The association of pre-existing mental health conditions and patient outcomes after lower extremity orthopaedic trauma: a scoping review.

INTRODUCTION: Existing research has established a correlation between post-traumatic mental health conditions, including anxiety and depression, and various aspects of recovery, such as pain exacerbations, reduced functional recovery, and lowered patient satisfaction. However, the influence of pre-existing mental health conditions on orthopaedic trauma outcomes has not been thoroughly investigated. The objective of this study was to systematically review literature addressing the association between pre-existing mental health conditions and patient outcomes following surgical interventions for lower extremity fractures in non-geriatric populations. METHODS: A systematic literature review was conducted using Medline, Embase, and Scopus databases following PRISMA-ScR guidelines to select studies that examined lower extremity orthopaedic trauma outcomes in relation to pre-existing mental health conditions. Studies that evaluated patients with surgically treated lower extremity fractures and a history of mental health conditions such as anxiety, depression, or mood disorders were included. Studies with a mean patient age above 65 years of age were excluded to focus on non-geriatric injury patterns. RESULTS: The systematic review identified 12 studies investigating the relationship between surgical outcomes of orthopaedic lower extremity fractures and pre-existing mental health disorders in non-geriatric populations. Studies included patients with pelvis, femur, tibia, and ankle fractures. A majority (83%) of these studies demonstrated that patients with pre-existing mental health diagnoses had inferior functional outcomes, heightened pain levels, or an increase in postoperative complications. DISCUSSION: The presence of pre-existing mental health conditions, particularly anxiety and depression, may predispose orthopaedic trauma patients to an elevated risk of suboptimal functional outcomes, increased pain, or complications after surgical intervention for lower extremity fractures. Future research should focus on interventions that mitigate the impact of mental health conditions on orthopaedic outcomes and patient wellness in this population.

A Framework for Studying Healthcare Equity in Adolescent Idiopathic Scoliosis: Scoping Review and Meta-Analysis of Existing Literature.

INTRODUCTION: Health inequities remain a notable barrier for pediatric patients, especially in conditions such as adolescent idiopathic scoliosis (AIS), where the efficacy of nonsurgical treatment is dependent on early diagnosis and referral to a specialist. Social determinants of health (SDOH) are nonmedical factors that affect health outcomes, such as economic stability, neighborhood environment, and discrimination. Although these factors have been studied throughout the AIS literature, considerable inconsistencies remain across studies regarding the investigation of SDOH for this population. Through a scoping review, we analyze the existing literature to propose a comprehensive framework to consider when designing future prospective and retrospective studies of healthcare equity in AIS. METHODS: A systematic review was executed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. A meta-analysis was performed for each reported SDOH (race, ethnicity, insurance provider, and socioeconomic status) including only studies with complete and consistent variables and outcomes. Cobb angle measurements were aggregated and summarized as the weighted mean difference with 95% confidence interval using a fixed or random-effects model (substantial heterogeneity identified). RESULTS: Of 7,539 studies reviewed, nine studies met all the inclusion criteria. As expected, considerable inconsistencies were found across the nine studies making it difficult to aggregate data. Within the meta-analyses, the mean difference between White non-Hispanic and Hispanic patients was statistically significant (1.71; 95% confidence interval 0.78 to 2.65; P < 0.001). No other statistically significant differences were identified among the SDOH and presenting main Cobb angle magnitude. CONCLUSION: These studies provide insight into healthcare inequities in AIS, although notable inconsistencies make it difficult to aggregate data and draw the conclusions needed to drive necessary public health changes. However, our proposed framework can provide a guideline for future prospective and retrospective studies to standardize data reporting and allow for improved collaboration, study design, and future systematic reviews and meta-analyses.

Financial Impact of Imaging Examination Site of Service in the Medicare Population.

PURPOSE: The financial sustainability of the US healthcare system is a growing concern in an environment of declining reimbursement and rising costs. Variable Centers for Medicare and Medicaid (CMS) reimbursement and denial rates for specific imaging examinations exist across sites of service, adding complexity to financial planning for healthcare organizations. Understanding the financial implications of site of service in existing CMS reimbursement for imaging may be of strategic importance for organizations going forward. MATERIALS AND METHODS: Current Procedural Terminology (CPT) codes were obtained for common cross-sectional imaging examinations using the 2022 CMS Medicare Physician Fee Schedule. Using reimbursement rates with historical volumes and denial rates, a simulation was created to estimate the overall reimbursement of paired hospital outpatient departments (HOPD) and free-standing office (FSO) sites. A baseline simulation was performed with random allocation of imaging examinations between sites of service, and an optimized simulation was performed to estimate the maximum financial impact of targeted allocation between sites. These simulations were performed for paired CT and MR scanners separately. RESULTS: For CT, the baseline simulation estimated annual average reimbursement for combined HOPD and FSO was $3.25M. Reimbursement increased to $3.51M after optimized reallocation of studies between sites of service, resulting in an expected gain of $260,162 for a set of paired HOPD and FSO scanners. For MR, the same approach resulted in baseline reimbursement of $2.51M, increasing to $2.60M upon reallocation between sites for an expected gain of $87,532. Assuming a stable cost of service delivery, this approach would result in improved margins of 8% for CT and 3.5% for MR. There were 28 CT and 19 MRI daily patient imaging appointments at each respective HOPD and FSO scanners, unchanged between baseline and optimized cases. Differences in reimbursement rates between sites were the dominant driver of increased margins at low denial rates, although denial rates became dominant at values greater than 50%. CONCLUSION: Given CMS payment and denial rate variability, optimally allocating imaging studies between sites of service may improve reimbursement for the same services delivered. Although financial incentives exist for site allocation, such decisions should require physician input to assess safety and appropriate level of care. This work contributes to an understanding of financial incentives of existing reimbursement policy and may guide future policy design towards high value care.