Registry Data Show Complication Rates and Cost in Revision Hip Arthroplasty.

BACKGROUND: Revision total hip arthroplaty (rTHA) places a burden on patients, surgeons, and health care systems because outcomes and costs are less predictable than primary THA. The purpose of this study was to define indications and treatments for rTHA, quantify risk for readmissions, and evaluate the economic impacts of rTHA in a hospital system. METHODS: The arthroplasty database of a hospital system was queried to generate a retrospective cohort of 793 rTHA procedures, performed on 518 patients, from 2017 to 2019 at 27 hospitals. Surgeons performed chart reviews to classify indication and revision procedure. Demographics, lengths of stay, discharge dispositions, and readmission data were collected. Analyses of direct costs were performed and categorized by revision type. RESULTS: Totally, 46.3% of patients presented for infection. Patients presenting for infection were 5.6 times more likely to have repeat rTHA than aseptic patients. Septic cases (4.3 days) had longer length of stay than aseptic ones (2.4) (P < .0001). However, 31% of patients discharged to a skilled nursing facility. Direct costs were greatest for a two-stage exchange ($37,642) and lowest for liner revision ($8,979). Septic revisions ($17,696) cost more than aseptic revisions ($11,204) (P < .0001). The 90-day readmission rate was 21.8%. Septic revisions had more readmissions (13.5%) than aseptic revisions (8.3%). CONCLUSIONS: Hip revisions, especially for infection, have an increased risk profile and create a major economic impact on hospital systems. Surgeons may use these data to counsel patients on risks of rTHA and advocate for improved reimbursement for the care of revision patients.

Robotic Versus Manual Total Knee Arthroplasty in High Volume Surgeons: A Comparison of Cost and Quality Metrics.

BACKGROUND: Robotic-assisted total knee arthroplasty (RTKA) was introduced to improve surgical accuracy and patient outcomes. However, RTKA may also increase operating time and add cost to TKA. This study sought to compare the differences in cost and quality measures between manual TKA (MTKA) and RTKA METHODS: All MTKAs and RTKAs performed between January 1, 2017 and December 31, 2019, by 6 high volume surgeons in each cohort, were retrospectively reviewed. Cohorts were propensity score matched. Operative time, length of stay (LOS), total direct cost, 90-day complications, utilization of postacute services, and 30-day readmissions were studied. RESULTS: After one-to-one matching, 2392 MTKAs and 2392 RTKAs were studied. In-room/out-of-room operating time was longer for RTKA (139 minutes) than for MTKA (107 minutes) P < .0001, as was procedure time (RTKA 78 minutes; MTKA 70 minutes), P < .0001. Median LOS was equal for MTKA and RTKA (33 hours). Total cost per case was greater for RTKA ($11,615) than MTKA ($8674), P < .0001. Home health care was utilized more frequently after RTKA (38%) than MTKA (29%), P < .0001. There was no significant difference in 90-day complication rates. Thirty-day readmissions occurred more often after MTKA (4.9%) than RTKA (1.2%), P < .0001. CONCLUSION: RTKA was a longer and costlier procedure than MTKA for experienced surgeons, without clinically significant differences in LOS or complications. Home health care was utilized more often after RTKA, but fewer readmissions occurred after RTKA. Longer term follow-up and functional outcome studies are required to determine if the greater cost of RTKA is offset by lower revision rates and/or improved functional results.

Oregon's Coordinated Care Organization Experiment: Are Members' Experiences of Care Actually Changing?

In 2012, Oregon embarked on an ambitious plan to redesign financing and care delivery for Medicaid. Oregon's Coordinated Care Organizations (CCOs) are the first statewide effort to use accountable care principles to pay for Medicaid benefits. We surveyed 8,864 Medicaid-eligible participants approximately 1 year before and 12 months after CCO implementation to assess the impact of CCOs on member-reported outcomes. We compared changes in outcomes over time between Medicaid CCO members, Medicaid fee-for-service (FFS) members, and those who were uninsured. After 1 year, Medicaid beneficiaries enrolled in CCOs reported better access to care, better quality care, and better connections to primary care than Medicaid FFS or uninsured persons. We did not find early evidence of improvements in preventive care and screenings or in ED utilization. Although these are early indicators, results suggest that Oregon's delivery system transformation is having a positive impact on patient experience outcomes.

Increasing and Retaining African Surgeons Working in Rural Hospitals: An Analysis of PAACS Surgeons with Twenty-Year Program Follow-Up.

BACKGROUND: African surgical workforce needs are significant, with largest disparities existing in rural settings. Pan-African Academy of Christian Surgeons (PAACS), a primarily rural-based general surgery training program, has published successes in producing rural African surgeons; however, long-term follow-up data are unreported. The goal of our study was to define characteristics of PAACS alumni surgeons working in rural hospitals, documenting successes and illuminating strategies for trainee recruitment and retention. METHOD: PAACS' twenty-year surgery residency database was reviewed for 12 programs throughout Africa regarding trainee demographics and graduate outcomes. Characteristics of PAACS' graduate surgeons were further analyzed with a 42-question survey. RESULTS: Among active PAACS graduates, 100% practice in Africa and 79% within their home country. PAACS graduates had 51% short-term and 35% long-term (beyond 5 years) rural retention rate (less than 50,000 population). CONCLUSION: Our study shows that PAACS general surgery training program has a high retention rate of African surgeons in rural settings compared to all programs reported to date, highlighting a multifaceted, rural-focused approach that could be emulated by surgical training programs worldwide.

Formerly Homeless People Had Lower Overall Health Care Expenditures After Moving Into Supportive Housing.

The provision of supportive housing is often recognized as important public policy, but it also plays a role in health care reform. Health care costs for the homeless reflect both their medical complexity and psychosocial risk factors. Supportive housing attempts to moderate both by providing stable places to live along with on-site integrated health services. In this pilot study we used a mixture of survey and administrative claims data to evaluate outcomes for formerly homeless people who were living in a supportive housing facility in Oregon between 2010 and 2014. Results from the claims analysis showed significantly lower overall health care expenditures for the people after they moved into supportive housing. Expenditure changes were driven primarily by reductions in emergency and inpatient care. Survey data suggest that the savings were not at the expense of quality: Respondents reported improved access to care, stronger primary care connections, and better subjective health outcomes. Together, these results indicate a potential association between supportive housing and reduced health care costs that warrants deeper consideration as part of ongoing health care reforms.

What does Medicaid expansion mean for cancer screening and prevention? Results from a randomized trial on the impacts of acquiring Medicaid coverage.

BACKGROUND: The Oregon Medicaid lottery provided a unique opportunity to assess the causal impacts of health insurance on cancer screening rates within the framework of a randomized controlled trial. Prior studies regarding the impacts of health insurance have almost always been limited to observational evidence, which cannot be used to make causal inferences. METHODS: The authors prospectively followed a representative panel of 16,204 individuals from the Oregon Medicaid lottery reservation list, collecting data before and after the Medicaid lottery drawings. The study panel was divided into 2 groups: a treatment group of individuals who were selected in the Medicaid lottery (6254 individuals) and a control group who were not (9950 individuals). The authors also created an elevated risk subpanel based on family cancer histories. One year after the lottery drawings, differences in cancer screening rates, preventive behaviors, and health status were compared between the study groups. RESULTS: Medicaid coverage resulted in significantly higher rates of several common cancer screenings, especially among women, as well as better primary care connections and self-reported health outcomes. There was little evidence found that acquiring Medicaid increased the adoption of preventive health behaviors that might reduce cancer risk. CONCLUSIONS: Medicaid coverage did not appear to directly impact lifestyle choices that might reduce cancer risk, but it did provide access to important care and screenings that could help to detect cancers earlier. These findings could have long-term population health implications for states considering or pursuing Medicaid expansion. Cancer 2016;122:791-797. © 2015 American Cancer Society.

Disparities in Alcohol, Drug Use, and Mental Health Condition Prevalence and Access to Care in Rural, Isolated, and Reservation Areas: Findings From the South Dakota Health Survey.

PURPOSE: Research on urban/rural disparities in alcohol, drug use, and mental health (ADM) conditions is inconsistent. This study describes ADM condition prevalence and access to care across diverse geographies in a predominantly rural state. METHODS: Multimodal cross-sectional survey in South Dakota from November 2013 to October 2014, with oversampling in rural areas and American Indian reservations. Measures assessed demographic characteristics, ADM condition prevalence using clinical screenings and participant self-report, perceived need for treatment, health service usage, and barriers to obtaining care. We tested for differences among urban, rural, isolated, and reservation geographic areas, controlling for participant age and gender. FINDINGS: We analyzed 7,675 surveys (48% response rate). Generally, ADM condition prevalence rates were not significantly different across geographies. However, respondents in isolated and reservation areas were significantly less likely to have access to primary care. Knowledge of treatment options was significantly lower in isolated regions and individuals in reservation areas had significantly lower odds of reporting receipt of all needed care. Across the sample there was substantial discordance between ADM clinical screenings and participant self-reported need; 98.1% of respondents who screened positive for alcohol or drug misuse and 63.8% of respondents who screened positive for a mental health condition did not perceive a need for care. CONCLUSION: In a predominantly rural state, geographic disparities in ADM conditions are related to differences in access as opposed to prevalence, particularly for individuals in isolated and reservation areas. Educational interventions about ADM condition characteristics may be as important as improving access to care.

Antenatal and intrapartum risk factors for use of emergency and restorative Medicaid dental services for children.

PURPOSE: To investigate the relationship between antenatal/intrapartum factors and Medicaid use. METHODS: Three databases were used: (1) birth records; (2) Medicaid files; and (3) Medicaid dental claims. RESULTS: Children of Caucasian mothers were 34 percent more likely to have more than one restorative claim versus children of African American mothers (odds ratio [OR] equals 1.34, 95 percent confidence interval [95% CI] equals 1.10 to 1.65, P<.005). Children born with low birth weight were 37 percent more likely to have emergency claims (OR equals 1.37, 95% CI equals 1.02 to 1.83, P=.03). The adjusted analysis found that Caucasian mothers had higher odds ratio of having a dental claim than African American mothers (P<.001): 33 percent for a restorative claim and 56 percent for an emergency claim. When race was analyzed, the odds of a restorative claim among African American mothers were 2.5 times higher in children delivered by C-section versus those vaginally delivered (OR equals 2.52, 95% CI equals 1.02-6.2, P<.001). CONCLUSIONS: This study found: an association between children of Caucasian mothers and the likelihood of experiencing claims; and a relationship between children born with low birth weight and C-section and the likelihood of use of Medicaid services.

Identifying demographic variables related to failed dental appointments in a university hospital-based residency program.

PURPOSE: The objective of this study was to identify characteristics of pediatric patients who failed to keep the majority of their scheduled dental appointments in a pediatric dental clinic staffed by pediatric dental residents and faculty members. METHODS: The electronic records of all patients appointed over a continuous 54 month period were analyzed. Appointment history and demographic variables were collected. The rate of failed appointments was calculated by dividing the number of failed appointments with the total number of appointments scheduled for the patient. RESULTS: There were 7,591 patients in the analyzable dataset scheduled with a total of 48,932 appointments. Factors associated with an increased rate of failed appointments included self-paying for dental care, having a resident versus a faculty member as the provider, rural residence, and adolescent aged patients. Multivariable regression models indicated self-paying patients had higher odds and rates of failed appointments than patients with Medicaid and private insurance. CONCLUSIONS: Access to care for children may be improved by increasing the availability of private and public insurance. The establishment of a dental home and its relationship to a child receiving continuous care in an institutional setting depends upon establishing a relationship with a specific dentist.

Anesthesiology resident personality type correlates with faculty assessment of resident performance.

STUDY OBJECTIVE: To study the association between anesthesiology residents' personality preference types, faculty evaluations of residents' performance, and knowledge. DESIGN: Convenience sample and prospective study. SETTING: Academic department of anesthesiology. SUBJECTS: Consenting anesthesiology residents (n = 36). INTERVENTIONS: All participants completed the Myers Briggs Type Indicator® (MBTI®). MEASUREMENTS: All residents' 6-month summation of daily focal evaluations completed by faculty [daily performance score (DPS); 1 = unsatisfactory, 2 = needs improvement, 3 = meets expectations, 4 = exceeds expectations], as well as a global assessment of performance (GAP) score based on placement of each resident into perceived quartile compared with their peers (ie,1 = first, or top, quartile) by senior faculty (n = 7) who also completed the MBTI, were obtained. The resident MBTI personality preferences were compared with the DPS and GAP scores, the United States Medical Licensing Examination (USMLE) I and II scores, and faculty MBTI personality type. MAIN RESULTS: There was no association between personality preference type and performance on standardized examinations (USMLE I, II). The mean GAP score was better (higher quartile score) for Extraverts than Introverts (median 2.0 vs 2.6, P = 0.0047) and for Sensing versus Intuition (median 2.0 vs 2.6, P = 0.0206) preference. Faculty evaluator MBTI preference type did not influence the GAP scores they assigned residents. Like GAP, the DPS was better for residents with Sensing versus Intuition preference (median 3.5 vs 3.3, P = 0.0111). No difference in DPS was noted between Extraverts and Introverts. CONCLUSIONS: Personality preference type was not associated with resident performance on standardized examinations, but it was associated with faculty evaluations of resident performance. Residents with Sensing personality preference were evaluated more favorably on global and focal faculty evaluations than those residents who chose the Intuition preference. Extraverted residents were evaluated more favorably on global but not focal assessment of performance.

Practice patterns of general dentists treating children in Kentucky: implications for access to care.

PURPOSE: The purpose of this study was to determine the impact of general dentists on access to care for children in Kentucky by assessing the extent to which they provide care for children. METHODS: A 41-question survey was mailed to all 1,774 general dentists practicing in Kentucky. It had 6 sections: (1) demographic data; (2) dental school education; (3) knowledge of national guidelines for the age 1 visit; (4) treatment of children; (5) clinical practices and desirability of additional education; and (6) participation in public insurance. RESULTS: The response rate was 33%, with a final sample size of 486. Ninety-four percent of respondents reported treating children younger than 12-years-old; however, 74% of children treated were between the ages of 7 and 14, with only 11% being younger than 3 years old. Children 3-years-old and younger and those on public insurance were represented in low numbers. CONCLUSIONS: While most general dentists reported treating children, few provided care for children 3-years-old or younger. Also, general dentists did not treat children with extensive numbers of carious lesions, and rarely performed pediatric restorative procedures such as pulpotomies and stainless steel crowns.