Medicaid Expansion Under the Affordable Care Act and Association With Cardiac Care: A Systematic Review

BACKGROUND

The goal of the Affordable Care Act was to improve health outcomes through expanding insurance, including through Medicaid expansion. We systematically reviewed the available literature on the association of Affordable Care Act Medicaid expansion with cardiac outcomes.

METHODS

Consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we performed systematic searches in PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature using the keywords such as Medicaid expansion and cardiac, cardiovascular, or heart to identify titles published from 1/2014 to 7/2022 that evaluated the association between Medicaid expansion and cardiac outcomes.

RESULTS

A total of 30 studies met inclusion and exclusion criteria. Of these, 14 studies (47%) used a difference-in-difference study design and 10 (33%) used a multiple time series design. The median number of postexpansion years evaluated was 2 (range, 0.5-6) and the median number of expansion states included was 23 (range, 1-33). Commonly assessed outcomes included insurance coverage of and utilization of cardiac treatments (25.0%), morbidity/mortality (19.6%), disparities in care (14.3%), and preventive care (41.1%). Medicaid expansion was generally associated with increased insurance coverage, reduction in overall cardiac morbidity/mortality outside of acute care settings, and some increase in screening for and treatment of cardiac comorbidities.

CONCLUSIONS

Current literature demonstrates that Medicaid expansion was generally associated with increased insurance coverage of cardiac treatments, improvement in cardiac outcomes outside of acute care settings, and some improvements in cardiac-focused prevention and screening. Conclusions are limited because quasi-experimental comparisons of expansion and nonexpansion states cannot account for unmeasured state-level confounders.

Predicting Risk of Recurrent Patellofemoral Instability With Measurements of Extensor Mechanism Containment

BACKGROUND

Identifying risk factors for recurrent patellar dislocation after a primary dislocation may help guide initial treatment. Magnetic resonance imaging (MRI) measurements relating the alignment of the extensor mechanism to trochlear morphology have been shown to distinguish patients with dislocations from controls, but their usefulness in predicting the risk of a second dislocation is not known.

PURPOSE

To identify the association of novel MRI measures of patellar containment with recurrent instability in pediatric patients presenting with a first-time patellar dislocation.

STUDY DESIGN

Cohort study (Prognosis); Level of evidence, 3.

METHODS

The study was conducted at a tertiary care children's hospital (2005-2014) on patients (age, 8-19 years) with a first-time patellar dislocation. MRI measurements were made by 2 independent raters. Interobserver reliability was assessed for all measurements via an intraclass correlation coefficient (ICC). Only measurements with an ICC >0.8 were included. Univariable and multivariable logistic regression analyses were used to evaluate variables associated with recurrence.

RESULTS

A total of 165 patients with a median age of 14 years and a slight (57.6%) female predominance was identified. The median follow-up length of the whole cohort was 12.2 months (interquartile range, 1.6-37.1 months). Subsequent instability was documented in 98 patients (59.4%). MRI measurements with excellent correlation (ICC > 0.8) were the tibial tubercle to trochlear groove distance (TT-TG), the tangential axial width of the patella, the tangential axial trochlear width, the axial width of the patellar tendon beyond the lateral trochlear ridge (LTR), and the tibial tubercle to LTR distance. In univariate analysis, all mentioned MRI measurements had significant association with recurrent instability. However, after both backward and forward stepwise regression analyses, the tibial tubercle to LTR distance was the only independent predictor of recurrent instability (P = .003 in both). Patients with a tibial tubercle to LTR distance value greater than -1 mm had a significantly higher rate of recurrent patellar dislocation (72%).

CONCLUSION

Of numerous axial view MRI parameters, only the tibial tubercle to LTR distance demonstrated a statistically significant association with recurrent patellar instability upon multivariable logistic regression analysis during short-term follow-up of a pediatric population presenting with initial lateral patellar dislocation. Interobserver correlation of the tibial tubercle to LTR distance was good (ICC > 0.8) and similar to that of TT-TG.

Drug Reimbursement Regulation in 6 Peer Countries

The US has nearly 4.5% of the world's population but accounts for more than 40% of global drug spending. With the upcoming 2020 election, a top priority of many voters is to better control drug prices and reform the pharmaceutical market. In this Special Communication, the drug price mechanisms and government regulations used in 6 representative peer countries are evaluated: Australia, France, Germany, Norway, Switzerland, and the United Kingdom. Drug price regulation is compared with that currently used in the US. Eight key lessons from the regulations used in these countries and which elements are incorporated into the bills currently making their way through the US Congress are evaluated (2 from the US House of Representatives and 1 from the US Senate). None of these bills is as systemic or comprehensive in its drug pricing mechanisms and regulations as the schemes in the other countries.

Malignant Transformation of Recurrent Synovial Chondromatosis: A Case Report and Review

Chondrosarcoma is the second most common primary malignant bone tumor. While the majority arrive de novo, a minority arise from malignant transformation of benign neoplasms, such as osteochondromas. Rarely, chondrosarcomas have been found to originate from other preexisting lesions, such as synovial chondromatosis. A 44-year-old male with a history of a spinal osteochondroma presented with one year of left hip pain and decreased range of motion. On examination, he had a palpable, irregular fullness in the left groin that was minimally tender to palpation. Radiographs and CT of the hip showed extensive soft tissue calcifications and erosion of the femoral neck. The lesion was debulked surgically and histologically diagnosed as synovial osteochondromatosis with no evidence of atypia or cellularity. One year later, his residual disease progressed and resulted in increasingly limited range of motion. He underwent left total hip arthroplasty with simultaneous debulking and the lesion was once again diagnosed as synovial osteochondromatosis. Two months postoperatively, the patient developed a new focus of calcification around the hip joint that was thought to be recurrent disease. Six months later, due to worsening symptoms, he underwent a repeat CT scan. This scan demonstrated extensive intra-articular disease extending into the iliopsoas bursa and around total hip arthroplasty, as well as a new soft tissue nodule with foci of calcification in the left gluteus maximus. The new lesion was debulked surgically and diagnosed as a grade 1 chondrosarcoma. Chondrosarcoma arising from synovial chondromatosis is a rare presentation of the second most common primary malignant bone tumor. It typically presents as an indolent, slowly growing painful mass of large joints in middle aged men. Conventional radiography shows punctate opacities, while MRI and CT reveal diffuse soft tissue calcification and cortical erosion. Low-grade chondrosarcomas are treated with intralesional curettage and adjuvant therapy, while higher grade chondrosarcomas are treated with wide, en bloc excision. Malignant transformation should be considered in any patient presenting with worsening symptoms and a history of a benign bony lesion.

Patellar Tendon-Lateral Trochlear Ridge Distance: A Novel Measurement of Patellofemoral Instability

BACKGROUND

Abnormalities in the trochlea-patella-tibia relationship have been shown to be risk factors for recurrent patellofemoral instability, although no current measurements quantify patellar containment in the trochlea. Standard measurements, such as tibial tubercle-trochlear groove (TT-TG) distance, do not account for the containment of the patella by the trochlea. Our goal was to develop a measurement to assess how well the trochlea contained the extensor mechanism.

HYPOTHESIS

A novel measurement describing the amount of the patellar tendon lateral to the lateral trochlear ridge (PT-LTR) would be a reliable measurement and significantly greater among patients with patellofemoral instability.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

The authors analyzed radiology records from 2005 to 2014 for patients aged 5 to 18 years with and without patellofemoral dislocations who had knee magnetic resonance imaging (MRI). Two blinded reviewers evaluated 215 MRI studies. Standard and novel morphology measurements were calculated for each knee and compared in a case-control design. Interobserver reliability of each measure was assessed by the intraclass correlation coefficient. Predictability for patellofemoral dislocation was calculated with 2-tailed independent-samples Student t tests. Discriminative capacity was calculated with receiver operating characteristic analyses and area under the curve (AUC). An optimal measurement cutoff with resultant sensitivity and specificity was calculated.

RESULTS

Standard measurements of TT-TG distance, tangential axial width of the patella (TAWP), and tangential axial trochlear width (TATW) had excellent agreement between raters; lateral femoral condyle length had good agreement; and the novel measurement-width of the tendon beyond the lateral femoral condyle (PT-LTR)-also had excellent agreement. These underwent predictability and discriminative capacity analyses. TT-TG, TAWP, TATW, and PT-LTR were significant predictors of patellofemoral instability. In receiver operating characteristic analysis, TAWP had an AUC of 0.65, below the 0.8 threshold. TATW had an AUC of 0.814 and, when <32.5 mm, was 76% sensitive and 77% specific for dislocations. TT-TG demonstrated an AUC of 0.806. TT-TG ≥13.5 mm was 76% sensitive and 76% specific for dislocations. PT-LTR demonstrated an AUC of 0.876 and, when ≥5.55 mm, was 73% sensitive and 89% specific for patellofemoral dislocation.

CONCLUSION

PT-LTR is reliable, predictable, and discriminative for patellofemoral dislocations. This measurement had sensitivity similar to that of TT-TG but with higher specificity.

Prenatal growth characteristics and pre/postnatal management of bronchopulmonary sequestrations

PURPOSE

The prenatal natural history of intralobar and extralobar bronchopulmonary sequestrations (BPSs), including lesion growth patterns and need for prenatal intervention, have not been fully characterized. We review our series of BPSs to determine their natural history and outcomes in the context of the need for prenatal intervention.

METHODS

A retrospective review of the pre/postnatal course of 103 fetuses with an intralobar (n=44) or extralobar BPS (n=59) managed at a single institution between 2008 and 2015 was performed. Outcomes included prenatal lesion growth trajectory, presence of hydrops, need for prenatal intervention, survival, and postnatal surgical management.

RESULTS

Most extralobar (71%) and intralobar BPSs (94%) decreased in size or became isoechoic from initial to final evaluation. Peak lesion size occurred at 26-28weeks gestation. Eight fetuses developed hydrothorax, four of which (all extralobar BPSs) also developed hydrops. All four hydropic fetuses received maternal betamethasone, and three hydropic fetuses underwent thoracentesis and/or thoracoamniotic shunt placement with subsequent hydrops resolution. All fetuses survived. Forty-one intralobar (93%) and 35 extralobar BPSs (59%) were resected after birth.

CONCLUSIONS

BPSs tend to decrease in size after 26-28weeks gestation and rarely require fetal intervention. Lesions resulting in hydrothorax ± hydrops can be effectively managed with maternal steroids and/or drainage of the hydrothorax.

LEVEL OF EVIDENCE

IV.

Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe

IMPORTANCE

The increasing legalization of euthanasia and physician-assisted suicide worldwide makes it important to understand related attitudes and practices.

OBJECTIVE

To review the legal status of euthanasia and physician-assisted suicide and the available data on attitudes and practices.

EVIDENCE REVIEW

Polling data and published surveys of the public and physicians, official state and country databases, interview studies with physicians, and death certificate studies (the Netherlands and Belgium) were reviewed for the period 1947 to 2016.

FINDINGS

Currently, euthanasia or physician-assisted suicide can be legally practiced in the Netherlands, Belgium, Luxembourg, Colombia, and Canada (Quebec since 2014, nationally as of June 2016). Physician-assisted suicide, excluding euthanasia, is legal in 5 US states (Oregon, Washington, Montana, Vermont, and California) and Switzerland. Public support for euthanasia and physician-assisted suicide in the United States has plateaued since the 1990s (range, 47%-69%). In Western Europe, an increasing and strong public support for euthanasia and physician-assisted suicide has been reported; in Central and Eastern Europe, support is decreasing. In the United States, less than 20% of physicians report having received requests for euthanasia or physician-assisted suicide, and 5% or less have complied. In Oregon and Washington state, less than 1% of licensed physicians write prescriptions for physician-assisted suicide per year. In the Netherlands and Belgium, about half or more of physicians reported ever having received a request; 60% of Dutch physicians have ever granted such requests. Between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal. The frequency of these deaths increased after legalization. More than 70% of cases involved patients with cancer. Typical patients are older, white, and well-educated. Pain is mostly not reported as the primary motivation. A large portion of patients receiving physician-assisted suicide in Oregon and Washington reported being enrolled in hospice or palliative care, as did patients in Belgium. In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or physician-assisted suicide at rates higher than those in the general population.

CONCLUSIONS AND RELEVANCE

Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices.

Predictors of Interest in an Alcohol Reduction Clinical Trial of Naltrexone among Undergraduates

Background

We tested predictors of interest in a clinical trial of naltrexone plus counseling for heavy drinking reduction in young adults using a web survey. Respondents could indicate interest in the clinical trial at the conclusion of the survey.

Methods

A random sample of university students completed the survey (N = 584, 60% female). Data were collected in October-November 2010.

Results

Among past-year drinkers (n = 411), 22.6% (n =93) indicated interest. Equivalent levels of interest were found among past-year heavy drinkers. Non-white race and current cigarette smoking predicted interest. Alcohol-related negative consequences score was a trend-level predictor in the full regression model, but a significant predictor in a reduced model.

Conclusions

Non-white students, smokers and those with a high number of negative consequences may be more amenable to drinking reduction via medication and counseling. These findings could facilitate efforts of researchers, administrators, counselors and other professionals to tailor drinking reduction messages and facilitate treatment engagement by undergraduates.