June 2000 Bulletin

Atlas finds wide variations in orthopaedic care

Why do people seeking treatment for back pain have a greater chance to undergo spine surgery in the United States than in other countries?

Why is there a greater chance of having spine surgery in the states of Washington and Oregon than in New Hampshire or Maine?

Why are less than 50 percent of fractures treated surgically in Detroit, Mich., while more than 80 percent of fractures are treated surgically in Tucson, Ariz.?

The man raising the questions is James Weinstein, DO, principal investigator and editor of a publication that presents an eye-opening view of musculoskeletal care in the United States. Dr. Weinstein doesn’t have the answers; he leaves it to the medical community to review, analyze and use the information in The Dartmouth Atlas of Musculoskeletal Health Care. The Atlas, which is expected to be published this summer, is a collaborative effort of the AAOS, American Hospital Association and Center for the Evaluative Clinical Sciences (CECS) at Dartmouth.

The Atlas presents information drawn from 35 million Medicare patient records over two years–70 million data. The findings are sometimes surprising and the issues raised are provocative and perhaps, unsettling.

Take the data on spine surgery. "Clearly, there’s epidemiologic evidence that the rates of back pain and leg symptoms are no greater in our country than any other country," Dr. Weinstein told an AAOS Annual Meeting symposium in March. "However, if we look at the rates of [spine] surgery over the last five years in the United States, they’ve increased about 40 percent, the rates of fusions have increased 72 percent and the utilization of instrumentation and devices has increased over 100 percent. Yet, we have very little literature to support the efficacy of such treatment."

Countries such as Scotland, England and Sweden "have similar populations [as the United States], but treat these things much differently," he observed. "Their populations do not seem to be at any greater risk. We must be prepared to answer these questions."

There’s not only variation between countries, but also between communities within the United States. "We see that the rates of spine surgery vary from about 1.5 per thousand to almost nine per thousand, depending on where you live," he said. "In some ways, this suggests that geography is destiny."

The data also shows a correlation with the number of orthopaedic surgeons in a community and the rate of spine surgery. "People are asking why and what’s the efficacy of these treatments," he said. "So you might say, what you get depends on where you live and who you see."

The variation of treatment across geographic areas is not limited to orthopaedics. Dr. Weinstein has found even more variations in treatments in other specialties.

And, the surgeons performing the spine surgery are not necessarily orthopaedists. Dr. Weinstein was surprised to find that 66 percent of the spine surgery procedures in the United States are performed by neurosurgeons, not orthopaedic surgeons.

The data spotlights geographic variations in the number of fractures and rates of surgical treatments. "Why does Alabama with such a high rate of fractures, have such a low rate of [surgical] treatment, when all of these patients have Medicare and insurance?" Dr. Weinstein asked. "When we look at the total rate of fractures and the orthopaedic workforce, we see some matching of supply induced demand."

The data on joint arthroplasty presents a similar story. The rates of total joint replacements in the last 10 years have gone up about 100 percent," Dr. Weinstein said. "The rates of knee replacement about 120 percent, the rates of hip replacement about 70 percent and the rates of shoulder surgery replacement about 126 percent. Doesn’t seem to be a bad thing; joint replacement is a good operation, the population is growing and more [procedures] are being done.

"But there’s still tremendous variation in how we practice, both within and outside of academic medical centers. The rates of variation in joint replacement surgery are almost fivefold."

What’s the right rate of surgery? That’s a question many people will want answered–orthopaedic surgeons, insurance companies and even the government. Dr. Weinstein doesn’t have the answer; he recommends that state societies form new partnerships to look at local or regional benchmarks. He suggests this approach in Florida where a patient is about 84 percent more likely to have spine surgery in Ft. Myers, Fla. than if the patient lives in St. Petersburg, Fla. A patient is about 40 percent more likely to have arthroplasty if he or she lives in Ft. Myers vs. St. Petersburg.

"The workforce in Ft. Myers is average for the United States," Dr. Weinstein points out. "There is not an absolute increase in orthopaedic surgeons there per population." So, what’s the right rate of surgery?

The issue of surgical signature was addressed by Jack Wennberg, MD, in the 1998 Dartmouth Atlas of Health Care in the U.S. Dr. Wennberg, professor for Evaluative Clinical Sciences, and director of CECS, suggested solutions based on outcomes research and the creation of the opportunity for patients to participate actively in the choice of treatment. When patients participate in medical decisions–shared decision-making–local rates reflect what informed patients actually want. The second part of the strategy involves comparing regions with high levels of resource allocation and spending to areas where resources and spending are more constrained. By using benchmarking, the outcomes question can be approached from the perspective of the population living in such regions.

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