Objectives: To determine if the use of intrawound vancomycin powder reduces surgical-site infection after open reduction and internal fixation of bicondylar tibial plateau, tibial pilon, and calcaneus fractures. Design: Retrospective analysis. Setting: Level I trauma center. Patients: All fractures operatively treated from January 2011 to February 2015 were reviewed; 583 high-risk fractures were included, of which 35 received topical vancomycin powder. A previously published prospectively collected cohort of 235 similar high-risk fractures treated at our center from 2007 through 2010 served as a second comparison group. Intervention: Topical vancomycin powder at wound closure. Main Outcome Measurements: Deep surgical-site infection. Analyses used both univariate comparison of all patients and 1:2 matching analysis using both nearest neighbor and propensity-based matching. Results: Compared with a control group of fractures treated during the same time period without vancomycin powder, the infection rate with vancomycin powder was significantly lower [0% (0/35) vs. 10.6% (58/548), P = 0.04]. Compared with our previously published historical infection rate of 13% for these injuries, vancomycin powder was also associated with significantly decreased deep surgical-site infection (0% vs. 13%, P = 0.02). These results agreed with the matched analyses, which also showed lower infection in the vancomycin powder group (0% vs. 11%–16%, P ≤ 0.05). Conclusions: Vancomycin powder may play a role in lowering surgical-site infection rates after fracture fixation. A larger randomized controlled trial is needed to validate our findings. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
ObjectiveOccupational therapy is often prescribed after the acute treatment of upper extremity fractures. However, high out-of-pocket expenses and logistical constraints can reduce access to formal therapy services. We aimed to quantify preferences of patients with upper extremity fracture for attending occupational therapy, when considering possible differences in clinical outcomes.DesignDiscrete choice experiment.SettingLevel 1 trauma centre in Baltimore, Maryland, USA.Participants134 adult patients with upper extremity fractures.Primary outcome measuresThe scenarios were described with five attributes: cost, duration of therapy session, location of therapy, final range of motion and pain. We report the relative importance of each attribute as a proportion of total importance, and the willingness to pay for benefits of the therapy services.ResultsOf the 134 study participants, the mean age was 47 years and 53% were men. Cost (32%) and range of motion (29%) were the attributes of greatest relative importance. Pain (17%), duration of therapy (13%) and location of therapy (8%) were of lesser importance. Patients were willing to pay $85 more per therapy session for a 40% improvement in their range of motion. Patients were willing to pay $43 more per therapy session to improve from severe pain to mild pain. Patients were indifferent to whether the therapy treatment was home-based or in a clinical environment.ConclusionsWhen deciding on an upper extremity fracture therapy programme, out-of-pocket costs are a paramount consideration of patients. Improvements in range of motion are of greater importance than residual pain, the duration of therapy sessions and the location of service provision. Patients with upper extremity fracture should be prescribed occupational therapy services that align with these patients’ preferences.
Nearly half of adult fracture patients are vitamin D deficient (serum 25‐hydroxyvitamin D [25(OH)D] levels <20 ng/mL). Many surgeons advocate prescribing vitamin D supplements to improve fracture healing outcomes; however, data supporting the effectiveness of vitamin D 3 supplements to improve acute fracture healing are lacking. We tested the effectiveness of vitamin D 3 supplementation for improving tibia and femur fracture healing. We conducted a single‐center, double ‐ blinded phase II screening randomized controlled trial with a 12‐month follow‐up. Patients aged 18–50 years receiving an intramedullary nail for a tibia or femoral shaft fracture were randomized 1:1:1:1 to receive (i) 150,000 IU loading dose vitamin D 3 at injury and 6 weeks ( n = 27); (ii) 4000 IU vitamin D 3 daily ( n = 24); (iii) 600 IU vitamin D 3 daily ( n = 24); or (iv) placebo ( n = 27). Primary outcomes were clinical fracture healing (Function IndeX for Trauma [FIX‐IT]) and radiographic fracture healing (Radiographic Union Score for Tibial fractures [RUST]) at 3 months. One hundred two patients with a mean age of 29 years (standard deviation 8) were randomized. The majority were male (69%), and 56% were vitamin D 3 deficient at baseline . Ninety‐nine patients completed the 3‐month follow‐up. In our prespecified comparisons, no clinically important or statistically significant differences were detected in RUST or FIX‐IT scores between groups when measured at 3 months and over 12 months. However, in a post hoc comparison, high doses of vitamin D 3 were associated with improved clinical fracture healing relative to placebo at 3 months (mean difference [MD] 0.90, 80% confidence interval [CI], 0.08 to 1.79; p = 0.16) and within 12 months (MD 0.89, 80% CI, 0.05 to 1.74; p = 0.18). The study was designed to identify potential evidence to support the effectiveness of vitamin D 3 supplementation in improving acute fracture healing. Vitamin D 3 supplementation, particularly high doses, might modestly improve acute tibia or femoral shaft fracture healing in healthy adults, but confirmatory studies are required. The Vita‐Shock trial was awarded the Orthopaedic Trauma Association's (OTA) Bovill Award in 2020. This award is presented annually to the authors of the most outstanding OTA Annual Meeting scientific paper. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
ISSUE: It is widely recognized that social factors, such as unstable housing and lack of healthy food, have a substantial impact on health outcomes and spending, particularly with respect to lower-income populations. For Medicaid, now dominated by managed care, this raises the question of how states can establish managed care rates to sustain investments in social supports. GOAL: To explore practical strategies that states can deploy to support Medicaid managed care plans and their network providers in addressing social issues. METHODS: Literature review, interviews with stakeholders, and analysis of federal regulations. FINDINGS AND CONCLUSIONS: We identify the following options: 1) classify certain social services as covered benefits under the state's Medicaid plan; 2) explore the additional flexibility afforded states through Section 1115 waivers; 3) use value-based payments to support provider investment in social interventions; 4) use incentives and withholds to encourage plan investment in social interventions; 5) integrate efforts to address social issues into quality improvement activities; and 6) reward plans through higher rates for effective investments in social interventions. More needs to be done, however, to assist interested states in using these options and identifying pathways to braid Medicaid dollars with other social services funding. KEY TAKEAWAYS Social factors like unstable housing and lack of healthy food are widely known to affect health care outcomes and spending. While Medicaid traditionally has not covered or reimbursed for social interventions, it offers more practical options for doing so than is commonly recognized. With the predominance of Medicaid managed care, states require new contract and ratesetting strategies to enable plan and provider investment in social interventions. Options available to address social drivers of health include: classifying certain social services as covered Medicaid benefits, using value-based payments to support provider investment in social interventions, and rewarding managed care plans with higher payment rates.
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