Clinical orthopaedics and related research
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Clin. Orthop. Relat. Res. · Nov 2009
Comparative StudyPredictors of prognosis for elderly patients with poststroke hemiplegia experiencing hip fractures.
Hip fracture is an important cause of mortality and disability in elderly patients, particularly in those with poststroke hemiplegia, but little information is available regarding differences of general characteristics between patients with and without hemiplegia who experience hip fractures, factors predicting recovery of prefracture ambulatory status, and mortality of patients with poststroke hemiplegia with hip fractures. We retrospectively reviewed 1379 consecutive prospectively followed patients with hip fractures treated from January 2000 to May 2006. Of the 1379 patients, 101 (7.3%) had poststroke hemiplegia. All patients were followed a minimum of 1 year if they survived more than a year or until death if they died within a year after surgery (mean, 19.5 months; range, 4-49 months). According to the American Society of Anesthesiologists (ASA) rating, the patients with hemiplegia were sicker than patients without hemiplegia, more likely to have three or more comorbidities, lower cognitive ability, weaker prefracture ambulatory status, more days of hospitalization, and higher mortality rate. Gender, ASA rating, number of comorbidities, and prefracture ambulatory status predicted mortality of hip fractures in elderly patients with poststroke hemiplegia, and the ASA rating, number of comorbidities, and cognitive ability predicted recovery of prefracture ambulatory status for these patients. ⋯ Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Nov 2009
Multicenter Study Comparative StudyIs locking nailing of humeral head fractures superior to locking plate fixation?
The optimal surgical treatment of displaced proximal humeral fractures is controversial. New implants providing angular stability have been introduced to maintain the intraoperative reduction. In a multi-institutional study, we prospectively enrolled and followed 152 patients with unilateral displaced and unstable proximal humeral fractures treated either with an antegrade angular and sliding stable proximal interlocking nail or an angular stable plate. Fractures were classified according to the Neer four-segment classification. Clinical, functional, and radiographic followups were performed 3, 6, and 12 months after surgery. Absolute and relative (to the contralateral shoulder) Constant-Murley scores were used to assess postoperative shoulder function. Using age, gender, and fracture type, we identified 76 pairs (152 patients) for a matched-pairs analysis. Relative Constant-Murley scores 12 months after treatment with an angular and sliding stable nail and after plate fixation were 81% and 77%, respectively. We observed no differences between the two groups. Stabilization of displaced proximal humeral fractures with either an angular stable intramedullary or an extramedullary implant seems suitable with both surgical treatment options. ⋯ Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Oct 2009
ReviewGetting to equal: strategies to understand and eliminate general and orthopaedic healthcare disparities.
The 2001 Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care pointed out extensive healthcare disparities in the United States even when controlling for disease severity, socioeconomic status, education, and access. The literature identifies several groups of Americans who receive disparate healthcare: ethnic minorities, women, children, the elderly, the handicapped, the poor, prisoners, lesbians, gays, and the transgender population. ⋯ While healthcare disparities have roots in multiple sources, racial stereotypes and biases remain a major contributing factor and are prototypical of biases based on age, physical handicap, socioeconomic status, religion, sexual orientation or other differences. Given that such disparities have a strong basis in racial biases, and that the principles of racism are similar to those of other "isms", we summarize the current state of healthcare disparities, the goals of their eradication, and the various potential solutions from a conceptual model of racism affecting patients (internalized racism), caregivers (personally mediated racism), and society (institutionalized racism).
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Clin. Orthop. Relat. Res. · Oct 2009
Economic incentives to promote innovation in healthcare delivery.
Economics influences how medical care is delivered, organized, and progresses. Fee-for-service payment encourages delivery of services. Fee-for-individual-service, however, offers no incentives for clinicians to efficiently organize the care their patients need. ⋯ Modifications to gainsharing and antikickback rules, as well as reforms to malpractice liability laws, will facilitate the functioning of the care delivery teams. The implicit financial incentives encourage efficient care for the patient; the episode focus will facilitate measuring patient outcomes. Payment can be based on the resources used by those care delivery teams achieving superior outcomes, thereby fostering innovation improving outcomes and reducing waste.