Patterns in Pediatric Dental Surgery under General Anesthesia across 7 State Medicaid Programs.

OBJECTIVES: Children's access to dental general anesthesia (DGA) is limited, with highly variable wait times. Access factors occur at the levels of facility, dental provider, and anesthesia provider. It is unknown if these factors also influence utilization of dental surgery. We characterized patterns in DGA utilization by system, provider, population, and individual disease levels to explain variation. METHODS: We conducted a cross-sectional analysis of Medicaid-enrolled children (≤9 y) who received DGA in Massachusetts, Maryland, Texas, Connecticut, Washington, Illinois, and Florida from 2011 to 2012. DGA events were characterized by the place of service, measures of disease burden, average reimbursements for dental provider and anesthesia provider, and average total expenditures. RESULTS: A total of 10,149,793 children met study eligibility criteria. States with similar patterns of caries-related visits, such as Illinois (16% of Medicaid enrollees had a caries-related claim) and Washington (22%), had different DGA rates (1% and 17%, respectively). Reimbursement rates for dental providers, DGA services, and nonhospital places of services did not consistently align in states with higher DGA rates. Surgical extraction rates, as a proxy for the most severe disease, exceeded 75% in Maryland, which had the lowest DGA rate (0.3%). CONCLUSIONS: Variation in DGA rates across states was not explained by reimbursements rates (provider, DGA services, place of service) or population or individual level of caries burden. Efforts to evaluate and alter utilization of DGA should consider factors such as dental and anesthesia provider capacity, health facility capacity (hospital vs. ambulatory surgery center vs. office), and population- and individual-level disease burden. Our negative findings suggest the presence of other social determinants of oral health that influence utilization of services (e.g., race/ethnicity, language preference, immigration status, policy and budget goals), which should be explored. Our findings also raise the specter that variation in surgical rates may represent instances of unmet needs or overtreatment. KNOWLEDGE TRANSFER STATEMENT: The results of this study can be used by clinicians and policy makers as they address policy and clinical interventions to influence children with severe caries. Interventions to change utilization of surgical services on a population level may need to include state-specific factors that extend beyond reimbursement, disease burden, anesthesia provider type, or facility type.

The long-term effects of Medicaid managed care on obstetrics care in three California counties.

OBJECTIVE: To evaluate the long-term effects of Medicaid managed care (MMC) on obstetric service use and program costs in California. DATA SOURCES/STUDY SETTING: Longitudinal administrative data on Medi-Cal enrollment and claims and encounters related to pregnancy and delivery services were gathered from three counties--two long-standing MMC counties and one traditional fee-for-service Medicaid county--in California between 1987 and 1992. STUDY DESIGN: We studied Aid to Families with Dependent Children (AFDC) beneficiaries with live singleton vaginal deliveries with associated hospital stays of 14 days or less. Effects of managed care were examined with respect to prenatal visits, length of stay for delivery, maternal postpartum readmission rates, and total program expenditures. Multivariate analyses examined how the relative effect of managed care on service use and program expenditures in each MMC county evolves over time in comparison to fee-for-service. We controlled for length of Medi-Cal enrollment prior to delivery, data censoring, and individual characteristics such as race and age. PRINCIPAL FINDINGS: Prenatal care use is consistently lower in the MMC counties, although all three counties' prenatal care provision is well below the national standard. Drastic increases in one-day-stay deliveries were found: up to almost 50 percent of deliveries in MMC counties were one-day stays. Program cost savings associated with MMC enrollment are unambiguous. CONCLUSIONS: MMC cost savings might have come at the expense of reduced provision of prenatal care and shorter delivery length of stay. Future studies should verify any possible causal link and the effects on maternal and infant health outcomes.

Racial disparities in service use among Medicaid beneficiaries after mandatory enrollment in managed care: a difference-in-differences approach.

Managed care may improve access to health care to previously underserved populations when providers need plan enrollees. However, capitation and utilization management often give providers the incentive to withhold care. Managed care organizations have yet to demonstrate that racial disparities in treatment are not exacerbated. Using Medicaid eligibility, claims, and managed care encounter data, we examine racial disparities in service use among Medicaid beneficiaries after mandatory enrollment in managed care. We use count data models adjusted for nonrandom selection within difference-in-differences econometric approaches. The results show that mandatory enrollment has disproportionately reduced the relative use of physician and inpatient services among African-American beneficiaries.

The effect of changing state health policy on hospital uncompensated care.

This paper examines the effect of changing state policy, such as Medicaid eligibility, payment generosity, and HMO enrollment on provision of hospital uncompensated care. Using national data from the American Hospital Association for the period 1990 through 1995, we find that not-for-profit and public hospitals' uncompensated care levels respond positively to Medicaid payment generosity, although the magnitude of the effect is small. Not-for-profit hospitals respond negatively to Medicaid HMO penetration. Public and for-profit hospitals respond negatively to increases in Medicaid eligibility. Results suggest that public insurance payment generosity is an effective but inefficient policy instrument for influencing uncompensated care among not-for-profit hospitals. Further, in localities with high HMO penetration or high penetration of for-profit hospitals, it may be necessary to establish explicit payments for care of the uninsured.

Rates of lower-extremity amputation and arterial reconstruction in the United States, 1979 to 1996.

OBJECTIVES: This report describes trends in the rates of lower-extremity amputation and revascularization procedures and vascular disease risk factors. METHODS: We analyzed trends in National Hospital Discharge Survey data for 1979 through 1996 and in National Health Interview Study data for 1983 through 1994. RESULTS: Despite a decline between 1983/84 and 1991/92, by 1995/96 the rate of major amputation had increased 10.6% since 1979/80. The earlier 12-year decline was positively correlated with reductions in the prevalence of smoking (r = 0.88, P < .0001), hypertension (r = 0.65, P = .02), and heart disease (r = 0.73, P = .007), but not diabetes (r = -0.33, P = .29). During the 1980s, amputation and angioplasty rates were inversely correlated (r = -0.75, P = .001), but the decline in amputation rates occurred before the increase in angioplasty. The major amputation rate, which has increased since 1993, was 24.95 per 100,000 people in 1996. CONCLUSIONS: Major amputation rates fell in the years following the diffusion of distal bypass surgery but before the widespread use of peripheral angioplasty. Because disease prevalence and primary amputation rates are unknown, it is difficult to estimate the contribution of recent improvements in vascular surgery to limb preservation.

Transient paralysis of the diaphragm following radical neck surgery.

We have observed transient diaphragmatic paralysis with high alveolar to arterial oxygen partial pressure difference following radical neck surgery. Patients required supplemental oxygen for maintenance of arterial oxygenation. Patients following radical and neck surgery should be followed with chest roentgenograph to exclude pneumothorax and diaphragmatic paralysis and arterial blood gases in the immediate postoperative period.

Reduction of enflurane-induced spike activity by scopolamine.

The possibility of enflurane-induced spike activity being related to a cholinergic mechanism was investigated. Thirty mongrel dogs were anesthetized with an inspired enflurane concentration of 3.5 +/- 0.09% (mean +/- SD) to obtain a sustained EEG spike activity. Scopolamine, in 0.04 mg/kg to 0.4 mg/kg IV doses, significantly decreased the spike activity (p less than 0.05). We speculate that a central cholinergic muscarinic mechanism is at least partly responsible for the EEG spike activity produced by enflurane.

Bacterial contamination potential of sterile, prefilled humidifiers and nebulizer reservoirs.

Contaminated respiratory therapy equipment may be responsible for the spread of pathogens to hospital patients. This study focused on the potential for contamination of prefilled, sterile, disposable water and saline systems for humidification and nebulization. Gas and liquid samples from 48 prepacked oxygen humidifier/cannula and 26 prepacked nebulization setups were taken at the initial application of devices and at 8, 24, 48, and 72 hour intervals, totaling 386 cultures. All samples from the humidifier units were found to be pathogen-free for up to 3 days. A total of six or 3.84% of the nebulizer samples showed contamination with Enterobacter cloacae after 8 to 24 hours of operation. It was concluded that the potential for contamination of the humidifiers is low for up to 72 hours, but the nebulizer units should be changed after 24 hours even though their contamination rate is markedly lower than that of conventional nondisposable units.

Significance and application of blood gas determinations from the left atrial catheter.

Left atrial catheters are used to measure left heart filling pressure in patients after open-heart surgery. It was observed that in some patients blood gases obtained from the left atrial catheters had a markedly higher PO2 as compared to PaO2 in the presence of severe hypoxemia. Twenty-five patients were studied consecutively; pulmonary venous admixture calculated from arterial blood was higher in 19 patients and lower in 5 as compared with that calculated from blood withdrawn from the left atrial catheter. These differences in venous admixture are due to regional changes in the lungs. This observation can be utilized in concentrating respiratory therapy to the regions of the lungs involved with significant therapeutic benefit to the patient.

Acquired right-to-left intracardiac shunts and severe hypoxemia.

Critically ill hypoxemic patients without significant radiological changes on the chest x-ray present a diagnostic and therapeutic problem. Three patients with patent foramen ovale and a patient with a spontaneously closed congenital ventricular septal defect which reopened due to ischemic changes in the ventricular septum are presented. In reviewing the literature, we could not find this type of presentation. Their hypoxemia was associated with right-to-left intracardiac shunts demonstrated by dye dilution cardiac output curves. Because of the risk of systemic embolism associated with a right-to-left intracardiac shunt, air bubbles and particulate material in the intravenous infusion should be avoided. Use of anticoagulants may be beneficial. High inspired oxygen concentration may not correct the associated hypoxemia. The detection of these shunts is easily done at the bedside.

The anesthetic and perioperative management of a patient with documented hereditary angioneurotic edema.

A patient with documented hereditary angioneurotic edema was admitted for elective surgical extraction of 3 impacted 3rd molars under local anesthesia. In order to increase his C'1-INH level, he was prepared for operation with 2 units of fresh-frozen plasma 24 hours preoperatively. Postoperatively, he was observed in the ICU for 24 hours and on the ward for 2 days, and was discharged without any complications from the surgical trauma.

Respiratory distress with left aortic arch, right descending aorta, and right ligamentum arteriosum: a case report.

A 7-year-old girl manifested the rare anomaly of a ventricular septal defect (VSD) with left aortic arch, right descending aorta, and right ligamentum arteriosum. After open-heart surgery to correct the VSD, symptoms of tracheal obstruction on spontaneous breathing developed, due to tracheal compression by the right ligamentum arteriosum. The compressed segment of the trachea was found to be thin and unstable following division of the ligamentum. Positive-pressure breathing and continuous positive airway pressure breathing effectively splinted the patient's airway during the postoperative period, with recovery of the patient.