Project description:PurposeTo determine whether patients insured through Medicaid exhibit differences in patient-reported outcomes, return to sport rates, and reinjury and reoperation metrics after anterior cruciate ligament (ACL) reconstruction compared with patients insured with private insurance.MethodsPatients insured through Medicaid who had undergone a primary ACL reconstruction were identified and compared with a matched cohort of patients insured through private insurance with the same age and sex. Patients were contacted via telephone and emailed a questionnaire containing the International Knee Documentation Committee (IKDC) score, return to sport questions, and reinjury and reoperation metrics. Physical therapy (PT) notes were also reviewed to determine number of PT visits attended and distance from patients' home address to PT facility.ResultsA total of 26 patients insured through Medicaid and 25 insured through private insurance were enrolled in this study. The 2 groups demonstrated no statistically significant differences in age, body mass index, or sex. There were no differences in preoperative meniscus injuries or concomitant meniscus repair or meniscectomy procedures between the 2 groups. There were no differences in preoperative IKDC scores; however, the Medicaid group demonstrated a significantly lower postoperative IKDC score (74.7 vs 90.5; P = .005). Patients insured through Medicaid also demonstrated a significantly lower rate of return to sport and attended significantly fewer PT visits following surgery. There were no significant differences in reinjury or reoperation to the index knee between the 2 groups. The threshold number of PT visits for return to sport was determined to be 31.5 visits. Within the private insurance cohort, 17 of 23 patients (73.9%) exceeded this threshold. However, in the Medicaid cohort, 5 of 18 patients (27.8%) exceeded this threshold.ConclusionsPatients with Medicaid insurance undergoing ACL reconstruction had lower postoperative IKDC scores and were less likely overall to return to sport than their private insurance counterparts at final follow-up in this study. Preoperative IKDC scores, incidence of preoperative meniscus injury, number of concomitant meniscus procedures, average distance from home to PT facility, return to same level of sport, and reinjury and reoperation rate were similar between groups. However, the number of postoperative PT sessions attended by patients insured through Medicaid was significantly lower than private insurance patients.Level of evidenceIII, retrospective comparative study.

Project description:Importance:Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills ("surprise bills") from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians. Objective:To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities. Design, Setting, and Participants:Retrospective analysis of claims data from a large US commercial insurer, representing 347?356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116?749]; laparoscopic cholecystectomy [82?372]; hysterectomy [67?452]; total knee replacement [42?313]; breast lumpectomy [18?018]; colectomy [14?074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017. Exposure:Patient, clinician, and insurance factors potentially related to out-of-network bills. Main Outcomes and Measures:The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service. Results:Among 347?356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P?<?.001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P?<?.001). Among 83?021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill. Conclusions and Relevance:In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.

Project description:Background & aimsHospitalized patients with acute severe ulcerative colitis (ASUC) often require surgery. Although the tumor necrosis factor antagonist infliximab is an effective salvage therapy to prevent colectomy in patients with ASUC, optimal dosing is unclear. Calculated infliximab clearance has been associated with important outcomes in patients with ulcerative colitis, but its utility in patients with ASUC has not been established. We assessed the relationship between calculated the baseline infliximab clearance before infliximab salvage therapy and the requirement for colectomy in patients hospitalized for ASUC.MethodsWe obtained data from hospitalized patients with ASUC who initiated infliximab therapy. We then calculated the baseline infliximab drug clearance in these patients based on an existing formula. The primary aim was to compare clearance between patients who required colectomy 6 months later and patients who did not require colectomy. Receiver operating characteristic curve analyses evaluated clearance thresholds for colectomy. Multivariable logistic regression analysis evaluated factors associated with colectomy.ResultsIn 39 patients with ASUC, the median baseline calculated clearance was higher in patients requiring colectomy at 6 months than in patients without colectomy (0.733 vs 0.569 L/d; P = .005). An infliximab clearance threshold of 0.627 L/d identified patients who required colectomy with 80.0% sensitivity and 82.8% specificity (area under the curve, 0.80). A higher proportion of patients with infliximab clearance of 0.627 L/d or more underwent colectomy within 6 months (61.5%) than patients with lower infliximab clearance values (7.7%) (P = .001). Multivariable analysis identified baseline infliximab clearance as the only factor associated with colectomy. The infliximab dose in the hospital was higher in patients who required colectomy. Results were similar at 30 days and 1 year.ConclusionsIn patients hospitalized with ASUC, higher values of calculated infliximab clearance before infliximab administration is associated with higher rates of colectomy. Although patients who required colectomies received higher doses, data on infliximab concentrations are lacking. Infliximab pharmacokinetic models are needed for patients with ASUC to allow comparative trials on clearance-based vs standard dosing.

Dataset Information

Use of Biological Medications Does Not Increase Postoperative Complications Among Patients With Ulcerative Colitis Undergoing Colectomy: A Retrospective Cohort Analysis of Privately Insured Patients.

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