An evaluation of immediate-use steam sterilization practices in adult knee and hip arthroplasty procedures.

Background: Immediate-use steam sterilization (IUSS) is a safe method to sterilize emergently contaminated instruments, but inappropriate use may lead to an increased risk for surgical site infection. This study aimed to identify risk factors, rationale, and variability in procedural adherence in cases of IUSS.

Methods: This retrospective, case-control study compared adult patients undergoing hip and knee arthroplasty in which IUSS was (n = 104) and was not (n = 81) performed.

Undocumented immigrants, left out of health reform, likely to continue to grow as share of the uninsured.

The increase in undocumented immigration between 1999 and 2007 contributed to an increase in the number of uninsured people in the United States. During this period, the number of undocumented immigrants increased from an estimated 8.5 million to 11.

Understanding the concept of medialization in scapula fractures.

Objective: To determine whether medial displacement of the glenoid with respect to the midline occurs in scapula fractures and the potential impact on fracture reduction technique.

Design: Retrospective case series.

Setting: Level I trauma medical center.

Conflicts regarding genetic counseling for fragile X syndrome screening: a survey of clinical geneticists and genetic counselors in Israel.

Although fragile X screening has been offered in Israel since 1994, issues related to potential neurological and gynecological symptoms in carriers make counseling for fragile X different from recessive disorders. We evaluated the attitudes of clinical geneticists and genetic counselors regarding genetic counseling given to the women undergoing screening. We performed a self-administered questionnaire including 13 study questions mailed to all clinical geneticists and genetic counselors in Israel.

Medical spending and the health of the elderly.

Objective: To estimate the relationship between variations in medical spending and health outcomes of the elderly.

Data Sources: 1992-2002 Medicare Current Beneficiary Surveys.

Study Design: We used instrumental variable (IV) estimation to identify the relationships between alternative measures of elderly Medicare beneficiaries' medical spending over a 3-year observation period and health status, measured by the Health and Activity Limitation Index (HALex) and survival status at the end of the 3 years.

Reforming beneficiary cost sharing to improve Medicare performance.

This paper explores options for reforming Medicare cost sharing in an effort to provide better financial protection for those beneficiaries with the greatest health care needs. Using data from the Health and Retirement Study (HRS) and the Medicare Current Beneficiary Survey (MCBS), we consider how unified annual deductibles, alternative coinsurance rates, and a limit on out-of-pocket spending would alter program spending, beneficiary cost sharing, and premiums for supplemental coverage. We show that adding an out-of-pocket limit and raising deductibles and coinsurance slightly would provide better safeguards to beneficiaries with high costs than the current Medicare benefit structure.

CADASIL can mimic multiple sclerosis.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) can be confused with multiple sclerosis (MS). We report a man with a father diagnosed with MS via magnetic resonance imaging (MRI). The index patient was subsequently diagnosed with MS after MRI for evaluation of migraine headaches.

Clarifying sources of geographic differences in Medicare spending.

Background: Although geographic differences in Medicare spending are widely considered to be evidence of program inefficiency, policymakers need to understand how differences in beneficiaries' health and personal characteristics and specific geographic factors affect the amount of Medicare spending per beneficiary before formulating policies to reduce geographic differences in spending.

Methods: We used Medicare Current Beneficiary Surveys from 2000 through 2002 to examine differences across geographic areas (grouped into quintiles on the basis of Medicare spending per beneficiary over the same period). We estimated multivariate-regression models of individual spending that included demographic and baseline health characteristics, changes in health status, other individual determinants of demand, and area-level measures of the supply of health care resources.

Medicare savings programs: analyzing options for expanding eligibility.

The Medicare Savings Programs (MSPs) are designed to provide financial assistance to Medicare beneficiaries who do not qualify for full Medicaid coverage. This paper considers changes in eligibility that would better align MSP program rules with those related to receiving low-income subsidies for the Medicare Part D drug benefit. These changes would make more people eligible for the MSPs and could encourage greater participation; similar changes were incorporated in recently passed legislation.

Medicare fees and the volume of physicians' services.

This paper estimates the relationship between Medicare fees and quantities provided by physicians for eight specific services. It uses data for 13,707 physicians who responded to surveys in 2000/2001 and/or 2004/2005 and were linked to all Medicare claims for their Medicare patients. Results show that Medicare fees are positively related to quantity provided for all eight services, and are significantly different from zero and elastic for five of them.

Identification of regulatory Hck and PAI-2 proteins in the monocyte response to PEG-containing matrices.

Mass spectrometry is a powerful proteomic tool enabling researchers to survey the global proteome of a cell. This technique has only recently been employed to investigate cell-material interactions. We had previously identified material scarcity and limited adherent cells as challenges facing mass spectrometric analysis of cell-material interactions.

Trends in Medicaid physician fees, 2003-2008.

Medicaid physician fees increased 15.1 percent, on average, between 2003 and 2008. This was below the general rate of inflation, resulting in a reduction in real fees.

Missouri's 2005 Medicaid cuts: how did they affect enrollees and providers?

In 2005, Missouri adopted sweeping Medicaid cutbacks. More than 100,000 people lost coverage, and many more faced reduced benefits and higher cost sharing. Using a range of data sources, we show that the cutbacks were followed by a major increase in the numbers of uninsured people, greater uncompensated care burden on hospitals, and revenue shortfalls that forced community health centers to obtain larger state grants and charge patients more.

Adolescent Dose and Ratings of an Internet-Based Depression Prevention Program: A Randomized Trial of Primary Care Physician Brief Advice versus a Motivational Interview.

BACKGROUND: Internet-based interventions for education and behavior change have proliferated, but most adolescents may not be sufficiently motivated to engage in Internet-based behavior change interventions. We sought to determine how two different forms of primary care physician engagement, brief advice (BA) versus motivational interview (MI), could enhance participation outcomes in an Internet-based depression prevention intervention. METHODS: Eighty-three adolescents at risk for developing major depression were recruited by screening in primary care and randomized to two groups: BA (1-2 minutes) + Internet program versus MI (10-15 minutes) + Internet program.

A house is not a home: keeping patients at the center of practice redesign.

The "patient-centered medical home" has been promoted as an enhanced model of primary care. Based on a literature review and interviews with practicing physicians, we find that medical home advocates and physicians have somewhat different, although not necessarily inconsistent, expectations of what the medical home should accomplish-from greater responsiveness to the needs of all patients to increased focus on care management for patients with chronic conditions. As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.

Attitudes of couples identified through screening as carriers of Gaucher disease type 1.

Gaucher disease (GD) type 1 is the most frequent autosomal recessive disorder among Ashkenazi Jews, but because the phenotype is tremendously variable, including it in the 'Ashkenazi Panel' of carrier screening is controversial. As part of a nationwide study conducted in Israel to evaluate the outcomes of carrier screening for GD, we studied the experience of 65/82 (79%) of the couples identified as being at risk for an affected child. We found that pre-test information was regarded as insufficient and improved in post-result counseling.

Medicaid and SCHIP coverage: findings from California and North Carolina.

This article examines experiences under Medicaid and the State Children's Health Insurance Program (SCHIP), drawing on surveys of over 3,000 enrollees in California and North Carolina in 2002. In both States, Medicaid enrollees were less likely than SCHIP enrollees to have parents who were covered by employer-sponsored insurance (ESI). With the exception of dental care and provider perceptions, access experiences were fairly comparable across the two programs, despite differences in the characteristics of the children served by the two programs.

State responses to new flexibility in medicaid.

Context: States have long lobbied to be given more flexibility in designing their Medicaid programs, the nation's health insurance program for the low-income, the elderly, and individuals with disabilities. The Bush administration and the Deficit Reduction Act of 2005 have put in place policies to make it easier to grant states this flexibility.

Methods: This article explores trends in states' Medicaid flexibility and discusses some of the implications for the program and its beneficiaries.

Impact of resource-based practice expenses on the Medicare physician volume.

In 1999, Medicare implemented a resource-based relative value unit (RVU) system for physician practice expense payments, and increased the number of services for which practice expense payments differ by site. Using 1998-2004 data, we examined RVU growth and decomposed that growth into resource-based RVUs, site of service, and service quantity and mix. We found that the number services with site of service differentials doubled, and that shifts in site of service and introduction of resource-based practice expenses (RBPE)were important sources of change in practice expense RVU volume.

Ensuring appropriate timing of antimicrobial prophylaxis.

Background: Delivery of intravenous antibiotic prophylaxis within one hour prior to surgical incision is considered important in helping to decrease the incidence of surgical site infections, but methods to ensure compliance have not been established.

Methods: All patients at our institution are subjected to a surgical "time-out" protocol to prevent wrong-site surgery. During a seven-week period, all patients undergoing spine surgery, total hip arthroplasty, or total knee arthroplasty had another safety initiative, that of ensuring that prophylactic intravenous antibiotics were administered at least one hour prior to incision, "piggybacked" onto our existing time-out verification checklist.

Assessing the value of the NHIS for studying changes in state coverage policies: the case of New York.

Research Objective: (1) To assess the effects of New York's Health Care Reform Act of 2000 on the insurance coverage of eligible adults and (2) to explore the feasibility of using the National Health Interview Survey (NHIS) as opposed to the Current Population Survey (CPS) to conduct evaluations of state health reform initiatives.

Study Design: We take advantage of the natural experiment that occurred in New York to compare health insurance coverage for adults before and after the state implemented its coverage initiative using a difference-in-differences framework. We estimate the effects of New York's initiative on insurance coverage using the NHIS, comparing the results to estimates based on the CPS, the most widely used data source for studies of state coverage policy changes.

Carrier screening for Gaucher disease: lessons for low-penetrance, treatable diseases.

Context: The aim of carrier screening is to prevent severe, untreatable genetic disease by identifying couples at risk before the birth of an affected child, and providing such couples with options for reproductive outcomes for affected pregnancies. Gaucher disease (GD) is an autosomal recessive storage disorder, relatively frequent in Ashkenazi Jews. Carrier screening for GD is controversial because common type 1 GD is often asymptomatic and effective treatment exists.

Restoring fiscal integrity to medicaid financing?

Using survey data, we examined Medicaid supplemental payments (SPs), including disproportionate-share hospital (DSH) and upper payment limit (UPL) payments in 2005 and changes in these payments between 2001 and 2005. We found that states increased their use of general funds in financing of DSH payments while expanding the size and scope of other SPs considerably. Although the federal government has made some headway in reforming state Medicaid financing, our findings suggest that more work remains.