Orthopaedic Surgeon Distribution in the United States

Trends of Surgery, Patient, and Surgeon Characteristics for Corneal Transplants in the Medicare Population From 2011 to 2020

PURPOSE

The aim of this study was to describe recent trends in corneal transplants and patient and surgeon characteristics for corneal transplants that occurred in the Medicare population.

METHODS

This was a retrospective, cross-sectional study using Current Procedural Terminology codes. We identified Medicare Fee-For-Service (FFS) claims for different types of corneal transplant procedures performed on Medicare beneficiaries aged 65 years or older from 2011 to 2020. Number and types of corneal transplants performed each year and patient and surgeon demographics and characteristics were analyzed.

RESULTS

We analyzed 148,981 corneal transplants performed by 2972 surgeons within the study period. Most corneal transplants performed were endothelial keratoplasties (70.1%). Most patients were women (60.3%) and White (85.8%). 18.2% of patients lived in a rural area, whereas only 3.5% of transplants occurred in a rural area and 5% of surgeons practiced in a rural area. Male surgeons represented 77.8% of all surgeons and performed 84.9% of all corneal transplants in the study period. The proportion of corneal transplants performed by female surgeons gradually increased over time, from 12.1% in 2011 to 19.0% in 2020. The proportion of female surgeons also increased from 16.2% in 2011 to 23.8% in 2020. Most surgeons (67%) performed <6 corneal transplants per year.

CONCLUSIONS

Although the number of female corneal transplant surgeons has increased over time, women remain underrepresented in the surgical workforce. Further investigation should be conducted to identify the underlying reason and address the identified disparities within the landscape of corneal transplantation.

Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer

BACKGROUND

The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases.

METHODS

This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals.

RESULTS

A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients.

DISCUSSION

Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.

Trends in Orthopaedic Surgery Workforce Diversity: Analyzing Changes Over Time

INTRODUCTION

There are many reasons why orthopaedic surgeons move or change careers. We asked the questions: (1) What is the geographic distribution of orthopaedic surgeons with respect to age, sex, and race and ethnicity? (2) How has our workforce changed over time with regard to these factors? (3) Are there any patterns or trends detected regarding policy or regulatory events that coincide with these differences?

METHODS

The American Academy of Orthopaedic Surgeons surveys over 30,000 members, collecting data on demographics, age, race sex, and practice statistics. We calculated geographic distributions and evaluated these differences over time-potential influences from malpractice suits or tort reform were investigated.

RESULTS

Overall surgeon density increased over time. The largest negative changes were noted in District of Columbia, Wyoming, and North Dakota and positive changes in Colorado, South Dakota, and West Virginia. Age across all states increased (mean 1.7 years). Number of female surgeons increased in most states (4.6% to 5.7%). Number of  African Americans increased from 1.6% to 1.8%, Hispanic/LatinX from 1.8% to 2.2%, Asian from 5.5% to 6.7%, and multiracial from 0.8% to 1.2%. No change was noted in the percentage of Native American surgeons.

DISCUSSION

Surgeon density increased from 2012 to 2018; the cause for this change was not evident. Small increases in surgeon population, female surgeons, and in some underrepresented minorities were seen.

Increased 90-Day Readmissions and Complications Following Hip Arthroscopy in Centers With Low Surgical Volume in New York State

PURPOSE

To (1) classify surgical centers in New York State by volume of hip arthroscopies performed, (2) calculate rates of readmissions and complications by center volume, and (3) identify socioeconomic predictive factors for readmissions and complications following hip arthroscopy.

METHODS

Patients who underwent hip arthroscopy at New York State health care facilities from 2010 to 2020 were retrospectively identified using the New York Statewide Planning and Research Cooperative System (SPARCS) database. Hip arthroscopic procedures were identified using the following Current Procedural Terminology codes. Surgical center volumes were classified into 3 categories: low (<85th percentile), medium (85th-95th percentile), and high (>95th percentile). Incidence of readmissions and complications within 90 days was abstracted from SPARCS. Neighborhood socioeconomic status was quantified using the U.S. Area Deprivation Index. Multivariable logistic regression was used to determine whether center volume and other socioeconomic variables were independent predictors of outcomes.

RESULTS

In total, 50,252 patients who underwent hip arthroscopy were identified in SPARCS from 2010 to 2020. Of these patients, 13,861 (27.6%) underwent surgery at low-volume centers, 11,757 (23.4%) at medium-volume centers, and 24,634 (49.0%) at high-volume centers. Minorities, publicly insured patients, and patients from lower socioeconomic status neighborhoods made up a larger proportion of cases seen by low-volume centers versus high-volume centers (P < .001). Patients in the low-volume group experienced significantly greater 90-day rates of readmissions (P < .001) and all-cause complications (P < .001) than the other groups. Furthermore, high-volume centers were independently associated with lower odds of readmission (odds ratio 0.57, P < .001) and all-cause complications (odds ratio 0.73, P < .001) versus low-volume centers.

CONCLUSIONS

Low-volume surgical centers are associated with increased readmission and complication rates following hip arthroscopy, independent of other socioeconomic factors such as age, sex, race, insurance status, and neighborhood socioeconomic status.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

What Factors Are Associated With Early Career Attrition Among Orthopaedic Surgeons in the United States?

BACKGROUND

The attrition of medical personnel in the United States healthcare system has been an ongoing concern among physicians and policymakers alike. Prior studies have shown that reasons for leaving clinical practice vary widely and may range from professional dissatisfaction or disability to the pursuit of alternative career opportunities. Whereas attrition among older personnel has often been understood as a natural phenomenon, attrition among early-career surgeons may pose a host of additional challenges from an individual and societal perspective.

QUESTIONS/PURPOSES

(1) What percentage of orthopaedic surgeons experience early-career attrition, defined as leaving active clinical practice within the first 10 years after completion of training? (2) What are the surgeon and practice characteristics associated with early-career attrition?

METHODS

In this retrospective analysis drawn from a large database, we used the 2014 Physician Compare National Downloadable File (PC-NDF), a registry of all healthcare professionals in the United States participating in Medicare. A total of 18,107 orthopaedic surgeons were identified, 4853 of whom were within the first 10 years of training completion. The PC-NDF registry was chosen because it has a high degree of granularity, national representativeness, independent validation through the Medicare claims adjudication and enrollment process, and the ability to longitudinally monitor the entry and exit of surgeons from active clinical practice. The primary outcome of early-career attrition was defined by three conditions, all of which had to be simultaneously satisfied ("condition one" AND "condition two" AND "condition three"). The first condition was presence in the Q1 2014 PC-NDF dataset and absence from the same dataset the following year (Q1 2015 PC-NDF). The second condition was consistent absence from the PC-NDF dataset for the following 6 years (Q1 2016, Q1 2017, Q1 2018, Q1 2019, Q1 2020, and Q1 2021), and the third condition was absence from the Centers for Medicare and Medicaid Services Opt-Out registry, which tracks clinicians who have formally discontinued enrollment in the Medicare program. Of the 18,107 orthopaedic surgeons identified in the dataset, 5% (938) were women, 33% (6045) were subspecialty-trained, 77% (13,949) practiced in groups of 10 or more, 24% (4405) practiced in the Midwest, 87% (15,816) practiced in urban areas, and 22% (3887) practiced at academic centers. Surgeons not enrolled in the Medicare program are not represented in this study cohort. A multivariable logistic regression model with adjusted odds ratios and 95% confidence intervals was constructed to investigate characteristics associated with early-career attrition.

RESULTS

Among the 4853 early-career orthopaedic surgeons identified in the dataset, 2% (78) were determined to experience attrition between the first quarter 2014 and the same point in 2015. After controlling for potential confounding variables such as years since training completion, practice size, and geographic region, we found that women were more likely than men to experience early-career attrition (adjusted OR 2.8 [95% CI 1.5 to 5.0]; p = 0.006]), as were academic orthopaedic surgeons compared with private practitioners (adjusted OR 1.7 [95% CI 1.02 to 3.0]; p = 0.04), while general orthopaedic surgeons were less likely to experience attrition than subspecialists (adjusted OR 0.5 [95% CI 0.3 to 0.8]; p = 0.01).

CONCLUSION

A small but important proportion of orthopaedic surgeons leave the specialty during the first 10 years of practice. Factors most-strongly associated with this attrition were academic affiliation, being a woman, and clinical subspecialization.

CLINICAL RELEVANCE

Based on these findings, academic orthopaedic practices might consider expanding the role of routine exit interviews to identify instances in which early-career surgeons face illness, disability, burnout, or any other forms of severe personal hardships. If attrition occurs because of such factors, these individuals could benefit from connection to well-vetted coaching or counseling services. Professional societies might be well positioned to conduct detailed surveys to assess the precise reasons for early attrition and characterize any inequities in workforce retention across a diverse range of demographic subgroups. Future studies should also determine whether orthopaedics is an outlier, or whether 2% attrition is similar to the proportion in the overall medical profession.

What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study

BACKGROUND

Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized.

QUESTIONS/PURPOSES

(1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states?

METHODS

We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions.

RESULTS

A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08).

CONCLUSION

As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately.

CLINICAL RELEVANCE

To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings.