Patient-reported outcomes in young patients with isolated fracture of the hip.

AIMS: Hip fractures in patients < 60 years old currently account for only 3% to 4% of all hip fractures in England, but this proportion is increasing. Little is known about the longer-term patient-reported outcomes in this potentially more active population. The primary aim is to examine patient-reported outcomes following isolated hip fracture in patients aged < 60 years. The secondary aim is to determine an association between outcomes and different types of fracture pattern and/or treatment implants. METHODS: All hip fracture patients aged 18 to 60 years admitted to a single centre over a 15-year period were used to identify the study group. Fracture pattern (undisplaced intracapsular, displaced intracapsular, and extracapsular) and type of operation (multiple cannulated hip screws, angular stable fixation, hemiarthroplasty, and total hip replacement) were recorded. The primary outcome measures were the Oxford Hip Score (OHS), the EuroQol five-dimension questionnaire (EQ-5D-3L), and EQ-visual analogue scale (VAS) scores. Preinjury scores were recorded by patient recall and postinjury scores were collected at a mean of 57 months (9 to 118) postinjury. Ethics approval was obtained prior to study commencement. RESULTS: A total of 72 patients were included. There was a significant difference in pre- and post-injury OHS (mean 9.8 point reduction (38 to -20; p < 0.001)), EQ-5D (mean 0.208 reduction in index (0.897 to -0.630; p < 0.001)), and VAS , and VAS (mean 11.6 point reduction (70 to -55; p < 0.001)) Fracture pattern had a significant influence on OHS (p < 0.001) with extracapsular fractures showing the least favourable long-term outcome. Fixation type also impacted significantly on OHS (p = 0.011) with the worst outcomes in patients treated by hemiarthroplasty or angular stable fixation. CONCLUSION: There is a significant reduction in function and quality of life following injury, with all three patient-reported outcome measures used, indicating that this is a substantial injury in younger patients. Treatment with hemiarthroplasty or angular stable devices in this cohort were associated with a less favourable hip score outcome. Cite this article: Bone Joint J 2020;102-B(6):766-771.

Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials.

AIMS: Flail chest from a blunt injury to the thorax is associated with significant morbidity and mortality. Its management globally is predominantly non-operative; however, there are an increasing number of centres which undertake surgical stabilisation. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management. PATIENTS AND METHODS: A systematic search of the literature was carried out to identify randomised controlled trials (RCTs) which compared the clinical outcome of patients with a traumatic flail chest treated by surgical stabilisation of any kind with that of non-operative management. RESULTS: Of 1273 papers identified, three RCTs reported the results of 123 patients with a flail chest. Surgical stabilisation was associated with a two thirds reduction in the incidence of pneumonia when compared with non-operative management (risk ratio 0.36, 95% confidence interval (CI) 0.15 to 0.85, p = 0.02). The duration of mechanical ventilation (mean difference -6.30 days, 95% CI -12.16 to -0.43, p = 0.04) and length of stay in an intensive care unit (mean difference -6.46 days, 95% CI 9.73 to -3.19, p = 0.0001) were significantly shorter in the operative group, as was the overall length of stay in hospital (mean difference -11.39, 95% CI -12.39 to -10.38, p < 0.0001). CONCLUSION: Surgical stabilisation for a traumatic flail chest is associated with significant clinical benefits in this meta-analysis of three relatively small RCTs. Cite this article: Bone Joint J 2016;98-B:1119-25.

Commercial health plan participation in Medicaid managed care: an examination of six markets.

This study examines six local health care markets to gain a better understanding of the factors associated with the decision by commercial plans to participate in Medicaid managed care (MMC). Findings suggest that no single factor explained why plans chose to participate in MMC in a particular market. Instead, a combination of factors--generally economic but not always--determined whether a plan participated. While rate adequacy was central, it was not the only factor. Results indicate that it is capitation rates relative to other factors (such as provider costs, administrative costs, enrollment volume, growth opportunities in other markets) that matter rather than simply the level of rates.

Impacts of Medicaid managed care on children.

OBJECTIVE: To assess the impact of switching from a fee-for-service (FFS) delivery system to managed care on access to, use of, and satisfaction with health care for children. DATA SOURCES/STUDY SETTING: A 1998 survey of Medicaid recipients in rural Minnesota. STUDY DESIGN: Using a quasi-experimental framework, we compare the experiences of children on Medicaid living in counties that had switched to managed care with those of children living in counties operating under FFS Medicaid. We address the impact of Medicaid managed care (MMC) on access to, use of, and satisfaction with care. DATA COLLECTION METHODS: A stratified random sample of children on Medicaid was drawn based on Medicaid enrollment files. Telephone interviews were conducted with the child's parent or guardian between March and June 1998. An overall response rate of 70 percent was achieved, yielding a sample of 1,106 children (814 in MMC and 792 in Medicaid FFS). PRINCIPAL FINDINGS: We find very few significant differences in access to, use of, or satisfaction with health care services for children under MMC relative to FFS. MMC did not change the patterns of health care service use or the location at which care is delivered, two major goals of MMC initiatives. CONCLUSIONS: Our results suggest that the Medicaid program's shift from FFS to managed care had little impact on the pattern of children's health care use, the location at which they obtained care, or the satisfaction with the care they received.

Access and use by children on Medicaid: does state matter?

Although Medicaid is a central component of health care for children, the program is not uniform across the states. Using state and nationally representative data from the 1997 National Survey of America's Families (NSAF), a survey of the economic, health and social characteristics of children, nonaged adults and their families, we examine differences in access and use by children on Medicaid across 13 states, and compare those differences to national estimates. We find significant differences in access and use across the states for children on Medicaid. The characteristics of the children and their local health care environment explain some, but not all, of the state differences in access and use.

Effects of medicaid managed care on adults.

BACKGROUND: Despite the rapid growth in Medicaid managed care (MMC) during the 1990s, only limited research exists on how such care affects beneficiaries. OBJECTIVE: The objective of this study was to assess how switching from a fee-for-service (FFS) delivery system to managed care affects Medicaid beneficiaries' access to, use of, quality of, and satisfaction with health care services. METHODS: Using a quasi-experimental design framework, we compared the experiences of 540 Minnesota Medicaid recipients living in counties that had switched to managed care with those of 528 recipients living in counties operating under FFS. The data for the analysis came from a 1998 survey of Minnesota Medicaid clients. Data were analyzed by logit regression. RESULTS: We find limited effects of MMC on access to, use of, quality of, and satisfaction with health care. Among others, we found no significant differences between the share of managed care and FFS enrollees (78.5% versus 76%) who had a health care visit during the last year. We also found no evidence of a significant reduction in the proportion of managed care and FFS enrollees (17.6% versus 17%) who had had a hospital stay during the past year. The results did show some negative effects of MMC on satisfaction with care, the most consistent being that managed care enrollees are somewhat less satisfied with their health care than their FFS counterparts. CONCLUSIONS: Our results suggest that a shift from FFS to MMC did not fundamentally change the patterns of health care service use, the location at which care was delivered, or quality.

Reforming the Medicaid disproportionate share hospital program.

Since 1991, three Federal laws have sought to reform the Medicaid disproportionate share hospital (DSH) program, which is designed to help safety net hospitals. This article provides findings from a 40-State survey about Medicaid DSH and supplemental payment programs in 1997. Results indicate that the overall size of the DSH program did not grow from 1993 to 1997, but the composition of DSH revenues and expenditures changed substantially: A much higher share of the DSH funds were being paid to local hospitals and relatively less was being retained by the States. The study also revealed that large differences in States' use of DSH still persist.

A conflict of strategies: Medicaid managed care and Medicaid maximization.

OBJECTIVE: To examine the influence of state strategies aimed at increasing federal Medicaid matching dollars on the design of states' Medicaid managed care programs. STUDY DESIGN: Data obtained from the 1996-1997 case studies of 13 states to examine how states have adapted the design of their Medicaid managed care programs in part because of maximization strategies, to accommodate the many roles and responsibilities that Medicaid has assumed over the years. PRINCIPAL FINDINGS: Our study showed that as states made the shift to managed care, some found that the responsibilities undertaken in part through maximization strategies proved to be in conflict with their Medicaid managed care initiatives. Among other things, the study revealed that most states included provisions that preserved the health care safety net, such as adapting the managed care benefit package and promoting the participation of safety net providers in managed care programs. In addition, most of the study states continued to pay special subsidies to safety net providers, including hospitals and clinics. CONCLUSIONS: States have made real progress in moving a large number of Medicaid beneficiaries into managed care. At the same time, many states have specially crafted their managed care programs to accommodate safety net providers and existing funding mechanisms. By making these adaptations states, in the long run, may compromise the central goals of managed care: controlling costs and improving Medicaid beneficiaries' access to and quality of care.

Sliding-scale premium health insurance programs: four states' experiences.

As publicly funded health insurance shifts more toward coverage of working families of low and moderate incomes, there has been growing interest in beneficiary cost sharing, in the form of sliding-scale premiums. In the 1990s, Hawaii, Minnesota, Tennessee, and Washington initiated expansion programs that used sliding-scale premiums for working-class families. The experience in these states indicates that it is feasible to require cost sharing of premiums, but there are a number of design and operational complexities. A preliminary analysis indicates that, as expected, higher out-of-pocket premium shares were associated with lower participation rates.

Changing state and federal payment policies for Medicaid disproportionate-share hospitals.

The Medicaid disproportionate-share hospital (DSH) program has been the subject of considerable policy debate throughout the 1990s, prompting Congress to revise the program three times since 1991. Using Medicaid administrative data and information obtained from twelve state case studies, we examined how the study states dealt with the federal reforms. We found a variety of state responses, ranging from not spending their full DSH allotments to seeking new, "DSH-like" federal money to help support safety-net providers.

Medicaid disproportionate share and other special financing programs.

Medicaid disproportionate share hospital (DSH) and related programs, such as provider-specific taxes or intergovernmental transfers (IGTs), help support uncompensated care and effectively reduce State Medicaid expenditures by increasing Federal matching funds. We analyze the uses of these funds, based on a survey completed by 39 States and case studies of 6 States. We find that only a small share of these funds were available to cover the costs of uncompensated care. One method to ensure that funds are used for health care would be to reprogram funds into health insurance subsidies. An alternative to improve equity of funding across the Nation would be to create a substitute Federal grant program to directly support uncompensated care.

State responses to the Medicaid spending crisis: 1988 to 1992.

In recent years the growth of Medicaid spending has been a serious state budgetary problem. Between 1988 and 1992, state Medicaid expenditures increased at an average annual rate of 21 percent. Even when accounting for funds from special revenue programs, such as provider tax and donation programs, state Medicaid spending increased by 16 percent each year between 1988 and 1992, which is far higher than in previous years. This rapid expenditure growth occurred when states were having economic slowdowns and facing fiscal pressures in many other areas. Using a case study approach, we investigated the strategies used by nine states to address the recent surge in Medicaid spending. Despite fiscal pressures, the states generally avoided large-scale cutbacks in Medicaid. Instead they implemented a wide range of budgetary actions to reduce the effect of Medicaid growth, including increment program cutbacks, constraining other budgetary sectors, shifting program costs to the federal government, and raising state taxes.

Home care for the disabled elderly: predictors and expected costs.

While interest in publicly funded home care for the disabled elderly is keen, basic policy issues need to be addressed before an appropriate program can be adopted and financed. This article presents findings from a study in which the cost implications of anticipated behavioral responses (for example, caregiver substitution) are estimated. Using simulation techniques, the results demonstrate that anticipated behavioral responses would likely add between $1.8 and $2.7 billion (1990 dollars) to the costs of a public home care program. Results from a variety of cost simulations are presented. The data base for the study was the 1982 National Long-Term Care Survey.

Severely disabled elderly persons with financially catastrophic health care expenses: sources and determinants.

This article describes the sources of financially catastrophic health care expenses among disabled elderly persons. Using a cost-to-income approach and data from the 1981-1982 Channeling Demonstration project, we examined the types of health care costs (hospital, physician and ancillary care, nursing home, and prescription medicine) that contributed to overall expenses. For the Channeling sample, out-of-pocket expenses for prescription medicines and for nursing home care were the principle source of catastrophic expenses.

Determinants of transitory and permanent nursing home admissions.

This article describes an analysis of data from the 1982-84 National Long-Term Care Demonstration Project to estimate the risks of any nursing home admission, a temporary or transitory admission, and a permanent admission. Using a multinomial logit model, the relative predictive power of several individual characteristics on nursing home use and admission type were evaluated. It was found that the cognitively impaired subgroup was at the greatest risk of entering a nursing home, especially on a permanent basis. The results also demonstrated that the combination of cognitive impairment and functional impairment further increased the risk of a nursing home admission, particularly a permanent one. Other subgroups that had high probabilities of experiencing a nursing home admission were whites, nonhomeowners, those living alone, and those with prior nursing home stays. The findings identified several aged subgroups that were at no greater risk of nursing home admission regardless of admission type: older persons who were unmarried, had a low income, had no assets, and those on Medicaid.

Costs of community care for disabled elderly persons: the policy implications.

This paper presents results from our analysis of the National Long-Term Care Channeling Demonstration Project data. We used this data to estimate the costs of community-based long-term care services for disabled elderly persons. Our results indicate that both costs per community day and the likelihood that any costs would be incurred, would increase noticeably if a program similar to the Channeling project were implemented nationally. To illustrate the effects of disability-based eligibility criteria on total program costs, we present unit costs in conjunction with numbers of persons having different levels of ADL dependency.

Health care costs of older persons with cognitive impairments.

The 1981-1982 National Long-Term Care Channeling Demonstration Project data revealed that the mean annual cost per capita for home and institutional care for cognitively impaired persons was +18,500. The equivalent figure for cognitively intact persons was +16,650. Cognitively impaired persons used nursing homes at twice the rate of cognitively intact persons. Use differences for other health services were slight. A pre- and post-nursing home admission analysis indicated that for the cognitively impaired the annual cost of community care was +11,700, whereas the cost of nursing home care was +22,300.