Healthcare Policy and Arthroscopic Rotator Cuff Repair Prices in the United States.

BACKGROUND: Arthroscopic rotator cuff repair (ARCR) is one of the most common orthopedic procedures in the general population. Despite its prevalence, the price of ARCR varies significantly across regions, hospital models, and settings. The purpose of this study was to examine the effect of Geographic Region, Certificate of Need (CON) laws, and Medicaid expansion on ARCR pricing. METHODS: This cross-sectional observational study utilized hospital payer-specific ARCR prices from the Turquoise Health Database using CPT code 29827. These prices are negotiated rates or charges that hospitals establish with various payers, including insurance companies, Medicare, Medicaid, and self-pay patients, for medical services and treatments provided. Outliers below the 10th percentile and above the 90th percentile were excluded. State policies, including CON status and Medicaid expansion, were obtained from public sources, while additional socioeconomic and demographic data were sourced from the US Census. The state's region classification was determined based on one of four Geographic Regions defined by the US Census Bureau. A detailed analysis was also conducted for North Carolina, examining county-level data on urbanization and the Area Deprivation Index (ADI). RESULTS: There were 57,270 ARCR prices from 2,503 hospitals across the United States, with a median interquartile range (IQR) listed price of $6,428.17 (IQR: $2,886.88). States with CON regulations had significantly lower ARCR prices compared to those without ($6,500 vs. $8,000, p<0.0001). Multivariable analysis indicated that hospitals in the Northeast and West Regions listed significantly higher prices for ARCR compared to those in the Midwest Region (p<0.0001). In contrast, hospitals in the South Region listed lower prices for ARCR compared to those in the Midwest Region (p<0.0001). Medicaid expansion was associated with increased ARCR prices (p<0.0001), while CON laws were linked to reduced prices (p< .0001). In North Carolina, ADI and urbanization status did not significantly affect ARCR prices. CONCLUSION: The prices listed for ARCR varied significantly depending on the Geographic Region where hospitals were located. Additionally, CON laws were associated with reduced ARCR prices, while Medicaid expansion correlated with increased prices. These findings highlight the complex interplay between healthcare policy, regulatory frameworks, and socioeconomic factors in determining surgical prices.

Similar outcomes between biceps tenodesis and SLAP repair for SLAP tears in younger patients - A meta-analysis.

OBJECTIVES: The purpose of this study is to systematically review the comparative studies in the literature to ascertain if biceps tenodesis or superior-labrum anterior to posterior (SLAP) repair results in superior clinical outcomes in the treatment of type II SLAP tears in patients under 40. METHODS: A systematic search of articles in Pubmed, EMBASE and The Cochrane Library databases was carried out according to the PRISMA guidelines. Cohort studies comparing biceps tenodesis to repair in type II SLAP tears in patients under 40 were included. Clinical outcomes were extracted including return to play, reoperations, ASES, and VAS for pain. All statistical analysis was performed using Review Manager. A p-value of <0.05 was considered to be statistically significant. RESULTS: Five studies were included. Biceps tenodesis resulted in comparable rates of return to play compared to SLAP repair (78.5% vs 67.7%, p â€‹= â€‹0.33), and there was no significant difference in return to play in overhead athletes (83.6% vs 74%, p â€‹= â€‹0.82). There was no significant difference in ASES score (87.2 vs 86.2, p â€‹= â€‹0.27) or VAS score for pain (1.8 vs 2.1, p â€‹= â€‹0.48). There was no significant difference in re-operation rates (2.9% vs 10.8%, p â€‹= â€‹0.22). CONCLUSION: This study found that biceps tenodesis has no significant difference in rates of return to play in athletes, as well as in functional outcome scores and rates of revision surgery in younger patients compared to SLAP repair. LEVEL OF EVIDENCE: Level III, Systematic review of Level III studies.

Histologic Differences in Human Rotator Cuff Muscle Based on Tear Characteristics.

BACKGROUND: Fatty accumulation in the rotator cuff is associated with shoulder dysfunction and a risk of failure of rotator cuff repair. The aims of this study were to (1) describe cellular findings in rotator cuff muscles in patients presenting with varying degrees of rotator cuff tendon pathology by examining fat content and myofiber cross-sectional area of rotator cuff muscles and (2) correlate histologic features to magnetic resonance imaging (MRI) grades derived with the Goutallier classification. METHODS: Rotator cuff muscle biopsies were performed in a consecutive series of patients undergoing arthroscopic shoulder surgery. Rotator cuffs were graded according to the Goutallier classification and labeled as either partial-thickness or full-thickness. Patients without a rotator cuff tear undergoing arthroscopic surgery served as controls. The biopsy specimens were examined using LipidTOX to visualize lipid accumulation. Laminin was used to quantify myofiber cross-sectional area. RESULTS: Twenty-seven patients with a rotator cuff tear and 12 without a tear (controls) were included. There were 24 males (62%). The mean age was 55 years. Patients in the control cohort were younger (mean, 46 years) than those in the treatment group (mean, 60 years, p < 0.01). Within the treatment group, 12 and 15 patients were recorded as having partial and full-thickness rotator cuff tears, respectively. Lipid accumulation visualized at the cellular level was fairly-to-moderately correlated with the Goutallier classification on MRI (R s = 0.705, 95% confidence interval [CI] = 0.513, 0.829). Muscle biopsy specimens with a Goutallier grade of 2+ had significantly more lipid accumulation than those with grade-0 (p < 0.01) or grade-1 (p < 0.01) fatty accumulation. Muscle biopsies at the sites of full-thickness tears showed significantly greater lipid accumulation than those associated with either partial (p < 0.01) or no (p < 0.01) tears. Partial-thickness rotator cuff tears had no difference in lipid accumulation in comparison to the control group. Muscle biopsy specimens from full-thickness tears had significantly smaller myofiber cross-sectional area when compared with partial-thickness tears (p = 0.02) and controls (p < 0.01). CONCLUSIONS: Cellular lipid accumulation correlates with the MRI Goutallier grade of fatty accumulation, thus verifying the Goutallier classification at the cellular level. Muscle biopsy specimens from partial-thickness tears are more similar to controls than to those from full-thickness tears, whereas full-thickness tears of all sizes showed significantly greater lipid content and smaller myofiber cross-sectional area compared with partial-thickness tears and controls. CLINICAL RELEVANCE: Our research confirms the utility of using the Goutallier classification to predict rotator cuff muscle quality and shows that tendon attachment, even if partially torn, protects the muscle from fatty accumulation.

Heterogeneity of pain-related psychological distress in patients seeking care for shoulder pathology.

BACKGROUND: Psychological distress is associated with disability and quality of life for patients with shoulder pain. However, uncertainty around heterogeneity of psychological distress has limited the adoption of shoulder care models that address psychological characteristics. In a cohort of patients with shoulder pain, our study sought to (1) describe the prevalence of various subtypes of psychological distress; (2) evaluate associations between psychological distress and self-reported shoulder pain, disability, and function; and (3) determine differences in psychological distress profiles between patients receiving nonoperative vs. operative treatment. METHODS: The sample included 277 patients who were evaluated in clinic by a shoulder surgeon and completed the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Assessment Tool (OSPRO-YF) from 2019 to 2021. This tool categorizes maladaptive and adaptive psychological traits, and the number of yellow flags (YFs) ranges from 0 to 11, with higher YF counts indicating higher pain-related psychological distress. Operative and nonoperative cohorts were compared using χ2 test and Student t test. Linear regression was used to evaluate the association between pain, disability, and YFs, whereas Poisson regression evaluated the association between operative treatment and psychological distress. K-means cluster analysis was performed to propose potential psychological distress phenotypes. RESULTS: Two hundred fifty-one patients (91%) had at least 1 YF on the OSPRO-YF tool, with a mean number of 6 ± 3.5 YFs. YFs in unhelpful coping (85%) and helpful coping domains (78%) were most prevalent. The number of YFs was significantly associated with baseline shoulder pain (P < .001), Single Assessment Numeric Evaluation (P < .001), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) scores. Comparing operative and nonoperative cohorts, the operative cohort had a significantly higher mean number of YFs (6.5 vs. 5.6, P = .035), presence of any YF (94.3% vs. 85.7%, P = .015), and presence of YFs within the unhelpful coping domain (91.8% vs. 75.6%, P < .001). Three phenotypes were described, corresponding to low, moderate, and severe psychological distress (P < .001), with females (P = .037) and smokers (P = .018) associated with higher psychological distress phenotypes. CONCLUSIONS: YFs, particularly within the unhelpful coping and helpful coping domains, were highly prevalent in a cohort of patients presenting to a shoulder surgeon's clinic. Additionally, operative patients were found to have a significantly higher rate of YFs across multiple dimensions of psychological distress. These findings stress the importance of routine attentiveness to multiple dimensions of pain-related psychological distress in shoulder populations, which can provide an opportunity to reinforce healthy interpretation of pain while minimizing distress in appropriately identified patients.

The Association between Stress Measured by Allostatic Load Score and Physiologic Dysregulation in African Immigrants: The Africans in America Study.

INTRODUCTION: Allostatic load score (ALS) summarizes the physiological effect of stress on cardiovascular, metabolic and immune systems. As immigration is stressful, ALS could be affected. OBJECTIVE: Associations between age of immigration, reason for immigration, and unhealthy assimilation behavior and ALS were determined in 238 African immigrants to the United States (age 40 ± 10, mean ± SD, range 21-64 years). METHODS: ALS was calculated using 10 variables from three domains; cardiovascular (SBP, DBP, cholesterol, triglyceride, homocysteine), metabolic [BMI, A1C, albumin, estimated glomerular filtration rate (eGFR)], and immunological [high-sensitivity C-reactive protein (hsCRP)]. Variables were divided into sex-specific quartiles with high-risk defined by the highest quartile for each variable except for albumin and eGFR, which used the lowest quartile. One point was assigned if the variable was in the high-risk range and 0 if not. Unhealthy assimilation behavior was defined by a higher prevalence of smoking, alcohol consumption, or sedentary activity in immigrants who lived in the US for ≥10 years compare to <10 years. RESULTS: Sixteen percent of the immigrants arrived in the US as children (age < 18 years); 84% arrived as adults (age ≥ 18 years). Compared to adulthood immigrants, childhood immigrants were younger (30 ± 7 vs. 42 ± 9, P < 0.01) but had lived in the US longer (20 ± 8 vs. 12 ± 9 years, P < 0.01). Age-adjusted ALS was similar in childhood and adulthood immigrants (2.78 ± 1.83 vs. 2.73 ± 1.69, P = 0.87). For adulthood immigrants, multiple regression analysis (adj R2 = 0.20) revealed older age at immigration and more years in the US were associated with higher ALS (both P < 0.05); whereas, current age, education, income, and gender had no significant influence (all P ≥ 0.4). The prevalence of smoking, alcohol intake, and physical activity did not differ in adulthood immigrants living in the US for ≥10 years vs. <10 years (all P ≥ 0.2). Reason for immigration was available for 77 participants. The reasons included: family reunification, lottery, marriage, work, education, and asylum. Compared to all other reasons combined, immigration for family reunification was associated with the lowest ALS (1.94 ± 1.51 vs. 3.03 ± 1.86, P = 0.03). CONCLUSION: African immigrants do not appear to respond to the stress of immigration by developing unhealthy assimilation behaviors. However, older age at immigration and increased duration of stay in the US are associated with higher ALS; whereas, family reunification is associated with lower ALS. CLINICAL TRIALSGOV IDENTIFIER: NCT00001853.