Effects of Musculoskeletal Surgery Rates on Outcomes

肌肉骨骼（MSK）疾病影响超过一半的美国人口，占五分之一 保健访问。MSK护理每年的直接费用超过1760亿美元，间接费用超过8760亿美元 医疗保健成本和人均成本大幅增加。然而，在第一阶段， 支持这种医疗保健利用水平的证据，在适当治疗方面几乎没有共识 跨MSK条件的方法。由于随机化和设盲的困难， 10%的MSK相关研究是临床试验，其中不到40%符合最低指导原则。 因此，毫不奇怪，在使用侵入性和昂贵的药物方面存在着巨大的地理差异。 治疗MSK条件。大众媒体利用轶事建议，新生儿早期手术 MSK条件被过度使用。模拟研究表明，较低的治疗利用率 有临床证据支持，如外科手术治疗MSK疾病，可以大大降低医疗保险费用 而不牺牲质量。然而，除了轶事和模拟研究，没有证据表明， 支持这样的观点，即降低MSK患者的手术率将降低成本， 保持质量。较低的手术率可能会使那些从手术中获益甚少的患者无法接受手术。 手术相反，较低的手术率可能导致许多患者延迟有益的治疗 导致MSK条件恶化并导致较差的结果和较高的长期成本。 我们的方法是将早期手术率的地理差异视为自然现象 实验和应用工具变量估计，以评估早期高利率的影响， 手术的结果和成本。此外，我们将使用为患者样本提取的图表， 测量医疗保险索赔中未测量的混杂因素，以评估我们的假设 自然实验然后，我们将仔细解释我们的估计考虑的结果衡量 以及与治疗效果异质性和混杂相关的假设的有效性。 调查小组有丰富的经验，评估治疗效果使用医疗保险 数据和强大的MSK临床和经验背景。这项研究建立在我们的肩膀相关 使用2011年的医疗保险数据进行研究。它将确定早期手术与 选择，治疗成功和MSK患者的费用。AHRQ有权进行 并支持研究，以反映医疗保险计划的需求和优先事项。这项研究将 为政策制定者评估这些MSK疾病的早期手术是否已经结束提供关键证据 或在医疗保险患者的实践中未充分使用。我们的研究目标与AHRQ的目标一致，即“生产 可用于提高卫生保健的可负担性和效率的证据”。 1

Musculoskeletal (MSK) conditions affect more than half of the U.S. population and account for 1 in 5 healthcare visits. MSK care annual costs exceed $176 billion in direct and $876 billion in indirect healthcare costs and show large increases in per capita costs. Yet, there is remarkably little Level I evidence supporting this level of healthcare utilization with little consensus on proper treatment approaches across MSK conditions. Because of difficulties with randomization and blinding, less than 10% of MSK related-studies are clinical trials, and of the trials, less than 40% meet minimal guidelines. Thus, it is not surprising that substantial geographic variation exists in the use of invasive and costly treatments for MSK conditions. Using anecdotes, the popular press suggests that early surgery for new MSK conditions is overused. Simulation studies suggest that lower utilization rates of treatments not supported by clinical evidence, like surgery for MSK conditions, can dramatically lower Medicare costs without sacrificing quality. However, beyond anecdote and simulation studies, there is no evidence supporting the notion that lower surgery rates for patients with MSK conditions will lower costs and maintain quality. Lower surgery rates may keep surgery from patients who would benefit little from surgery. Conversely, lower surgery rates may result in many patients delaying beneficial treatment causing MSK conditions to worsen and result in poorer outcomes and higher long run costs. Our approach is to use the documented geographic variation in early surgery rates as natural experiments and apply instrumental variable estimators to assess the impact of higher rates of early surgery on outcomes and costs. In addition, we will use charts abstracted for a sample of patients to measure confounders unmeasured in Medicare claims to assess the assumptions underlying our natural experiment. We will then carefully interpret our estimates considering the outcomes measured and the validity of the assumptions associated with treatment effect heterogeneity and confounding. The investigative team has substantial experience assessing treatment effectiveness using Medicare data and a strong MSK clinical and empirical background. This study builds on our shoulder-related research using Medicare data from 2011. It will identify important relationships between early surgery choice, treatment success and costs for patients with MSK conditions. AHRQ has authority to conduct and support research to reflect the needs and priorities of the Medicare program. This research will provide key evidence for policy makers to assess whether early surgery for these MSK conditions are over or underused in practice for Medicare patients. Our study goals align with AHRQ’s goal of “producing evidence that can be used to increase the affordability and efficiency of health care”. 1