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Background: Valid outcome measurement tools are required to reliably demonstrate the effectiveness and clinical outcomes of lower-extremity arthroplasty. Having ascertained a lack of a practical and valid measure of the change in actual daily physical activity that occurs prior to and following lower-limb arthroplasty, we developed and validated a lower-extremity activity scale.Methods: The eighteen-level self-administered scale was developed with the aid of content experts to ensure face validity. Validity and reliability were assessed with the use of (1) pedometer measurements of seventy subjects over seven days; (2) next-of-kin proxy measurements of the activity levels of ninety patients before they underwent lower-limb arthroplasty; and (3) application, and correlation with the Western Ontario and McMaster Universities Osteoarthritis Index scores, in a prospective seventeen-center clinical study of 297 consecutive patients undergoing revision total knee arthroplasty. In this latter study, demographic and comorbidity data were also collected. Univariate and bivariate correlations were performed, and a multivariate structured equation modeling approach was used to further test responsiveness, reliability, and validity of the lower-extremity activity scale.Results: Pedometer readings correlated with the activity levels derived with the lower-extremity activity scale (r = 0.79). Of note was the finding that age, weight, and body mass index did not correlate well with the average number of steps per day (r = -0.32, -0.32, and -0.25, respectively). A significant correlation was found between the lower-extremity activity scores recorded by the patients and those reported by their next of kin (Pearson correlation, r = 0.715; p = 0.0001) and between the initial lower-extremity activity scores and two-week-retest scores (intraclass correlation = 0.9147; p < 0.0001), demonstrating the validity and reliability of the scale. The lower-extremity activity scale was responsive, accurately reflecting changes in the patient's condition between baseline and the time of follow-up (p < 0.001), and it was reliable, with baseline values correlating with follow-up scores (p < 0.001). The convergent validity of the lower-extremity activity scale was established by correlations with the function scores (r = -0.301, p < 0.001) and pain scores (r = -0.241, p < 0.001) derived with the Western Ontario and McMaster Universities Osteoarthritis Index and with a higher number of comorbidities (r = -0.244, p < 0.001). Multivariate path modeling further demonstrated diminished activity in patients who had more difficulty in functioning and a greater number of comorbidities.Conclusions: We developed a lower-extremity activity scale and validated that it was an effective instrument for the assessment of patients' actual activity levels. It is easy to apply and interpret, and it is valid and ready for use in the clinical setting. This scale will allow more accurate analysis and prediction of outcomes. Consequently, it will become a useful, practical adjunct to objective clinical decision-making and intervention for patients undergoing arthroplasty. [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]

OBJECTIVES: This study explores how well staff and family proxies' reports on selected quality-of-life (QOL) domains (comfort, dignity, functional competence, privacy, meaningful activity, food enjoyment, relationships, security, and autonomy) correspond to residents' own reports. METHODS: We compared QOL domain scores for nursing home residents and 1,326 staff proxies and 989 family proxies at the individual and facility level using means, Pearson correlation statistics, and intraclass correlations. Regression models adjusted for residents' age, gender, length of stay, ability to perform activities of daily living, and cognition. RESULTS: For each domain in more than half the cases, proxy means were within 1 SD of the resident means. Resident and family proxy individual reports for selected domains were correlated at 0.14 to 0.46 (all p <.000). Resident and staff proxy individual reports were correlated at 0.13 to 0.37 (all p <.000). Correlation of mean levels by facility for staff proxies was 0.26 to 0.64 (generally p <.05) and for family proxies 0.13 to 0.61 (p <.01 except for one domain). DISCUSSION: Although staff and family proxy domain scores are significantly correlated with resident scores, the level of correlation suggests they cannot simply be substituted for resident reports of QOL. Determining how proxy reports can be used for residents who cannot be interviewed at all remains an unresolved challenge. [ABSTRACT FROM AUTHOR]

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 joint-specific 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., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Femoral component size selection during total knee arthroplasty should not vary from surgeon to surgeon for patients with the same bone size. This study explored if systematic variations in femoral component size selection exist. Thirteen surgeons' choices of femoral component size (Duracon, n = 1388; Triathlon, n = 740) were analyzed using a generalized linear model with femoral component size as the dependent variable and surgeon identification, years in practice, and adult reconstruction fellowship training as the independent variables. The model adjusted for differences in bone size. It was found that more experienced surgeons implant larger femoral components. New instruments and training protocols may be necessary to adjust for surgeon experience.

Background: In sarcoma patients the roles of smoking history, family cancer history, and leukoreduced blood transfusions have not been studied and the effect of preoperative radiation on blood loss has not been examined., Methods: Seventy-seven patients with non-metastatic and non-recurrent thigh sarcomas surgically treated at the Cleveland Clinic were identified. Among patient variables studied were: close family history of cancer, perioperative transfusion history, smoking history, and radiation history. Median follow-up for the survivors was 3.2 years., Results: We found that tumor grade, transfusion >3 U (P = 0.022), and pre- or post-operative radiation therapy (P = 0.041) were risk factors for distant metastasis. Tumor grade (P = 0.008), positive smoking history (P = 0.039), and >3 U of non-leukoreduced blood transfused (P = 0.037) were risk factors for death of any-cause. Close family history of cancer correlated with having a grade 3 sarcoma (P = 0.044). Neoadjuvant radiotherapy correlated with >3 U of blood transfused (P = 0.001) and biopsy performed at the treating institution led to a significant decrease in rate of recurrence (P = 0.016)., Conclusions: We present novel findings in terms of transfusions, family history of cancer and site of initial biopsy in sarcoma patients.

Background: The purpose of this study was to investigate further the effect of medical comorbidity on a patient reported shoulder specific health related quality of life (HRQoL) measure. We investigated which types of comorbidities have a detrimental effect upon shoulder specific HRQoL. We hypothesized that general medical comorbidity would not negatively affect shoulder specific HRQoL questionnaires, but that comorbidities specific to the chest region would, when properly controlling for other patient factors., Methods: A cohort of 173 consecutive patients who underwent shoulder surgery for osteoarthritis and/or rotator cuff repair was extracted from a clinical outcomes database. Their health related quality of life (HRQoL) was evaluated with the University of Pennsylvania (PENN) shoulder score and the Short Form-36 (SF-36). Nonadjusted and multivariate risk-adjusted models were built to investigate the effect of medial comorbidity on shoulder specific HRQoL and were tested using linear modeling., Results: Nonadjusted models showed patients with more total comorbidities (P=.01) and more chest-related comorbidities (P=.006) had lower PENN scores. But, when risk adjusting for other patient factors, the PENN scores decreased with an increase in the number of chest comorbidities (P=.008), but not the number of total comorbidites (P=.391) or other (nonchest) comorbidities (P=.163)., Conclusion: Shoulder specific HRQoL measures are joint specific, but they are influenced by disease or conditions that affect the chest region. This may be important in understanding why patients with certain comorbid diseases report worse shoulder pain and function and may respond differently to treatment over time., ((c) 2010 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Purpose: The purpose of this study was to develop and validate a model predicting whether patients would have shorter-than-typical or longer-than-typical recoveries after hip arthroscopy for labral tears., Methods: We retrospectively reviewed 268 cases of hip arthroscopy implemented between 2000 and 2007 by 2 orthopaedic surgeons at our institution. The development cohort consisted of patients with magnetic resonance angiography-identified labral tears and a history and physical examination consistent with either labral pathology or loose bodies. Univariate analysis targeted preoperative patient characteristics correlated with the risk of longer-than-typical recoveries. Multivariate logistic regression was applied to generate an algorithm predicting risk of longer-than-typical recovery based on baseline characteristics. The algorithm was tested in the validation sample of 52 patients who were treated in 2007 and was found to be valid., Results: Five predictors for longer-than-typical recovery were identified: Workers' Compensation status, female gender, use of pain medications, presence of a limp, and presence of a lateral labral tear. The multivariate algorithm was developed and successfully validated., Conclusions: This study identifies many new predictors of recovery, and it also corroborates those that have already been identified. The 5 predictors for longer-than-typical recovery identified by our validated multivariate algorithm were Workers' Compensation status, female gender, use of pain medications, presence of a limp, and presence of a lateral labral tear., Level of Evidence: Level IV, therapeutic case series., (Copyright 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

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.

Background: Despite the numerous outcomes measures described it remains unclear what aspects of patient outcome are important in determining actual improvement following total knee arthroplasty revisions (TKAR). We performed a prospective cohort study of TKAR to determine the components of clinical improvement and how they are related and best measured., Methods: An improvement scale was devised utilizing data from 186 consecutive TKAR patients on SF-36 physical (PCS) and mental (MCS) components, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index, Knee Society Score (KSS), a novel Activity Scale (AS) and a physician derived severity assessment scale performed both preoperatively and at 6 month post-operative follow-up. The change in each of these scores was analyzed using factor analysis, deriving a composite improvement scale., Results: All the instruments demonstrated statistically significantly better scores following TKAR (except the SF-36 MCS). Furthermore, all significant correlations between the scores were positive. Statistical factor analysis demonstrated that scores could be arranged into 4 related factor groupings with high internal consistency (Cronbach Alpha = 0.7). Factor 1 reflected patient perceived functional outcomes, Factor 2 activity levels, Factor 3 the MCS and Factor 4 the KSS., Conclusion: This study demonstrates that improvement following TKAR has a multidimensional structure. The improvement scales represent a more coordinated method of the previously fragmented analysis of TKAR outcomes. This will improve assessment of the actual effectiveness of TKAR for patients and what aspects of improvement are most critical.

Even though several studies have revealed excellent clinical results with arthroscopic repair of rotator cuff tendons, poor healing of the repair and retearing of the tendon occur in many cases. Patterns of outcome correlating functional capacity and anatomic integrity of the repaired rotator cuff are not well defined. The goal of this prospective study was to determine the pattern of anatomic and functional outcomes among patients undergoing single-row arthroscopic rotator cuff repair. This study confirmed that single-row arthroscopic repair of small- and medium-sized supraspinatus tendon tears significantly improves rotator cuff integrity and functional outcomes. A completely healed tendon was observed in 60% of the cases. Age is a predictor of cuff integrity after the operation. Functional improvement was greater and significant in patients with complete healing at follow-up; however, a recurrent tear did not preclude positive functional results.

The myelodysplastic syndromes (MDS) represent a heterogeneous group of disorders. Low-risk MDS represent a subgroup with a relatively good prognosis, but with few trials evaluating outcomes. A pooled analysis based upon a MEDLINE search identified 162 original articles describing patient characteristics and effect of therapy on 2592 individuals with pathologically confirmed refractory anaemia or refractory anaemia with ringed sideroblasts with <5% bone marrow blasts. Treatments were categorised as growth factors (GF) or non-growth factors (NGF). International Prognostic Scoring System (IPSS) score was documented or calculated when possible. Responses and outcomes were standardised according to the International Working Group MDS criteria. Growth factors produced higher overall response rates (39.5% vs. 31.4% for NGF, P = 0.019), while NGF yielded better CR/PR rates (25.6% vs. 9.1% for GF, P = 0.03). Over 2 years of follow-up, those receiving GF demonstrated greater overall and progression-free survival than NGF, after controlling for baseline patient characteristics. Decision tools need to be developed to determine which therapy to choose for patients with low-risk MDS.

Purpose: Making good consumer decisions requires having good information. This study compared long-term-care recommendations among various types of health professionals., Design and Methods: We gave randomly varied scenarios to a convenience national sample of 211 professionals from varying disciplines and work locations. For each scenario, we asked the professional to recommend the appropriate forms of long-term care., Results: Although the professional respondents used the full spectrum of options offered to them, some professionals tended to favor the sector they worked in. Advanced practice nurses recommended day care and homemaking more and adult foster care less. Gerontologists used skilled nursing-facility placement more actively and rehabilitation, homemaking, and home health care less actively. Geriatricians and primary care physicians both favored rehabilitation and skilled nursing-facility care and were both less enthusiastic about assisted living, homemaking, and informal care, but the geriatricians favored day care more than did the primary care physicians. Registered nurses were highly supportive of assisted living, adult foster care, homemaking, and home health care, and they opposed skilled nursing-facility care. Social workers were less likely than other participants to endorse rehabilitation and adult foster care., Implications: Because consumer preference should be a major factor in making long-term-care decisions, many consumers need information about what options may best fit their situation. In the absence of empirical data on which types of long-term care work best for whom, consumers have to rely on expert judgment-but that judgment varies. Clients should be aware that an expert's background (as defined by discipline and work situation) may affect his or her recommendations. Each discipline appears to have its own set of experiences and beliefs that may influence recommendations.

Purpose: A newly developed brief measure of nursing facility (NF) resident self-reported quality of life (QOL) has been proposed for inclusion in a modified version of the minimum data set (MDS). There is considerable interest in determining whether it is possible to develop indicators of QOL that are more convenient and less expensive than direct, in-person interviews with residents., Design and Methods: QOL interview data from 2,829 residents living in 101 NFs using a 14-item version of a longer instrument were merged with data from the MDS and the Online Survey and Certification Automated Record (OSCAR). Bivariate and multivariate hierarchical linear modeling were used to assess the association of QOL with potential resident and facility level indicators., Results: Resident and facility level indicators were associated with self-reported QOL in the expected direction. At the individual resident level, QOL is negatively associated with physical function, visual acuity, continence, being bedfast, depression, conflict in relationships, and positively associated with social engagement. At the facility level, QOL is negatively associated with citations for failing to accommodate resident needs or providing a clean, safe environment. The ratio of activities staff to residents is positively associated with QOL. This study did not find an association between QOL and either use of restraints or nurse staff levels. Approximately 9 percent of the total variance in self-reported QOL can be attributed to differences among facilities; 91 percent can be attributed to differences among residents. Resident level indicators explained about 4 percent of the variance attributable to differences among residents, and facility factors explained 49 percent of the variance attributable to differences among NFs. However, the different variables explained only 10 percent of the variance in self-reported QOL., Implications: A brief self-report measure of NF resident QOL is consistently associated with measures that can be constructed from extant data sources. However, the level of prediction possible from these data sources does not justify reliance on external indicators of resident QOL for policy purposes.

Objectives: To compare the effects of the Wisconsin Partnership Program (WPP) on hospital, emergency department (ED), and nursing home utilization with those of traditional care., Design: Quasi-experimental longitudinal cohort design., Setting: Selected counties in Wisconsin., Participants: WPP elderly enrollees and two matched control groups consisting of frail older people enrolled in fee-for-service insurance plans, Medicare, and Medicaid and receiving home- and community-based waiver services, one from the same geographic area as the WPP and another from a location in the state where the WPP was not offered., Measurements: Data came from administrative records. Regression and survival analyses were adjusted for case-mix variables., Results: No significant differences in hospital utilization, ED visits, preventable hospitalizations, risk of entry into nursing homes, or mortality were found. WPP enrollees had more contact with care providers than did controls., Conclusion: WPP did not dramatically alter the pattern of care. Part of the weak effect may be attributable to the small numbers of WPP cases per participating physician.

Background: No definitive explanation for the difference in rate of male and female noncontact ACL injury has been found. The hormonal environment, known to be different in men and women has been hypothesized as a possible source for this difference in injury rate., Purpose: To confirm earlier work looking at periodicity of noncontact ACL injury. To increase sample size by adding ankle sprains. To determine the rate of noncontact ACL injury and ankle sprains in collegiate basketball and soccer. To determine if the use of oral contraceptives affects the rate of noncontact ACL injury and ankle sprains., Methods: Data was collected from a sample of NCAA schools over the 2000-2001 basketball and the 2001-2002 basketball and soccer seasons., Results: Recall and prospective data collection of length of menstrual cycle did not produce equivalent results. Periodicity was present only in the recall group of "off pill" users. The rate of noncontact ACL injury and noncontact ankle sprains was twice as high in basketball as in soccer. There was no difference in rate of injuries between those athletes using hormonal therapy and those athletes not using hormonal therapy., Conclusions: Noncontact ACL injuries and ankle sprains occurred at significantly higher rates in basketball than in soccer but this rate difference was not linked to hormonal therapy usage. The overall rate of noncontact ACL injury and ankle sprain to women's collegiate basketball and soccer players is very low.

Purpose: Because leaders at medical schools and teaching hospitals need current data to estimate the clinical costs of graduate medical education, the authors developed a new methodology to estimate the hospital costs associated with the presence of teaching physicians for the year 2002., Method: A hospital accounting system was used to determine the case mix-adjusted direct variable costs for 41,522 inpatient admissions associated with or without a teaching physician., Results: Prior to adjustment, teaching cases had greater median costs than non-teaching cases. After severity adjustment, teaching cases in aggregate were associated with an additional 4.4% of the total direct variable cost of inpatient admissions, or US 3.6 million dollars. The size of the teaching effect varied by service, ranging from -5.7% for medical services to 13 percent for behavioral services. The effect of teaching on cost centers such as laboratory, pharmacy, and radiology varied by specialty service. Teaching was associated with a negligible 0.7% relative difference in length of stay., Conclusion: The incremental effects of teaching on hospital patient care costs are modest. These analyses can be repeated annually to detect changes in teaching costs and to target areas of excessive cost for interventions that improve efficiency. Our results and methods for identifying hospital costs associated with teaching services may prove useful in negotiations between academic health centers and affiliated teaching hospitals.

Background: Female collegiate athletes have been reported to have a higher rate of anterior cruciate ligament injury compared to male collegiate athletes. This finding has spawned a branch of research focused on understanding and preventing this injury pattern., Purpose: To determine if the trends reported in 1994 have continued., Study Type: Descriptive epidemiology study., Methods: The National Collegiate Athletic Association Injury Surveillance System database was reviewed for all data relating to men's and women's basketball and soccer anterior cruciate ligament injuries for 1990 to 2002., Results: No significant difference was seen in basketball comparing frequency of contact versus noncontact injuries between men (70.1%) and women (75.7%). Male basketball players sustained 37 contact injuries and 78 noncontact injuries. Female basketball players sustained 100 contact injuries and 305 noncontact injuries. In soccer, there was a significant difference in frequency of injury for male (49.6%) and female (58.3%) athletes when comparing contact and noncontact injuries (chi2=4.1, P<.05). Male soccer players sustained 72 contact injuries and 66 noncontact injuries. Female soccer players sustained 115 contact injuries and 161 noncontact injuries. The magnitude of the difference in injury rates between male and female basketball players (0.32-0.21, P=.93) remained constant, whereas the magnitude of the difference in the rate of injuries between male and female soccer players (0.16-0.21, P=.08) widened. Comparing injury within gender by sport, soccer players consistently sustained more anterior cruciate ligament injuries than did basketball players. The rate of anterior cruciate ligament injury for male soccer players was 0.11 compared to 0.08 for male basketball players (P=.002). The rate of anterior cruciate ligament injury for female soccer players was 0.33 and for female basketball players was 0.29 (P=.04). The rates for all anterior cruciate ligament injuries for women were statistically significantly higher (P<.01) than the rates for all anterior cruciate ligament injuries for men, regardless of the sport. In soccer, the rate of all anterior cruciate ligament injuries across the 13 years for male soccer players significantly decreased (P=.02), whereas it remained constant for female players., Conclusions: In this sample, the rate of anterior cruciate ligament injury, regardless of mechanism of injury, continues to be significantly higher for female collegiate athletes than for male collegiate athletes in both soccer and basketball., Clinical Relevance: Despite vast attention to the discrepancy between anterior cruciate ligament injury rates between men and women, these differences continue to exist in collegiate basketball and soccer players. Also demonstrated is that although the rate of injury for women is higher than for men, the actual rate of injury remains low and should not be a deterrent to participation in sports.

In 1994 the American Academy of Orthopaedic Surgeons established an outcomes initiative. The Musculoskeletal Outcomes Data Evaluation and Management System had two goals: (1) to create validated patient-based functional health questionnaires that would become the gold standard for musculoskeletal research, and (2) to collect data from practicing orthopaedists using these instruments. We assessed the adequacy of the hip and knee portion of the Musculoskeletal Outcomes Data Evaluation and Management System data collection process to learn how to improve these processes. Database elements included demographic and clinical information and health and well-being scales. Only 715 records or 578 patients of the initial 2419 records (30%) had complete baseline and followup information for either hip or knee replacement procedure. Only 17% of the patients who had a knee replacement and 20% of the patients who had a hip replacement returned for followup between 7 and 9 months. The Musculoskeletal Outcomes Data Evaluation and Management System achieved its goal regarding the development of validated questionnaires, but the data collection component did not. The project's implementation and management were flawed. This experience offers the field of orthopaedics valuable lessons that can be applied to future large-scale data collection efforts.

Objectives: To compare the use of medical services provided under the Minnesota Senior Health Options (MSHO) (a special program designed to serve dually eligible older persons) with that provided to controls who received fee-for-service Medicare and Medicaid managed care., Design: Quasi-experimental design using two control groups; separate matched cohort and rolling cross-sectional analyses; regression models used to adjust for case-mix differences., Setting: Urban Minnesota community and nursing home long-term care., Participants: Dually eligible elderly MSHO enrollees in the community and in nursing homes were compared with two sets of controls; one was drawn from nonenrollees living in the same area (control-in) and another from comparable persons living in another urban area where the program was not available (control-out). Cohorts living in the community and in nursing homes were included., Measurements: Use of hospitals and emergency rooms, physician visits., Results: In the community cohort, there were no significant differences in hospital admission rates or in hospital days. MSHO enrollees had significantly fewer preventable hospital admissions and significantly fewer preventable emergency services than the control-in group. MSHO nursing home enrollees had significantly fewer hospital admissions than either control group with or without adjustment at 12 and 18 months. MSHO enrollees had significantly fewer hospital days and preventable hospitalizations than the control-in group. MSHO enrollees had significantly fewer emergency room visits and preventable emergency room visits than either control group., Conclusion: In general, the results of this evaluation are mixed but favor MSHO. The effect of MSHO was stronger for nursing home enrollees than community enrollees. The lower rate of preventable hospitalizations and emergency room visits of MSHO enrollees suggests that MSHO affected the process of care by providing more of some types of preventive and community-care services for community residents.

Objectives: To examine the use of hospital and related medical care services of a novel managed care program using nurse practitioners (NPs) and directed specifically at long-stay nursing home residents., Design: Quasi-experimental posttest design with two control groups to minimize selection bias., Setting: Nursing homes., Participants: Evercare enrollees in five sites were compared with two sets of controls: nursing home residents in the same nursing homes who did not enroll in Evercare (control-in) and residents of nursing homes that did not participate in Evercare (control-out)., Measurements: Utilization data from Medicare and United Healthcare (the parent corporation for Evercare) were obtained for slightly more than 2 years. Patterns of use were assessed by calculating the monthly use rate for each group and aggregating to form annual rates. Usages addressed included hospital admissions and days, emergency room visits, therapy services, mental health services, and podiatry. Adjustments were made to correct for age, race, and sex. Because the groups differed in terms of the rate of cognitive impairment, the analysis was stratified on this variable., Results: The incidence of hospitalizations was twice as high in control residents as in Evercare residents (4.63 and 4.67 per 100 enrollees per month vs 2.43 in the 15 months after census, P<.001). This difference corresponded to Evercare's use of intensive service days. The same pattern held for preventable hospitalizations (0.80 and 0.86 vs 0.28, P<.001). The pattern held when residents were stratified by cognitive status. On average, using a NP is estimated to save about $103,000 a year in hospital costs per NP., Conclusion: The use of active primary care provided by NPs may have prevented the occurrence of some hospitalizable events, but its major effect was allowing cases to be managed more cost-effectively.

Allocations for the State Children's Health Insurance Program (SCHIP) varied 22% per state between 1999 and 2002. The funding fluctuations present significant problems for states as they develop budget priorities under difficult fiscal conditions. We examine sources of the variation in state allocations during the first four years of SCHIP, focusing on the Current Population Survey's "child component" of the allocation formula. We consider the trade-offs in using alternative estimates from the American Community Survey and model-based estimation. Obtaining reliable estimates of need for SCHIP allocations is critical for states dependent on federal support for insurance programs.

Purpose: To assess changes in various functional and satisfaction measures between older persons enrolled in Minnesota Senior Health Options (MSHO), a managed care program for older persons eligible for both Medicare and Medicaid., Design and Methods: We used two sets of matched controls for MSHO enrollees and their families and matched controls living in the community and in nursing homes: Persons in the same county who were eligible to enroll but did not enroll in MSHO and persons in other metropolitan areas where MSHO is not available. For the community sample, we used questionnaires to measure functional status (activities of daily living), pain, unmet care needs, satisfaction, and caregiver burden. Approximately 2 years after the first survey, we resurveyed respondents who lived in the community at the time of the first survey. For the nursing home residents, we used annual assessments to calculate case mix to compare changes in functional levels over time., Results: There were few significant differences in change over time between the MSHO sample and the two control groups. Out-of-area controls showed greater increases in pain but in-area controls showed less interference from pain. Compared with out-of-area controls, MSHO clients showed greater increase in homemaker use, meals on wheels, and outpatient rehabilitation. Compared with in-area controls, they showed more use of meals on wheels and less help from family with household tasks. There were few differences in satisfaction, but the MSHO families showed significantly lower burden than controls on five items., Implications: The analyses show only modest evidence of benefit from MSHO compared with the two control groups. The model represented by MSHO does not appear to generate substantial differences in outcomes across function, satisfaction, and caregiver burden.

Background: Deep wound infection (DWI) in total knee (TKA) and total hip (THA) arthroplasty has been shown to highly correlate with superficial surgical site infection (SSSI). Although several studies have reported hospital factors that predispose to SSSI, patient factors have not been clearly elucidated., Methods: All patients undergoing TKA (n = 1181) and THA (n = 1124) surgery during the period 1977-1995 at our institution were observed at the end of a 30-day post-operative period. Thirty-three patients that developed SSSI during this period constituted the study group. The control group was composed of 64 matched subjects that did not develop SSSI. A chart review was applied to abstract DWI cases during the first 18 post-operative months for the study group and for an average of 6.7 years for the control group (range 5-18.2 years). Potential risk factors for SSSI were used as predictors of SSSI in a logistic regression analysis., Results: During the 18-month observation period 19 out of the 33 study subjects (58%) developed DWI. No DWI was registered in the control group (the difference was significant, p < 0.0001). Of the nine pre-operative, five intra-operative, and five postoperative factors examined, only hematoma formation (odds ratio = 11.8; p = 0.001) and days of post-operative drainage (odds ratio = 1.32; p = 0.01) were significant predictors of SSSI. The cases consumed more health care resources at all stages of the medical process., Conclusions: Our results (1) confirm the strong correlation between the probability of developing DWI and SSSI; (2) indicate that hematoma formation and persistent post-operative drainage increase the risk of SSSI. We hypothesize that post-operative monitoring of patients for hematoma and persistent drainage enables earlier intervention that may lower the risk of developing SSSI and subsequent DWI.

Objectives: To compare the characteristics of a sample of EverCare nursing home residents with two control groups: one composed of other residents in the same homes and another made up of residents in matched nursing homes. To compare levels of unmet need, satisfaction with medical care, and the use of advance directives., Design: Quasi-experimental design using two control groups to minimize selection effects. Information collected by in-person surveys of nursing home residents and telephone surveys of proxies and family members., Setting: Nursing homes affiliated with EverCare and matched control homes., Participants: Nursing home residents and their family members., Measurements: Questionnaire addressing function (activities of daily living (ADLs)), unmet care needs, pain, use of advance directives, satisfaction, and caregiver burden., Results: In general, the experimental and control groups were similar, but the EverCare sample had more dementia and less ADL disability. Family members in the EverCare sample expressed greater satisfaction with several aspects of the medical care they received than did controls. Satisfaction of residents in the EverCare sample was more comparable with that of controls. There was no difference in experience with advance directives between EverCare and control groups., Conclusions: EverCare appears to be a model of managed care worth tracking. It is producing care that is at least comparable with what is available in the fee-for-service environment, with evidence that families seem to appreciate the added attention. There is some suggestion that it has enrolled a less disabled but more demented population. Pending results on the effects of this care on hospitalization and emergency care should shed useful light.

Background: Approximately 80,000 anterior cruciate ligament (ACL) tears occur per year in the United States. The majority of all ACL injuries are thought to be noncontact in nature with no clear mechanism of injury present. The increased rate of noncontact ACL injury in female athletes as compared to male athletes in some sports is well-documented. It explains an interest in the biochemical components as a predisposition to sustain an injury., Objective: The goal of this study was to analyze the 28-day periodicity of noncontact ACL injuries in female athletes taking and not taking oral contraceptives (OCs)., Design: From 1996 to 1999, a descriptive project in the National Collegiate Athletic Association and National Association of Intercollegiate Athletics member schools allowed for an assessment of the commonality in the characteristics of the noncontact-ACL-injured athletes., Subjects: Of the 128 female athletes, 83 satisfied the study inclusion criteria. Twenty-five of the subjects represented the "On-Pills" subgroup and 58 of them represented the "Off-Pills" subgroup., Methods: The data were collected directly from the athletes by the certified athletic trainer at the school., Statistical Analysis: Centered moving average with a span of four days as well as linear and nonlinear regression were used to analyze the data., Results: A significant 28-day periodicity of injuries was present in the entire population as well as in the two subgroups. High- and low-risk time intervals were associated primarily with follicular and luteal phases. There was a significant difference in the time dependency of the number of injuries between the two subgroups: female athletes taking OCs demonstrated a greater difference between high and low risks, with a high-risk period shifted toward the beginning of the cycle., Conclusion: There is a significant relationship between the occurrence of a noncontact ACL injury and the collegiate athlete's menstrual cycle regardless of oral contraceptive use status.

In an effort to develop a method for standardizing patients' reports of pain intensity, we tested seven different approaches to employing patients' ratings of four consistent types of pain as a means of correcting their reports (the average of the four standard pain measures, the average of the greater pains--finger in a door and tooth drilling, the average of the lesser pains--blister and leg cramp, the predicted back pain VAS from a regression of the standard pains, a conversion to the same scale based on population mean, the difference between individual mean and population mean of the four standard pain measures, and the difference between individual range and population range of the four standard pain measures). None of the adjustments proved to be a substantial improvement over the unstandardized approach. The best adjuster was the approach that used the average of the greater pain scores.

A project designed to demonstrate the benefits of integrating behavioral healthcare services in primary medical care settings provided an opportunity to further investigate the psychometric properties of the SA-45 using data from a sample of 126 adults seeking medical services in a family practice setting. Specifically, the appropriateness of the SA-45 s adult nonpatient norms, as well as cross-validation of its test-retest reliability and construct validity, was investigated from the first set of data gathered for this project. The results suggested that use of the SA-45 nonpatient norms with primary care populations is appropriate. Three-month test-retest correlations between Depression scale scores and SA-45 and SA-24-predicted GSI scores were found to be moderate but highly significant. In addition, correlations among the SA-45 scales and indices and their correlations with the SF-12 Mental and Physical Component Summary scales added further support for the psychometric integrity of the SA-45. Finally, only partial indirect support was obtained for the SA-45 s ability to accurately classify patients as requiring further evaluation for behavioral health problems. Limitations of the study are discussed and suggestions for future research are presented.

Preliminary reliability and validity data are reported on a new, brief measure of psychiatric symptomatology. The Symptom Assessment-45 Questionnaire (SA-45) is a 45-item, patient self-report symptom inventory derived from the original Symptom Checklist-90-R (SCL-90), using cluster analytic methods. The SA-45 consists of nine 5-item scales assessing each of the same symptom domains as its parent instrument with no item overlap across domains. The vast majority of the internal consistency reliabilities for the SA-45's nine scales were in the .70s and .80s across different age and patient status samples. As expected, both adolescent and adult patient samples generally differed significantly from nonpatient control samples, and patients at treatment follow-up differed significantly from patients at intake. Moreover, depressed patients with and without psychotic features differed significantly on three scales. A cluster analysis generally supported the nine-scale structure of the inventory, but it failed to consistently support the distinction between the Paranoid Ideation and Interpersonal Sensitivity scales. Limitations to the study are noted, but overall, the initial findings support the use of the SA-45 in clinical settings. Suggestions for needed future research are presented., (© 1997 SAGE Publications.)

Objective: To determine if early enteral feeding, in an intensive care unit (ICU) patient population, using a formula supplemented with arginine, dietary nucleotides, and fish oil (Impact), results in a shorter hospital stay and a reduced frequency of infectious complications, when compared with feeding a common use enteral formula (Osmolite.HN)., Design: A prospective, randomized, double-blind, multicenter trial., Setting: ICUs in eight different hospitals., Patients: Of 326 patients enrolled in the study, 296 patients were eligible for analysis. They were admitted to the ICU after an event such as trauma, surgery, or sepsis, and met a risk assessment screen (Acute Physiology and Chronic Health Evaluation II [APACHE II] score of > or = 10, or a Therapeutic Intervention Scoring System score of > or = 20) and study eligibility requirements. Patients were stratified by age (< 60 or > or = 60 yrs of age) and disease (septic or systemic inflammatory response syndrome)., Interventions: Patients were enrolled and full-strength tube feedings were initiated within 48 hrs of the study entry event. Enteral feedings were advanced to a target volume of 60 mL/hr by 96 hrs of the event. One hundred sixty-eight patients were randomized to receive the experimental formula, and 158 patients were randomized to receive the common use control formula., Measurements and Main Results: Both groups tolerated early enteral feeding well, and the frequency of tube feeding-related complications was low. There were no significant differences in nitrogen balance between groups on study days 4 and 7. Patients receiving the experimental formula had a significant (p = .0001) increase in plasma arginine and ornithine concentrations by study day 7. Plasma fatty acid profiles demonstrated higher concentrations of linoleic acid (p < .01) in the patients receiving the common use formula and higher concentrations of eicosapentaenoic and docosahexaenoic acid (p < .01) in the patients receiving the experimental formula. The mortality rate was not different between the groups and was significantly (p < .001) lower than predicted by the admission severity scores in both feeding groups. In patients who received at least 821 mL/day of the experimental formula, the hospital median length of stay was reduced by 8 days (p < .05). In patients stratified as septic, the median length of hospital stay was reduced by 10 days (p < .05), along with a major reduction in the frequency of acquired infections (p < .01) in the patients who received the experimental formula. In the septic subgroup fed at least 821 mL/day, the median length of stay was reduced by 11.5 days, along with a major reduction in acquired infections (both p < .05) in the patients who received the experimental formula., Conclusions: Early enteral feeding of the experimental formula was safe and well tolerated in ICU patients. In patients who received the experimental formula, particularly if they were septic on admission to the study, a substantial reduction in hospital length of stay was observed, along with a significant reduction in the frequency of acquired infections.