What rate of utilization is appropriate in musculoskeletal care?

Abstract

Musculoskeletal procedures often show wide variation in rates across geographic areas, which begs the question, "Which rate is right?" Clearly, there is no simple answer to this question. We summarize a conceptual framework for thinking about how to approach this question for different types of interventions. One guiding principle is the "right rate" is usually the one that results from the choices of a fully informed and empowered patient population. For truly effective care without substantial tradeoffs, the right rate may approach 100%. The rate of operative treatment of hip fracture, for example, approaches the underlying incidence of disease; however, the rate of some forms of effective care, like osteoporosis evaluation and treatment after a fragility fracture, is often quite low and undoubtedly reflects underuse. The recommended approach to underuse is to improve the reliability and accountability of the delivery system. Many other musculoskeletal interventions fall into the category of "preference-sensitive care." These interventions involve important tradeoffs between risks and benefits. Variations in these procedure rates may represent insufficient focus on patient values and preferences, relying instead on the enthusiasm of the physician for treatment alternatives. The recommended approach in this setting is the use of decision aids and other approaches to informed choice.

Level of evidence: Level V, expert opinion. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1

The geographic variation in rates of orthopaedic procedures varies dramatically between different procedures with greater variability seen for procedures having greater scientific uncertainty about their effectiveness. All data are 2002–2003. (Reprinted with permission from Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine. 2006;31:2707–2714.)

Fig. 2

The rates of spine surgery among Medicare beneficiaries 1999-2000, stratified by race and gender, show much higher rates among whites.

Fig. 3

The rates of spine surgery increase monotonically across deciles of zip-code level income with areas of higher income showing higher rates of surgery.