Clinical Orthopaedics and Related Research®

, Volume 467, Issue 10, pp 2506–2511

What Rate of Utilization is Appropriate in Musculoskeletal Care?

Symposium: ABJS Carl T. Brighton Workshop on Health Policy Issues in Orthopaedic Surgery


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.


  1. 1.
    Baicker K, Chandra A, Skinner JS. Geographic variation in health care and the problem of measuring racial disparities. Perspect Biol Med. 2005;48(1 Suppl):S42–S53.PubMedGoogle Scholar
  2. 2.
    Bruyere O, Brandi ML, Burlet N, Harvey N, Lyritis G, Minne H, Boonen S, Reginster JY, Rizzoli R, Akesson K. Post-fracture management of patients with hip fracture: a perspective. Current Medical Research and Opinion. 2008;24:2841–2851.PubMedCrossRefGoogle Scholar
  3. 3.
    Dartmouth Medical School, Weinstein JN. Birkmeyer JD, ed. Dartmouth Atlas of Musculoskeletal Health Care. Chicago, IL: AHA Press; 2000.Google Scholar
  4. 4.
    Escalante A, Barrett J, del Rincon I, Cornell JE, Phillips CB, Katz JN. Disparity in total hip replacement affecting Hispanic Medicare beneficiaries. Med Care. 2002;40:451–460.PubMedCrossRefGoogle Scholar
  5. 5.
    Fanuele JC, Lurie JD, Zhou W, Koval KJ, Weinstein JN. Variations in hip fracture treatment: are black and white patients treated equally? Am J Orthop. 2009;38:E13–E17.PubMedGoogle Scholar
  6. 6.
    Fisher ES, Staiger DO, Bynum JP, Gottlieb DJ. Creating accountable care organizations: the extended hospital medical staff. Health Aff (Millwood). 2007;26:w44–w57.CrossRefGoogle Scholar
  7. 7.
    Fisher ES, Wennberg JE, Stukel TA, Sharp SM. Hospital readmission rates for cohorts of Medicare beneficiaries in Boston and New Haven. N Engl J Med. 1994;331:989–995.PubMedCrossRefGoogle Scholar
  8. 8.
    Gittelsohn AM, Halpern J, Sanchez RL. Income, race, and surgery in Maryland. Am J Public Health. 1991;81:1435–1441.PubMedCrossRefGoogle Scholar
  9. 9.
    Hawker GA, Wright JG, Coyte PC, Williams JI, Harvey B, Glazier R, Wilkins A, Badley EM. Determining the need for hip and knee arthroplasty: the role of clinical severity and patients’ preferences. Med Care. 2001;39:206–216.PubMedCrossRefGoogle Scholar
  10. 10.
    Hawker GA, Wright JG, Glazier RH, Coyte PC, Harvey B, Williams JI, Badley EM. The effect of education and income on need and willingness to undergo total joint arthroplasty. Arthritis Rheum. 2002;46:3331–3339.PubMedCrossRefGoogle Scholar
  11. 11.
    Insitute of Medicine, ed. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.Google Scholar
  12. 12.
    Katz J. Preferences, disparities, and the authenticity of patient choices. J Rheumatology. 2003;30(S68):12–14.Google Scholar
  13. 13.
    Katz JN. Patient preferences and health disparities. JAMA. 2001;286:1506–1509.PubMedCrossRefGoogle Scholar
  14. 14.
    Koval KJ, Lurie J, Zhou W, Sparks MB, Cantu RV, Sporer SM, Weinstein J. Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma. 2005;19:635–639.PubMedCrossRefGoogle Scholar
  15. 15.
    Lurie J, Berven S, Gibson J, Tosteson TD, Tosteson ANA, Hu SS, Weinstein J. Patient preferences and expectations for care: determinants in patients with lumbar intervertebral disc herniation. Spine. 2008;33:2663–2668.PubMedCrossRefGoogle Scholar
  16. 16.
    Lurie J, Tosteson ANA, Zhou W, Weinstein J. Patterns of Vertebroplasty Use Among Medicare Beneficiaries. International Society for Study of the Lumbar Spine. Hong Kong, PRC; 2007.Google Scholar
  17. 17.
    Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine. 2003;28:616–620.PubMedCrossRefGoogle Scholar
  18. 18.
    Lüthje P, Nurmi-Lüthje I, Kaukonen JP, Kuurne S, Naboulsi H, Kataja M. Undertreatment of osteoporosis following hip fracture in the elderly. Arch Gerontol Geriatr. 2008 Aug 13. [Epub ahead of print].Google Scholar
  19. 19.
    Metje CJ, Leslie WD, Manness L-J, Yogandran M, Yuen CK, Kvern B. Postfracture care for older women: gaps between optimal care and actual care. Can Fam Physician. 2008;54:1270–1276.Google Scholar
  20. 20.
    Phelan EA, Deyo RA, Cherkin DC, Weinstein JN, Ciol MA, Kreuter W, Howe JF. Helping patients decide about back surgery: a randomized trial of an interactive video program. Spine. 2001;26:206–211;discussion 212.PubMedCrossRefGoogle Scholar
  21. 21.
    Rabenda V, Vanoverloop J, Fabri V, Mertens R, Sumkay F, Vannecke C, Deswaef A, Verpooten GA, Reginster JY. Low incidence of anti-osteoporosis treatment after hip fracture. J Bone Joint Surg Am. 2008;90:2142–2148.PubMedCrossRefGoogle Scholar
  22. 22.
    Shortell SM, Casalino LP. Health care reform requires accountable care systems. JAMA. 2008;300:95–97.PubMedCrossRefGoogle Scholar
  23. 23.
    Sirovich BE, Gottlieb DJ, Welch HG, Fisher ES. Regional variations in health care intensity and physician perceptions of quality of care. Ann Intern Med. 2006;144:641–649.PubMedGoogle Scholar
  24. 24.
    Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349:1350–1359.PubMedCrossRefGoogle Scholar
  25. 25.
    Weinstein JN, Bronner KK, Morgan TS, Wennberg JE. Trends and geographic variations in major surgery for degenerative diseases of the hip, knee, and spine. Health Aff (Millwood). 2004;Suppl Web Exclusives:VAR81-9.Google Scholar
  26. 26.
    Weinstein JN, Clay K, Morgan TS. Informed patient choice: patient-centered valuing of surgical risks and benefits. Health Aff (Millwood). 2007;26:726–730.CrossRefGoogle Scholar
  27. 27.
    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.PubMedGoogle Scholar
  28. 28.
    Wennberg JE, Fisher ES, Skinner JS. Geography and the debate over Medicare reform. Health Aff (Millwood). 2002;Suppl Web Exclusives:W96-114.Google Scholar
  29. 29.
    Wright JG, Hawker GA, Bombardier C, Croxford R, Dittus RS, Freund DA, Coyte PC. Physician enthusiasm as an explanation for area variation in the utilization of knee replacement surgery. Med Care. 1999;37:946–956.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2009

Authors and Affiliations

  1. 1.Dartmouth Medical School and The Dartmouth Institute for Health Policy and Clinical Practice (TDI)LebanonUSA

Personalised recommendations