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Mapping the Diffusion of Technology in Orthopaedic Surgery: Understanding the Spread of Arthroscopic Rotator Cuff Repair in the United States

Austin, Daniel C. MD, MS; Torchia, Michael T. MD, MS; Lurie, Jonathan D. MD, MS; Jevsevar, David S. MD, MBA; Bell, John-Erik MD, MS

Clinical Orthopaedics and Related Research: November 2019 - Volume 477 - Issue 11 - p 2399-2410
doi: 10.1097/CORR.0000000000000860
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Background The mechanism by which surgical innovation is spread in orthopaedic surgery is not well studied. The recent widespread transition from open to arthroscopic rotator cuff repair techniques provides us with the opportunity to study the spread of new technology; doing so would be important because it is unclear how novel orthopaedic techniques disseminate across time and geography, and previous studies of innovation in healthcare may not apply to the orthopaedic community.

Questions/purposes (1) How much regional variation was associated with the adoption of arthroscopic rotator cuff repair in the United States Medicare population between 2006 and 2014 and how did this change over time? (2) In which regions of the United States was arthroscopic rotator cuff repair first adopted and how did it spread geographically? (3) Which regional factors were associated with the adoption of this new technology?

Methods We divided the United States into 306 hospital referral regions based upon referral patterns observed in the Centers for Medicare & Medicaid Services MedPAR database, which records all Medicare hospital admissions; this has been done in numerous previous studies using methodology introduced by the Dartmouth Atlas. The proportion of arthroscopic rotator cuff repairs versus open rotator cuff repairs in each hospital referral region was calculated using adjusted procedural rates from the Medicare Part B Carrier File from 2006 to 2014, as it provided a nationwide sample of patients, and was used as a measure of adoption. A population-weighted, multivariable linear regression analysis was used to identify regional characteristics independently associated with adoption.

Results There was substantial regional variation associated with the adoption of arthroscopy for rotator cuff repair as the percentage of rotator cuff repair completed arthroscopically in 2006 ranged widely among hospital referral regions with a high of 85.3% in Provo, UT, USA, and a low of 16.7% in Seattle, WA, USA (OR 30, 95% CI 17.6 to 52.2; p < 0.001). In 2006, regions in the top quartiles for Medicare spending (+9.1%; p = 0.008) independently had higher adoption rates than those in the bottom quartile, as did regions with a greater proportion of college-educated residents (+12.0%; p = 0.009). The Northwest region (-14.4%; p = 0.009) and the presence of an academic medical center (-5.8%; p = 0.026) independently had lower adoption than other regions and those without academic medical centers. In 2014, regions in the top quartiles for Medicare spending (+5.7%; p = 0.033) and regions with a greater proportion of college-educated residents (+9.4%; p = 0.005) independently had higher adoption rates than those in the bottom quartiles, while the Northwest (-9.6%; p = 0.009) and Midwest regions (-5.1%; p = 0.017) independently had lower adoption than other regions.

Conclusion The heterogeneous diffusion of arthroscopic rotator cuff repair across the United States highlights that Medicare beneficiaries across regions did not have equal access to these procedures and that these discrepancies continued to persist over time. A higher level of education and increased healthcare spending were both associated with greater adoption in a region and conversely suggest that regions with lower education and healthcare spending may pursue innovation more slowly. There was evidence that regions with academic medical centers adopted this technology more slowly and may highlight the role that private industry and physicians in nonacademic organizations play in surgical innovation. Future studies are needed to understand if this later adoption leads to inequalities in the quality and value of surgical care delivered to patients in these regions.

Level of Evidence Level III, therapeutic study.

D. C. Austin, M. T. Torchia, J. D. Lurie, D. S. Jevsevar, J.-E. Bell, Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA

J. D. Lurie, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA

J. D. Lurie, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA

D. C. Austin, Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA, Email: Daniel.C.Austin@hitchcock.org

The institution of one or more of the authors (DCA) has received, during the study period, funding from the National Institute of Health Grant 5T32AR049710-14.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Each author certifies that his institution waived approval for the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

This work was performed at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.

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Introduction

The diffusion of innovation is a well-studied concept across a variety of disciplines including economics, sociology, agriculture and healthcare and was first defined more than 50 years ago [6, 18, 41]. However, the diffusion of innovative orthopaedic surgical procedures has not been studied previously, and it remains unknown if there is substantial geographic variation in the adoption of orthopaedic technology in the United States. The relatively rapid rise of arthroscopic rotator cuff repair [15, 26, 51] provides a unique opportunity to study the dissemination of a novel surgical technique across time and geography in the field of orthopaedic surgery. Rotator cuff repair is one of the most frequently performed orthopaedic surgical procedures in the United States [21], and use of the procedure has increased substantially in the last two decades [15, 19, 26]. Rotator cuff repair was historically performed exclusively in an open fashion [14] until the development of arthroscopic techniques in the late 1980s [9]. Arthroscopic techniques were refined in the 1990s [10, 20, 22, 43, 44], and the perceived advantages of arthroscopic rotator cuff repair include its minimally invasive nature and improved visualization of the glenohumeral joint [2, 39, 50]. After the dispersal of arthroscopic tools and techniques [2, 34, 39, 50], the use of arthroscopic shoulder surgery expanded greatly [15, 26, 51]. At baseline, there is substantial geographic variation in the use of various orthopaedic procedures in the United States [5, 7, 28, 30, 42, 46], including rotator cuff repair [47], and it is likely that the adoption of arthroscopic rotator cuff repair also occurred heterogeneously across the United States.

Studying the diffusion of technology in orthopaedic surgery, by understanding where and how arthroscopic rotator cuff repair was adopted, can provide insight into what geographic regions innovate relatively earlier and can elucidate regional patterns and factors that are associated with innovation. For instance, it is unclear how the socioeconomic profile of the population or the healthcare intensity of a region are related to the adoption of new orthopaedic technology. Although a previous study indicated that newly trained surgeons practicing in the Northwest and Midwest complete fewer arthroscopic rotator cuff repairs compared with newly trained surgeons in the Northeast [33], a more granular analysis evaluating the adoption of arthroscopic rotator cuff repair across local areas has not been completed. Additionally, studies evaluating innovation in other surgical fields, such as results showing that robotic urologic procedures were adopted later in the Southern United States [35], may not translate to orthopaedics. Ultimately, studying the diffusion of new technology helps to understand the relative access that patients from different regions have to these innovations.

We sought to determine (1) How much regional variation was associated with the adoption of arthroscopic rotator cuff repair in the US Medicare population between 2006 and 2014 and how did this change over time? (2) In which regions of the United States was arthroscopic rotator cuff repair first adopted and how did it spread geographically? (3) Which regional factors were associated with the adoption of this new technology?

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Patients and Methods

Procedural Data

We queried the Medicare Part B File (Carrier File) from 2004 to 2014 to determine procedure counts. This source provided a 40% nationwide sample in 2004 and 2005, and a 100% nationwide sample from 2006 to 2014. We accessed the Medicare denominator file to determine the annual number of eligible beneficiaries. These databases were chosen for this study because of the ability of Medicare data to provide a truly nationwide sample that included residents from all regions of the United States. All patients with traditional Medicare were included in the study, although we excluded patients younger 65 years on Medicare because of disability or endstage renal disease. Procedures of interest were identified with the following Current Procedural Terminology (CPT) codes: open rotator cuff repair, acute: 23410; open rotator cuff repair, chronic: 23412; and arthroscopic rotator cuff repair: 29827. Arthroscopic rotator cuff repair received a unique CPT code in 2003, precluding earlier analysis. In 2006, 24,898 arthroscopic procedures were performed in 27,648,918 patients nationwide, and this number increased to 48,884 arthroscopic procedures in 27,767,493 patients in 2014.

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Geographic Data

Hospital referral regions within the United States were defined according to a well-described protocol developed by Wennberg et al. [17, 48]. The methods involved dividing the United States into 306 hospital referral regions centered around tertiary-care facilities based on referral patterns for cardiac and neurosurgical procedures from the 1992-1993 MedPAR database, which recorded all inpatient Medicare beneficiary admissions [17]. These hospital referral region boundaries defined in The Dartmouth Atlas of Health Care have been used in all subsequent studies based upon this methodology to maintain consistency [17]. Patients in this study were assigned to one of these predefined hospital referral regions based upon their home zip code. The characteristics of hospital referral regions were obtained from publicly available databases from The Dartmouth Atlas of Health Care [16, 17]. Within these data, demographic information including population density, education level, and mean income were extracted from 2010 US Census data. Physician densities were based on information from the American Medical Association Physician Masterfile. Total Medicare spending per capita, indirectly adjusted for price, age, sex, and race, was calculated from the Medicare 100% Claims File. When hospital referral region data were not available for the years of interest, we used data from the closest available year. Consequently, we used 2011 data for the density of total physicians, orthopaedic surgeons, and resident physicians. The presence of an academic medical center within a region was determined using the membership list of the Council of Teaching Hospitals from 2017 and was based on the street address of member hospitals [1]. Hospital referral region annual procedural rate data were available in less than 50% of regions in 2004 and 2005 because of the 40% nationwide sample, precluding hospital referral region level analyses during these years. Hospital referral region level data were available for 237 regions in 2006 and 291 regions in 2014.

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Outcomes

We calculated crude procedural rates for each hospital referral region by determining the number of eligible procedures per year and dividing this number by the mid-year Medicare population. These rates were then adjusted using the indirect method [17] for age, sex, and race, and adjusted values were used for all regression analyses. Rates based on fewer than 11 procedures per region were suppressed for patient confidentiality, while rates based on procedural counts of 12 to 26 were suppressed because of the lack of statistical precision. The primary outcome was the proportion of arthroscopic rotator cuff repairs versus open rotator cuff repairs within a given region, a measure of the degree to which the procedure was adopted. We determined this value by dividing the adjusted annual rate of arthroscopic repairs by the adjusted annual rate of total rotator cuff repairs in each region.

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Statistical Analysis

The degree of geographic variation in the adoption of arthroscopic rotator cuff repairs among hospital referral regions was quantified annually using extremal quotients (high/low), interquartile ranges, and coefficients of variation, similar to previous studies on variation [5, 7, 45]. We used ordinary least-squares linear regression models to perform population-weighted, multivariable analyses to evaluate independent associations between hospital referral region characteristics of interest and the proportion of arthroscopic repairs among regions in 2006 and 2014. In all analyses, a p value < 0.05 was considered significant, and all statistical testing was performed using STATA version 15.0 (Stata Corp LLC, College Station, TX, USA). The study did not use identifiable patient information and was thereby exempt from institutional review board approval.

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Results

How Much Regional Variation was Associated with the Adoption of Arthroscopic Rotator Cuff Repair in the United States Medicare Population Between 2006 and 2014 and How Did This Change Over Time?

There was substantial geographic variation in the adoption of arthroscopic rotator cuff repair, although this did decrease in subsequent years (Table 1). Between 2006 and 2014, the regions that adopted arthroscopic rotator cuff repair early continued to use it, while regions initially doing fewer arthroscopic increased their use of the technology over time, consistent with an overall decrease in variation as demonstrated by the turnip plots showing increasing consolidation over time between 2006 (Fig. 1A), 2008 (Fig. 1B), 2011 (Fig. 1C), and 2014 (Fig. 1D). There was 5.1-fold and 2.8-fold variations in adoption among regions in 2006 and 2014, respectively. Geographic variation in the proportion of arthroscopic repairs across regions, as measured by the coefficient of variation, decreased substantially from 28.3 to 17.2 between 2006 and 2014. Similarly, the interquartile ratio of the proportion of arthroscopic repairs by hospital referral region also decreased from 1.50 to 1.25 during this time period.

Table 1.

Table 1.

Fig. 1

Fig. 1

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In Which Regions of the United States Was Arthroscopic Rotator Cuff Repair First Adopted and How Did it Spread Geographically?

Adoption maps demonstrated generally higher adoption in the Northeast and Mountain West than in other regions in 2006 (Fig. 2A) and increasingly widespread adoption across the country in 2008 (Fig. 2B), 2011 (Fig. 2C), and 2014 (Fig. 2D). Based upon adjusted rates, the proportion of rotator cuff repairs performed arthroscopically in 2006 ranged widely among regions, with a high of 85% in Provo, UT, USA (133 of 155 rotator cuff repairs completed arthroscopically) and a low of 17% in Seattle, WA, USA (82 of 489 rotator cuff repairs completed arthroscopically, OR 30, 95% CI 17.6 to 52.2; p < 0.001, Table 1). In 2014, the percentage of repairs performed arthroscopically ranged from 35% in Chico, CA, USA (49 of 141 rotator cuff repairs completed arthroscopically) to 96% in Altoona, PA, USA (49 of 51 rotator cuff repairs completed arthroscopically, OR 46, 95% CI 11.1 to 399.4; p < 0.001).

Fig. 2

Fig. 2

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Which Regional Factors Were Associated With the Adoption of This New Technology?

After controlling for potentially confounding variables, including the density of orthopaedic surgeons and the population density of the region, we found that compared with the bottom quartiles, higher Medicare spending and higher proportions of college-educated patients were associated with greater adoption of arthroscopic rotator cuff repair in 2006, and the presence of an academic medical center and location in the Northwest region were associated with lower adoption (Table 2). Similarly, higher Medicare spending and higher proportions of college-educated patients were associated with greater adoption of arthroscopic rotator cuff repair in 2014, while location in the Northwest or Midwest were associated with lower adoption of arthroscopic rotator cuff repair (Table 3). The 2006 regression analysis demonstrated that compared with the bottom quartiles, regions with the highest quartile of total Medicare spending per beneficiary demonstrated higher rates of adoption (+9%; 95% CI 2 to 16; p = 0.008), and that the highest quartile of regions with college-educated residents had higher use of arthroscopic rotator cuff repair (+12%; 95% CI 3 to 21; p = 0.009, Table 2). Regions home to an academic medical center had lower adoption than regions without an academic institution (-6%; 95% CI -11 to -1; p = 0.026), and the Northwest region had lower adoption than the Northeast (-14%; 95% CI -25 to -4; p = 0.009). In 2014, compared with the bottom quartiles, regions with the highest quartile of total Medicare spending per beneficiary again demonstrated higher rates of adoption (+6%; 95% CI 0.4 to 11; p = 0.033), and the highest quartile of regions with college-educated residents also had higher use of arthroscopic rotator cuff repair (+9%; 95% CI 3 to 16; p = 0.005, Table 3). In 2014, the Northwest (-10%; 95% CI -17 to -2; p = 0.009) and Midwest regions (-5%; 95% CI -9 to -1; p = 0.017) had lower adoption of arthroscopic rotator cuff repair than the Northeast region. The density of orthopaedic surgeons, density of total physicians, and density of resident physicians was not independently associated with adoption in either 2006 or 2014. Additionally, population density, household income, and overall annual rotator cuff repair rates were not independently associated with adoption in either model. The adjusted r2 values for the regression models were 0.24 in 2006 and 0.22 in 2014.

Table 2.

Table 2.

Table 2.-a

Table 2.-a

Table 3.

Table 3.

Table 3.-a

Table 3.-a

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Discussion

Although the diffusion of innovation is a well-studied concept in health care [6, 18, 41], the dissemination of innovation in the field of orthopaedic surgery has not been evaluated previously and is valuable for understanding which regions are particularly innovative, and for identifying regional characteristics that may be associated with adoption. Furthermore, previous studies evaluating innovation in other surgical fields [35] may not apply to the field of orthopaedic surgery. There is substantial geographic variation in the use of orthopaedic procedures in the United States [5, 7, 28, 30, 42, 45, 46, 47], and it is likely that these trends can lead to geographic variations in the adoption of novel technology or procedures. Arthroscopic rotator cuff repair was introduced as a novel procedure nearly two decades ago, and grew rapidly in the United States [15, 26, 51], thereby providing a unique opportunity to investigate how this procedure spread across time and geography. Our results demonstrated that there was substantial geographic variation in the adoption of arthroscopic rotator cuff repair in the United States with nearly threefold variation in the use of arthroscopic techniques persisting in 2014. Regression modeling identified several regional characteristics that were independently associated with increased adoption, including higher Medicare spending and a more educated population, whereas location in the Northwest and Midwest regions and the presence of an academical medical center within a region were associated with lower adoption.

There are many limitations to this study, most significant of which was the use of procedural rates starting in 2006, a delay of 3 years after the introduction of a unique arthroscopic rotator cuff repair CPT code in 2003, and nearly a decade after arthroscopic techniques were well described in the literature [22, 43, 44]. Recognizing this delay is important as it frames the phase of diffusion that we were able to study. Diffusion science defines innovators or early adopters to be the first 16% of individuals to adopt innovation, while the next 34% are generally termed the early majority [6, 18]. In 2006, 50% of rotator cuff repair procedures were already being completed arthroscopically suggesting that we are unable to meaningfully evaluate the characteristics of regions that might be considered innovators or early adopters. Instead, our 2006 analysis is effective for evaluating the early majority phase of diffusion as the critical mass had been reached and widespread adoption had already begun to occur [6, 18]. In 2014, 72% of rotator cuff repair were being completed arthroscopically and the analysis from this time is more effective for understanding patterns related to the late majority or laggards [6, 18]. Altogether, this limitation makes it impossible for us to determine what regions or characteristics are associated with early adoption, but instead provides insight into how novel technology spreads throughout the orthopaedic community after it is a proven option. A second major limitation was the use of the Medicare population as our study cohort, since this group of patients is not necessarily where innovative procedures are introduced. The trends that we observed within this group of patients may not hold true for younger patients where innovative procedures may be offered or pursued more often. Another major limitation was our assumption that the adoption of arthroscopic rotator cuff repair represented a novel step forward that should be pursued, while studies including a recent high-quality randomized control trial [11], continue to suggest that long-term outcomes between open and arthroscopic rotator cuff repair are equivalent. It is possible that individual surgeons or institutions realized early on that arthroscopic repair did not provide superior outcomes and chose to stay with their proven open techniques.

An additional limitation was the use of hospital referral regions that varied in population, since they were defined according to referral patterns and could vary substantially across rural or urban areas. In regions with a relatively small population, the preferences of a single surgeon can affect the overall proportion of procedures being completed arthroscopically in a more significant manner than in areas with larger populations and many surgeons. This issue could help to explain why several relatively small hospital referral regions including Provo, UT, USA, or Altoona, PA, USA, ended up at the top of the adoption list. To adjust for these discrepancies, we completed population-weighted regression to better understand trends across regions. Another limitation was the use of administrative CPT code-based data that may include errors made at the time of billing. For example, there was evidence that a small number (< 1%) of rotator cuff repair procedures were coded as both open and arthroscopic within the Medicare database. Because of the methods used for extraction, we could not individually identify these procedures to remove them from the analysis; thus, they remained in the overall counts. However, this should not have affected our overall conclusions because the number of such occurrences was small. A statistical limitation was our inability to perform a Bonferroni correction to the p value cutoff considered to be significant, a technique that could have been applied since we evaluated several independent associations within our regression models. Our sample size was relatively small and limited by the number of regions within the United States, making it impossible to gain the power necessary to utilize a p value cutoff less than 0.05, as would be indicated by the Bonferroni correction. This issue raises the possibility of observing spurious statistically significant results simply by chance, making it necessary to consider the plausibility and reproducibility of the associations. Furthermore, we did not have information to model regional differences in disease severity or surgical conditions, which may influence the decision whether to pursue open or arthroscopic repair. Therefore, we assumed that these factors were similar between regions. We measured innovation by determining the proportion of procedures performed arthroscopically so that differences in underlying use among regions would not influence our overall conclusions. Similarly, we were unable to quantify the density of shoulder specialists by region, another factor that could have influenced the use of novel technology, because there is no single professional organization or designation to identify these surgeons. Another limitation was the use of the membership of the Council of Teaching Hospitals [1] as our marker of an academic medical center because some institutions that are not on this list likely consider themselves academically focused. However, we felt that this list effectively captured information on the largest and most influential educational institutions in the United States. Importantly, our results only apply to the adoption of arthroscopic rotator cuff repair and would likely be different if evaluating the diffusion of other procedures, such as hip arthroscopy, where different surgeons and/or regions might be found to be relatively earlier adopters.

We found substantial variation in the adoption of arthroscopic rotator cuff repair. With considerable geographic variation in orthopaedic surgical practice at baseline [5, 13, 29, 45], we expected substantial heterogeneity in the adoption of arthroscopic rotator cuff repair. Using data from 2007, Chung et al. [13] noted 10-fold variation in the use of open reduction and internal fixation for distal radius fractures, a technique considered new at the time. This is larger than the fivefold variation in the adoption of arthroscopic rotator cuff repair we observed and may be owing to differences in the nature of the innovations or timepoints along the innovation curve at which the data were collected. Chung et al. [13] suggested that the high degree of variation in the adoption of internal fixation was because of ambiguity in previous studies regarding the optimal treatment; this theory also applies to the adoption of arthroscopic rotator cuff repair because other studies continued to show equivalent outcomes between open and arthroscopic repair [3, 11, 27, 31, 37, 40, 49]. Altogether, the considerable geographic variation observed in the use of arthroscopic rotator cuff repair highlights that Medicare beneficiaries do not have equal access to this procedure across the United States.

We found strong evidence for a geographic pattern of adoption on a larger regional level as demonstrated by mapping and regression modeling. In 2006, there was higher adoption in the Northeast and Mountain West than in other regions, with widespread adoption nationally by 2014. Our study also demonstrated that specific regions—the Northwest and Midwest—had lower rates of adoption than did other regions. A previous study on surgeries performed by newly trained surgeons observed that there were more arthroscopic shoulder procedures in the Northeast, and more open procedures in the Northwest and Midwest [33], consistent with our results. Regional trends may be further reinforced if surgeons who train in a given area choose to stay there and ultimately practice in ways similar to their mentors. These trends in the spread of new technology do not necessarily cross surgical disciplines; a recent study in urology demonstrated that fewer robotic procedures, considered a recent innovation, were performed in the South than in other regions [35], an area noted in our study to adopt arthroscopic rotator cuff repair relatively early. The reason for this discrepancy is unclear, but it highlights that technology diffusion patterns may vary based on the cost of technology; a surgical robot is a much more expensive innovation than arthroscopic equipment.

We found that several independent factors were associated with earlier adoption of arthroscopic repair within a given hospital referral region including a more educated population. The characteristics of a community are an important component affecting technology diffusion [6, 18], and these results demonstrate a potential connection between this factor and the motivation for surgeons to innovate. Studies on arthroplasty have demonstrated that more educated patients are more likely to pursue joint arthroplasty than less educated patients [24, 25, 38], and our results suggest that education may also be associated with the desire for the most innovative surgical techniques. When considering the cost and benefits of innovation [6, 18], surgeons may find novel technology particularly advantageous in more educated markets. Increased Medicare expenditures were also associated with adoption, and higher regional spending may occur in areas that are more innovative, as technological innovation is a major contributor to health care costs [8]. It is important to consider that novel procedures are not always a step forward, as has been demonstrated by synthetic ACL grafts [4], thermal capsulorrhaphy [23], and metal-on-metal hip replacements [32], and the presence of checkpoints along the pathway of adoption is important. The observation that regions home to academic medical centers had lower adoption rates in 2006 is consistent with diffusion science principles, which suggest that thought-leaders wait to endorse novel technology until its effectiveness has been proven by early adopters [6, 18], and may suggest that academic institutions play a gatekeeper role in technology dissemination. In contrast to basic science innovations, which often originate in large academic centers and then spread outwards [36], orthopaedic surgical innovation may be more likely to be developed by private industry, as was the case with arthroscopic rotator cuff repair [9], and then spread back into academia. Alternatively, physicians in academic institutions may not have been influenced by the financial [12] and competitive advantages associated with arthroscopic repair, or may have appreciated the equivalence between open and arthroscopic repair [11], either of which could have led to lower adoption. Diffusion science has long recognized the impact of context on the diffusion of innovation, and these results help to frame regional factors that were associated with adoption of arthroscopic rotator cuff repair.

Although the use of arthroscopic rotator cuff repair grew rapidly over the last two decades, adoption of this procedure in the Medicare population occurred heterogeneously in the United States demonstrating that patients do not have equal access to innovative techniques across the country. While the Mountain West was noted to adopt relatively earlier than other areas, the Northwest and Midwest were associated with lower adoption of arthroscpic procedures, highlighting how larger regional trends in innovation are present. A more educated population was associated with innovation and highlights the connection between the context of a community and the motivation for surgeons to adopt novel techniques. Higher healthcare spending was also associated with adoption and illustrates the tension between controlling costs and encouraging innovation within a region. Future prospective studies that account for patient and surgeon characteristics, in addition to surgical indications, are necessary for understanding whether these trends in innovation are true across other orthopaedic procedures.

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Acknowledgments

We thank JoAnna Leyenaar MD, PhD for her assistance with statistical analysis and manuscript editing.

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