Medical services and associated costs vary widely among surgeons treating patients with hand osteoarthritis.

BACKGROUND: There are substantial variations in medical services that are difficult to explain based on differences in pathophysiology alone. The scale of variation and the number of people affected suggest substantial potential to lower healthcare costs with the reduction of practice variation. Our study assessed practice variation across three affiliated urban sites in one city in the United States and related healthcare costs following the diagnosis of hand osteoarthritis (OA) in patients. QUESTIONS/PURPOSES: (1) What are the factors associated with increased costs and surgery in the first year after diagnosis of hand OA? (2) How much practice variation exists among hand surgeons in terms of the number of patient visits, use of imaging tests, use of injections, occupational therapy use, and surgery? (3) What proportion of total cost is accounted for by patients who consult with an additional provider? METHODS: Patients receiving a new diagnosis of primary hand OA between January 1, 2007, and December 31, 2011, were identified from the research database of three affiliated urban hospitals in a single city in the United States. We included 2814 patients (69%, 1929 women) treated by six hand surgeons. We recorded all visits, imaging tests, injections, occupational therapy visits, and surgical procedures in the first year after that diagnosis. Costs were extracted from the Medicare Physician Fee Schedule. Reliability of the database was assessed by manual checking of 120 patient charts (4.3% of all data); reliability was determined to be 94% (113 of 120) for diagnoses, 97% (116 of 120) correct surgeon, 100% (120 of 120) second surgeon, 99% (278 of 282) visits, 99% (132 of 134) imaging procedures, 92% (11 of 12) injections, 95% (21 of 22) surgical procedures, and 85% (102 of 120) prescribing occupational therapy. RESULTS: Predictors of increased costs included younger patient age (regression coefficient [ß] -3.5, semipartial R(2) 0.0049, 95% confidence interval [CI] -5.4 to -1.7, p < 0.001), seeing a second surgeon (ß 283, semipartial R(2) 0.0095, 95% CI 176-391, p < 0.001), and specific surgeons (surgeon 1: ß -243, semipartial R(2) 0.026, 95% CI -298 to -188, p < 0.001; surgeon 2: ß -177, semipartial R(2) 0.0090, 95% CI -246 to -109, p < 0.001; surgeon 6: ß 124, semipartial R(2) 0.0050, 95% CI 59-189, p < 0.001) (adjusted R(2) = 0.056). Similarly, factors associated with increased surgical intervention included younger patient age (ß -0.0026, semipartial R(2) 0.0071, 95% CI -0.0037 to -0.0015, p < 0.001), male sex (ß 0.041, semipartial R(2) 0.0028, 95% CI -0.069 to -0.012, p = 0.005), seeing a second surgeon (ß 0.16, semipartial R(2) 0.0091, 95% CI 0.094-0.22, p < 0.001), and specific surgeons (surgeon 1: ß -0.14, semipartial R(2) 0.026, 95% CI -0.18 to -0.11, p < 0.001; surgeon 2: ß -0.13, semipartial R(2) 0.014, 95% CI -0.17 to -0.091, p < 0.001). There were large variations in the average number of visits (1.5-fold), imaging tests (threefold), use of injections (51-fold), occupational therapy (twofold), and surgery rates (sevenfold) among providers. One hundred twenty patients (4.3%) consulted a second surgeon within the first year after receiving the diagnosis of hand OA, which accounted for 8.1% (USD 68,826/USD 845,304) of the total costs. CONCLUSIONS: Patients who saw additional providers and who were of younger age incurred higher costs and a greater likelihood of undergoing surgery; the latter was also greater in male patients. Use of medical services and associated costs vary widely among providers treating patients with hand OA. Initiatives addressing practice variation-increased use of decision aids, for example-merit additional study. LEVEL OF EVIDENCE: Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Time from Booking Until Appointment and Healthcare Utilization in Hand Surgery Patients with Discretionary Conditions.

Delaying treatment for benign musculoskeletal conditions may allow patients to learn self-efficacy and develop coping strategies, leading to less medical intervention and reduced cost. We tested the hypothesis that time from booking until appointment is not associated with healthcare costs. We further tested the secondary hypothesis that time from booking to appointment is not associated with specific healthcare utilizations. We identified 16,750 patients (55 % women; mean age 50 years) making first clinic visits to hand surgeons at our hospital between January 1, 2003 and December 31, 2012. Booking time was defined as the time between the scheduling of an appointment and the actual visit. Imaging procedures, injections, nerve conduction studies, occupational therapy visits, surgery, and referrals were determined up until the patient's second visit with the surgeon, or 90 days. Costs were determined in Relative Value Units. Duration between booking and office visit was not associated with higher cost (regression coefficient [ß] 0.0023, P = 0.77). Duration between booking and office visit was associated with a higher rate of nerve conduction studies (odds ratio [OR] 1.02, P < 0.001) and a lower rate of occupational therapy (OR 0.98, P < 0.001). There was substantial variation between surgeons. Greater wait time was not therapeutic, but is associated with different diagnostic and treatment measures that suggest people that are willing to wait have different types of problems. The variation by surgeon may make variation based on other factors, including time between booking and appointment, difficult to discern.