Variation in Rheumatoid Hand and Wrist Surgery among Medicare Beneficiaries: A Population-based Cohort Study

Abstract

Objective.To examine the rate and variation in rheumatoid arthritis (RA)-related hand and wrist surgery among Medicare (elderly) beneficiaries in the United States, and to identify the patient and provider factors that influence surgical rates.Methods.Using the 2006–2010 100% Medicare claims data of beneficiaries with RA diagnosis, we examined rates of rheumatoid hand and wrist arthroplasty, arthrodesis, and hand tendon reconstruction in the United States. We used multivariate logistic regression models to examine variation in receipt of surgery by patient and regional characteristics (density of providers, intensity of use of biologic disease-modifying antirheumatic drugs).Results.Between 2006 and 2010, the annual rate of RA-related hand and wrist arthroplasty or arthrodesis was 23.1 per 10,000 patients, and the annual rate of hand tendon reconstruction was 4.2 per 10,000 patients. The rates of surgery varied 9-fold across hospital referral regions in the United States. Younger patient age, female sex, white race, higher socioeconomic status (SES), and rural residence were associated with a higher likelihood of undergoing arthroplasty and arthrodesis. We observed a significant decline in rate of arthroplasty and arthrodesis with increasing density of rheumatologists. Tendon reconstruction was not influenced by provider factors, but was correlated with age, race, SES, and rural status of the patients.Conclusion.Surgical reconstruction of rheumatoid hand deformities varies widely across the United States, driven by both regional availability of subspecialty care in rheumatology and individual patient factors.