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- MATERIALS AND METHODS
Rheumatoid arthritis (RA) is a debilitating and progressive disease, affecting an estimated 2.1 million Americans (1). Although RA is a systemic disease extending beyond the musculoskeletal system, more than 70% of RA patients have some form of hand disability (2). The disease often progresses to crippling hand deformities despite aggressive medical treatment, and few patients ever achieve disease control (3).
The role of surgery in the rheumatoid hand has been controversial, with rheumatologists and surgeons debating the efficacy of surgical treatments. This controversy may result in uncertainty in patient management, which can lead to large variation in surgical practice across the country (4). Furthermore, given the uncertainty of treatment efficacy cited in the medical literature, the rheumatoid population may be particularly vulnerable to treatment biases, with influences ranging from patient sex to the density of health care providers (5–11).
The purpose of our research was to use a large, population-based sample to evaluate surgical practice patterns of the rheumatoid hand in the US. Specifically, we evaluated 3 surgical procedure rates across the country, looking for evidence of geographic variation in practice patterns. We also evaluated aggressiveness of care between men and women, comparing the rates of end-stage reconstructive procedures, arthroplasty and arthrodesis, with the rates of prophylactic tenosynovectomy. In addition, the procedure rates were compared with the density of surgeons, assessing the possibility of physician-induced demand.
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- MATERIALS AND METHODS
Of the procedures we evaluated, Medicare covered 44–64% of the patients, private health insurance covered 29–38%, and fewer than 7% of the patients were uninsured. Of the 772 hospitals included in the sample population, 427 (55%) performed at least 1 arthroplasty, 214 (28%) performed at least 1 arthrodesis, and 601 (78%) performed at least 1 tenosynovectomy. The distribution of the procedures was almost evenly split between reconstructive and prophylactic procedures: 52% versus 48%, respectively. Of the reconstructive procedures, 34% were arthroplasty and 18% were arthrodesis techniques. The length of hospital stay was 1 day for 50% of fusions, 50% of arthroplasties, and 69% of tenosynovectomies; the remainder of the cases generally stayed 5 or fewer days. The percentage of procedures performed in the urban teaching and nonteaching hospitals was evenly split, with urban hospitals accounting for approximately 90% of the procedures performed. Patient demographics were similar across the 3 procedures, except for age and sex.
Table 1 illustrates procedure rates for men compared with women. Women outnumbered men in arthroplasty (7.7 versus 2.3, respectively; OR = 3.36, P < 0.001) and in arthrodesis procedures (3.4 versus 2.6, respectively; OR = 1.3, P = 0.009). However, women were less likely to receive tenosynovectomy procedures (5.8 versus 13.9, respectively; OR = 0.42, P < 0.001). In addition, tenosynovectomy procedures were associated with a significantly younger age at treatment for men compared with women (54 versus 59 years, respectively; P < 0.001).
Table 1. Differences in procedure rates between women and men
| ||Procedure rate (95% CI)*||Odds ratio†||P|
|Arthroplasty||2.3 (1.7–3.0)||7.7 (7.0–8.5)||3.36||0.001|
|Arthrodesis||2.6 (2.0–3.3)||3.4 (2.9–3.9)||1.30||0.009|
|Tenosynovectomy||13.9 (12.4–15.4)||5.8 (5.2–6.5)||0.42||0.001|
Table 2 displays the annual rates for each procedure along with the 95% CIs for each of the sampled states. Large variations in procedure rates across the 19 states were found. These variations were highly significant for all 3 procedures (P < 0.0001), with the difference in rates between the highest and lowest states varying by a factor of 9.4 in arthroplasty, 11.7 in arthrodesis, and 9.5 in tenosynovectomy procedures.
Table 2. Annual rates of arthroplasty, arthrodesis, and tenosynovectomy procedures in the sampled states*
|AZ||4.1 (2.5–6.5)||2.0 (0.9–3.7)||14.8 (11.5–18.7)|
|CA||6.7 (5.8–7.8)||3.2 (2.6–4.0)||10.9 (9.6–12.2)|
|CO||2.9 (1.5–5.1)||1.7 (0.7–3.5)||5.8 (3.8–8.7)|
|FL||6.7 (5.5–8.0)||2.2 (1.5–3.0)||7.7 (6.4–9.1)|
|IL||3.2 (2.3–4.3)||2.0 (1.3–3.0)||6.4 (5.1–8.0)|
|IA||10.3 (7.4–13.9)||3.0 (1.6–5.3)||2.0 (0.9–4.0)|
|KS||6.4 (4.0–9.8)||2.2 (0.9–4.4)||2.8 (1.3–5.2)|
|MA||7.1 (5.4–9.2)||2.7 (1.7–4.1)||4.4 (3.2–6.0)|
|MD||7.8 (5.5–10.6)||4.3 (2.7–6.5)||10.8 (8.1–14.1)|
|MO||4.9 (3.4–6.9)||2.0 (1.1–3.3)||6.7 (4.9–9.0)|
|NJ||4.5 (3.2–6.1)||0.9 (0.4–1.8)||9.9 (7.9–12.2)|
|NY||4.8 (3.8–5.8)||2.4 (1.7–3.2)||4.1 (3.3–5.1)|
|OR||5.9 (3.8–8.7)||10.5 (7.6–14.1)||16.1 (12.5–20.5)|
|PA||13.2 (11.5–15.1)||8.0 (6.7–9.5)||12.6 (11.0–14.4)|
|SC||1.4 (0.5–3.2)||1.4 (0.5–3.2)||1.7 (0.6–3.6)|
|TN||2.6 (1.5–4.2)||2.6 (1.5–4.2)||6.9 (5.0–9.3)|
|WA||2.2 (1.2–3.6)||3.3 (2.0–5.0)||3.0 (1.8–4.6)|
|WI||11.5 (9.1–14.4)||4.2 (2.8–6.1)||11.1 (8.7–13.9)|
The Pearson correlation matrix of procedure rates and density of surgeons by state is seen in Table 3. The evaluation of one procedure rate with another revealed a strong positive correlation between the 2 reconstructive procedures, arthroplasty and arthrodesis (r = 0.80). This relationship is visually displayed in Figure 1. However, tenosynovectomy rates were only modestly correlated with arthroplasty and arthrodesis rates (r = 0.20 and 0.23, respectively). Therefore, states that perform more reconstructive procedures are only slightly more likely to perform prophylactic procedures. Each state's density of hand surgeons was then compared with the different procedure rates. There was no evidence that greater surgeon density was associated with greater arthroplasty, arthrodesis, or tenosynovectomy rates, and the trend actually went in the opposite direction (r = −0.37, −0.18, and −0.12, respectively).
Table 3. Associations between procedure rates and surgeon density by state*
| ||Arthrodesis||Tenosynovectomy||Surgeon density|
Figure 1. Correlation between rates of arthroplasty and arthrodesis by state. * Arthroplasty and arthrodesis rates are per 10,000 rheumatoid arthritis patients.
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- Top of page
- MATERIALS AND METHODS
Rheumatoid arthritis is a crippling systemic disease that affects an estimated 1% of the US population at the prime of their lives (1). Treatment options are limited, with no cure available. Medical management is aimed at limiting synovial proliferation and slowing the progression of joint destruction. Surgical options for hand deformities are also limited, defined as either reconstructive (arthrodesis or arthroplasty) or prophylactic (tenosynovectomy). Unfortunately, there is little information available on these procedures from rigorous outcomes research or randomized clinical trials, forcing physicians to rely on uncontrolled case series for clinical decision making.
Although RA differentially affects women, one must still consider the possibility of differences in health care delivery based on patient sex. Many studies have aroused concern regarding underutilization of surgical interventions in women, such as coronary revascularization, renal transplantation, and hip or knee arthroscopy (5–8). In our analysis, women were 3.4 times more likely than men to receive arthroplasty procedures and 1.3 times more likely to receive arthrodesis procedures compared with men. However, men were 2.4 times more likely than women to receive tenosynovectomy procedures. Conclusions from these results are limited due to a lack of information regarding the patients' disease severity and willingness to undergo surgery. Because men have higher rates of the prophylactic procedure—tenosynovectomy—and receive this procedure at a younger age than women, the question must be raised whether men are receiving more aggressive care than women. In addition, variations in procedure rates between the sexes may be the result of differences in disease manifestations, patient preferences, or physician biases and deserves further investigation.
The literature regarding treatment of the rheumatoid hand is controversial, with the efficacy of prophylactic tenosynovectomy often at the crux of the debate (9, 12–14). Surgeons complain of exclusion from RA management teams, as they are often called on as a source of last resort when all else fails (15). In contrast, rheumatologists portray synovectomy procedures as delaying strategies with minimal long-term efficacy (16). Many rheumatologists define the role of surgery as a salvage technique and are reluctant to consider surgery in the early stages of the disease (17). Our results indicate that some physicians believe in the efficacy of prophylactic procedures in the RA hand, as tenosynovectomy accounted for 48% of the procedures studied. This is surprising considering the lack of confidence in the rheumatology literature regarding prophylactic procedures on RA hands (16). Furthermore, advances in technology have improved arthroplasty outcomes (18, 19), which may alleviate some of the pressure on surgeons to intervene early with prophylactic procedures on functional hands. However, we do not know if surgeons are performing prophylactic procedures at higher or lower rates than in the past, given the changes in medical management, arthroplasty materials, and referral patterns.
Variations in practice patterns can arise when multiple clinical options are available, particularly when there is uncertainty about optimal management. For example, greater geographic variation exists with hysterectomy than with colectomy rates, due to greater treatment options for uterine fibroids and dysfunctional bleeding (4). Treatments considered to be the universal standard usually have limited practice pattern variations. Studying practice patterns is important for delineating clinical conditions for which intervention decisions may need more rigorous evaluation. Although many factors can contribute to variations, such as differences in illness rates, environmental conditions, patient preferences, access to care, and economic incentives, a large percentage of practice variations can be explained by disagreement among physicians regarding appropriate therapy (4). Generally, physicians lack consensus in patient management when treatment outcomes are poorly defined (4). The significant variation in procedure rates across states in our analyses was not surprising, given the lack of consensus in the literature regarding the treatment of the rheumatoid hand. We expected to find less variation in the rates of end-stage procedures because the literature appears less controversial in these areas. However, we found a higher than expected positive correlation between arthroplasty and arthrodesis procedures within each state. Thus, a state likely to perform one type of end-stage procedure was also likely to perform the other type. The reason for this correlation—patient preference, disease manifestations, or physician preference—cannot be elucidated from our data. However, these procedures are often used in combination to maximize stability and function, which may account for some of the correlation. For example, proximal interphalangeal fusions are combined with metacarpophalangeal arthroplasties to correct for swan neck deformities. Nevertheless, our study clearly demonstrates that one of the most influential factors in the treatment of the rheumatoid hand is the state in which the patient lives. Therefore, we now need to determine the reasons behind such wide variation in treatment.
From a health policy perspective, concern exists regarding the cost of specialized care, including hand surgery. In general, the US has an overabundance of specialized physicians, contributing to the escalating costs of health care (20). Physicians are believed to sometimes induce the demand for their own services; therefore, one attempt to control healthcare costs is to control the number of specialty providers (21). In Canada, health policy experts attribute practice pattern variations to physician density, believing that physicians induce demand for their services, which increases health care costs. Plans for restructuring the fee schedules of specialty physicians and relocating specialists to rural locations have been discussed to unify practice patterns. However, an orthopedic study of knee replacement rates showed surgery rates and density of surgeons to be unrelated, arguing against the restructuring efforts (22). Similar to the Canadian study, we found no evidence that specialized surgeons are inducing demand for their services. We found no significant relationship between the density of hand surgeons in a state and the rate of hand procedures in RA patients. Answering the question of specialty physician-induced demand is challenging and may be better approached at the county rather than the state level. However, the database does not provide zip codes, so the possibility of physician-induced demand at the county or hospital level cannot be evaluated. In addition, because the HCUP database does not identify the provider, we had no means of identifying surgeons performing these procedures who were not ASSH members. However, rheumatoid hand surgery is very complex and, according to our data, 90% of the procedures were performed in urban areas with available ASSH surgeons. Therefore, we believe that our sample of ASSH members probably reflects the general membership of physicians who care for these patients.
Although using a national database aids in the generalizability of the study results, limitations still exist. For example, the procedure rates for the sampled states were probably underestimated, because we were unable to account for patients in the population already treated by surgery and patients who had received outpatient surgery (although the popularity of ambulatory surgery was at its infancy at this time). Our study results were also limited to the white patient population due to our limited sample size of nonwhites. However, white people represent 92% of RA patients in this country so we believe that our sample adequately represented the study population (23). Lastly, databases are susceptible to errors in coding, which may underestimate or overestimate procedure rates. RA is difficult to diagnose, and patients with inflammatory arthritis may be incorrectly diagnosed as having RA. However, we used the most accurate method available to define the RA population, which was through the use of ICD-9-CM diagnostic codes.
In conclusion, the surgical treatment of the rheumatoid hand is a complex multidimensional process with limited evidence-based research and limited agreement among physicians as to appropriate treatment modalities. Not surprisingly, we found significant variations in physician practice patterns on a national level, influenced both by the state in which the procedure was performed and the patient's sex, but not by the density of hand surgeons. Our future research initiatives will investigate whether this variation represents differences in physician behavior or differences in patients' wants or needs.