William E. Golden

Perioperative asymptomatic venous thrombosis: Role of duplex scanning versus venography * **

We compared combined B-mode/Doppler (duplex ultrasonic scanning and venography in routine preoperative and postoperative screening for major proximal deep vein thrombosis in 78 patients undergoing total hip or knee arthroplasty. Of 309 extremity examinations, duplex scanning had an overall sensitivity of 85.7% (12/14) and a specificity of 97.3% (287/295). The preoperative prevalence and postoperative incidence of major deep vein thrombosis were 2.5% and 14.1% of patients, respectively, despite intensive mechanical and pharmacologic prophylaxis. In addition, venography documented a preoperative prevalence and postoperative incidence of isolated calf deep vein thrombosis in 2.5% and 16.7% of patients, respectively. Whereas such disease extended proximally even in the absence of anticoagulation in only 18% of patients studied by serial duplex scans, calf deep vein thrombosis accounted for the only two instances of pulmonary embolism in this study. There were no deaths related to pulmonary embolism. This study suggests that duplex scanning is useful in screening for perioperative deep vein thrombosis in patients undergoing total hip or knee arthroplasty, which carries a significant risk of venous thromboembolism despite routine prophylaxis.

Laparoscopic cholecystectomy in the geriatric population.

OBJECTIVE: To assess effectiveness and conversion rates of inpatient laparoscopic cholecystectomy in older people living in the community.

HEALTH STATUS MEASUREMENT : IMPLEMENTATION STRATEGIES

The creation of valid instruments of health status measurement does not guarantee their use in the clinical setting. Traditional continuing medical education has not been shown to effect physician behavioral change. Examination of the literature on the dissemination of new technology underscores the need for the acceptance and use of new methods by local opinion leaders whose behavior serves as a model for their colleagues. Since health status measurement will require a new way of evaluating the patient visit and the creation of new provider behaviors, widespread implementation will require the recruitment of local clinical leaders to serve as spokesmen for reconsideration of office care procedures. Advocates of health status measurement should seize on a variety of opportunities to disseminate their work. Medical school curricula in courses such as physical diagnosis could expose different approaches to the patient encounter to a new generation of physicians in a fairly painless and seamless manner. Academic practice plans, by virtue of their increasing trend to centralization, could commit to patient-oriented data collection--if not for instructional purposes, then for the overall health of the delivery system. The instruction of nurses and paraprofessionals in the collection of these data could expand the measures and help drive the system when physicians are not embracing the technology. There is need to exploit the enhanced capacity of computer hardware and software in the service of efficient data collection and trend analysis of health status.(ABSTRACT TRUNCATED AT 250 WORDS)

Health Policy Basics: Medicaid Expansion

Since its inception in 1965, the Medicaid program has evolved to become the largest single source of health coverage in the United States, providing insurance for more than 62 million low-income persons and families in 2013 (1). For most of its history, Medicaid has provided coverage to low-income children, pregnant women, and elderly and disabled persons. It is also the largest provider of long-term care benefits. Before passage of the Patient Protection and Affordable Care Act (ACA), few states provided comprehensive Medicaid coverage to low-income childless adults, leaving an enormous hole in the U.S. health care safety net. The ACA sought to mend this coverage gap by expanding Medicaid coverage to all eligible persons with incomes up to 138% of the federal poverty level (FPL) starting in January 2014. (The law expands eligibility to persons with incomes up to 133% of the FPL but includes an income disregard that increases coverage to 138% of the FPL.) However, in June 2012, a U.S. Supreme Court ruling gave states the option to expand their Medicaid programs to meet ACA standards or keep them as they were. This article provides a brief overview of the Medicaid expansion, the people and benefits it will cover, and how it will affect patients and physicians. Coverage Expansion Before the ACA, there was no federal requirement that Medicaid cover childless adults. Some states provide limited Medicaid benefits through a federal waiver or state-funded program. However, the coverage for this group is sparse. In 2009, only 5 states provided benefits similar to Medicaid, 15 provided benefits that were less than Medicaid, 4 had a premium assistance program, and the remaining 27 provided no coverage for childless adults (2). The ACA filled this immense coverage gap by requiring that states expand Medicaid eligibility to all persons with incomes up to 138% of the FPL, or roughly

Quality improvement in psychiatry: why measures matter.

15850 for an individual and

Development of evidence-based performance measures for bipolar disorder: overview of methodology.

32500 for a family of 4 in 2013 dollars. Opponents of the ACA argued that the federal government had overreached in mandating that a state expand eligibility or lose federal funding for its existing Medicaid program, and in June 2012, the U.S. Supreme Court ruled that Medicaid expansion would be optional for states. As of 22 November 2013, twenty-five states and the District of Columbia have indicated that they will participate in the Medicaid expansion (3). Despite the refusal of some states to support the expansion, the Congressional Budget Office maintains that most states will ultimately choose to expand eligibility. In May 2013, the Congressional Budget Office estimated that Medicaid and the Childrens Health Insurance Program will cover an additional 13 million persons by 2023, roughly 4 million fewer than 10-year estimates made when expansion was mandatory (4, 5). Benefits The newly covered adult population will receive Alternative Benefit Plan (ABP) coverage that will be aligned with or actuarially equivalent to a benchmark plan chosen by the state, such as the Standard Blue Cross/Blue Shield preferred provider option plan offered to federal employees or the states traditional Medicaid benefit package. The ABP must also cover the 10 essential health benefit categories required of new individual and small group market insurance plans (Table). Newly eligible adults deemed to be medically frail may choose to receive the ABP package or the states traditional benefit package. Alternative Benefit Plans must also cover Early and Periodic Screening, Diagnostic, and Treatment services for enrollees younger than 21 years. Mental health parity regulations, nonemergency transportation, and family planning coverage requirements also apply to ABP benefits. Table. Essential Health Benefit Categories for Alternative Benefit Plans Recent federal regulations set new guidelines for Medicaid cost sharing, although many enrollees, such as very poor children, cannot be subject to cost sharing. The newly eligible adult Medicaid enrollees, for example, may be subject to limited cost sharing for receiving nonemergency services provided in an emergency department. Financing Medicaid is funded by federal and state expenditures. The federal governments share depends on the states average per capita income and currently ranges from 50% to 73% of expenditures. The ACA requires the federal government to fully fund coverage for persons who are newly eligible under the Medicaid expansion from 2014 to 2016. After that, the states share of costs will gradually increase to 10% of expenditures in 2020 and beyond. Provider Payments Historically, Medicaid has paid physicians well below commercial and Medicare reimbursement rates. In 2012, average Medicaid primary care reimbursement rates were 59% of Medicare rates (6). Evidence suggests that low reimbursement is one of the reasons some physicians do not participate in the Medicaid program (7). To help ensure that Medicaid enrollees have access to physicians, the ACA increases reimbursements for certain primary care services to Medicare levels in 2013 and 2014. Arkansas Premium Assistance Waiver Many politically conservative states remain unwilling to expand Medicaid. Among the reasons cited are concerns that Medicaid would replace private insurance coverage and that states would be financially responsible for a portion of the expansions cost, as well as philosophical concerns about expanding the federal governments role in providing health insurance (8). The Obama administration has indicated a willingness to allow states to expand Medicaid coverage through private insurance plans as long as the program cost, benefits, cost sharing, and scope are similar to those of Medicaid expansion coverage. Arkansas recently received a waiver from the federal government to implement a premium assistance program allowing the state to use Medicaid expansion funding to provide private qualified health insurance through the ACAs Health Insurance Marketplace, an entity intended to increase access to and affordability of commercial insurance. Several states, including Iowa and Pennsylvania, are exploring the premium assistance option as a means to expanding coverage for persons who are newly eligible for Medicaid (9). What Are the Implications of Medicaid Expansion for Patients? The Medicaid expansion will close substantial gaps in the U.S. health coverage safety net by ensuring that all low-income citizens and permanent residents can enroll in coverage. Evidence shows that expanding Medicaid eligibility to previously uninsured adults leads to better self-reported health; substantially less health carerelated financial stress; and elevated use of preventive services, such as mammography (10, 11). Although low-income patients in states that have chosen to expand Medicaid will reap the benefits of health insurance, those residing in states that have not yet expanded will probably remain uninsured. Persons with incomes between 100% and 138% of the FPL will be able to receive tax credits and cost-sharing assistance to purchase Marketplace-based coverage. The Kaiser Commission on Medicaid and the Uninsured estimates that almost 5 million uninsured adults with incomes below the federal poverty levelthe poorest of the poorwill fall into the coverage gap and will be unable to enroll in Medicaid unless their state decides to expand eligibility (12). Although research shows that access to care and health improves when uninsured persons enroll in Medicaid, there are still areas of concern within the program. Depending on the states benefit benchmark, the newly eligible group may not receive benefits as comprehensive as traditional Medicaid (13). Patients may also have difficulty finding a physician who is willing to accept new Medicaid patients despite reimbursement enhancements designed to attract physicians to Medicaid (14). What Are the Implications of Medicaid Expansion for Physicians? For the first time, physicians will be able to provide regular care to a population that has historically been denied Medicaid coverage and is less likely to have access to employer-based coverage. Adults receiving Medicaid are more likely than uninsured adults to have a regular source of care and to report seeing a physician in the past 12 months (15). Furthermore, the volume of uncompensated care should decrease, thus reducing bad debt incurred by physician offices, clinics, and hospitals. With assistance from Center for Medicare & Medicaid Innovation grants and other sources, Medicaid is also experiencing a shift toward coordinated care models, such as the patient-centered medical home, which may help contain costs and enhance provider collaboration. Physicians may also see negative consequences. Hospitals in states that do not expand Medicaid will continue to absorb uncompensated care costs, a problem that will be compounded by the ACA-mandated decrease in reimbursements to hospitals that provide care to uninsured persons. The temporary nature of the primary care pay parity boost may attract physicians, but other problems with Medicaid, such as administrative hassles and the limited number of physician specialists participating, may persist, thus discouraging physicians from accepting new Medicaid patients (16). Conclusion The Medicaid expansion will help close substantial gaps in the U.S. health care safety net, but only if all states elect to expand their programs. By not expanding, states are forgoing an opportunity for their poor citizens to achieve financial peace of mind, obtain a regular source of medical care, and receive preventive services to help stave off serious complications. Medicaid remains an imperfect program, with low reimbursement and frustrating administrative burdens that can discourage physicians from participating. Despite these challenges, the Medicaid expansion poses an opportunity for states to provide health coverage to a population historically excluded from the program.

MRI of the Knee and Shoulder Performed Before Radiography

Increasing attention has been directed in healthcare today to the importance of performance measurement, (i.e., the implementation of measurable methods to demonstrate that practitioners are engaged in high-quality, evidence-based medicine). Many medical specialties, as well as many state medical licensing boards, now require that candidates submit performance measurement data, to be eligible for maintenance of board certification or medical licensure. National organizations such as the National Quality Forum and the Physicians Consortium for Performance Improvement of the American Medical Association are active collaborators with federal, state, and medical specialty initiatives to improve healthcare. These developing efforts are summarized here, with a specific focus on the status of these efforts in the field of psychiatry.

Pseudothrombocytopenia in an elderly preoperative patient.

The STAndards for BipoLar Excellence (STABLE) Project was organized in 2005 to improve quality of care for bipolar disorder by developing and testing a set of evidence-based clinical process performance measures related to identifying, assessing, managing, and coordinating care for bipolar disorder. This article first briefly reviews the literature on the science of performance measurement and the use of performance measures as a tool for quality improvement. It then presents a detailed overview of the methodology used to develop the STABLE performance measures. Steps included choosing a clinical area to be measured, selecting key aspects of care for measurement, designing specifications for the measures, developing a data collection strategy, testing the scientific strength (validity, reliability, feasibility) of the measures, and obtaining, analyzing, and reporting conformance findings for the measures. Five of the STABLE measures have been endorsed by the National Quality Forum as part of their Standardizing Ambulatory Care Performance Measures project: screening for bipolar mania/hypomania in patients diagnosed with depression, assessment for risk of suicide, assessment for substance use, screening for hyperglycemia when atypical antipsychotic agents are prescribed, and monitoring change in level of functioning in response to treatment. Additional STABLE measures will be submitted to appropriate national organizations in the future. It is hoped that these measures will be used in quality assessment activities and that the results will inform efforts to improve care for individuals with bipolar disorder.

Megatrends in medical education.

PURPOSE Available data are limited on the level of adherence to established guidelines for appropriate utilization of MR in musculoskeletal imaging. This study estimates the percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography, which thus may fall outside the ACR Appropriateness Criteria for the Medicare and commercially insured populations. METHODS The percentage of MRI examinations for knee and shoulder pain or tendonitis performed without prior radiography was estimated among patients in the Medicare 5% carrier claims limited data set and among commercially insured patients in the Truven Marketscan Treatment Pathways database in 2010. RESULTS Approximately 28% of all knee MRIs, and 35%-37% of all shoulder MRIs were performed without recent prior radiographs. The extrapolated expense of these potentially unwarranted MRIs in the entire fee-for-service Medicare population was between

Access to Spacers and Peak Flow Meters Among Medicaid Patients with Asthma

20 and