International Pediatric Multidisciplinary Management Using Telemedicine to Promote Equitable Care.

Objective: To evaluate the use of telemedicine as a collaboration tool between a pediatrician and subspecialists looking to address challenges, such as the lack of health care specialists, which are present in the Dominican Republic. Study design: During this 6-year study, 65 patients were evaluated by a medical team consisting of a local pediatrician and 17 subspecialists from a leading academic medical center in the Unites States. Patient's age ranged from 2 months to 16 years of age (mean 8 years old). The most common reasons for referral were masses or malignancies, vascular malformations, urogenital anomalies, stuttering, and cochlear implant programming. Results: A total of 39 out of 65 cases (60%) carried an initial diagnosis. Of the 65 cases, a change in medical management occurred in 92.31% of cases (60 cases). There was no change in medical diagnosis or treatment in 5 of 65 cases (8%). Conclusion: This protocol exhibited high patient satisfaction with the technology and platform and direct patient savings from transportation costs. It also demonstrated the importance of thorough diagnosis in providing appropriate treatment and solutions. Telemedicine use in comparable practices should be studied further to aid in the development of policies for the diagnosis and management of chronic illnesses that require referrals to subspecialists.

Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-based Medicine.

BACKGROUND: Multiple randomized trials have showed equivalent outcomes and improved patient/family satisfaction using a removable brace to treat pediatric distal radius buckle fractures (DRBF). We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at 2 tertiary care orthopaedic clinics from a baseline of 34.8% to 80%. METHODS: Clinic billing records were reviewed monthly to determine treatment (brace vs. cast) of DRBF and tracked using control charts (p-chart). Balance measures including correct application of the diagnostic criteria and algorithm were monitored. Process measures including the number of follow-up visits, radiographs obtained, and total cost of treatment were collected. Baseline data were obtained over a 3-month period, followed by a 12-month period of interventions using Plan-Do-Study-Act cycles targeting both individuals and groups of providers. RESULTS: The proportion of DRBF treated in a brace increased from a combined baseline of 34.8% to a combined 84% at the end of the study period. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as >67%), with only 1 provider continuing to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at 1 of 2 institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 following intervention. CONCLUSIONS: Implementation of brace treatment for pediatric DRBF using QI methodology resulted in a shift toward brace treatment in the majority of patients, leading to substantial medical and nonmedical cost savings. Although patient preference was cited as the most common reason for persistent cast treatment, the data show the use of cast treatment to be more dependent upon individual provider preference. LEVEL OF EVIDENCE: Level II-therapeutic.

A Dedicated Fracture Reduction Room: A Cost-Effective Alternative to the Operating Room.

INTRODUCTION: Charges, procedural efficiency, return to activity, and complications after closed treatment of fractures performed in an operating room (OR) versus closed reduction in a dedicated fracture reduction room (FRR) were compared. METHODS: Patients with closed fractures of the forearm who underwent closed reduction in the year before (OR), and after implementation of the FRR, were retrospectively reviewed. Charges, American Society of Anesthesiologists class, sex, age, length of follow-up, prior reduction, fracture location/displacement, time from injury to procedure, procedural time, time to return to activity, and complications were recorded. RESULTS: Eighteen patients met the inclusion criteria in the FRR group (13 men, 5 women), and 22 in the OR group (18 men, 4 women). No notable differences in age, sex, follow-up, American Society of Anesthesiologists class, fracture location/displacement, incidence of prior reduction, or time to return to activity were observed. Two (9.5%) complications occurred in the FRR group versus 7 (32%) in the OR group, P > 0.05. No anesthesia complications were present. Patients treated in the FRR incurred charges of $5,299 ± $1,289 versus $10,455 ± $2,290 in the OR, P < 0.001. Total time of visit in the FRR was ∼30% less than the OR, P < 0.001. No notable delay in treatment was observed. DISCUSSION: In the era of finite resources and value-based care, implementation of a FRR resulted in safe, cost-effective, and increased procedural efficiency.

A Bundled Payment Model for Pediatric Distal Radius Fractures: Defining an Episode of Care.

BACKGROUND: Distal radius fractures are the most common fracture of childhood, occurring in ∼1 per 100 children annually. Given the high incidence of these fractures, we explored feasibility of a bundled payment model. We determined the total treatment costs for each child and identified components of fracture management that contributed to variations in cost. METHODS: We retrospectively reviewed all hospital and physician costs related to the treatment of closed distal radius fractures at a large academic children's hospital. We included all children age 2 to 15 years treated by an orthopaedic surgeon for an isolated closed distal radius fracture between 2013 and 2015. We compared total treatment costs by fracture management approach. We then estimated the contribution of each component of fracture management to total treatment costs using linear regression. RESULTS: We identified 5640 children meeting the inclusion criteria, of which 4602 (81.6%) received closed treatment without manipulation, 922 (16.3%) underwent closed reduction in the clinic, emergency department, or radiology procedure suite, and 116 (2.1%) underwent treatment in the operating room. The median cost for closed treatment without manipulation was $1390 [interquartile range (IQR) 1029 to 1801], compared with $4263 (IQR, 3740 to 4832) for closed reduction and $9389 (IQR, 8272 to 11,119) for closed reduction and percutaneous pinning (P<0.001). In multivariable regression analysis, fracture management approach and use of the operating room environment were the largest cost drivers (P<0.001, R=0.88). Closed reduction in the clinic or emergency department added $894 (95% confidence interval, 819-969) to treatment costs, while closed reduction in the operating room added $5568 (95% confidence interval, 5224-6297). Location of the initial clinical evaluation, number of radiographic imaging series obtained, and number of orthopaedic clinic visits also contributed to total costs. CONCLUSIONS: Closed pediatric distal radius fractures treated without manipulation show small variations in treatment costs, making them well suited for bundled payment. Bundled payments for these fractures could reduce costs by encouraging adoption of existing evidence-based practices. LEVEL OF EVIDENCE: Level III-therapeutic.

Can sustainable hospitals help bend the health care cost curve?

As policymakers seek to rein in the nation's escalating health care costs, one area deserving attention is the health system's costly environmental footprint. This study examines data from selected hospitals that have implemented programs to reduce energy use and waste and achieve operating room supply efficiencies. After standardizing metrics across the hospitals studied and generalizing results to hospitals nationwide, the analysis finds that savings achievable through these interventions could exceed $5.4 billion over five years and $15 billion over 10 years. Given the return on investment, the authors rec­ommend that all hospitals adopt such programs and, in cases where capital investments could be financially burdensome, that public funds be used to provide loans or grants, particularly to safety-net hospitals.

Improving care for depression: performance measures, outcomes and insights from the Health Disparities Collaboratives.

This paper reports 10 measures, outcomes, and insights from HRSA Depression Health Disparities Collaboratives, representing attempts to accelerate evidence-based guidelines into practice. The authors analyze interviews with leadership of high-performing centers. Monthly data was submitted on 38,000 patients from 94 centers. Regression analyses were conducted to identify process measures predictive of better outcomes. Results indicated that these 10 measures of care were effective in guiding and quantifying improved outcomes. One measure, early and sustained response (ESR), proved particularly useful as it reflects long term outcomes. Regression analyses identified one process measure (Patient Health Questionnaire Reassessment) strongly associated with improved clinical outcomes (n=37, R2=44%). Interviews identified 18 process changes deemed pivotal for meaningful change. In sum, well-designed approaches utilizing proven improvement methodologies resulted in substantial enhancements in depression care. This approach and these measures, especially ESR and PHQ Reassessment, may improve depression care in other under-served settings.

Limitations of the radiocapitellar line for assessment of pediatric elbow radiographs.

BACKGROUND: The radiocapitellar line (RCL) is recommended for evaluating radiocapitellar alignment in skeletally immature elbows, yet its parameters have not been clearly defined. This study systematically assesses the RCL relationship in normal elbows, investigating the impacts of radiographic view, choice of anatomic landmarks, patient age, forearm position, and observer bias on the manner in which the RCL intersects the capitellum. METHODS: On radiographs of 20 normal elbows (age range, 1 to 8 y), 3 pediatric orthopaedic surgeons, blinded to clinical history, drew lines (RCLs) on anteroposterior and lateral projections, along the radial shaft and neck, and with and without the capitellum visible. Line placement was repeated 2 weeks later. The relationship of each RCL to the capitellum was assessed continuously using the perpendicular distance to the center of the capitellum, normalized to capitellar width [line-capitellar distance (LCD)], and categorically as passing through the middle third, outer two-thirds, or outside the capitellum. RESULTS: Of the 480 RCLs drawn, 23 (5%) missed the capitellum and 224 (47%) missed the middle third. More radial neck than shaft lines intersected the middle third on both anteroposterior and lateral views (P < 0.05, Fisher exact test), with the lowest LCD values for neck lines on the lateral view (P < 0.05, analysis of variance (ANOVA)). More RCLs intersected the middle third when the capitellum was visible than when it was obscured (P = 0.03, Fisher exact test), suggesting an effect of observer bias. Patient age correlated inversely with LCD (P < 0.001). The angle between the neck and shaft lines correlated positively with LCD (P < 0.001), suggesting an impact of forearm rotation position. Intraobserver and interobserver reliability was moderate-to-substantial (κ = 0.40-0.75). CONCLUSIONS: The RCL best defines normal radiocapitellar alignment when the line is drawn along the radial neck on the lateral view, although this relationship is affected by bias, patient age, and forearm rotation position. The RCL does not reliably intersect the middle third of the capitellum, arguing against its sufficiency for assessing precise radiocapitellar alignment. LEVEL OF EVIDENCE: Diagnostic Level 3.