Friday, March 12, 2004
There is a striking delay in orthopaedic fracture treatment of Medi-Cal pediatric patients compared to privately insured children, said the authors of Scientific Paper 152 on Thursday. They also found that forearm fracture reduction competency among the non-orthopaedists who treated the children was questionable.
This study of actual patients measured the time from emergency department (ED) presentation to definitive treatment-reduction (manual straightening) of forearm fractures or operation on supracondylar elbow fractures-and compared the Medi-Cal group with a similar group of children covered by private insurance.
Researchers conducted a retrospective analysis of chart and claims encounter data for California children under age 16 enrolled in Medicaid (Medi-Cal) or with private insurance. The children had suffered isolated acute supracondylar humeral fractures (requiring operation) or forearm fractures (requiring reduction). The study period was July through December, 1999.
Of the 147 Medi-Cal patients, 25 percent with forearm fractures and 18 percent with supracondylar humeral fractures waited three or more days after initial ED presentation for definitive treatment. Of the 176 privately insured patients, 2 percent with forearm fractures and 3 percent with supracondylar humeral fractures waited that long after initial ED presentation for treatment. Researchers also found that forearm reductions initially performed by non-orthopaedic personnel on the Medi-Cal children had a 50 pecent re-reduction rate.
Primary author Donald A. Saroff, MD, explained that, "This study raises policy issues concerning access to orthoapedic care and treatment in community EDs for poor but insured children with broken arms. Both of the injuries we studied require definitive care beyond simple immobilzation. We also examined whether the type of provider (orthopaedic or ED-based) performing the initial forearm fracture reduction is associated with the need for re-reduction."
Researchers report that California ED providers were unable to 'find' surgical specialists 'willing' to treat Medi-Cal patients. "A recent 2002 report published by the Medi-Cal Policy Institute revealed that orthopaedic surgeons were the least likely of all specialists surveyed to treat Medi-Cal patients," reported the authors. "One study [we looked at] revealed that the phrase 'Medi-Cal' essentially shut doors to California orthopaedic surgeons offices. The delays found in the this study may be directly related to orthopaedic surgeons' unwillingness to treat Medi-Cal patients.
"Perhaps even more distrubing, our findings about the number of forearm fracture reductions being initially performed by ED providers (26 percent) lend credibility to anecdotal reports that ED physicians in California are unable to find specialists willing to treat Medi-Cal patients. Half of the fracture reductions performed by ED physicians required re-reduction. This rate is much higher than that reported in the literature."
Dr. Saroff pointed out that ED physicians may be 'trapped' between two bad choices. "They can discharge the patient from the ED with no definitive orthopaedic treatment, a choice that could result, as this study shows, in delayed treatment," he said. "The other choice is for ED physicians to attempt definitive orthopaedic treatment, an option that could result, as this study also shows, in a high re-reduction rate."
In conclusion, "Providing insurance coverage to poor people should help increase their ability to get care when they need it," noted the researchers. "However, Medicaid patients' ability to access orthopaedic care remains unstudied."
Dr. Sarnoff, of Alexandria, Va., co-authored the paper with Richard M. Dell, MD, of Bellflower, Calif.
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