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Scientific Articles   |    
The Rising Incidence of Acromioplasty
Mark A. Vitale, MD, MPH1; Raymond R. Arons, MPH, DrPH1; Shepard Hurwitz, MD2; Christopher S. Ahmad, MD1; William N. Levine, MD1
1 Center for Shoulder, Elbow and Sports Medicine, Department of Orthopaedic Surgery, New York-Presbyterian Medical Center, Columbia University, 622 West 168th Street, PH-1117, New York, NY 10032. E-mail address for W.N. Levine: wnl1@columbia.edu
2 American Board of Orthopaedic Surgery Research Committee, 400 Silver Cedar Court, Chapel Hill, NC 27514
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at New York-Presbyterian/Columbia University Medical Center, New York, NY

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Aug 04;92(9):1842-1850. doi: 10.2106/JBJS.I.01003
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Abstract

Background: 

Acromioplasty is considered a technically simple procedure but has become controversial with regard to its indications and therapeutic value.

Methods: 

Two complementary databases were used to ascertain the frequency of acromioplasty over a recent span of time. In Part A, the New York Statewide Planning and Research Cooperative System (SPARCS) ambulatory surgery database was searched from 1996 to 2006 to identify all ambulatory surgery acromioplasties as well as all orthopaedic ambulatory surgery procedures. In Part B, the American Board of Orthopaedic Surgery (ABOS) database was searched from 1999 to 2008 to identify all arthroscopic acromioplasties as well as all orthopaedic procedures.

Results: 

Part A revealed that in 1996 there were 5571 acromioplasties in New York State, representing a population incidence of 30.0 per 100,000. In 2006 there were 19,743 acromioplasties, representing a population incidence of 101.9 per 100,000. Over these eleven years, the volume of acromioplasties increased by 254.4%, compared with only a 78.3% increase in the volume of all orthopaedic ambulatory surgery procedures. In 2006, as compared with 1996, patients were 2.4 times more likely to have an acromioplasty compared with all other orthopaedic ambulatory procedures (p < 0.0001). Part B revealed that, in 1999, a mean of 2.6 arthroscopic acromioplasties were reported per candidate for Board certification. In 2008 a mean of 6.3 arthroscopic acromioplasties per candidate were reported. Over these ten years, the mean number of arthroscopic acromioplasties reported increased by 142.3%, compared with only a 13.0% increase in the mean number of all orthopaedic surgery procedures. In 2008, as compared with 1999, candidates were 2.2 times more likely to report an arthroscopic acromioplasty compared with all other orthopaedic procedures (p < 0.0001).

Conclusions: 

There has been a substantial increase in the overall volume and the population-based incidence of acromioplasties in recent years on both the state and national levels in the United States. The reasons for this increase have yet to be determined and are likely multifactorial, with patient-based, surgeon-based, and systems-based factors all playing a role.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    William N. Levine, MD
    Posted on September 06, 2010
    Drs. Levine and Vitale respond to Dr. Schneider
    Columbia University Medical Center, New York City, New York

    We commend Dr. Schneider for his thoughtful review of our manuscript and careful consideration of factors which may contribute to the increasing frequency and population-based incidence of acromioplasty procedures over the past decade as documented independently by both CPT codes (in the ABOS database) and ICD-9 procedure codes (in the SPARCS database). Dr. Schneider points out that while the incidence of coding of acromioplasty by ICD-9 procedure and CPT codes has increased, this may not necessarily reflect a true increase in the incidence of the procedure over this period, as there are other reasons to explain the increased coding, including “unbundling” of procedure codes for shoulder surgery, increasing pressures for coding documentation by the ABOS and growing financial incentive to bill for multiple codes given decreasing reimbursements from insurers.

    We did, however, use a control group for the possible confounder that we are measuring increases in codes rather than procedures. In part A we compared all acromioplasties (open or arthroscopic) as identified by an ICD-9 procedure code with all other orthopaedic procedures as identified by ICD-9 procedures codes performed in hospital or free-standing ambulatory surgery centers on an outpatient basis. In part B we compared all arthroscopic acromioplasties as identified by a CPT code with all other orthopaedic surgical procedures identified by CPT codes performed in hospital or free-standing ambulatory centers on an outpatient basis. If the increase in documentation of procedures merely represented an increase in coding and not an increase in the actual execution of procedures, one would expect similar increases in the codes for acromioplasties and other outpatient orthopaedic procedures (such as knee meniscectomies, carpal tunnel releases, hallux valgus realignments and other commonly performed outpatient procedures) since there are presumably the same phenomena of “unbundling”, pressures of documentation by the ABOS and increasing financial pressures to bill for multiple codes across different types of outpatient orthopaedic procedures.

    This was not the case, as in part A there was a 254.4% increase in the frequency of acromioplasties compared to only a 78.3% in other outpatient orthopaedic procedures in New York State and in part B there was a similar 142.3% increase in the mean number of arthroscopic acromioplasties compared to only a 13.0% increase in the mean number of all other outpatient orthopaedic procedures reported nationally by candidates taking part II of their orthopaedic board examination. It would be difficult to explain why there would be a preferential increase specifically in the reporting of ICD-9 procedure codes and CPT codes for acromioplasties but not other open and arthroscopic outpatient orthopaedic procedures.

    Additionally, the ICD-9 procedure code (not to be confused with ICD-9 diagnosis codes) for acromioplasty – code 81.83 – has not undergone modification to allow for unbundling in the way that CPT codes for shoulder surgery have over the past decade; there is today and has been for many years a single ICD-9 procedure code for open or arthroscopic acromioplasty.

    Furthermore, the codes entered in the SPARCS database each year are not ICD-9 or CPT codes reported by the physician for billing purposes, but rather this is hospital administrative data compiled by medical record coders who review physician written operative notes and produce the ICD-9 procedure codes from the medical records for transmission to the state Department of Health and insurance companies; while the operative notes are physician driven, the codes which are then documented in the SPARCS database are derived from independent medical coders who presumably do not have the same possible incentives that surgeons may have to report an increasing number of procedure codes.

    A second reason that Dr. Schneider offers to explain the observed increase in the frequency of acromioplasties in both parts of our study is a shift in the technique of acromioplasties from open to mini-open to all-arthroscopic procedures over the last decade, the later being performed on an outpatient basis in recent years in contrast to open acromioplasties in the earlier years of the study which may have been performed on an inpatient basis; Dr. Schneider speculates that since both the SPARCS and ABOS ambulatory databases only examined procedures performed on an outpatient basis the observed trend of increasing frequency and incidence of acromioplasty may reflect an increase in outpatient all-arthroscopic procedures but not an true increase in the number of procedures overall. While an increasing tendency to perform outpatient procedures may play some role in the overall increase in the documentation of acromioplasties observed, one would expect to therefore see an increase in the number of procedures performed at ambulatory centers over this period. This was not the case, as in the SPARCS database there was a similarly dramatic growth in the number of procedures performed in 1996 compared to 2006 on an outpatient basis at inpatient hospitals (262.9%) compared to ambulatory surgery centers (242.5%).

    While our goal of our manuscript was not to identify why there was an increase in the observed frequency and population-based incidence of acromioplasty, we speculate that this is due to a number of factors highlighted in the discussion, which include a combination of patient-based, surgeon-based and systems-based factors. The challenge for the future will be to further elucidate precisely why this has occurred.

    Marc C. Schneider, MD
    Posted on August 25, 2010
    Is the Incidence of Acromioplasty Really Rising?
    Cincinnati Bone and Joint Institute, Cincinnati, Ohio

    To the Editor:

    As Vitale et al. suggest in the discussion of their article, "The Rising Incidence of Acromioplasty" (2010;92:1842-50), the reasons for an increased number of acromioplasties is likely multifactorial and may not represent a true rise in the "incidence" of this procedure.

    This paper does indeed show there has been a rising incidence of CODING for acromioplasties over the last decade. However, a combination of factors, including advances in shoulder surgery and anesthesia, changes in ICD- 9/CPT codes and requirements by the ABOS and insurers have all played an influential role.

    In part, a shift in the surgical technique for repairing the rotator cuff has occurred in the last decade - "all open" to "combined open/arthroscopic" to "all arthroscopic." The data acquired from the SPARCS database only included hospital and free standing ASC's. In the late 1990's and early 2000's many open rotator cuff repairs were done on an inpatient or "observation" basis. Therefore the SPARCS data has been disproportionately impacted by this fact when compared to the ABOS data.

    Additionally, through the late 1990's and 2000's changes in CPT coding for shoulder surgery "unbundled" acromioplasty (arthroscopic and open) from the previous global open codes for "rotator cuff repair". This fact alone may have led to a dramatic "increase" in the coding for acromioplasties over the study period.

    Finally, as insurance reimbursements have decreased and the ABOS has required more stringent record keeping, there may be more pressure on orthopedic surgeons to bill multiple codes for a given procedure.

    Through ongoing research and increased subspecialization of young orthopedists via fellowship training, the indications for acromioplasty will be better defined.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

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