title: Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair.
abstract: BACKGROUND
  Although geographic variations in the rates of orthopaedic procedures have been well documented, considerable controversy remains regarding the factors that drive these variations, particularly the role of the availability of orthopaedic surgeons. Moreover, little attention has been specifically focused on variations in the rates of commonly performed shoulder procedures.
  
  
  METHODS
  The current study documents state-to-state variations in the rates of total shoulder replacement, humeral head replacement, and rotator cuff repair and examines factors that might account for these variations. The regional incidences of these three procedures were analyzed with use of the Health Care Financing Administration Medicare database (MEDPAR, 1992). The rates were age-adjusted, and variations were measured with use of high:low ratios, variation coefficients, and systematic components of variation. Potential causes of variation were analyzed with use of Spearman and partial correlations as well as with Poisson regression.
  
  
  RESULTS
  Rates for the three procedures that were studied varied from one state to another by as much as tenfold. Humeral head replacement had the lowest rate of variation according to all three measures. All three procedures were performed less often in states that were more densely populated. With the numbers available for study, no consistent, significant relationship was found between the density of orthopaedists and shoulder surgeons and the rates of any procedure.
  
  
  CONCLUSIONS
  The striking variations that were noted for these commonly performed procedures showed that there is a clear need for well designed clinical research to further define the factors that account for the variations and to examine the effectiveness and appropriate indications for the procedures.
authors.affiliation: New York Orthopaedic Hospital and International Center for Health Outcomes and Innovation Research, Columbia-Presbyterian Medical Center, New York City 10032, USA.
authors.forename: M G
authors.initials: MG
authors.lastname: Vitale
authors.forename: J J
authors.initials: JJ
authors.lastname: Krant
authors.forename: A C
authors.initials: AC
authors.lastname: Gelijns
authors.forename: D F
authors.initials: DF
authors.lastname: Heitjan
authors.forename: R R
authors.initials: RR
authors.lastname: Arons
authors.forename: L U
authors.initials: LU
authors.lastname: Bigliani
authors.forename: E L
authors.initials: EL
authors.lastname: Flatow
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019643:Arthroplasty, Replacement / Q000706:statistics & numerical data*; D014487:Centers for Medicare and Medicaid Services, U.S.; D016208:Databases, Factual; D005260:Female; D005843:Geography; D006801:Humans; D006811:Humerus / Q000601:surgery*; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D019637:Orthopedic Procedures / Q000706:statistics & numerical data*; D009985:Orthopedics / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D016012:Poisson Distribution; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012044:Regression Analysis; D012306:Risk; D017006:Rotator Cuff / Q000601:surgery*; D012785:Shoulder Joint / Q000601:surgery*; D014481:United States / Q000453:epidemiology; D000078329:Workforce