Mapping the Diffusion of Technology in Orthopaedic Surgery: Understanding the Spread of Arthroscopic Rotator Cuff Repair in the United States.

BACKGROUND: The mechanism by which surgical innovation is spread in orthopaedic surgery is not well studied. The recent widespread transition from open to arthroscopic rotator cuff repair techniques provides us with the opportunity to study the spread of new technology; doing so would be important because it is unclear how novel orthopaedic techniques disseminate across time and geography, and previous studies of innovation in healthcare may not apply to the orthopaedic community. QUESTIONS/PURPOSES: (1) How much regional variation was associated with the adoption of arthroscopic rotator cuff repair in the United States Medicare population between 2006 and 2014 and how did this change over time? (2) In which regions of the United States was arthroscopic rotator cuff repair first adopted and how did it spread geographically? (3) Which regional factors were associated with the adoption of this new technology? METHODS: We divided the United States into 306 hospital referral regions based upon referral patterns observed in the Centers for Medicare & Medicaid Services MedPAR database, which records all Medicare hospital admissions; this has been done in numerous previous studies using methodology introduced by the Dartmouth Atlas. The proportion of arthroscopic rotator cuff repairs versus open rotator cuff repairs in each hospital referral region was calculated using adjusted procedural rates from the Medicare Part B Carrier File from 2006 to 2014, as it provided a nationwide sample of patients, and was used as a measure of adoption. A population-weighted, multivariable linear regression analysis was used to identify regional characteristics independently associated with adoption. RESULTS: There was substantial regional variation associated with the adoption of arthroscopy for rotator cuff repair as the percentage of rotator cuff repair completed arthroscopically in 2006 ranged widely among hospital referral regions with a high of 85.3% in Provo, UT, USA, and a low of 16.7% in Seattle, WA, USA (OR 30, 95% CI 17.6 to 52.2; p < 0.001). In 2006, regions in the top quartiles for Medicare spending (+9.1%; p = 0.008) independently had higher adoption rates than those in the bottom quartile, as did regions with a greater proportion of college-educated residents (+12.0%; p = 0.009). The Northwest region (-14.4%; p = 0.009) and the presence of an academic medical center (-5.8%; p = 0.026) independently had lower adoption than other regions and those without academic medical centers. In 2014, regions in the top quartiles for Medicare spending (+5.7%; p = 0.033) and regions with a greater proportion of college-educated residents (+9.4%; p = 0.005) independently had higher adoption rates than those in the bottom quartiles, while the Northwest (-9.6%; p = 0.009) and Midwest regions (-5.1%; p = 0.017) independently had lower adoption than other regions. CONCLUSION: The heterogeneous diffusion of arthroscopic rotator cuff repair across the United States highlights that Medicare beneficiaries across regions did not have equal access to these procedures and that these discrepancies continued to persist over time. A higher level of education and increased healthcare spending were both associated with greater adoption in a region and conversely suggest that regions with lower education and healthcare spending may pursue innovation more slowly. There was evidence that regions with academic medical centers adopted this technology more slowly and may highlight the role that private industry and physicians in nonacademic organizations play in surgical innovation. Future studies are needed to understand if this later adoption leads to inequalities in the quality and value of surgical care delivered to patients in these regions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Duration of military service is associated with decision quality in Veterans considering total knee replacement: case series.

PURPOSE: Due to the nature of military service, the patient-physician relationship in Veterans is unlike that seen in civilian life. The structure of the military is hypothesized to result in barriers to open patient-physician communication and patient participation in elective care decision-making. Decision quality is a measure of concordance between a chosen treatment and the aspects of medical care that matter most to an informed patient; high decision quality is synonymous with patient-centered care. While past research has examined how age and other demographic factors affect decision quality in Veterans, duration of military service, rank at discharge, and years since discharge have not been studied. PATIENTS AND METHODS: We enrolled 25 Veterans with knee osteoarthritis at a VA hospital. Enrollees completed a survey with demographic, military service, and decision-making preference questions and the Hip-Knee Decision Quality Instrument (HK-DQI), which measures patients' knowledge about their disease process, concordance of their treatment decision, and the considered elements in their decision-making process. RESULTS: The HK-DQI knowledge score had a significant, positive correlation with duration of military service (R2=0.36, p=0.004). Rank at discharge and years since discharge did not show a significant correlation with decision quality (p=0.500 and p=0.317, respectively). The concordance score did not show a statistically significant correlation with rank, duration of service, and years since discharge (p=0.640, p=0.486 and p=0.795, respectively). Additionally, decision process score was not significantly associated with rank, duration of military service, and years since discharge (p=0.380, p=0.885, and p=0.474, respectively). CONCLUSION: Decision quality in Veterans considering treatment for knee osteoarthritis appears to be correlated positively with duration of military service. These findings may present an opportunity for identification of Veterans at most risk of low decision quality and customization of shared decision-making methods for Veterans by characteristics of military service.

Identifying regional characteristics influencing variation in the utilization of rotator cuff repair in the United States.

BACKGROUND: There is a lack of consensus regarding indications for surgical management of rotator cuff disease, which can lead to increased regional variation. The objectives of this study were to describe the geographic variation in rates of rotator cuff repair (RCR) in the United States over time and to identify regional characteristics associated with utilization. METHODS: The United States was divided into 306 hospital referral regions. The adjusted per capita RCR rate was calculated using procedural counts derived from the Medicare Part B Carrier File from 2004-2014. Population-weighted multivariable regression was used to identify regional characteristics independently associated with utilization in 2014. RESULTS: In 2014, an 8-fold difference in rates of RCR was found between regions. Between 2010 and 2014, the overall rate of RCR grew only 3.6% and regional variation decreased. Higher regional utilization of several other orthopedic procedures (P < .02), as well as the regional supply of orthopedic surgeons (P = .002), was independently associated with significantly increased utilization. The South, Southeast, and Southwest were independently associated with significantly higher utilization (P < .001) compared with the Northeast. A higher prevalence of resident physicians, a marker of the academic presence within a region, was independently associated with decreased utilization (P < .001). CONCLUSION: Utilization of RCR has increased substantially over the past decade, but the rate of growth appears to be slowing. RCR remains a procedure with significant regional variation, and increased utilization across regions is associated with higher orthopedic surgeon supply and increased rates of other orthopedic procedures.

Considering Spine Surgery: A Web-Based Calculator for Communicating Estimates of Personalized Treatment Outcomes.

STUDY DESIGN: Prospective evaluation of an informational web-based calculator for communicating estimates of personalized treatment outcomes. OBJECTIVE: To evaluate the usability, effectiveness in communicating benefits and risks, and impact on decision quality of a calculator tool for patients with intervertebral disc herniations, spinal stenosis, and degenerative spondylolisthesis who are deciding between surgical and nonsurgical treatments. SUMMARY OF BACKGROUND DATA: The decision to have back surgery is preference-sensitive and warrants shared decision making. However, more patient-specific, individualized tools for presenting clinical evidence on treatment outcomes are needed. METHODS: Using Spine Patient Outcomes Research Trial data, prediction models were designed and integrated into a web-based calculator tool: http://spinesurgerycalc.dartmouth.edu/calc/. Consumer Reports subscribers with back-related pain were invited to use the calculator via email, and patient participants were recruited to use the calculator in a prospective manner following an initial appointment at participating spine centers. Participants completed questionnaires before and after using the calculator. We randomly assigned previously validated questions that tested knowledge about the treatment options to be asked either before or after viewing the calculator. RESULTS: A total of 1256 consumer reports subscribers and 68 patient participants completed the calculator and questionnaires. Knowledge scores were higher in the postcalculator group compared to the precalculator group, indicating that calculator usage successfully informed users. Decisional conflict was lower when measured following calculator use, suggesting the calculator was beneficial in the decision-making process. Participants generally found the tool helpful and easy to use. CONCLUSION: Although the calculator is not a comprehensive decision aid, it does focus on communicating individualized risks and benefits for treatment options. Moreover, it appears to be helpful in achieving the goals of more traditional shared decision-making tools. It not only improved knowledge scores but also improved other aspects of decision quality. LEVEL OF EVIDENCE: 2.

Falling Down on the Job: Evaluation and Treatment of Fall Risk Among Older Adults With Upper Extremity Fragility Fractures.

Background: Clinical practice guidelines recommend fall risk assessment and intervention for older adults who sustain a fall-related injury to prevent future injury and mobility decline. Objective: The aim of this study was to describe how often Medicare beneficiaries with upper extremity fracture receive evaluation and treatment for fall risk. Design: Observational cohort. Methods: Participants were fee-for-service beneficiaries age 66 to 99 treated as outpatients for proximal humerus or distal radius/ulna ("wrist") fragility fractures. -Participants were studied using Carrier and Outpatient Hospital files. The proportion of patients evaluated or treated for fall risk up to 6 months after proximal humerus or wrist fracture from 2007-2009 was examined based on evaluation, treatment, and diagnosis codes. Time to evaluation and number of treatment sessions were calculated. Logistic regression was used to analyze patient characteristics that predicted receiving evaluation or treatment. Narrow (gait training) and broad (gait training or therapeutic exercise) definitions of service were used. Results: There were 309,947 beneficiaries who sustained proximal humerus (32%) or wrist fracture (68%); 10.7% received evaluation or treatment for fall risk or gait issues (humerus: 14.2%; wrist: 9.0%). Using the broader definition, the percentage increased to 18.5% (humerus: 23.4%; wrist: 16.3%). Factors associated with higher likelihood of services after fracture were: evaluation or treatment for falls or gait prior to fracture, more comorbidities, prior nursing home stay, older age, humerus fracture (vs wrist), female sex, and white race. Limitations: Claims analysis may underestimate physician and physical therapist fall assessments, but it is not likely to qualitatively change the results. Conclusions: A small proportion of older adults with upper extremity fracture received fall risk assessment and treatment. Providers and health systems must advance efforts to provide timely evidence-based management of fall risk in this population.

How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers' compensation systems.

BACKGROUND CONTEXT: In response to increasing use of lumbar fusion for improving back pain, despite unclear efficacy, particularly among injured workers, some insurers have developed limited coverage policies. Washington State's workers' compensation (WC) program requires imaging confirmation of instability and limits initial fusions to a single level. In contrast, California requires coverage if a second opinion supports surgery, allows initial multilevel fusion, and provides additional reimbursement for surgical implants. There are no studies that compare population-level effects of these policy differences on utilization, costs, and safety of lumbar fusion. PURPOSE: The purpose of this study was to compare population-level data on the use of complex fusion techniques, adverse outcomes within 3 months, and costs for two states with contrasting coverage policies. STUDY DESIGN AND SETTING: The study design was an analysis of WC patients in California and Washington using the Agency for Healthcare Research and Quality's State Inpatient Databases, 2008-2009. PATIENT SAMPLE: All patients undergoing an inpatient lumbar fusion for degenerative disease (n=4,628) were included the patient sample. OUTCOME MEASURE(S): Outcome measures included repeat lumbar spine surgery, all-cause readmission, life-threatening complications, wound problems, device complications, and costs. METHODS: Log-binomial regressions compared 3-month complications and costs between states, adjusting for patient characteristics. RESULTS: Overall rate of lumbar fusion operations through WC programs was 47% higher in California than in Washington. California WC patients were more likely than those in Washington to undergo fusion for controversial indications, such as nonspecific back pain (28% versus 21%) and disc herniation (37% versus 21%), as opposed to spinal stenosis (6% versus 15%), and spondylolisthesis (25% versus 41%). A higher percentage of patients in California received circumferential procedures (26% versus 5%), fusion of three or more levels (10% versus 5%), and bone morphogenetic protein (50% versus 31%). California had higher adjusted risk for reoperation (relative risk [RR] 2.28; 95% confidence interval [CI], 2.27-2.29), wound problems (RR 2.64; 95% CI, 2.62-2.65), device complications (RR 2.49; 95% CI, 2.38-2.61), and life-threatening complications (RR 1.31; 95% CI, 1.31-1.31). Hospital costs for the index procedure were greater in California ($49,430) than in Washington ($40,114). CONCLUSIONS: Broader lumbar fusion coverage policy was associated with greater use of lumbar fusion, use of more invasive operations, more reoperations, higher rates of complications, and greater inpatient costs.

Use of chiropractic spinal manipulation in older adults is strongly correlated with supply.

STUDY DESIGN: Retrospective cross-sectional analysis of administrative data. OBJECTIVE: To examine the relationship between regional chiropractic supply and both use and utilization intensity of chiropractic services among Medicare beneficiaries. SUMMARY OF BACKGROUND DATA: Numerous studies have documented trends and patterns in the utilization of chiropractic services in the United States, but little is known about geographic variation in the relationship between chiropractic supply and utilization. METHODS: We analyzed Medicare claims data for services provided by chiropractic physicians in 2008. We aggregated the data to the hospital referral region level and used small area analysis techniques to generate descriptive statistics. We mapped geographic variations in chiropractic supply, use and utilization intensity (treatments per user), and quantified the variation by coefficient of variation and extremal ratio. We used Spearman rank correlation coefficient to correlate use with supply. We used a logistic regression model for chiropractic use and a multiple linear regression model for chiropractic utilization intensity. RESULTS: The average regional supply of chiropractic physicians was 21.5 per 100,000 adult capita. The average percentage of beneficiaries who used chiropractic was approximately 7.6 (SD, 3.9). The average utilization intensity was 10.6 (SD, 1.8). Regional chiropractic supply varied more than 14-fold, and chiropractic use varied more than 17-fold. Chiropractic supply and use were positively correlated (Spearman ρ, 0.68; P < 0.001). A low back or cervical spine problem was strongly associated with chiropractic use (odds ratios, 21.6 and 14.3, respectively). Increased chiropractic supply was associated with increased chiropractic use (odds ratio, 1.04) but not with increased chiropractic utilization intensity. CONCLUSION: Both the supply of chiropractors and the utilization of chiropractic by older US adults varied widely by region. Increased chiropractic supply was associated with increased chiropractic use but not with increased chiropractic utilization intensity. Utilization of chiropractic care is likely sensitive to both supply and patient preference.