successful in terms of sampling yield and accuracy.