Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty.

BACKGROUND: The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty. METHODS: Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management. RESULTS: A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n = 70; 59.3%) followed by review or expert opinion articles (n = 35; 29.7%). Most references were of level IV evidence (n = 60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty. CONCLUSION: The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.

Most patient education materials on shoulder conditions from the American Academy of Orthopaedic Surgeons exceed recommended readability levels.

Background: A growing number of patients use the internet to learn about their conditions and management options, but there may exist a disconnect between the readability of online education materials and a patient's health literacy. This issue is of particular relevance for shoulder conditions, where even with traumatic injuries (eg, clavicle fracture, shoulder dislocation), treatment is discretionary, directed primarily at quality of life, and therefore highly preference-sensitive.The purpose of this study was to utilize multiple readability algorithms to calculate the readability of the American Academy of Orthopaedic Surgeons (AAOS) patient education materials pertaining to diseases and conditions of the shoulder. Methods: Online patient education articles from the AAOS pertaining to diseases and conditions of the shoulder were reviewed. The articles were modified for analysis using Readability Pro and readability scores were computed using the following 9 algorithms: Flesch-Kincaid Grade Level, Flesch Reading Ease, Gunning Fog Index, Coleman-Liau Index, Simple Measure of the Gobbledygook Index (SMOG), Automated Readability Index, FORCAST, and New Dale and Chall Index. A list of suggested word changes to improve the readability of included articles was compiled from Readable Pro. The average number of illustrations (images and/or videos) included per article was documented. Results: Twenty-eight articles were included for analysis. For each of the algorithms studied, the average scores were as follows: Flesch Kincaid Grade Level was 8.8 ± .8 [range, 7.2-10.2]; recommended score: ≤ 8.0, Flesch Reading Ease 54.3 ± 5.3 [range, 45.3-64.1]; recommended score: ≥ 60, Gunning Fog 10.8 ± 1.2 [range, 8.3-13.1]; recommended score: ≤ 8.0, Coleman-Liau 11.2 ± .9 [range, 9.2-12.9]; recommended score: ≤8.0, SMOG index 11.4 ± .8 [range, 9.2-12.9]; recommended score: ≤ 8.0 , Automated Readability Index 8.4 ± .8 [range, 6.9-10.0]; recommended score: ≤ 8.0, FORCAST 11.2 ± .4 [range, 10.2-12.0]; recommended score: ≤ 9.0, and New Dale and Chall Index 5.8 ± .5 [range, 4.9-7.2 recommended score: ≤ 6.0-6.9]. The average number of illustrations per article was 4.5 ± 3.1 [range, 1-14]. Conclusion: The readability of most patient education materials from the AAOS pertaining to diseases and conditions of the shoulder is higher than recommended across a variety of algorithms. Efforts to revise the readability of online education materials are important to facilitate shared decision-making, particularly in practice settings where most decisions are preference-sensitive.

Evaluation of the National Institutes of Health-Supported Relative Citation Ratio Among Fellowship-Trained American Orthopaedic Joint Reconstruction Surgery Faculty: A New Bibliometric Measure of Scientific Influence.

BACKGROUND: The relative citation ratio (RCR), a novel National Institutes of Health-Supported measure of research productivity, allows for accurate interdisciplinary comparison of publication influence. This study evaluates the RCR of fellowship-trained adult reconstructive orthopaedic surgeons with the goal of analyzing potentially influential physician demographics. METHODS: Adult Reconstruction Accreditation Council for Graduate Medical Education fellowship-trained faculty for orthopaedic residency programs were identified via departmental websites. The National Institutes of Health's iCite database was retrospectively reviewed for mean RCR, weighted RCR, and publication count by surgeon. Multivariate analyses were performed using the Wilcoxon rank-sum tests and analyses of variance testing to compare sex, career length, academic rank, and professional degrees in addition to an MD or DO. Significance was considered P < .05. RESULTS: A total of 488 fellowship-trained adult reconstruction faculty from 144 programs were included in the analysis. Overall, the faculty recorded a median RCR of 1.65 (interquartile range: 1.01-2.28) and a median weighted RCR of 16.59 (interquartile range: 3.98-61.92). The weighted RCR and total number of publications were associated with academic rank and career longevity, while the mean RCR was associated with academic rank. The median RCR ranged from 1.12 to 1.87 for all subgroups. CONCLUSION: Adult reconstruction faculty are exceptionally productive and generate highly impactful studies as evidenced by the high median RCR value relative to the National Institutes of Health standard value of 1.0. Our data have important implications in the assessment of grant outcomes, promotion, and continued evaluation of research influence within the hip and knee community.

Ankle Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents.

Purpose: To evaluate graduating orthopaedic resident case volume and variability for ankle arthroscopy from 2016 to 2020. Methods: The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents was assessed. Arthroscopy procedures of the leg/ankle were categorized. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability. Results: There was no significant change in the average number of leg/ankle arthroscopy cases from 2016 to 2020 (6.2 ± 5 [range 0-35] vs 6.1 ± 6 [range 0-76] P = .732), despite a 19% increase in the average number of total leg/ankle procedures performed over time (168.4 ± 47 [range 55-414] in 2016; 200.8 ± 57 in 2020 [range 67-601], P < .001). There was wide variability in ankle arthroscopy case volume among residents. The 90th percentile of residents performed 13 cases in 2020, compared with 5 in 50th percentile, and 1 in the 10th percentile. Conclusions: Orthopaedic surgery resident exposure to ankle arthroscopy has remained low and highly variable overtime, despite an overall increase in the total number of leg/ankle procedures performed. Clinical Relevance: Understanding ankle arthroscopy in case volume and variability is important for programs to ensure that orthopaedic residents are gaining adequate exposure to increasingly popular procedures. Orthopaedic surgery residency programs should explore methods to increase resident exposure to ankle arthroscopy.

Evaluation of the National Institutes of Health-supported relative citation ratio among American orthopedic spine surgery faculty: A new bibliometric measure of scientific influence.

Background: Publication metrics have been traditionally used to compare research productivity amongst academic faculty. However, traditional bibliometrics lack field-normalization and are often biased towards time-dependent publication factors. The National Institutes of Health (NIH) has developed a new, field-normalized, article-level metric, known as the "relative citation ratio" (RCR), that can be used to make accurate self, departmental, and cross-specialty comparisons of research productivity. This study evaluates the use of the RCR amongst academic orthopedic spine surgery faculty and analyzes physician factors associated with RCR values. Methods: A retrospective data analysis was performed using the iCite database for all fellowship trained orthopedic spine surgery (OSS) faculty associated with Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopedic surgery residency program. Mean RCR, weighted RCR, and total publication count were compared by sex, career duration, academic rank, and presence of additional degrees. A value of 1.0 is the NIH-funded field-normalized standard. Student t-tests were used for two-group analyses whereas the analysis of variance tests (ANOVA) was used for between-group comparisons of three or more subgroups. Statistical significance was achieved at P < 0.05. Results: A total of 502 academic OSS faculty members from 159 institutions were included in the analysis. Overall, OSS faculty were highly productive, with a median RCR of 1.62 (IQR 1.38-2.32) and a median weighted RCR of 68.98 (IQR 21.06-212.70). Advancing academic rank was associated with weighted RCR, career longevity was associated with mean RCR score, and male sex was associated with having increased mean and weighted RCR scores. All subgroups analyzed had an RCR value above 1.0. Conclusions: Academic orthopedic spine surgery faculty produce impactful research as evidenced by the high median RCR relative to the standard value set by the NIH of 1.0. Our data can be used to evaluate research productivity in the orthopedic spine community.

Evaluation of the Relative Citation Ratio Among Academic Orthopedic Hand Surgeons: A Novel Measure of Research Impact.

Background: Publication metrics such as article citation count and the Hirsch index (h-index) are used to evaluate research productivity among academic faculty. However, these bibliometric indices are not field-normalized and yield inaccurate cross-specialty comparisons. We evaluate the use of the relative citation ratio (RCR), a new field-normalized article-level metric developed by the National Institutes of Health (NIH), among academic orthopedic hand surgeons and analyze physician factors associated with RCR values. Methods: A retrospective analysis was performed using the iCite database. Fellowship-trained orthopedic hand surgeons affiliated with accredited orthopedic surgery residency programs were included. Mean RCR, weighted RCR, and publication count were compared by sex, career duration, academic rank, and presence of additional degrees. Mean RCR represents the total number of citations per year of a publication divided by the average number of citations per year received by NIH-funded papers in the same field. Mean RCR serves as a measure of overall research impact. A value of 1.0 is the NIH-funded field-normalized standard. Weighted RCR is the sum of all article-level RCR scores and represents overall research productivity. Results: A total of 620 academic orthopedic hand surgeons from 164 programs were included. These physicians produced highly impactful research with a median RCR of 1.27 (interquartile range [IQR] 0.86-1.66). Weighted RCR was associated with advanced degree, advanced academic rank, and longer career duration. Conclusions: Fellowship-trained academic orthopedic hand surgeons produce highly impactful research. Our benchmark data can be used to assess grant outcomes, promotion, and continued evaluation of research productivity within the hand surgery community.

Hip Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents.

Purpose: The purpose of this study was to evaluate case volume and variability of hip arthroscopy exposure among graduating orthopaedic residents. Methods: The Accreditation Council for Graduate Medical Education (ACGME) surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents were assessed. Arthroscopy procedures of the pelvis/hip were identified. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability. Results: There was no change in the number of hip arthroscopy procedures between 2016 and 2020 [average: 8.4 ± 10 (range: 0 to 87) vs. 9.8 ± 12 (range: 0 to 101)] (P = .995). There was a wide variability in case volume among residents. The 90th percentile of residents performed 24 cases in 2020, compared to 2 cases in the 30th percentile and 0 cases amongst the 10th percentile of residents. Conclusions: Despite the growing popularity of hip arthroscopy, resident exposure to this highly technical procedure remains limited, with about one-third of residents performing 2 or less cases by graduation. Clinical Relevance: Understanding case volume and variability is important for orthopaedic surgery programs to ensure that graduating residents are gaining adequate exposure.

Evaluation of the National Institutes of Health-supported relative citation ratio among American Shoulder and Elbow Surgeons fellowship faculty: a new bibliometric measure of scientific influence.

BACKGROUND: Publication metrics are used to evaluate and compare research productivity among academic faculty. However, traditional bibliometrics, such as the Hirsch index and article citation count, are limited by lack of field-normalization and yield inaccurate cross-specialty comparisons. Herein, we evaluate the use of a new field-normalized article-level metric developed by the National Institutes of Health (NIH), known as the relative citation ratio (RCR), among American Shoulder and Elbow Surgeons (ASES) fellowship faculty and analyzed physician factors associated with RCR values. METHODS: A retrospective data analysis was performed using the iCite database for all shoulder and elbow surgery fellowship faculty listed on the American Shoulder and Elbow Surgeons (ASES) directory as of November 14, 2021. Mean RCR, weighted RCR, and total publication count were compared by sex, career duration, academic rank, and presence of additional degrees. Mean RCR represents the total number of article citations per year of a publication divided by the average number of citations per year received by NIH-funded papers in the same field; mean RCR serves as a measure of overall research impact. A value of 1.0 is the NIH-funded field-normalized standard. The weighted RCR represents the sum of all article-level RCR scores and is a measure of overall research productivity. Student t tests were used for two-group analyses whereas analyses of variance were used for between-group comparisons of 3 or more subgroups. RESULTS: A total of 145 ASES fellowship faculty members from 33 fellowship programs were included in the analysis. Overall, ASES fellowship faculty produced highly impactful research with a median RCR of 1.8 (interquartile range [IQR] 1.4-2.3) and a median weighted RCR of 67.0 (IQR 21.1-212.7). Advanced academic rank and career longevity were associated with increased weighted RCR and total publication count. All subgroups analyzed had an RCR value above 1.0. CONCLUSIONS: ASES fellowship faculty are exceptionally productive and produce highly impactful research, as evidenced by the high median RCR value relative to the benchmark NIH RCR value of 1.0. This information can be used as a standard to assess the improvement of grant outcomes, promotion, fellowship education, and continued evaluation of research productivity in the shoulder and elbow community.

Twitter Mentions Influence Academic Citation Count of Shoulder and Elbow Surgery Publications.

Background Social media use among scholars and journals is growing and has augmented the academic impact of published articles in several areas of medicine. However, the influence of social media postings on academic citations of shoulder and elbow surgery publications is not known. In this study, we sought (1) to quantify the adoption of Twitter use for the dissemination of research publications by three prominent shoulder and elbow surgery journals and (2) to determine the correlation between Twitter mentions and academic citations in shoulder and elbow surgery publications. Methodology A total of 396 original research articles from three shoulder and elbow surgery journals (Journal of Shoulder and Elbow Surgery (JSES), Shoulder & Elbow, and JSES International) published in 2018 were assessed 34 to 45 months after print publication. For each article, the total number of Twitter mentions were obtained using Altmetric Bookmarklet and grouped into those tweeted by authors, an official outlet, or a third party. Article citation data was obtained using the Google Scholar search engine. Pearson correlation was used to determine the association between the number of Twitter mentions and citation count. Results Of all articles, 51% (202/396) had at least one Twitter mention. Of all Twitter mentions, 12.7% (367/2,879) occurred within the first week of online publication dates, while 51.5% (1,482/2,879) occurred between online and print publication dates. Articles mentioned on Twitter had 1.3-fold more Google Scholar citations (17.7 ± 15.2) than articles with no Twitter mentions (14.0 ± 15.7) (p = 0.017). The number of Twitter mentions had a weakly positive correlation with academic citation count (r = 0.25; p < 0.001). No significant difference in academic citation rates was found between articles tweeted by authors or official outlets when compared to articles tweeted by a third party only (p = 0.97 and p = 0.34, respectively). Conclusions Approximately half of shoulder and elbow surgery publications are shared on Twitter, with the majority of the activity occurring prior to their print publication date. The finding that tweeted articles have more academic citations within three years of release suggests that social media activity seems to amplify the academic impact of shoulder and elbow surgery publications.

The number of shoulder and elbow questions on the orthopedic in-training examination is increasing with greater emphasis on critical thinking over recall.

Background: It is critical for orthopedic surgery residents and residency programs to have a current understanding of the content and resources utilized by the Orthopedic In-Training Examination (OITE) to continuously guide study and educational efforts. This study presents an updated analysis of the shoulder and elbow section of the OITE. Methods: All OITE questions, answers, and references from 2013 to 2019 were reviewed. The number of shoulder and elbow questions per year was recorded, and questions were analyzed for topic, imaging modalities, cognitive taxonomy, and references. We compared our data to the results of a previous study that analyzed shoulder and elbow OITE questions from 2002 to 2007 to examine trends and changes in this domain overtime. Results: There were 177 shoulder and elbow questions (126 shoulder, 71.2%; 51 elbow, 28.8%) of 1863 OITE questions (9.5%) over a 7-year period. The most commonly tested topics included degenerative joint disease/stiffness/arthroplasty (31.6%), anatomy/biomechanics (16.9%), instability/athletic injury (15.3%), trauma (14.7%), and rotator cuff (13.6%). Half of all questions involved clinical management decisions (49.7%). A total of 417 references were cited from 56 different sources, the most common of which were the Journal of Shoulder and Elbow Surgery (23.3%), Journal of the American Academy of Orthopaedic Surgeons (20.4%), and Journal of Bone and Joint Surgery (American Volume) (16%). The average time lag from article publication to OITE reference was 7.7 years. Compared with a prior analysis from 2002 to 2007, there was a significant increase in the number of shoulder and elbow questions on the OITE (5.5% to 9.5%; P < .001). Recent exams incorporated more complex multistep treatment questions (4.4% vs. 49.7%; P < .001) and fewer recall questions (42.2% vs. 22%; P < .001). There was a significant increase in the use of imaging modalities (53.3% vs. 79.1%; P < .001). No significant differences in the distribution of question topics were found. Conclusions: The percentage of shoulder and elbow questions on the OITE has nearly doubled over the past decade with greater emphasis on critical thinking (eg, clinical management decisions) over recall of facts. These findings should prompt educators to direct didactic efforts (eg, morning conferences and journal club) toward case-based learning to foster critical thinking and clinical reasoning skills.