Treatment of Closed Femoral Shaft Fractures in Children Aged 6 to 10

BACKGROUND: Management of pediatric femoral shaft fractures remains controversial, particularly in children between the ages of 6 and 10. In the current push toward cost containment, hospital type, and surgeon subspecialization have emerged as important factors influencing this treatment decision. Thus, in the present study, we use a nationwide pediatric inpatient database to compare the: (a) incidence; (b) demographic characteristics; (c) hospital costs; (d) length of stay; and (e) treatment method of pediatric closed femoral shaft fractures admitted to general versus children\u27s hospitals. METHODS: The Kids\u27 Inpatient Database (KID) was queried for all patients aged 6 to 10 who sustained a closed femoral shaft fracture in 2009 or 2012, and patient records were stratified into children\u27s hospitals and general hospitals. Primary outcome measures included method of treatment, total hospital costs, and length of stay. Student/Welch t testing and χ analysis were utilized to compare continuous and categorical outcomes, respectively, between hospital types. RESULTS: The total incidence of closed femoral shaft fractures decreased between 2009 and 2012 (1919 to 1581 patients; P=0.020), as did the proportion of patients treated in children\u27s hospitals (58.6% to 32.3%; P CONCLUSIONS: The present study demonstrates a decrease in the incidence of closed femoral shaft fractures in 6- to 10-year old patients from 2009 to 2012, as well as decreased definitive management in children\u27s hospitals and increased selection of operative treatment. In addition, treatment in a nonchildren\u27s hospital was associated with decreased total inpatient costs and decreased treatment with closed reduction with internal fixation in favor of open reduction with internal fixation. Future studies should seek to identify the specific surgical procedures performed and match patients more closely based specific fracture pattern. LEVEL OF EVIDENCE: Prognostic level II

Global Budget Revenue on a Single Institution\u27s Costs and Outcomes in Patients Undergoing Total Hip Arthroplasty

Background: The state of Maryland was granted a waiver by the Center for Medicare and Medicaid Services to implement a Global Budget Revenue (GBR) reimbursement model. This study aims to compare (1) costs of inpatient hospital stays; (2) postacute care costs; (3) lengths of stay (LOS); and (4) discharge disposition who underwent primary total hip arthroplasty at a single Maryland-based orthopedic institution before and after the implementation of GBR. Methods: The Maryland Center for Medicare and Medicaid Services database was queried to obtain all Medicare patients who underwent total hip arthroplasty at a single institution before and after the implementation of GBR. We compared the differences in costs for the following: inpatient care, the postacute care period, and readmissions. In addition, we evaluated differences in LOS, discharge disposition, and complication rates. Results: There was a significant decrease in inpatient costs ($26,575 vs$23,712), an increase in mean home health costs ($627 vs 1608), and a decrease in mean durable medical equipment costs ($604 vs $82) and LOS (2.92 days vs 2.33 days). There was an increase in discharge to home rates (72.3% vs 78.9%) and a decrease in discharge to acute rehabilitation (4.3% vs 1.8%) Conclusion: Under the GBR model, our institution experienced significant cost savings during the inpatient and postacute care episodes. Thus, GBR may serve as a viable solution to reducing costs to Medicare for high-volume arthroplasty institutions with a large Medicare population. Multicentered studies are needed to verify our results

Global Budget Revenue on a Single Institution\u27s Costs, Outcomes, and Patient Quality Metrics in Patients Undergoing Total Knee Arthroplasty

BACKGROUND: Maryland was granted a waiver to implement a Global Budget Revenue (GBR) reimbursement model. Statewide results for combined medical and surgical services have been reported for fiscal years 2015 and 2016. A paucity of studies exists exploring the change in care costs and outcomes for total knee arthroplasty (TKA) recipients under GBR. This study aims to assess the effects of GBR on cost of care and resource utilization related to TKA at a single institution before and after GBR. METHODS: The Maryland Center for Medicare and Medicaid Services database was used to find Medicare patients who underwent TKA at a single institution before (2012-2013) and after (2014-2015) GBR. A total of 150 and 161 TKAs were performed in 2012 and 2015. Cost differences were compared for each inpatient care episode, postacute care period, and readmissions. We also evaluated differences in length of stay, discharge disposition, and complication rates. RESULTS: Mean inpatient cost was significantly lower in 2015 vs 2012 (P = .0014); however, analysis of postacute costs showed a nonsignificant increase in price between years (P = .1008). We demonstrated significant increase in home health (P \u3c .0001) and significant decrease in acute rehabilitation (P = .0481). Durable medical equipment costs significantly decreased (P = .0087). CONCLUSION: We demonstrate lower mean inpatient costs since GBR initiation. We reveal increased mean postacute care costs, which may be due to increased acuity for patients needing postacute care. Our results show nonsignificant reductions in length of stay, complications, and increased rate of home discharge, suggesting GBR may be effective in orchestrating reduced costs for TKA at high-volume institutions

An Analysis of Centers for Medicare & Medicaid Service Payment in Maryland: Can a Global Budget Revenue Model Save Money in Lower Extremity Arthroplasty?

BACKGROUND: Maryland is the only state utilizing the Global Budget Revenue (GBR) model to reduce costs. The purpose of this study is to evaluate whether the GBR payment model effectively reduced the following: (1) costs of inpatient hospital stays; (2) post-acute care costs; (3) lengths of stay (LOS); (4) readmission rates; and (5) discharge disposition in patients who underwent primary total hip and knee arthroplasty (THA and TKA). METHODS: We evaluated the Maryland Centers for Medicare & Medicaid Service database for THAs and TKAs performed at 6 hospitals 1 year prior to (2012) and after the initiation of GBR (2015). We compared differences in costs for each inpatient care episode, post-acute care periods (total costs, acute rehabilitation, short-term nursing facility, home health, durable medical equipment), readmissions, LOS, and discharge disposition. RESULTS: Hospitals had a significant reduction in mean inpatient care costs for THA and TKA (P \u3c .0001). There was a significant reduction in total post-acute care costs following THA (P \u3c .001). Home healthcare had a significant increase in cost following THA and TKA (P \u3c .0001). There was a significant reduction in durable medical equipment costs for THA (P \u3c .0001). There was a significant decrease in LOS for THA and TKA (P \u3c .0001). There was a significant increase in patients discharged home (THA, P = .0262; TKA, P = .0058). CONCLUSION: The Maryland healthcare model may be associated with a reduction in inpatient and post-acute care costs. Furthermore, implementation of GBR may result in reductions in LOS and readmission rates

Progresso e mimesis: ideias políticas, imitação e desenvolvimento Progress and mimesis: political ideas, imitation, and development

A ciência política comparativa vinha ignorando o papel central que ideias e modelos políticos têm na criação e no desenvolvimento das instituições. Com o colapso do bloco soviético e o fervor intelectual que acompanhou esse evento, criou-se uma abertura pela qual os efeitos do pensamento político passaram a ser vistos como importantes. Articuladas por pensadores políticos, as ideias dirigem ações, refletem entendimentos dominantes entre as elites sobre a realidade ou fornecem uma base para a crítica desses entendimentos. Nesse sentido, seu estudo pode revelar alguns aspectos do esforço de constituição de um regime. Este artigo sugere uma forma de abordar o problema: examinar como as ideias são adotadas, adaptadas e assimiladas pelos atores políticos.<br>Comparative political science has ignored the central role that political ideas and models have on the creation and development of institutions. With the collapse of the Soviet bloc and the intellectual fervor that accompanied this event, possibilities of paying attention to the effects of political thought grew. Articulated by political thinkers, ideas direct actions, reflect dominant understandings among elites on the truth or provide a basis for criticism of these understandings. In this sense, their study may reveal some aspects of the effort to set up a regime. This article suggests an approach to the problem: focusing on how ideas are adopted, adapted and supported by the political actors