Date of Award
12-2024
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Department
Applied Health Research and Evaluation
Committee Chair/Advisor
Dr. Sarah Bauer Floyd
Committee Member
Dr. Sarah Griffin
Committee Member
Dr. Xia Jing
Committee Member
Dr. Lu Shi
Committee Member
Dr. John Brooks
Abstract
Proximal humerus fractures (PHF) are a common injury affecting older adults, though clinical decision making for these fractures remains challenging for physicians. Over the past two decades, clinical decision making has evolved with the emergence of new evidence like the ProFHER trial and the dissemination of reverse total shoulder arthroplasty (RTSA). There is a need to characterize the effects of these changes across geographic areas and evaluate the impact of differences in surgical procedure utilization rates on patient outcomes. Therefore, the goal of this dissertation was to gain a better understanding of the utilization patterns and outcomes associated with different surgical procedure options for PHF. We utilize 100% nationwide Medicare fee-for-service (FFS) administrative claims data, allowing us to obtain a comprehensive understanding of how treatment utilization patterns have evolved across all geographic areas.
We first focused on the decision of operative or non-operative management. We found that early surgery utilization for PHF varied widely across local practice areas in 2011 and 2017, with hospital referral region (HRR) risk-adjusted surgery rates ranging from 2.1% to 32.5% and 1.6% to 28.8%, respectively. However, HRRs maintained relatively consistent surgery utilization patterns across time, providing evidence for the concept of surgical signatures. These results are even more surprising given the changes in clinical decision making for PHF during this time period. The relative stability of these practice patterns implies that the treatment a patient receives is partially dependent on where they live.
Examining the use of different surgical procedures, we found that RTSA dissemination from 2011 to 2017 varied widely across local practice areas. This variation was unattributable to differences in measured local area characteristics such as medical device manufacturer payments and orthopaedic physician supply. However, higher RTSA use in 2011 was significantly associated with higher RTSA use in 2017, consistent with the concept of surgical signatures. These findings suggest that areas with higher RTSA use in 2011 continued to use RTSA at higher rates in 2017, though persistent inequities in access to RTSA may exist that are attributable to factors difficult to measure at the population level.
Using instrumental variables (IV) analysis, we found that for patients whose treatment choice is influenced by their local area practice style, higher RTSA use rates were significantly associated with higher treatment benefit rates and lower major shoulder complication rates. Collectively, the results of this dissertation provide evidence of treatment signatures in a proclivity for both surgical treatment and surgical procedure choice. Further, in terms of clinical outcomes, our results suggest that greater diffusion of RTSA use may improve patient outcomes. These findings serve as a first step in investigating the potential value of expanding RTSA use and, ultimately, addressing strategies to mitigate disparities in access to effective care for PHF patients.
Recommended Citation
Lindros, Sydney, "Characterizing Treatment Patterns and Associated Outcomes for Medicare Beneficiaries with Proximal Humerus Fractures" (2024). All Dissertations. 3812.
https://open.clemson.edu/all_dissertations/3812
Author ORCID Identifier
0000-0001-6744-2821