RESUMEN
BACKGROUND: The use of musculoskeletal ultrasound (MSKUS) for point-of-care (POC) evaluation of hemophilic arthropathy is growing rapidly. However, the extent to which MSKUS influences clinical treatment decisions is unknown. METHODS: We conducted a three-year, prospective, multi-center study at three hemophilia treatment centers in the United States to evaluate the utilization of POC-MSKUS for routine clinical decision-making in adult persons with hemophilic arthropathy. Bilateral elbows, knees and ankles were assessed clinically [Hemophilia Joint Health Score (HJHS)] and with POC-MSKUS by the Joint TissueActivity and Damage Exam (JADE) protocol at baseline and approximately annually for two additional times. Treatment decisions, including physical therapy (PT) and "medical" (joint injections/aspirations, referrals to orthopedics, changes/adjustments of hemostatic plans, and use of oral anti-inflammatory medications) were recorded in relation to POC-MSKUS. RESULTS: Forty-four persons [median age 37 years (IQR 29, 51)], mostly with severe Hemophilia A on clotting factor prophylaxis, completed 129 visits, yielding 792 joint exams by POC-MSKUS and HJHS [median at baseline 27 (IQR 18, 42)] over a median follow up of 584 days (range: 363 to 1072). Among 157 management decisions, 70% were related to PT plans (n = 110) and 30% were "medical". Point-of-care MSKUS influenced 47/110 (43%) PT plans, mostly informing treatment of specific arthropathic joints (45/47 plans) in patients with high HJHS. Physical therapy plans influenced by POC-MSKUS directed more manual therapy/therapeutic exercises, while plans based on physical exam were focused more on global exercises and wellness. Treatment decisions were mostly based on the identification of specific musculoskeletal abnormalities visualized by POC-MSKUS. Of note 20/47 (43%) POC-MSKUS plans included de-escalation strategies, thereby reducing exercise intensity, mostly for joint instability and subclinical hemarthroses. Point-of-care MSKUS also informed 68% (32/47) of "medical" decisions, surprisingly mostly for injections/aspirations and referrals to orthopedics, and not for adjustments of hemostatic treatment. Although not formally studied, ultrasound images were used frequently for patient education. CONCLUSION: Routine joint evaluations with POC-MSKUS resulted in few changes regarding medical management decisions but had a profound effect on the formulation of PT plans. Based on these findings, new studies are essential to determine the benefit of MSKUS-informed management plans on joint health outcomes.
Asunto(s)
Artritis , Hemofilia A , Hemostáticos , Adulto , Humanos , Hemofilia A/diagnóstico por imagen , Hemofilia A/terapia , Sistemas de Atención de Punto , Estudios Prospectivos , HemartrosisRESUMEN
Dentists need to be able to make informed decisions about the contracts they are considering. Knowledge of participation agreements and typical provisions provides means for evaluating the potential impact of individual contracts on a dental practice.
Asunto(s)
Servicios Contratados/legislación & jurisprudencia , Odontólogos/legislación & jurisprudencia , Organizaciones del Seguro de Salud/legislación & jurisprudencia , Contabilidad/legislación & jurisprudencia , Confidencialidad/legislación & jurisprudencia , Habilitación Profesional/legislación & jurisprudencia , Administración Financiera/legislación & jurisprudencia , Humanos , Responsabilidad Legal , New York , Derivación y Consulta/legislación & jurisprudenciaAsunto(s)
Beneficios del Seguro/legislación & jurisprudencia , Seguro Odontológico/legislación & jurisprudencia , Atención Odontológica/legislación & jurisprudencia , Humanos , Revisión de Utilización de Seguros/legislación & jurisprudencia , Reembolso de Seguro de Salud/legislación & jurisprudencia , New YorkRESUMEN
America appears to be moving inexorably toward managed medical care. Where does that leave dentists? By not joining in the movement they run the risk of losing out altogether. Organized dentistry hopes to provide an answer through its bid for legislation to allow its members to compete fairly in the ever-changing health care marketplace.