These authors used the 2010 to 2012 Medicare administrative database to investigate factors related to the treatment selected for atraumatic rotator cuff tears documented.
Among 32,203 patients who were identified as having a new, symptomatic,MRI-confirmed atraumatic rotator cuff tears 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 lower odds of surgery and 2.36-times 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. 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.
The authors concluded that 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.
The authors concluded that 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.
Comment: This is a most interesting study. Only 20% of these new symptomatic cuff tears were treated with initial surgery and selection is biased by the type of provider (surgeon vs non surgeon) that the patient is likely to have seen as well as the likely insurance reimbursement for the care received (Medicare vs the lower reimbursing Medicaid dual-eligibility).
Thus study does not answer the important question: is an atraumatic tear in someone over the age of 65 a problem that shoulder receive surgery as its initial management? The very meaning of "atraumatic" suggests that there is an opportunity for non-operative management without a rush to the OR as initial management.
Wouldn't it be wonderful if the Medicare database included the patients self-assessed shoulder comfort and function at the time of the initial visit and one year later. With these data we'd be closer answering the question: "do older patients with atraumatic cuff tears fare better if they receive surgical treatment?"
Here's my atraumatic cuff tear
Here's my atraumatic cuff tear
And here's my shoulder function with non-operative management
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