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The Impact of Comparative Effectiveness Research in the Surgical Treatment of Thumb Basilar Joint Arthritis
Oluseyi Aliu, MD, Matthew M. Davis, MD, MAPP, Kevin C. Chung, MD, MS.
University of Michigan, Ann Arbor, MI, USA.

PURPOSE:
The national healthcare reform law contains initiatives to facilitate the use of evidence to influence clinical practice and reimbursement policies. One source for this evidence is scientific studies that compare the effectiveness of alternative treatments for common diagnoses. Basilar joint arthritis is significant to the national healthcare system because it affects approximately 20% of people older than 50 years who are the fastest growing demographic group. Moreover, multiple comparative studies on the surgical treatment of basilar joint arthritis suggest that simple trapeziectomy has equivalent outcomes and possibly fewer complications in comparison to trapeziectomy with ligament reconstruction and tendon interposition (LRTI). Hence, we used population level data to examine if clinical practice reflects evidence from these comparative studies. We hypothesized that factors such as third-party payer policies rather than scientific evidence significantly influence surgical treatment choice.
METHODS: We performed a 4-year (2006-2009) cross-sectional study of 6,776 patients who underwent surgical treatment for basilar joint arthritis using the Healthcare Cost and Utilization Project outpatient surgery database for Florida (a state with high proportion of patients > 50 years). This database captures 100% of ambulatory surgeries performed in the state. We used multinomial regression for statistical analyses. We evaluated associations between the procedure used to treat each patient and predictor variables including the third-party payer and the number of techniques a patient’s surgeon uses in their practice. We controlled for demographic, clinical, and surgeon practice related factors. Finally, we calculated adjusted probabilities of undergoing different procedures based on surgeon and payer characteristics.
RESULTS: Of 6,776 patients with basilar joint arthritis, 92% underwent trapeziectomy with LRTI and 4% underwent simple trapeziectomy. The probability of an average patient in the study undergoing simple trapeziectomy was 1.9% and the probability was 96.6% for treatment with trapeziectomy with LRTI. However, patients treated by surgeons who use > 1 technique in their practice had a higher probability of treatment with simple trapeziectomy (3.2%-16.0%; figure 1). Furthermore, a patient’s health plan type (managed vs. fee-for-service) was associated with treatment choice. Patients in private fee-for-service plans were significantly more at risk for treatment with simple trapeziectomy (RRR=1.8; 95% CI 1.2-2.6) with a higher overall probability than the average patient (figure 2).
CONCLUSION: Simple trapeziectomy is not widely used for the treatment of basilar joint arthritis despite evidence from multiple comparative studies that its outcomes are equivalent to trapeziectomy with LRTI. Our findings show that third-party payers may take the initiative to influence clinical practice when providers lag in applying published evidence. These findings highlight the need to investigate specific barriers to reliably incorporating scientific evidence into surgeons’ practices. Furthermore, researchers must investigate effective ways to disseminate findings from sound comparative studies to surgeons on the frontlines of patient care.


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