WHO IS TAKING CARE OF GERIATRIC TRAUMA Kirton, Orlando C.; Virnig, Beth A.; McKenney, Mark G. ...
Critical care medicine,
01/1998, Letnik:
26, Številka:
Supplement
Journal Article
Background Intramedullary nails provide no clear outcomes benefit in the majority of patients with intertrochanteric hip fracture, yet their use in the United States continues to increase. ...Non-patient factors that are associated with intramedullary nail use among Medicare patients have not been examined. The goal of this study was to identify the surgeon and hospital characteristics that were associated with the use of intramedullary nails compared with plate-and-screw devices among elderly Medicare patients with intertrochanteric hip fractures. Methods Medicare beneficiaries who were sixty-five years of age or older and underwent inpatient surgery to treat an intertrochanteric femoral fracture with use of an intramedullary nail or a plate-and-screw device were identified from the United States Medicare files for 2000 to 2002. Surgeon and hospital characteristics from the Medicare provider enrollment files were merged with the claims. Generalized linear mixed models with fixed and random effects modeled the association between surgeon and hospital factors and intramedullary nail use (compared with plate and screws), controlling for patient age, sex, and race; subtrochanteric fracture; Charlson comorbidity score; nursing home residence; and Medicaid-administered assistance. The adjusted odds ratios of receiving an intramedullary nail by year, surgeon, and hospital factors are reported. Results There were 192,365 claims for surgery to treat an intertrochanteric hip fracture that met the inclusion criteria and matched with surgeon and hospital information. There were 15,091 surgeons who performed intertrochanteric hip fracture surgeries in Medicare patients in 3480 hospitals between March 1, 2000, and December 31, 2002. The surgeon factors associated with intramedullary nail use include younger surgeon age (less than forty-five years old), an osteopathy degree, and operating at more than one hospital. The hospital factors associated with intramedullary nail use include a higher volume of intertrochanteric hip fracture surgeries, teaching hospital status, and having resident assistance during surgery. Surgeon factors improved the model fit more than hospital factors. Conclusions The use of intramedullary nails was strongly associated with early-career surgeons and surgeon training programs. Our findings suggest that orthopaedic faculty at teaching hospitals and younger surgeons may be selecting orthopaedic implants on the basis of factors other than clinical outcomes evidence. We expect that intramedullary nail use will continue to increase as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospital's burden of their choices for higher cost devices under the Medicare payment system. Level of Evidence Prognostic Level II . See Instructions to Authors for a complete description of levels of evidence.
Background Research on the relationship between orthopaedic volume and outcomes has focused almost exclusively on elective arthroplasty procedures. Geriatric patients who have sustained an ...intertrochanteric hip fracture are older and have a heavier comorbidity burden in comparison with patients undergoing elective arthroplasty; therefore, any advantage of provider volume in terms of mortality could be overwhelmed by the severity of the hip fracture condition itself. This study examined the association between surgeon and hospital volumes of procedures performed for the treatment of intertrochanteric hip fractures in Medicare beneficiaries and inpatient through ninety-day postoperative mortality. Methods The Medicare 100% files of hospital and physician claims plus the beneficiary enrollment files for 2000 through 2002 identified beneficiaries who were sixty-five years of age or older and who underwent inpatient surgery for the treatment of an intertrochanteric hip fracture with internal fixation. Provider volumes of intertrochanteric hip fracture cases were calculated with use of unique surgeon and hospital provider numbers in the claims. Fixed effects regression analysis using generalized estimating equations was used to model the association between hospital and surgeon intertrochanteric hip fracture volume and inpatient through ninety-day mortality, controlling for age, sex, race, Charlson comorbidity score, subtrochanteric fracture, prefracture nursing home residence, Medicaid-administered assistance, surgical device, and year. The unadjusted inpatient, thirty, sixty, and ninety-day mortality rates and adjusted relative risks are reported. Results Between March 1, 2000, and December 31, 2002, 192,365 claims met inclusion criteria and matched with provider information. The unadjusted inpatient, thirty-day, sixty-day, and ninety-day mortality rates were 2.91%, 7.92%, 12.34%, and 15.19%, respectively. Patients managed at lower-volume hospitals had significantly higher (10% to 20%) adjusted risks of inpatient mortality than those managed at the highest-volume hospitals. By sixty days postoperatively, the increased mortality risk persisted only among patients managed at the lowest-volume hospitals (six cases per year or fewer). Patients who were managed by surgeons who treated an average of two or three cases per year had the highest mortality risks when compared with patients managed by the highest-volume surgeons. Conclusions Only the highest-volume hospitals showed an inpatient mortality benefit for Medicare patients with intertrochanteric hip fractures. Unlike the situation with elective arthroplasty procedures, our findings do not indicate a need to direct patients with routine hip fractures exclusively to high-volume centers, although the higher mortality rates found in the lowest-volume hospitals warrant further investigation. Level of Evidence Prognostic Level II . See Instructions to Authors for a complete description of levels of evidence.
The association between smoking and occupational status is explored using data from the Minnesota Heart Survey. 7,381 currently employed subjects were included in the study (2,949 from the 1980–1982 ...survey and 4,432 from the 1985–1987 survey). In the first survey the prevalence of current smokers ranged from 23 (professional) to 57% (service occupations) in men and from 15 (artists and writers) to 59 (repair and craft occupations) in women. Educational level, age, race, and sex were important predictors of smoking status in a logistic regression analysis using combined data from the two surveys; occupational status was significantly associated with smoking after controlling for these covariables. Public health efforts should focus more on preventing smoking in lower educational groups and in those occupational groups that have the highest prevalence of smoking.
The Medicare-HMO Revolving Door Josephson, D G; Grana, J R; Hanchak, N A
The New England journal of medicine,
12/1997, Letnik:
337, Številka:
25
Journal Article
Recenzirano
To the Editor:
We have major questions about the methods and conclusions of Morgan et al. (July 17 issue)
1
in their study of the Medicare–health maintenance organization (HMO) revolving door. The ...authors admit that the study area, southern Florida, is unique, having “more Medicare beneficiaries than each of 35 states, one of the nation's highest per capita health care costs, and the nation's second highest Medicare capitated rate.” Nevertheless, the authors generalize their results to the whole nation without reservation or qualification — a serious leap of faith and lapse of judgment.
In addition, the authors excluded Medicare recipients who . . .
Background Hip fractures in the elderly are a common and costly problem, with intertrochanteric fractures accounting for almost half of these fractures. Most intertrochanteric fractures are treated ...with either a plate-and-screw device or an intramedullary nail device. We assessed the degree of geographic variation in use of intramedullary nailing for intertrochanteric femoral fractures among Medicare beneficiaries between 2000 and 2002. Methods Medicare 100% files (hospital and physician claims, and enrollment) for 2000 through 2002 were used to identify beneficiaries, sixty-five years of age or older, who had undergone inpatient surgery for the treatment of an intertrochanteric femoral fracture with a plate-and-screw device or an intramedullary nail. We used multiple logistic regression analysis to model the use of an intramedullary nail (as opposed to a plate-and-screw device) by state and year, after adjusting for patient age, sex, race, subtrochanteric fracture, comorbidities, and Medicaid-administered assistance. The odds ratios of receiving an intramedullary nail device are reported. The adjusted state rates of intramedullary nailing per 100 Medicare patients with an intertrochanteric fracture are reported for 2000 through 2002. Results In this study, 212,821 claims for operations to treat patients with an intertrochanteric fracture from 2000 through 2002 met the inclusion criteria. There was considerable geographic variation in intramedullary nail use by state across all years. The mean adjusted intramedullary nailing rate per 100 Medicare patients with an intertrochanteric fracture increased nationally from 7.84 in 2000 to 16.98 in 2002. In 2000, surgeons in sixteen states used an intramedullary nail in fewer than one of every twenty Medicare patients with an intertrochanteric fracture. By 2002, surgeons in only two states used an intramedullary nail in fewer than one of every twenty patients with an intertrochanteric fracture, and in eight states they used an intramedullary nail in more than one of every four patients with an intertrochanteric fracture. Conclusions There was substantial geographic variation in the use of intramedullary nailing by state from 2000 through 2002 that was largely not explained by patient-related factors.
Data from the 1980-1982 & 1985-1987 Minnesota Heart Surveys of currently employed Ss (N = 2,949 & 4,432, respectively) are used to explore the association between smoking & occupational status. In ...the first survey, the prevalence of current smokers ranged from 23% (professional) to 57% (service occupations) in men & from 15% (artists & writers) to 59% (repair & craft occupations) in women. Educational level, age, race, & sex were important predictors of smoking status in a logistic regression analysis that combined data from both surveys; occupational status was significantly associated with smoking after controlling for these covariables. Public health efforts should focus more on preventing smoking in lower educational groups & in occupational groups with the highest prevalence of smoking. 3 Tables, 17 References. Adapted from the source document.
BACKGROUND While disparities in access to care are well documented, little is known
about the quality of mental health care received by racial and ethnic minorities.
We examined the quality of mental ...health care received by elderly enrollees
in Medicare + Choice plans. METHODS An observational study was performed using individual-level Health Plan
Employer Data and Information Set data. From 4182 to 5 016 028 individuals
65 years or older and enrolled in Medicare + Choice plans in 1999 were involved
in different measures. Rates of mental health inpatient discharges, average
length of stay, percentage of members receiving mental health services, rates
of follow-up after hospitalization for mental illness, optimal practitioner
contacts for antidepressant medication management, and effective acute- and
continuation-phase treatment were assessed. RESULTS Compared with whites, minorities received substantially less follow-up
after hospitalization for mental illness. The 30-day follow-up rates for whites,
African Americans, Asians, and Hispanics were 60.2%, 42.4%, 54.1%, and 52.6%,
respectively. Minorities also had lower rates of antidepressant medication
management for newly diagnosed episodes of depression. The rates of optimal
practitioner contacts for whites, African Americans, Asians, and Hispanics
were 12.5%, 12.0%, 11.1%, and 10.6%; the rates of effective acute-phase treatment
were 60.1%, 48.5%, 40.7%, and 57.6%; and the rates of effective continuation-phase
treatment were 46.7%, 32.7%, 31.9%, and 39.6%, respectively. The statistically
significant disparities persisted after adjusting for effects of age, sex,
income, plan model, profit status, and region of the country. CONCLUSIONS The overall quality of mental health care for people enrolled in Medicare
+ Choice managed care plans is far from optimal. There are large and persistent
racial differences that merit further attention to better understand their
underlying causes and solutions.Arch Gen Psychiatry. 2004;61:201-205-->
Group B Streptococcus (GBS) is an important cause of perinatal morbidity and mortality in the United States. In 1996, guidelines from the Centers for Disease Control and Prevention (CDC) recommended ...that prenatal care providers either screen all pregnant women for GBS carriage and offer intrapartum antibiotic prophylaxis (IAP) to women who test positive, or offer IAP to women who have risk factors for early-onset GBS (EOGBS) disease during pregnancy. A recent multi-state retrospective cohort compared the efficacy of the 2 methods and found the screening-based method to be significantly more effective at reducing the incidence of EOGBS. One of the study sites was the 7-county Minneapolis-St. Paul metropolitan area. Analysis of Minnesota data also found screening to be more effective in reducing EOGBS than the risk-based approach. In August 2002, the CDC published new guidelines that recommend adoption of a universal screening approach to management of perinatal GBS infections.
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