Not the Last Word: Choosing Wisely

Bernstein, Joseph

doi:10.1007/s11999-015-4490-8

Cited by 8 publications

(11 citation statements)

References 21 publications

(19 reference statements)

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“…The low surgery rate across time also suggests that surgeons recognize that there are detriments associated with surgical treatment and that for many patients the risks associated with surgery (e.g., complications, infections, mortality) may be greater than the expected benefits. Consequently, the relevant question is not whether either surgery or conservative care is “the” effective treatment for all patients with PHF, but rather what is the effective surgery rate of treatments across PHF patients [40–42]. The effective rate can be defined as the surgery rate that when all patients receive their optimal treatments, the treatment that suits them the best [39].…”

Section: Discussionmentioning

confidence: 99%

Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus

et al. 2019

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BackgroundUsing a larger, more comprehensive sample, and inclusion of the reverse shoulder arthroplasty as a primary surgical approach for proximal humerus fracture, we report on geographic variation in the treatment of proximal humerus fracture in 2011 and comment on whether treatment consensus is being reached.MethodsThis was a retrospective cohort study of Medicare patients with an x-ray-confirmed diagnosis of proximal humerus fracture in 2011. Patients receiving reverse shoulder arthroplasty, hemiarthroplasty, or open reduction internal fixation within 60 days of their diagnosis were classified as surgical management patients. Unadjusted observed surgery rates and area treatment ratios adjusted for patient demographic and clinical characteristics were calculated at the hospital referral region level.ResultsAmong patients with proximal humerus fracture (N = 77,053), 15.4% received surgery and 84.6% received conservative management. Unadjusted surgery rates varied from 1.7 to 33.3% across hospital referral regions. Among patients receiving surgery, 22.3% received hemiarthroplasty, 65.8% received open reduction internal fixation, and 11.8% received reverse shoulder arthroplasty. Patients that were female, were younger, had fewer medical comorbidities, had a lower frailty index, were white, or were not dual-eligible for Medicaid during the month of their index fracture were more likely to receive surgery (p < .0001). Geographic variation in the treatment of proximal humerus fracture persisted after adjustment for patient demographic and clinical differences across local areas. Average surgery rates ranged from 9.9 to 21.2% across area treatment ratio quintiles.ConclusionsPersistent geographic variation in surgery rates for proximal humerus fracture across the USA suggests no treatment consensus has been reached.

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Section: Discussionmentioning

confidence: 99%

Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus

et al. 2019

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“…Additionally, not all patients may be appropriate to a given mix of interventions with similar conditions. Thus, determining an effective treatment mix may provide more clinically useful information as opposed to a single treatment approach that demonstrates an effective average treatment effect [17][18][19]. Sadly, although causal mediation designs are often secondary analyses within an RCT, an RCT in isolation does not provide that information.…”

Section: Limitationsmentioning

confidence: 99%

Five good reasons to be disappointed with randomized trials

Cook

Thigpen

2019

Journal of Manual & Manipulative Therapy

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“…15,[22][23][24][25][26][27][28] For example, surgical treatments in orthopaedics can affect patient function, pain, and the risk of various adverse events including death, and there is a tacit acknowledgement in the orthopaedics literature that surgery effects on these outcomes are heterogeneous across patients. [29][30][31][32][33] Because surgery for orthopaedic conditions have both beneficial and detrimental effects that can vary across patients, surgery may be best for some patients and conservative management best for others. [29][30][31][32][33] Therefore, the key question in orthopaedics is not whether surgery or conservative management is "the" best treatment for patients with a given condition, but rather which treatment is best-suited for each patient.…”

Section: Introductionmentioning

confidence: 99%

Personalizing Evidence for Shoulder Fracture Patients Using an Extended Instrumental Variable Causal Forest Algorithm

Brooks

Chapman

Floyd

et al. 2021

Preprint

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Objective: To assess the ability of an extended Instrumental Variable Causal Forest Algorithm (IV-CFA) to provide personalized evidence of early surgery effects on benefits and detriments for elderly shoulder fracture patients. Data Sources/Study Setting: Population of 72,751 fee-for-service Medicare beneficiaries with proximal humerus fractures (PHFs) in 2011 who survived a 60-day treatment window after an index PHF and were continuously Medicare fee-for-service eligible over the period 12 months prior to index to the minimum of 12 months after index or death. Study Design: IV-CFA estimated early surgery effects on both beneficial and detrimental outcomes for each patient in the study population. Classification and regression trees (CART) were applied to these estimates to create patient reference classes. Two-stage least squares (2SLS) estimators were applied to patients in each reference class to scrutinize the estimates relative to the known 2SLS properties. Principal Findings: This approach uncovered distinct reference classes of elderly PHF patients with respect to early surgery effects on benefit and detriment. Older, frailer patients with more comorbidities, and lower utilizers of healthcare were less likely to gain benefit and more likely to have detriment from early surgery. Reference classes were characterized by the appropriateness of early surgery rates with respect to benefit and detriment. Conclusions: Extended IV-CFA provides an illuminating method to uncover reference classes of patients based on treatment effects using observational data with a strong instrumental variable. This study isolated reference classes of new PHF patients in which changes in early surgery rates would improve patient outcomes. The inability to measure fracture complexity in Medicare claims means providers will need to discuss the appropriateness of these estimates to patients within a reference class in context of this missing information.

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Not the Last Word: Choosing Wisely

Cited by 8 publications

References 21 publications

Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus

Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus

Five good reasons to be disappointed with randomized trials

Personalizing Evidence for Shoulder Fracture Patients Using an Extended Instrumental Variable Causal Forest Algorithm

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