Browsing by Author "Mather, Richard C"

Now showing 1 - 7 of 7
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    Acetabular Paralabral Cyst: An Unusual Cause of Lower Extremity Pain and Paresthesia.
    (J Orthop Sports Phys Ther, 2016-01) Reiman, Michael P; Hash, Thomas W; Mather, Richard C
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    Cost-effectiveness analysis of the diagnosis of meniscus tears.
    (Am J Sports Med, 2015-01) Mather, Richard C; Garrett, William E; Cole, Brian J; Hussey, Kristen; Bolognesi, Michael P; Lassiter, Tally; Orlando, Lori A
    BACKGROUND: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy. PURPOSE: To identify the most efficient strategy for the diagnosis of meniscus tears. STUDY DESIGN: Economic and decision analysis; Level of evidence, 1. METHODS: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER). RESULTS: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively. CONCLUSION: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test. CLINICAL RELEVANCE: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.
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    Economic evaluation of access to musculoskeletal care: the case of waiting for total knee arthroplasty.
    (BMC Musculoskelet Disord, 2014-01-18) Mather, Richard C; Hug, Kevin T; Orlando, Lori A; Watters, Tyler Steven; Koenig, Lane; Nunley, Ryan M; Bolognesi, Michael P
    BACKGROUND: The projected demand for total knee arthroplasty is staggering. At its root, the solution involves increasing supply or decreasing demand. Other developed nations have used rationing and wait times to distribute this service. However, economic impact and cost-effectiveness of waiting for TKA is unknown. METHODS: A Markov decision model was constructed for a cost-utility analysis of three treatment strategies for end-stage knee osteoarthritis: 1) TKA without delay, 2) a waiting period with no non-operative treatment and 3) a non-operative treatment bridge during that waiting period in a cohort of 60 year-old patients. Outcome probabilities and effectiveness were derived from the literature. Costs were estimated from the societal perspective with national average Medicare reimbursement. Effectiveness was expressed in quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, effectiveness, and quality-adjusted life years; and net health benefits. RESULTS: In the base case, a 2-year wait-time both with and without a non-operative treatment bridge resulted in a lower number of average QALYs gained (11.57 (no bridge) and 11.95 (bridge) vs. 12.14 (no delay). The average cost was $1,660 higher for TKA without delay than wait-time with no bridge, but $1,810 less than wait-time with non-operative bridge. The incremental cost-effectiveness ratio comparing wait-time with no bridge to TKA without delay was $2,901/QALY. When comparing TKA without delay to waiting with non-operative bridge, TKA without delay produced greater utility at a lower cost to society. CONCLUSIONS: TKA without delay is the preferred cost-effective treatment strategy when compared to a waiting for TKA without non-operative bridge. TKA without delay is cost saving when a non-operative bridge is used during the waiting period. As it is unlikely that patients waiting for TKA would not receive non-operative treatment, TKA without delay may be an overall cost-saving health care delivery strategy. Policies aimed at increasing the supply of TKA should be considered as savings exist that could indirectly fund those strategies.
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    Patient-Preference Diagnostics: Adapting Stated-Preference Methods to Inform Effective Shared Decision Making.
    (Medical decision making : an international journal of the Society for Medical Decision Making, 2022-07-29) Gonzalez Sepulveda, Juan Marcos; Johnson, F Reed; Reed, Shelby D; Muiruri, Charles; Hutyra, Carolyn A; Mather, Richard C

    Background

    While clinical practice guidelines underscore the need to incorporate patient preferences in clinical decision making, incorporating meaningful assessment of patient preferences in clinical encounters is challenging. Structured approaches that combine quantitative patient preferences and clinical evidence could facilitate effective patient-provider communication and more patient-centric health care decisions. Adaptive conjoint or stated-preference approaches can identify individual preference parameters, but they can require a relatively large number of choice questions or simplifying assumptions about the error with which preferences are elicited.

    Method

    We propose an approach to efficiently diagnose preferences of patients for outcomes of treatment alternatives by leveraging prior information on patient preferences to generate adaptive choice questions to identify a patient's proximity to known preference phenotypes. This information can be used for measuring sensitivity and specificity, much like any other diagnostic procedure. We simulated responses with varying levels of choice errors for hypothetical patients with specific preference profiles to measure sensitivity and specificity of a 2-question preference diagnostic.

    Results

    We identified 4 classes representing distinct preference profiles for patients who participated in a previous first-time anterior shoulder dislocation (FTASD) survey. Posterior probabilities of class membership at the end of a 2-question sequence ranged from 87% to 89%. We found that specificity and sensitivity of the 2-question sequences were robust to respondent errors. The questions appeared to have better specificity than sensitivity.

    Conclusions

    Our results suggest that this approach could help diagnose patient preferences for treatments for a condition such as FTASD with acceptable precision using as few as 2 choice questions. Such preference-diagnostic tools could be used to improve and document alignment of treatment choices and patient preferences.

    Highlights

    Approaches that combine patient preferences and clinical evidence can facilitate effective patient-provider communication and more patient-centric healthcare decisions. However, diagnosing individual-level preferences is challenging, and no formal diagnostic tools exist.We propose a structured approach to efficiently diagnose patient preferences based on prior information on the distribution of patient preferences in a population.We generated a 2-question test of preferences for the outcomes associated with the treatment of first-time anterior shoulder dislocation.The diagnosis of preferences can help physicians discuss relevant aspects of the treatment options and proactively address patient concerns during the clinical encounter.
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    Surgeon Applications of Patient Preferences in Treatment Decision Making for First-Time Anterior Shoulder Dislocation.
    (Orthopaedic journal of sports medicine, 2020-12-04) Lau, Brian C; Hutyra, Carolyn A; Streufert, Benjamin; Reed, Shelby D; Orlando, Lori A; Huber, Joel C; Taylor, Dean C; Mather, Richard C

    Background

    Treatment of a first-time anterior shoulder dislocation (FTASD) is sensitive to patient preferences. The operative or nonoperative management debate provides an excellent opportunity to learn how surgeons apply patient preferences in treatment decisions.

    Purpose

    To determine how patient preferences (repeat dislocation risk, recovery difficulties, fear of surgery, treatment costs) and surgeon factors influence a surgeon's treatment plan for FTASD.

    Study design

    Cross-sectional study.

    Methods

    Eight clinical vignettes of hypothetical patients with FTASD (including age, sex, and activity level) were presented to members of the Magellan Society. A second set of matched vignettes with patient preferences and clinical variables were also presented. The vignettes represented scenarios in which evidence does not favor one treatment over another. Respondents were asked how they would manage each hypothetical case. Respondents also estimated the risk of redislocation for the nonoperative cases for comparison with the published rates. Finally, respondents completed a Likert-scale questionnaire to determine their perceptions on factors influencing their decisions.

    Results

    A total of 103 orthopaedic surgeons completed the survey; 48% practiced in an academic hospital; 79% were in practice for 10 years or longer; and 75% had completed a sports medicine fellowship. Patient preferences were the single most important factor influencing treatment recommendation, with activity type and age also important. Just 62% of the surgeon estimates of the risk of redislocation were consistent with the published rates. The inclusion of patient preferences to clinical variables changed treatment recommendations in 62.5% of our hypothetical cases. Respondents rated patient treatment preference as the leading factor in their treatment decision making.

    Conclusion

    Patient preferences were important when deciding the appropriate treatment for FTASD. Respondents were inconsistent when applying evidence in their decision making and estimates of recurrent instability. Decision support tools that deliver patient preferences and personalized evidence-based outcome estimates improve the quality of decision making at the point of care.
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    The Air-Lift Technique for Improving Ease and Safety When Establishing the Modified Midanterior Portal in Hip Arthroscopy.
    (Arthroscopy techniques, 2024-02) Bond, Elizabeth C; Jarvis, D Landry; Scott, Elizabeth J; Mather, Richard C
    Hip arthroscopy continues to increase in popularity and has an ever-expanding range of indications; however, the steep learning curve introduces significant risk of iatrogenic chondrolabral injury when accessing the joint and establishing arthroscopic portals. This article presents a technique for establishing the modified midanterior portal and is particularly useful when the available space is tight. We present "the air-lift" as a safe and simple adjunct to standard portal creation when performing hip arthroscopy in the supine position.
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    Understanding Preferences for Treatment After Hypothetical First-Time Anterior Shoulder Dislocation: Surveying an Online Panel Utilizing a Novel Shared Decision-Making Tool.
    (Orthop J Sports Med, 2017-03) Streufert, Ben; Reed, Shelby D; Orlando, Lori A; Taylor, Dean C; Huber, Joel C; Mather, Richard C
    BACKGROUND: Although surgical management of a first-time anterior shoulder dislocation (FTASD) can reduce the risk of recurrent dislocation, other treatment characteristics, costs, and outcomes are important to patients considering treatment options. While patient preferences, such as those elicited by conjoint analysis, have been shown to be important in medical decision-making, the magnitudes or effects of patient preferences in treating an FTASD are unknown. PURPOSE: To test a novel shared decision-making tool after sustained FTASD. Specifically measured were the following: (1) importance of aspects of operative versus nonoperative treatment, (2) respondents' agreement with results generated by the tool, (3) willingness to share these results with physicians, and (4) association of results with choice of treatment after FTASD. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A tool was designed and tested using members of Amazon Mechanical Turk, an online panel. The tool included an adaptive conjoint analysis exercise, a method to understand individuals' perceived importance of the following attributes of treatment: (1) chance of recurrent dislocation, (2) cost, (3) short-term limits on shoulder motion, (4) limits on participation in high-risk activities, and (5) duration of physical therapy. Respondents then chose between operative and nonoperative treatment for hypothetical shoulder dislocation. RESULTS: Overall, 374 of 501 (75%) respondents met the inclusion criteria, of which most were young, active males; one-third reported prior dislocation. From the conjoint analysis, the importance of recurrent dislocation and cost of treatment were the most important attributes. A substantial majority agreed with the tool's ability to generate representative preferences and indicated that they would share these preferences with their physician. Importance of recurrence proved significantly predictive of respondents' treatment choices, independent of sex or age; however, activity level was important to previous dislocators. A total of 125 (55%) males and 33 (23%) females chose surgery after FTASD, as did 37% of previous dislocators compared with 45% of nondislocators. CONCLUSION: When given thorough information about the risks and benefits, respondents had strong preferences for operative treatment after an FTASD. Respondents agreed with the survey results and wanted to share the information with providers. Recurrence was the most important attribute and played a role in decisions about treatment.