What rate of utilization is appropriate in musculoskeletal care?
Musculoskeletal procedures often show wide variation in rates across geographic areas, which begs the question, "Which rate is right?" Clearly, there is no simple answer to this question. We summarize a conceptual framework for thinking about how to approach this question for different types of interventions. One guiding principle is the "right rate" is usually the one that results from the choices of a fully informed and empowered patient population. For truly effective care without substantial tradeoffs, the right rate may approach 100%. The rate of operative treatment of hip fracture, for example, approaches the underlying incidence of disease; however, the rate of some forms of effective care, like osteoporosis evaluation and treatment after a fragility fracture, is often quite low and undoubtedly reflects underuse. The recommended approach to underuse is to improve the reliability and accountability of the delivery system. Many other musculoskeletal interventions fall into the category of "preference-sensitive care." These interventions involve important tradeoffs between risks and benefits. Variations in these procedure rates may represent insufficient focus on patient values and preferences, relying instead on the enthusiasm of the physician for treatment alternatives. The recommended approach in this setting is the use of decision aids and other approaches to informed choice.


METHODS
Level V, expert opinion. See Guidelines for Authors for a complete description of levels of evidence.
Lurie
Jon D
JD
Dartmouth Medical School and The Dartmouth Institute for Health Policy and Clinical Practice (TDI), DHMC One Medical Center Drive, Lebanon, NH 03756, USA. jon.d.lurie@dartmouth.edu
Bell
John Erik
JE
Weinstein
Jim
J
D001291:Attitude of Health Personnel; D003695:Delivery of Health Care; D005006:Ethnicity; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D009140:Musculoskeletal Diseases / Q000628:therapy*; D019637:Orthopedic Procedures / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care; D017060:Patient Satisfaction; D018579:Patient Selection; D026741:Physical Therapy Modalities / Q000706:statistics & numerical data*; D012111:Residence Characteristics; D012737:Sex Factors; D016896:Treatment Outcome; D014481:United States