When it comes to access to many things people look for, big cities offer numerous advantages over small towns. This seems to be true for consumer goods and services—and for access to health care, especially “high-tech” procedures. That is one issue that Suchman et al. touch on in their retrospective database study in the September 19, 2018 issue of The Journal.
The study evaluated almost 650,000 patients who underwent one of three meniscal procedures (meniscectomy, meniscal repair, or meniscal allograft transplantation) in New York State from 2003 to 2015. In determining which procedures were performed where, the authors found that meniscectomies and meniscal repairs—the vast majority of the procedures performed—were scattered throughout the state, but that meniscal transplants were performed almost exclusively at urban, academic hospitals. This finding is not surprising, considering the technical complexity of allograft transplantation. However, if a patient who would benefit from a meniscal allograft lived three hours from an urban, academic setting, they would either have to travel to the city to be evaluated, treated, and followed, or settle for a different procedure from a surgeon closer to home. Neither option would be optimal in terms of quality care.
At the same time, this article emphasizes that not every patient needs to go to a large hospital to receive excellent care. While a preponderance of recent data shows an association between hospital and surgeon procedure volume and patient outcomes, those data do not mean that smaller hospitals or “medium volume” surgeons should not perform certain procedures. In fact, medium volume surgeons performed the largest proportion of meniscal procedures evaluated in this study.
The fact is that the “delivery” of health care does not happen via FedEx or UPS. The burden falls on patients to transport themselves to the physician, not vice versa. And until that model drastically changes, access disparities based on geography will likely remain.
However, Suchman et al. also found that the majority of patients who underwent any meniscal procedure had private insurance—and that Medicaid patients had the lowest rates of meniscal surgery. Although disparities arising from socioeconomic/insurance status are also very difficult to address, they would seem to be more remediable than disparities related to geography.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the April 15, 2015 Specialty Update on sports medicine:
–A systematic review of Level-I and II studies suggests that the structural integrity of rotator cuff repairs (or lack thereof) does not correlate with validated patient subjective outcome measures.
–Authors of a randomized clinical trial comparing open and arthroscopic stabilization for recurrent anterior shoulder instability concluded that young male patients with visible Hill-Sachs lesions on radiographs may fare better with open repairs.
–A quantitative literature synthesis of 31 studies (2,813 shoulders) supported primary surgery for highly active young adults who sustain an anterior shoulder dislocation.
–Following rotator cuff surgery, patients randomized to receive a combined axillary and suprascapular nerve block experienced less pain and a lower frequency of rebound pain in the first 36 hours than those receiving only a suprascapular nerve block.
–A Level-II meta-analysis of early passive motion versus strict sling immobilization after arthroscopic rotator cuff repair found that early passive motion resulted in improved forward flexion at 6 and 12 months, with no apparent increased retear rate.
–A randomized trial comparing single- and double-bundle ACL reconstruction with the use of hamstring autograft found no differences in pivot shift or clinical scores at two years.
–Twenty patients with subacute ACL injuries were randomized to “prehabilitation” or control groups. At 12 weeks after surgery, the prehab group showed sustained improvements in single-leg hop and Cincinnati scores, but peak torque and muscle-mass gains had regressed to levels similar to those in the control group.
–A randomized study comparing contralateral versus ipsilateral hamstring tendon harvest for ACL repair identified neither drawbacks nor advantages with the contralateral approach.
–Sixty patients who’d received an isolated meniscal repair were randomized to get either a traditional rehab protocol (brace and toe-touch weigh bearing) or “free rehabilitation.” Based on MRI, partial healing or lack of healing occurred in 28% of the free rehabilitation group and in 36% of the traditional group.
–Authors of a systematic review concluded that nonirradiated allogenic tissue may be superior to radiated allografts for primary ACL reconstruction.
–A randomized controlled trail comparing microfracture alone to microfracture plus application of a novel chitosan-based device demonstrated greater lesion filling and superior repair tissue with the novel device, although there were no differences in clinical benefit and safety at 12 months.
–A randomized controlled trial comparing accelerated with conventional rehabilitation following cartilage repair found that the accelerated group reached full weight-bearing two weeks earlier than the conventional group and reported higher quality-of-life scores.
–In a Level-II study of a population with acute hamstring injuries, those who received a single autologous platelet-rich plasma injection plus rehab had significantly reduced return-to-play time than a group that received rehab without the injection.
–A randomized study of 230 patients with chronic lateral epicondylitis found that those receiving leukocyte-enriched platelet-rich plasma had “clinically meaningful improvement” in pain at 24 weeks, compared to those in an “active control” group.
Foot & Ankle
–A randomized study of 84 patients with nonsurgically treated Achilles tendon tears showed no significant differences in rerupture rates or return-to-work times between a group given a weight-bearing cast and a group given a non-weight-bearing cast.
–A randomized trial of 200 patients with Achilles ruptures compared stable surgical repair and accelerated rehabilitation to nonoperative management. Surgical repair was not found to be superior to nonoperative treatment in terms of functional results, physical activity, or quality of life.