Location, Location, Location: Geographic Disparities in Orthopaedic Care?
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
Let Unstable Chondral Lesions Be During Partial Meniscectomy
More than 900,000 patients every year undergo knee arthroscopy in the US. Many of those procedures involve a partial meniscectomy to address symptomatic meniscal tears. Surgeons “scoping” knees under these circumstances often encounter a chondral lesion—and most proceed to debride it.
However, in the July 5, 2017 issue of JBJS, Bisson et al. report on a randomized controlled trial that suggests there is no benefit to arthroscopic debridement of most unstable chondral lesions when they are encountered during partial meniscectomy. With about 100 patients ≥30 years old in each group, the authors found no significant differences in function and pain outcomes between the debridement and observation groups at the 1-year follow-up. In fact, relative to the debridement group, the observation group had more improvement in WOMAC and KOOS pain scores at 6 weeks, better SF-36 physical function scores at 3 months, and increased quadriceps circumference at 6 months.
The authors conclude that these findings “challenge the current standards” of typically debriding chondral lesions in the setting of arthroscopic partial meniscectomy. They also surmise that, in conjunction with declining Medicare reimbursements for meniscectomies with chondral debridement, these results “may lead to a reduction in the rate of arthroscopic debridement.”
Updated Knee Content from JBJS
The recently launched JBJS Knee Spotlight offers highly relevant and potentially practice-changing knee content from the most trusted source of orthopaedic information.
Here are the five JBJS articles to which you will have full-text access through the Knee Spotlight during the month of December 2016:
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Adult Human Mesenchymal Stem Cells Delivered via Intra-Articular Injection to the Knee Following Partial Medial Meniscectomy
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Computer Navigation for Total Knee Arthroplasty Reduces Revision Rate for Patients Less Than Sixty-five Years of Age
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Comparison of Closing-Wedge and Opening-Wedge High Tibial Osteotomy for Medial Compartment Osteoarthritis of the Knee
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Weight-Bearing Compared with Non-Weight-Bearing Following Osteochondral Autograft Transfer for Small Defects in Weight-Bearing Areas in the Femoral Articular Cartilage of the Knee
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Early Patient Outcomes After Primary Total Knee Arthroplasty with Quadriceps-Sparing Subvastus and Medial Parapatellar Techniques
Knee studies offered on the JBJS Knee Spotlight will be updated monthly, so check the site often.
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