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Treatment for Rotator Cuff Tear Is Influenced by Demographics and Characteristics of the Area Where Patients Live

Chapman, Cole G., PhDa,1; Floyd, Sarah Bauer, PhD1; Thigpen, Charles A., PhD, PT, ATC1,2; Tokish, John M., MD3; Chen, Brian, JD, PhD1; Brooks, John M., PhD1

doi: 10.2106/JBJS.OA.18.00005
Scientific Articles: PDF Only

Background: Atraumatic rotator cuff tear is a common orthopaedic complaint for people >60 years of age. Lack of evidence or consensus on appropriate treatment for this type of injury creates the potential for substantial discretion in treatment decisions. To our knowledge, no study has assessed the implications of this discretion on treatment patterns across the United States.

Methods: All Medicare beneficiaries in the United States with a new magnetic resonance imaging (MRI)-confirmed atraumatic rotator cuff tear were identified with use of 2010 to 2012 Medicare administrative data and were categorized according to initial treatment (surgery, physical therapy, or watchful waiting). Treatment was modeled as a function of the clinical and demographic characteristics of each patient. Variation in treatment rates across hospital referral regions and the presence of area treatment signatures, representing the extent that treatment rates varied across hospital referral regions after controlling for patient characteristics, were assessed. Correlations between measures of area treatment signatures and measures of physician access in hospital referral regions were examined.

Results: Among patients who were identified as having a new, symptomatic, MRI-confirmed atraumatic rotator cuff tear (n = 32,203), 19.8% were managed with initial surgery; 41.3%, with initial physical therapy; and 38.8%, with watchful waiting. Patients who were older, had more comorbidity, or were female, of non-white race, or dual-eligible for Medicaid were less likely to receive surgery (p < 0.0001). Black, dual-eligible females had 0.42-times (95% confidence interval [CI], 0.34 to 0.50) lower odds of surgery and 2.36-times (95% CI, 2.02 to 2.70) greater odds of watchful waiting. Covariate-adjusted odds of surgery varied dramatically across hospital referral regions; unadjusted surgery and physical therapy rates varied from 0% to 73% and from 6% to 74%, respectively. On average, patients in high-surgery areas were 62% more likely to receive surgery than the average patient with identical measured characteristics, and patients in low-surgery areas were half as likely to receive surgery than the average comparable patient. The supply of orthopaedic surgeons and the supply of physical therapists were associated with greater use of initial surgery and physical therapy, respectively.

Conclusions: Patient characteristics had a significant influence on treatment for atraumatic rotator cuff tear but did not explain the wide-ranging variation in treatment rates across areas. Local-area physician supply and specialty mix were correlated with treatment, independent of the patient’s measured characteristics.

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1Departments of Health Services Policy and Management (C.G.C., S.B.F., B.C., and J.M.B.) and Exercise Science (C.A.T.), Center for Effectiveness Research in Orthopaedics, University of South Carolina, Columbia, South Carolina

2ATI Physical Therapy, Greenville, South Carolina

3Orthopedic Sports Medicine, Mayo Clinic Arizona

E-mail address for C.G. Chapman:

Investigation performed at the Center for Effectiveness Research in Orthopaedics (CERortho), the University of South Carolina, Columbia, South Carolina

Disclosure: No external funds were received in support of this study. This study was funded, independent of results, by the Center for Effectiveness Research in Orthopaedics (CERortho), which is associated with the University of South Carolina. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (

© 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The Journal of Bone and Joint Surgery, Incorporated.