Treatment for Rotator Cuff Tear Is Influenced by Demographics and Characteristics of the Area Where Patients Live

Abstract

Background:Atraumatic rotator cuff tear is a common orthopaedic complaint for people >60 years of age. Lack of evidence or consensus on appropriate treatment for this type of injury creates the potential for substantial discretion in treatment decisions. To our knowledge, no study has assessed the implications of this discretion on treatment patterns across the United States.Methods:All Medicare beneficiaries in the United States with a new magnetic resonance imaging (MRI)-confirmed atraumatic rotator cuff tear were identified with use of 2010 to 2012 Medicare administrative data and were categorized according to initial treatment (surgery, physical therapy, or watchful waiting). Treatment was modeled as a function of the clinical and demographic characteristics of each patient. Variation in treatment rates across hospital referral regions and the presence of area treatment signatures, representing the extent that treatment rates varied across hospital referral regions after controlling for patient characteristics, were assessed. Correlations between measures of area treatment signatures and measures of physician access in hospital referral regions were examined.Results:Among patients who were identified as having a new, symptomatic, MRI-confirmed atraumatic rotator cuff tear (n = 32,203), 19.8% were managed with initial surgery; 41.3%, with initial physical therapy; and 38.8%, with watchful waiting. Patients who were older, had more comorbidity, or were female, of non-white race, or dual-eligible for Medicaid were less likely to receive surgery (p < 0.0001). Black, dual-eligible females had 0.42-times (95% confidence interval [CI], 0.34 to 0.50) lower odds of surgery and 2.36-times (95% CI, 2.02 to 2.70) greater odds of watchful waiting. Covariate-adjusted odds of surgery varied dramatically across hospital referral regions; unadjusted surgery and physical therapy rates varied from 0% to 73% and from 6% to 74%, respectively. On average, patients in high-surgery areas were 62% more likely to receive surgery than the average patient with identical measured characteristics, and patients in low-surgery areas were half as likely to receive surgery than the average comparable patient. The supply of orthopaedic surgeons and the supply of physical therapists were associated with greater use of initial surgery and physical therapy, respectively.Conclusions:Patient characteristics had a significant influence on treatment for atraumatic rotator cuff tear but did not explain the wide-ranging variation in treatment rates across areas. Local-area physician supply and specialty mix were correlated with treatment, independent of the patient’s measured characteristics.

Prevalence and predictors of no-shows to physical therapy for musculoskeletal conditions

“…Out of the 50 million people impacted by chronic pain, only 12 million people in the United States accessed outpatient physical or occupational therapy [13]. Across common MSK conditions, like low back pain and rotator cuff tear, physical therapy utilization ranges from 3-10% with significant variation across health referral regions [14][15][16]. Utilization is limited for physical therapy services in part by the available workforce.…”

Factors associated with choice for surgery in newly symptomatic degenerative rotator cuff tears: a prospective cohort evaluation

“…Studies have shown that there are significant differences in surgical indications between surgeons 9 as well as geographic variances in the incidence of rotator cuff surgery. 4,25 We sought to better define patient-and tear-related factors that may play a role in surgical decision making. In our cohort, the surgical team offered a balanced discussion regarding options for the treatment of the newly painful cuff tear and patients were counseled toward conservative treatment and continued surveillance.…”

Personalizing Evidence for Shoulder Fracture Patients Using an Extended Instrumental Variable Causal Forest Algorithm

“…Medicare claims in the year prior to the index PHF were used to estimate the Charlson Comorbidity Index (CCI), 121,122 the Frailty Risk Index (FRI) score, 123 and quintiles of patient-specific total Medicare spending in the year prior to index. 96,[124][125][126] Prior healthcare spending has been shown to be indicative of patient health status and health care utilization preferences. 96,125,126 For the IV-CFA, the five age groups, CCI, FRI, and the prior health cost quintiles were each specified as index variables so that concept "cut-offs" produced by IV-CFA implied monotonic relationships (e.g.…”

“…96,[124][125][126] Prior healthcare spending has been shown to be indicative of patient health status and health care utilization preferences. 96,125,126 For the IV-CFA, the five age groups, CCI, FRI, and the prior health cost quintiles were each specified as index variables so that concept "cut-offs" produced by IV-CFA implied monotonic relationships (e.g. a cut-off of less than or equal to age group 3 implies all patients age less than or equal to 79, versus 80 and above).…”