The impact of substance abuse treatment modality on birth weight and health care expenditures.

During the 1990s, substance abuse treatment programs were developed for pregnant women to help improve infant birth outcomes, reduce maternal drug dependency and promote positive lifestyle changes. This study compared the relative impact of five treatment modalities--residential, outpatient, residential/outpatient, methadone and detoxification-only--on infant birth weight and perinatal health care expenditures for a sample of 445 Medicaid-eligible pregnant women who received treatment in Massachusetts between 1992 and 1997. Costs and outcomes were measured using the Addiction Severity Index and data from birth certificates, substance abuse treatment records and Medicaid claims. Multiple regression was used to control for intake differences between the groups. Results showed a near linear relationship between birth weight and amount of treatment received. Women who received the most treatment (the residential/outpatient group) delivered infants who were 190 grams heavier than those who received the least treatment (the detoxification-only group) for an additional cost of $17,211. Outpatient programs were the most cost-effective option, increasing birth weight by 139 grams over detoxification-only for an investment of only $1,788 in additional health care and treatment costs. A second regression using five intermediate treatment outcomes--prenatal care, weight gain, relapse, tobacco use and infection--suggested that increases in birth weight were due primarily to improved nutrition and reduced drug use, behaviors which are perhaps more easily influenced in residential settings.

The costs of crime and the benefits of substance abuse treatment for pregnant women.

Although many pregnant, drug-dependent women report extensive criminal justice involvement, few studies have examined reductions in crime as an outcome of substance abuse treatment programs for pregnant women. This is unfortunate, because maternal criminal involvement can have serious health and cost implications for the unborn child, the mother and society. Using the Addiction Severity Index, differences in pre- and posttreatment criminal involvement were measured for a sample of 439 pregnant women who entered publicly funded treatment programs in Massachusetts between 1992 and 1997. Accepted cost of illness methods were supplemented with information from the Bureau of Justice Statistics to estimate the costs and benefits of five treatment modalities: detoxification only (used as a minimal treatment comparison group), methadone only, residential only, outpatient only, and residential/outpatient combined. Projected to a year, the net benefits (avoided costs of crime net of treatment costs) ranged from US$32,772 for residential only to US$3,072 for detoxification. Although all five modalities paid for themselves by reducing criminal activities, multivariate regressions controlling for baseline differences between the groups showed that reductions in crime and related costs were significantly greater for women in the two residential programs. The study provides economic justification for the continuation and possible expansion of residential substance abuse treatment programs for criminally involved pregnant women.

The role of ulnar nerve transposition in ulnar nerve repair: a cadaver study.

Ulnar nerve transposition at the elbow is recommended to diminish nerve gaps during neurorrhaphy. We undertook a cadaver study to determine the gap distance that can be overcome by subcutaneous transposition at the elbow, evaluating lacerations 2.0 cm distal to the medial epicondyle and 2.0 cm proximal to the wrist crease. With a 100-g load on each nerve stump, gaps that could be overcome were measured before and after transposition in different elbow and wrist positions. For the distal forearm lacerations, wrist position significantly affected nerve gap, while transposition and elbow position did not. Nerve gap was significantly reduced by approximately 11 mm with wrist flexion from 0 degrees to 45 degrees. For proximal forearm lacerations, gap distance was significantly affected by transposition and was dependent to a greater extent on the interaction between transposition and elbow position, with wrist position having no effect. A clinically relevant scenario for the proximal laceration compared the pretransposition gap with the elbow and wrist at neutral with the posttransposition gap with the elbow and wrist flexed. Posttransposition gap reduction, with elbow and wrist flexion at 45 degrees, was approximately 9 mm and was not significant. To span a gap near the elbow, we estimate that more than 45 degrees of elbow flexion is required.

Soft tissue attachments of the ulnar coronoid process. An anatomic study with radiographic correlation.

Regan and Morrey proposed a 3-type coronoid fracture classification observing that the incidence of concommitant elbow dislocation was proportional to fragment size. Elbow instability associated with coronoid fractures presumably is related to disrupted bony architecture and ineffective stabilizers attached to the free fragment. Twenty cadaveric elbows were dissected, measuring medial collateral ligament, anterior capsule, and brachialis muscle insertion loci on the coronoid. Radiographs were taken after radiopaque labeling of the stabilizer insertions. The anterior bundle of the medial collateral ligament insertion averaged 18.4 mm dorsal to the coronoid tip. Only in Type III fractures would it be attached to the free fragment. The capsule inserted an average of 6.4 mm distal to the coronoid tip. Rarely should Type I fractures result from a capsular avulsion, because only 3 of 20 specimens had the capsule inserting on the tip. The brachialis had a musculoaponeurotic insertion onto the elbow capsule, coronoid, and proximal ulna. The bony insertion averaged 26.3 mm in length, with its proximal margin averaging 11 mm distal to the coronoid tip. In only Type III fractures is the fragment large enough to include the brachialis bony insertion.

Mental health/substance abuse treatment in managed care: the Massachusetts Medicaid experience.

Massachusetts was the first state to introduce a statewide specialty mental health managed care plan for its Medicaid program. This study assesses the impact of this program on expenditures, access, and relative quality. Over a one-year period, expenditures were reduced by 22 percent below predicted levels without managed care, without any overall reduction in access or relative quality. Reduced lengths-of-stay, lower prices, and fewer inpatient admissions were the major factors. However, for one population segment--children and adolescents--readmission rates increased slightly, and providers for this group were less satisfied than they were before managed care was adopted. Less costly types of twenty-four-hour care were substituted for inpatient hospital care. This experience supports the usefulness of a managed care program for mental health and substance abuse services, and the applicability of such a program to high-risk populations.

Targeting services to chronically disabled elderly: the preliminary experiences of the National Long Term Care Channeling Demonstration.

In response to concerns about the adequate provision of long term care, the National Long Term Care Channeling Demonstration has been funded by the Department of Health and Human Services. The project is designed to provide coordinated community services as an alternative to institutionalization to those elderly individuals at risk of placement. This preliminary work examines the demonstration's experience in its attempt to target services to these individuals. Although final research results are not yet available, the method, problems, and results of the initial case finding and screening approaches provide additional knowledge concerning the targeting experience.

Targeting home care services to vulnerable elders: Massachusetts' Home Care Corporations.

This investigation evaluates how successfully the Massachusetts model of home care targets services to vulnerable elders. It compares data from a random sample of home care recipients with a probability sample of non-institutionalized elders in Massachusetts. The data indicate that the Massachusetts statewide system developed under minimum regulation and decentralized management has successfully reached the vulnerable elders, particularly those living alone and the widowed. The demand for home services exists but is neither excessive nor uncontrollable. These findings support the continued use of a social model of home care delivery instead of a more restrictive medical model.

Responsibility of families for their severely disabled elders.

In the past 13 years, total expenditures for nursing home care under the Medicaid program have increased drastically. They show no signs of abating. Government, therefore, has become aware of the need to control this rapid increase. Families, who currently provide a large amount of informal, long-term care for their disabled elderly, are seen as a potential resource to maintain people in the community. Although demographic elements appear to mitigate against increased family responsibility, governmental incentives may be able to reverse the trend. While demographic variables cannot be modified by public policies, programs can be developed to modify family situations, increasing family capacity--and willingness--to care for disabled, elderly adults.