title: Access to outpatient follow-up orthopedic care after pediatric emergency department visits: impact of implementation of a managed Medicaid program.
abstract: OBJECTIVE
  A Medicaid managed care (MMC) program was instituted regionally with the goal of improving quality and access to care for underserved populations. The purpose of this study was to determine whether the implementation of an MMC program has affected access to timely orthopedic follow-up care.
  
  
  METHODS
  All visits to 2 tertiary care pediatric emergency departments (PED) with a diagnosis of extremity fracture or dislocation were examined for a 5-month period after implementation of MMC and compared with the same periods during 2004 and 2005. Repeat visits for orthopedic concerns to the PED within 30 days of the initial fracture care were compared across the pre- and post-MMC periods.
  
  
  RESULTS
  Six thousand four hundred nine visits with a diagnosis of extremity fracture or dislocation were identified (4110 in the two 5-month pre-MMC periods and 2299 in the 5-month post-MMC period). A total of 167 return visits for orthopedic concerns were identified in the pre-MMC period (4.0%) compared with 150 return visits in the post-MMC period (6.5%) (P<0.001). Of these, 12 (7.2%) in the pre-MMC period and 55 (36.6%) in the post-MMC period were identified as related to the inability to access outpatient orthopedic follow-up (P<0.001). In both periods, Medicaid patients were more likely to return to the PED for inability to access care, compared with privately insured patients (odds ratio [OR], 6.1; 95% confidence interval [CI], 3.54-10.32).
  
  
  CONCLUSIONS
  After the implementation of a regional MMC program, patients were increasingly unable to access routine outpatient follow-up. This may shift additional cost and resource load to PED, while limiting access to vital services for medically vulnerable patients.
authors.affiliation: Department of Pediatrics, Children's Healthcare of Atlanta, USA. jesse.sturm@gmail.com
authors.forename: Jesse J
authors.initials: JJ
authors.lastname: Sturm
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Hirsh
authors.forename: Robert
authors.initials: R
authors.lastname: Massey
authors.forename: Naghma S
authors.initials: NS
authors.lastname: Khan
authors.forename: Harold K
authors.initials: HK
authors.lastname: Simon
mesh_terms: D000359:Aftercare / Q000706:statistics & numerical data*; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D002370:Casts, Surgical / Q000706:statistics & numerical data; D002648:Child; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005121:Extremities / Q000293:injuries; D005260:Female; D005500:Follow-Up Studies; D050723:Fractures, Bone / Q000453:epidemiology / Q000628:therapy*; D005845:Georgia / Q000453:epidemiology; D006297:Health Services Accessibility; D006801:Humans; D019458:Insurance Coverage; D004204:Joint Dislocations / Q000453:epidemiology / Q000628:therapy*; D008297:Male; D008329:Managed Care Programs; D008484:Medicaid / Q000458:organization & administration*; D019637:Orthopedic Procedures / Q000706:statistics & numerical data*; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D015397:Program Evaluation; D012189:Retrospective Studies; D013165:Splints / Q000706:statistics & numerical data; D014481:United States