Search

Background: Measurement of clinical outcomes is necessary to define best practice. It requires a validated tool that can be easily applied as part of clinical practice. We present the preliminary validation of a brief self-reported Review of Musculoskeletal System (ROMS) questionnaire that captures functional limitations due to musculoskeletal problems and other medical and emotional conditions. Methods: Data were derived from a clinical outcomes database (Orthopaedic Minimal Data Set [OrthoMiDaS]) that combines patient-reported data collected as part of routine care and secondary data extracted from electronic medical records. The study utilized 82,873 encounters collected from 24,116 consecutive patients with problems in the upper and lower extremities. In addition to the ROMS, the study used version 2 of the Short Form-12 (SF-12v2), the Penn Shoulder Score (PSS), the Hip disability and Osteoarthritis Outcome Score (HOOS), and the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaires. Fifteen cross-sectional samples were used to evaluate the floor and ceiling effects as well as the construct and content validity. Five longitudinal cohorts were used to measure test-retest reliability and responsiveness. Standard statistical tests were applied. Results: The floor and ceiling effects of the ROMS questionnaire in patients with shoulder, hip, and knee problems ranged from 1.3% to 8.5%. Construct-validity tests confirmed convergent and divergent validity of the ROMS. The tests also justified its additional value when the ROMS was used with joint-specific tools. When measuring test-retest reliability of the ROMS scales, intraclass correlation ranged from 0.80 to 0.90 at approximately one week and from 0.71 to 0.87 at approximately four weeks. Responsiveness of the ROMS was greater than that of the SF-12 and less than that of the jointspecific questionnaires. Conclusions: The ROMS is compatible with routine clinical process and has good psychometric properties in patients with shoulder, hip, and knee disorders. It can be used as a primary outcome tool for large observational studies and can supplement more specific tools in controlled studies. Clinical Relevance: The ROMS was developed as a tool to measure and monitor the clinical status of the musculoskeletal system in a population of patients during and after treatment as well as over time. [ABSTRACT FROM AUTHOR]

Visits to the emergency department (ED) are costly, and because some of them are potentially avoidable, some types of ED visits also may be indicative of poor care management, inadequate access to care, or poor choices on the part of beneficiaries. Billings and colleagues developed an algorithm to analyze ED visits and assign probabilities that each visit falls into several categories of appropriateness. The algorithm has been used previously to assess the appropriateness of ED visits at the community or facility level. In this analysis, the authors explain how the Billings algorithm works and how it can be applied to individual physician practices. The authors then present illustrative data from 2 years of Medicare claims data from 5 states. About one third of ED visits are deemed appropriate, and about half could have been treated in a primary care outpatient setting. Another 15% were deemed preventable or avoidable. [ABSTRACT FROM PUBLISHER]

Physical health status measures have been shown to predict death in heart failure (HF); however, few studies found significant associations after adjustment for confounders, and most were not representative of all HF patients.HF patients from southeastern MN were prospectively enrolled between 10/2007 and 12/2010, completed a 12-item Short Form Health Survey (SF-12) and a 6-minute walk, and were followed through 2011 for death from any cause. Scores 25 on the SF-12 physical component indicated low self-reported physical functioning, and the first question of the SF-12 measured self-rated general health. Low functional exercise capacity was defined as 300 m walked during a 6-minute walk. Over a mean follow-up of 2.3 years, 86 deaths occurred among the 352 participants. A 1.6-fold (95% confidence interval, 1.0-2.7) and 1.8-fold (95% confidence interval, 1.1-2.9) increased risk of death was observed among patients with low self-reported physical functioning and low functional exercise capacity, respectively. Poor self-rated general health corresponded to a 2.7-fold (95% confidence interval, 1.5-4.9) increased risk of death compared with good to excellent general health. All measures equally discriminated between who would die and who would survive (C-statistics: 0.729, 0.750, and 0.740 for self-reported physical functioning, self-rated general health, and functional exercise capacity, respectively).Three physical health status measures, captured by the SF-12 and a 6-minute walk, equally predict death among community HF patients. Therefore, the first question of the SF-12, which is the least burdensome to administer, may be sufficient to identify HF patients at greatest risk of death. [ABSTRACT FROM AUTHOR]

Background: There is a growing body of literature on surgical treatments for elderly patients with a hip fracture and the effects of various surgical procedures on complications and postoperative outcomes. No single review has previously summarized the literature on the effects of surgical procedures on outcomes after treatment across all types of hip fractures. We conducted a comprehensive systematic literature review to organize the clinical evidence for patient-centered outcomes across all types of geriatric hip fractures. Methods: We searched MEDLINE, the Cochrane Database of Systematic Reviews, Scirus, and ClinicalTrials.gov for randomized clinical trials and observational studies published between 1985 and 2008. We also manually searched reference lists from relevant systematic reviews. Results: We found eighty-one articles representing seventy-six unique,' randomized, controlled trials, including thirty-five on femoral neck fractures, forty on intertrochanteric fractures, and one on subtrochanteric fractures. Nine observational studies addressed the link between patient characteristics and outcome variables by fracture type. Age, sex, prefracture functioning, and cognitive impairment are related to mortality and functional outcomes. Fracture type does not appear to be independently related to patient outcomes. Mortality, pain, function, and quality of life did not differ by surgical implant class, or by implants within a class. Neither the randomized controlled trials nor the observational literature include the full complement of potential covariates that can impact treatment outcomes after treatment. Conclusions: The broader questions about the relationship of patient factors, fracture type, and specific treatments to the outcomes of mortality, functional status, and quality of life cannot be addressed with the existing literature. Research should include comprehensive conceptual models that capture complete sets of important independent variables. Studies of musculoskeletal outcomes, including hip fracture, require well-defined patient groups and consistent use of validated outcome measures. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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, Charison 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. [ABSTRACT FROM AUTHOR]

Background: Despite the increase in the number of total knee arthroplasty revisions, outcomes of such surgery and their correlates are poorly understood. The aim of this study was to characterize patterns of functional improvement after revision total knee arthroplasty over a two-year period and to investigate factors that affect such improvement patterns. Methods: Three hundred and eight patients in need of revision surgery were enrolled into the study, conducted at seventeen centers, and 221 (71.8%) were followed for two years. Short Form-36 (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lower-Extremity Activity Scale (LEAS) scores were collected at baseline and every six months for two years postoperatively. A piecewise general linear mixed model, which models correlation between repeated measures and estimates separate slopes for different follow-up time periods, was employed to examine functional improvement patterns. Results: Separate regression slopes were estimated for the zero to twelve-month and the twelve to twenty-four-month periods. The slopes for zero to twelve months showed significant improvement in all measures in the first year. The slopes for twelve to twenty-four months showed deterioration in the scores of the WOMAC pain subscale (slope = 0.67 ± 0.21, p < 0.01) and function subscale (slope = 1.66 ± 0.63, p < 0.05), whereas the slopes of the other measures had plateaued. A higher number of comorbidities was consistently the strongest deterrent of functional improvement across measures. The modes of failure of the primary total knee arthroplasty were instrument-specific predictors of outcome (for example, tibial bone lysis affected only the SF-36 physical component score [coefficient = -5.46 ± 1.91, p <0.01], while malalignment affected both the SF-36 physical component score [coefficient = 5.41 ± 2.35, p < 0.05] and the LEAS score [coefficient = 1.42 ± 0.69, p < 0.05]). Factors related to the surgical technique did not predict outcomes. Conclusions: The onset of worsening pain and knee-specific function in the second year following revision total knee arthroplasty indicates the need to closely monitor patients, irrespective of the mode of failure of the primary procedure or the surgical technique for the revision. This information may be especially important for patients with multiple comorbidities. [ABSTRACT FROM AUTHOR]

Purpose: To characterize cognitive test performance in a sample of US Army soldiers who had served in Iraq and Afghanistan and were tested after returning to their home base. To determine whether if a self-reported history of deployment-related traumatic brain injury (TBI), lifetime history of TBI, and the current postconcussive symptom status affected cognitive test performance. Methods: A convenience sample of 956 soldiers was administered the Automated Neuropsychological Assessment Metrics (ANAM) test battery as well as questionnaires asking about deployment-related TBI, lifetime TBI history, and current TBI-related symptoms. Results: Consistent with past mild TBI (MTBI) research, having a history of deployment-related MTBI up to 2 years prior to cognitive testing was not associated with poor ANAM performance after deployment. There also were no associations between poor ANAM performance and the number of lifetime TBIs, and injury severity and the number of problematic postconcussive symptoms. Conclusions: A history of self-reported MTBI or current postconcussive symptoms does not increase the risk of cognitive impairment in service members returning from Iraq and Afghanistan. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Nurses, certified nursing assistants, activity personnel, social workers, and physicians in 5 cities rated their ability to affect each of 17 quality of life (QoL) items for 2 hypothetical cases. Those closest to the residents feel the most empowered to make a difference. Overall, certified nursing assistants were consistently the most optimistic about their ability to influence QoL. Perceptions of ability to influence QoL were correlated with attitudes about nursing homes. These perceptions may be helpful in retaining such staff. [ABSTRACT FROM AUTHOR]

Objective: We sought to assess whether outcomes and reimbursement differ for Medicare beneficiaries with hip fracture when treated in an inpatient rehabilitation facility (IRF) compared with a skilled nursing facility (SNF) subacute rehabilitation program.Participants: Clinical data were linked with Medicare claims for 29,793 Medicare fee-for-service beneficiaries with a recent hip fracture who completed treatment in 1996 or 1997 in rehabilitation facilities that subscribed to the Uniform Data System for Medical Rehabilitation.Outcome Measures: We measured discharge destination, change in motor FIM rating, and Medicare Part A reimbursement.Results: For patients with moderate-to-severe and severe disabilities, case mix groups (CMGs) 704 and 705, the percentage of patients discharged to the community from IRFs was lower than for patients treated in subacute rehabilitation SNFs, after controlling for covariates. Adjusted odds ratios were 0.71 (95% confidence interval 0.55-0.92) for CMG 704 and 0.72 (95% confidence interval 0.63-0.83) for CMG 705. For patients in the 3 other CMGs, no significant differences were detected. Improvement in motor functional status was roughly equivalent for patients treated in IRFs and those treated in the subacute rehabilitation programs across all 5 CMGs, after controlling for covariates. Medicare Part A payments for IRFs were significantly higher than SNF payments across all CMGs.Conclusion: SNF-based subacute rehabilitation was less costly and outcomes were in most, but not all, instances similar or better than IRF-based rehabilitation for Medicare fee-for-service beneficiaries who had a recent hip fracture. [ABSTRACT FROM AUTHOR]

Background: As an elective procedure, total knee arthroplasty is under scrutiny to evaluate its cost-effectiveness. In this review, we examined the available literature on total knee arthroplasty to assess the evidence regarding factors associated with better functional outcomes. Methods: A structured literature search of English-language databases was performed to identify studies of the functional outcomes of total knee arthroplasty that had been published between 1995 and April 2003. Inclusion criteria were a study of primary total knee arthroplasty, more than 100 knees in the study, provision of baseline data and rating of postoperative outcomes with a standardized symptom scale, and an experimental or quasi-experimental study design. The abstracting form included a list of potential prognostic factors, including comorbidities, radiographic evidence of joint destruction, bone loss, integrity of the extensor mechanism, range of motion, alignment, tibiofemoral angle, and ligament integrity, as well as the characteristics of the operating surgeon, such as procedure volume and experience. Results: Sixty-two studies met the criteria and were reviewed. Total knee arthroplasty was found to be associated with substantial functional improvement, with the effect sizes varying with the measure that was used. Physician-derived measures showed effect sizes of 2.35 and 3.91, whereas patient-derived measures showed smaller effect sizes (1.27 and 1.62). Few investigators used multivariate models to identify associations between outcomes and patient characteristics. Conclusions: Total knee arthroplasty is a generally effective procedure, but the current English-language literature does not support specific recommendations about which patients are most likely to benefit from it. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to assess changes in outpatient and inpatient medical care utilization associated with outpatient and inpatient treatment of alcohol abuse by comparing alcoholics who engaged in treatment to alcoholics who presented for, but did not engage in, treatment.Research Design: Claims and encounter data of 29,122 adults receiving benefits from both a behavioral managed care company and its parent medical care insurance company who had a diagnosis of alcoholism were analyzed. The nontreated alcoholics in this sample (n = 13,133) were used for comparison and to control for historical time trend in medical utilization across the study years 1993-1999. A longitudinal over-dispersed Poisson regression model was fit by the generalized estimating equation method to compare differences in medical utilization before and after outpatient and inpatient alcoholism treatment.Results: The pattern of medical utilization before and after alcoholism treatment appears basically symmetric. There is a gradual increase, which accelerates in the year before treatment and then falls off rapidly for the first year after treatment and then falls more gradually. Such a pattern does not suggest any net savings over time. The area under the curve before treatment is basically equivalent to that after treatment. Slopes of medical utilization for both treatment groups before 1 year before treatment were statistically similar to the control groups, but during 1 year before treatment, both treatment groups' outpatient utilization increased 1.25% and inpatient utilization increased 1.8% relative to the nontreated group. The slopes posttreatment showed differential effects over time of inpatient versus outpatient alcoholism treatment on inpatient and outpatient medical utilization.Conclusions: Although a clear increase in medical utilization before treatment and a decrease in utilization after treatment was found, it is not clear if the change is linked to changes in the status of the individuals as they prepare to enter alcoholism treatment or if there is a real causal effect of the alcoholism treatment. [ABSTRACT FROM AUTHOR]

Background: It is unknown whether there is an optimal time for surgery-that is, whether waiting until a patient has greater disability results in a worse outcome. We examined the effect of baseline status on the outcome of total hip arthroplasty to determine if such a relationship existed.Methods: All Medicare patients undergoing total hip arthroplasty for osteoarthritis in twelve states were identified by the fiscal intermediary beginning in October 1994 and continuing for approximately eight months; 1640 eligible patients were identified. Consenting patients were surveyed within two months after the procedure and again at twelve months after the procedure, and their medical records were reviewed. The baseline survey, completed by 1120 patients, included items regarding the level of activity, the presence and severity of pain with walking, the need for assistance for walking, the distance that the patient could walk, and whether the patient could perform Instrumental Activities of Daily Living (IADLs). Data on comorbid diagnoses were collected from the medical records.Results: Patients with pain during walking at baseline were more likely to have pain at one year than those without pain at baseline (21% compared with 9%; p < 0.05). Patients who needed assistance with walking at baseline were more likely to need assistance at one year than those who did not need assistance at baseline (38% compared with 15%; p < 0.01). Similar results were seen with regard to the need for assistance with housework (39% compared with 18%; p < 0.01) and grocery shopping (37% compared with 14%; p < 0.01) and, to a lesser extent, for overall participation in moderate activity (17% compared with 10%; p < 0.01). These results persisted after controlling for comorbidities in a multiple regression equation. However, the worse a patient's preoperative status, the more he or she gained in all four measures (p < 0.01).Conclusions: The findings of the present study suggest that the worse a patient's preoperative status, the more he or she may benefit from total hip arthroplasty. However, our findings also suggest that patients who have a worse preoperative status may not have as good an outcome as those who have a better preoperative status. Patients and physicians should consider these findings when discussing the timing of total hip arthroplasty. [ABSTRACT FROM AUTHOR]

Discusses various issues dealing with orthopedic surgery. Lengthening of the Achilles tendon in diabetic patients; Ethics during residency training; Adverse events associated with autologous and allogenic blood transfusion.

PURPOSE: This goal of this research was to develop and evaluate the psychometrics of a health-related quality of life scale developed to address issues related specifically to fecal incontinence, the Fecal Incontinence Quality of Life Scale. METHODS: The Fecal Incontinence Quality of Life Scale is composed of a total of 29 Items; these items form four scales: Lifestyle (10 items), Coping/Behavior (9 items), Depression/Self-Perception (7 items), and Embarrassment (3 items). RESULTS: Psychometric evaluation of these scales demonstrates that they are both reliable and valid. Each of the scales demonstrate stability over time (test/retest reliability) and have acceptable internal reliability (Cronbach alpha > 0.70). Validity was assessed using discriminate and convergent techniques. Each of the four scales of the Fecal Incontinence Quality of Life Scale was capable of discriminating between patients with fecal incontinence and patients with other gastrointestinal problems. To evaluate convergent validity, the correlation of the scales in the Fecal Incontinence Quality of Life Scale with selected subscales in the SF-36 was analyzed. The scales in the Fecal Incontinence Quality of Life Scale demonstrated significant correlations with the subscales in the SF-36. CONCLUSIONS: The psychometric evaluation of the Fecal Incontinence Quality of Life Scale showed that this fecal incontinence-specific quality of life measure produces both reliable and valid measurement. [ABSTRACT FROM AUTHOR]

The purpose of this research was to develop and evaluate a severity rating score for fecal incontinence, the Fecal Incontinence Severity Index.The Fecal Incontinence Severity Index is based on a type × frequency matrix. The matrix includes four types of leakage commonly found in the fecal incontinent population: gas, mucus, and liquid and solid stool and five frequencies: one to three times per month, once per week, twice per week, once per day, and twice per day. The Fecal Incontinence Severity Index was developed using both colon and rectal surgeons and patient input for the specification of the weighting scores.Surgeons and patients had very similar weightings for each of the type × frequency combinations; significant differences occurred for only 3 of the 20 different weights. The Fecal Incontinence Severity Index score of a group of patients with fecal incontinence (N = 118) demonstrated significant correlations with three of the four scales found in a fecal incontinence quality-of-life scale.Evaluation of the Fecal Incontinence Severity Index indicates that the index is a tool that can be used to assess severity of fecal incontinence. Overall, patient and surgeon ratings of severity are similar, with minor differences associated with the accidental loss of solid stool. [ABSTRACT FROM AUTHOR]