Trends and Variability in the Use of Total Shoulder Arthroplasty for Medicare Patients

Introduction: As policies are implemented to encourage high-quality care, it is important to identify any persistent limitations to the uniform delivery of anatomic and reverse total shoulder arthroplasty (TSA). The study's goal was to assess current TSA use and identify predictors of geographic variability. Methods: We used data from 2012 through 2014 that was obtained from public Medicare databases to identify the case volume, locations, and names of surgeons performing >10 TSAs annually. We also recorded regional characteristics of the Medicare population, including demographic characteristics and health factors. Results: From 2012 through 2014, the number of surgeons performing >10 TSAs annually increased from 824 to 1,060 - an increase ranging from 0.75 to 0.95 TSAs per 1,000 beneficiaries. In 2012, there were 59 hospital referral regions with no TSAs performed; the number of regions decreased to 35 by 2014 (P = 0.009). The use of TSA varied widely across regions (range, 0.1 to 6.4 per 1,000 beneficiaries). A larger proportion of white patients and a smaller proportion of patients eligible for Medicaid were independent predictors for increased use of TSA. Despite this finding, 74.4% and 96.9% of the US population resided within 50 km and 200 km, respectively, of a surgeon performing at least 20 TSAs in Medicare patients annually. Discussion: TSA utilization in the Medicare population is increasing across the country. Although notable geographic disparities in the use of TSA persist, increased TSA utilization has provided greater access to surgeons with high-volume TSA caseloads. Conclusion: Substantial geographic variation in TSA use remains, largely due to socioeconomic factors.