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Drivers of Surgery for the Degenerative Hip, Knee, and Spine: A Systematic Review

  • Symposium: Value Based Healthcare
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Surgical treatment for degenerative conditions of the hip, knee, and spine has an impact on overall healthcare spending. Surgical rates have increased dramatically and considerable regional variation has been observed. The reasons behind these increasing rates and variation across regions have not been well elucidated.

Questions/purposes

We therefore identified demographic (D), social structure (SS), health belief (HB), personal (PR) and community resources (CR), and medical need (MN) factors that drive rates of hip, knee, and spine surgery.

Methods

We conducted a systematic review to include all observational, population-based studies that compared surgical rates with potential drivers (D, SS, HB, PR, CR, MN). We searched PubMed combining key words focusing on (1) disease and procedure; (2) study methodology; and (3) explanatory models. Independent investigators selected potentially eligible studies from abstract review and abstracted methodological and outcome data. From an initial search of 256 articles, we found 37 to be potentially eligible (kappa 0.86) but only 28 met all our inclusion criteria.

Results

Age, nonminority, insurance coverage, and surgeon enthusiasm all increased surgical rates. Rates of arthroplasty were higher for females with higher education, income, obesity, rurality, willingness to consider surgery, and prevalence of disease, whereas spinal rates increased with male gender, lower income, and the availability of advanced imaging.

Conclusions

Regional variation in these procedures exists because they are examples of preference-sensitive care. With strategies that may affect change in factors that are potentially modifiable by behavior or resources, extreme variation in rates may be reduced.

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Acknowledgments

We thank Linda Murphy and Bob Johnson from the Grunigen Medical Library at the UC Irvine Medical Center for assistance with our bibliographic search.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of California at Irvine, 101 The City Drive South, Pavilion III, Orange, CA, 92868, USA

    S. Samuel Bederman MD, PhD, FRCSC, Charles D. Rosen MD, Nitin N. Bhatia MD, FACS, P. Douglas Kiester MD & Ranjan Gupta MD

Authors
  1. S. Samuel Bederman MD, PhD, FRCSC
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  2. Charles D. Rosen MD
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  3. Nitin N. Bhatia MD, FACS
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  4. P. Douglas Kiester MD
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  5. Ranjan Gupta MD
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Corresponding author

Correspondence to S. Samuel Bederman MD, PhD, FRCSC.

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Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Appendices

Appendix 1. Search strategy

Performed September 16, 2010

(Physician’s Practice Patterns/utilization [mh] OR Health Services Research [mh] OR Health Services Accessibility [mh] OR Health Services Needs and Demand [mh] OR Hospitalization [mh] OR Residence Characteristics [mh] OR Socioeconomic Factors [mh] OR Databases, Factual [mh] OR Population Surveillance [mh] OR Small-Area Analysis [mh] OR Health Status Disparities [mh] OR Population Surveillance[mh] OR registries [mh] OR Medicare [mh] OR Medicaid [mh]) OR “population-based” OR “population based” OR register OR “procedure volume” OR “surgical rate*” OR “population based” OR “population-based” OR “Medicare” OR “administrative database” OR “claims database” OR “area variation” OR “geographic variation” OR “regional variation” OR “small area analysis” OR “procedure volume” OR “frequency of use”

[742359 references]

AND

Arthroplasty, Replacement[mh] OR Hip Prosthesis[mh] OR Spinal fusion[mh] OR Lumbar Vertebrae/surgery[mh] OR Spinal diseases/surgery[mh] OR joint prosthesis[mh]) OR “hip replacement” OR “knee replacement” OR “spine surgery” OR ((“low back” OR “spine” OR “hip” OR “knee”) and “degenerative” and (“surgery” or “surgical”)) OR “spinal fusion” OR “arthroplasty” OR “pedicle screw” OR “pedicle screws”

[86761 references]

AND

(“determinants” OR “influence” OR “driven” OR “drivers” OR “explanation” OR “explained” OR “correlated”)

[1232560 references]

COMBINE 1 and 2 and 3

[283 references]

LIMIT: English

[256 references]

Appendix 2

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Bederman, S.S., Rosen, C.D., Bhatia, N.N. et al. Drivers of Surgery for the Degenerative Hip, Knee, and Spine: A Systematic Review. Clin Orthop Relat Res 470, 1090–1105 (2012). https://doi.org/10.1007/s11999-011-2004-x

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  • DOI: https://doi.org/10.1007/s11999-011-2004-x

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