Abstract
Objectives:
Hip arthroscopy (HA) utilization has significantly increased over the past 20 years, yet the majority of early-career orthopaedic surgeons have little experience performing HA. This shortfall in HA training may create disparities in access to care, especially as the demand for HA from patients continues to rise. Consequently, the authors hypothesized that patients may be more inclined to seek treatment from out-of-network (OON) surgeons. The primary goals of this analysis were to (1) investigate whether patients who undergo HA are more likely to utilize OON surgeons than those undergoing more common orthopaedics sports procedures, including rotator cuff repair (RCR), partial meniscectomy (PM), and anterior cruciate ligament reconstruction (ACLR), (2) compare the HA OON surgeon rate with another less commonly performed procedure, meniscus allograft transplant (MAT), and (3) analyze trends and predictors of utilization of OON surgeons for all procedures overall and HA specifically.
Methods:
The 2013-2017 IBM MarketScan Commercial Claims and Encounters database was used to identify patients under 65 years of age who underwent HA, RCR, PM, ACLR, or MAT; procedure-specific cohorts with OON surgeon status were defined. Demographic differences between cohorts were determined using standardized differences. Cochran-Armitage analysis was used to analyze trends in OON surgeon utilization over the study period, broken down by procedure type. Multivariable logistic regression identified predictors of OON surgeon utilization for all procedures combined and HA specifically. Statistically significant p-values were less than 0.05 and significant standardized differences were more than 0.1.
Results:
410,184 patients were identified in total, of which 12,636 underwent HA, 87,607 RCR, 233,241 PM, and 76,700 ACLR. Due to small sample size (n=303), results for MAT were not reported but were controlled for in analysis. An increasing trend in OON surgeon utilization was observed specifically for HA, with rates rising from 7.98% in 2013 to 9.37% in 2017 (p=0.026). Compared to RCR, PM, and ACLR, HA was independently associated with higher odds of OON surgeon utilization. Usage of ambulatory surgery centers (ASCs) was strongly predictive of higher OON surgeon rates for orthopedic procedures overall. Procedure year of 2015, preferred provider organization and exclusive provider organization (PPO/EPO) insurance plan type, and Northeast geographic region also emerged as significant predictors. Conversely, HA procedures performed in an ASC were 13% less likely to have an OON surgeon (p<0.05).
Conclusions:
In conclusion, OON surgeon utilization generally declined for sports orthopaedic procedures but increased for HA over the study period. Among the procedures studied, HA was an independent predictor for OON surgeon status. This is likely due to HA being a more technically demanding procedure with fewer trained in-network providers. Other strong predictors of OON surgeon status for sports orthopaedic procedures include ASC as the surgical setting, insurance plan type being PPO/EPO, and the procedure being performed in the Northeast region. Our results show that there is a need to improve patient access to experienced HA providers—perhaps with prioritization of HA training in residency and fellowship programs—in order to address rising OON surgeon utilization.
