BACKGROUND

The impact of depression on outcome in implantable cardioverter defibrillator (ICD) recipients has not been fully appreciated. We assessed the prevalence of depression and its association with heart failure (HF) outcome among veterans with ICDs.

METHODS AND RESULTS

Patients enrolled between January 2005 and January 2010 in the Outcomes among Veterans with Implantable Defibrillators Registry were studied. We examined the cross-sectional association of depression with severity of HF functional class as well as the association of depression with the composite outcome of mortality or HF hospitalization over a mean follow-up time of 2.7 years. There were 3,862 patients enrolled. Patients with depression (1,162, 43%) were younger (63.1 ± 9.4 years vs 66.6 ± 9.9 years, P < 0.001), more likely to have a history of tobacco or alcohol abuse (P < 0.0001) or atrial fibrillation (P = 0.05) while having a higher ejection fraction (28.3% vs 27.4%, P = 0.03). Depression was associated with advanced HF class at time of implant; odds ratio (OR; vs class I) for class III: 1.65 (confidence interval [CI] 1.17-2.33), class IV: 1.73 (95% CI 1.08-2.76). Death or HF hospitalization was more likely to occur in patients with depression (35.2% vs 32.0%, HR: 1.15 [95% CI 0.99-1.33]). The predictive value of depression was stronger after multivariable adjustment; HR: 1.25 (95% CI 1.05-1.49).

CONCLUSION

Depression was prevalent among veterans with ICDs. Depression was associated with severity of HF. The predictive value of associated depression was significant after multivariable adjustment.

OBJECTIVES

The purpose of this study is to report the rate of anatomic reduction, articular subsidence, and clinical outcomes for Schatzker II tibial plateau fractures treated with structural bone allografts.

DESIGN

This is a retrospective case series.

SETTING

Academic Level I Trauma Center.

PATIENTS/PARTICIPANTS

A trauma registry was used to identify 77 Schatzker II tibial plateau fractures.

INTERVENTION

Schatzker II tibial plateau fracture open reduction internal fixation and structural bone graft using either Plexur P (N = 29) or fibular allograft (N = 48).

MAIN OUTCOME MEASUREMENT

The primary outcome was articular subsidence. Secondary outcomes included fracture malreduction and clinical outcomes including the Knee Outcome Survey Activities of Daily Living Scale, the Lower Extremity Functional Scale, and the Short Form (SF)-36.

RESULTS

No patients experienced subsidence > 2mm. This rate is significantly lower than published rates for autogenous iliac crest (30.3%, P < 0.0001) and calcium phosphate cement (8.7%, P = 0.0099). The rate of fracture malreduction was 11.7% (9/77); only 4 had more than 3 mm of residual incongruity. Average outcome scores were the following: Knee Outcome Survey Activities of Daily Living Scale, 81.7; Lower Extremity Functional Scale, 78.5; SF-36 physical component, 48.3; and SF-36 mental component, 53.1. There was no difference between patients treated with Plexur P or fibula with regard to the primary or secondary outcomes.

CONCLUSIONS

The use of structural allograft resulted in a high rate of anatomic reduction and negligible rate of articular subsidence and good clinical outcomes in the treatment of this population of Schatzker II tibial plateau fractures. This compares favorably with historical results using nonstructural grafts.

LEVEL OF EVIDENCE

Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

IMPORTANCE

There have been recent calls for increased access to mental health services, but access may be limited owing to psychiatrist refusal to accept insurance.

OBJECTIVE

To describe recent trends in acceptance of insurance by psychiatrists compared with physicians in other specialties.

DESIGN, SETTING, AND PARTICIPANTS

We used data from a national survey of office-based physicians in the United States to calculate rates of acceptance of private noncapitated insurance, Medicare, and Medicaid by psychiatrists vs physicians in other specialties and to compare characteristics of psychiatrists who accepted insurance and those who did not.

MAIN OUTCOMES AND MEASURES

Our main outcome variables were physician acceptance of new patients with private noncapitated insurance, Medicare, or Medicaid. Our main independent variables were physician specialty and year groupings (2005-2006, 2007-2008, and 2009-2010).

RESULTS

The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% [95% CI, 46.7%-63.8%] vs 88.7% [86.4%-90.7%]; P < .001) and had declined by 17.0% since 2005-2006. Similarly, the percentage of psychiatrists who accepted Medicare in 2009-2010 was significantly lower than that for other physicians (54.8% [95% CI, 46.6%-62.7%] vs 86.1% [84.4%-87.7%]; P < .001) and had declined by 19.5% since 2005-2006. Psychiatrists' Medicaid acceptance rates in 2009-2010 were also lower than those for other physicians (43.1% [95% CI, 34.9%-51.7%] vs 73.0% [70.3%-75.5%]; P < .001) but had not declined significantly from 2005-2006. Psychiatrists in the Midwest were more likely to accept private noncapitated insurance (85.1%) than those in the Northeast (48.5%), South (43.0%), or West (57.8%) (P = .02).

CONCLUSIONS AND RELEVANCE

Acceptance rates for all types of insurance were significantly lower for psychiatrists than for physicians in other specialties. These low rates of acceptance may pose a barrier to access to mental health services.