{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,2]],"date-time":"2025-12-02T18:46:20Z","timestamp":1764701180650,"version":"3.30.2"},"reference-count":36,"publisher":"MJS Publishing, Medical Journals Sweden AB","license":[{"start":{"date-parts":[[2024,9,20]],"date-time":"2024-09-20T00:00:00Z","timestamp":1726790400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["ActaO"],"abstract":"<jats:p>Background and purpose:\u00a0Healthcare systems globally are grappling with resource constraints and rising costs. Concerns have been raised about \u201clow-value\u201d care, which consumes healthcare resources without benefiting patients. We aimed to examine regional differences in common low-value musculoskeletal surgeries in Finland and explore explanatory factors behind the variation.Methods:\u00a0Using data from the Finnish Care Register for Health Care, surgeries conducted from 2006\u20132007 compared with 2020\u20132021 were analyzed across 20 hospital districts. Selected surgeries (acromioplasty, rotator cuff repair, partial meniscectomy, wrist arthroscopy, ankle arthroscopy, and distal radius fracture fixation) were categorized based on NOMESCO procedure codes, and incidence rates in older populations were calculated based on population size derived from Statistics Finland.Results:\u00a0We found substantial regional disparities in low-value surgeries. The incidence rates were higher in hospitals with high historical incidence rates and smaller population sizes, suggesting that the uptake of evidence is slower in small non-academic hospitals.Conclusion:\u00a0The incidence of low-value surgery is declining but regional differences remain large. It is unlikely that regional variation in disease incidence explains such large variation in low-value surgery. Instead, local treatment culture seems to be the driving force behind low-value surgery, and the practices seem to be more entrenched in small hospitals.<\/jats:p>","DOI":"10.2340\/17453674.2024.41930","type":"journal-article","created":{"date-parts":[[2024,9,20]],"date-time":"2024-09-20T11:30:07Z","timestamp":1726831807000},"source":"Crossref","is-referenced-by-count":4,"title":["Regional variation in low-value musculoskeletal surgery: a nationwide study from the Finnish Care Register"],"prefix":"10.2340","volume":"95","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5026-4560","authenticated-orcid":false,"given":"Ville","family":"Ponkilainen","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anniina","family":"Laurema","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ville M","family":"Mattila","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Teemu","family":"Karjalainen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1183","published-online":{"date-parts":[[2024,9,20]]},"reference":[{"key":"76472","unstructured":"Crosson F J. Change the microenvironment: delivery system reform essential to control costs. Mod Healthc 2009; 39: 20-21."},{"key":"76473","doi-asserted-by":"crossref","unstructured":"Saini V, Garcia-Armesto S, Klemperer D, Paris V, Elshaug A G, Brownlee S, et al. Drivers of poor medical care. Lancet 2017; 390: 178-90. doi: 10.1016\/S0140-6736(16)30947-3.","DOI":"10.1016\/S0140-6736(16)30947-3"},{"key":"76474","doi-asserted-by":"crossref","unstructured":"Lyu H, Xu T, Brotman D, Mayer-Blackwell B, Cooper M, Daniel M, et al. Overtreatment in the United States. PLoS One 2017; 12: e0181970. doi: 10.1371\/journal.pone.0181970.","DOI":"10.1371\/journal.pone.0181970"},{"key":"76475","doi-asserted-by":"crossref","unstructured":"Birkmeyer J D, Reames B N, McCulloch P, Carr A J, Campbell W B, Wennberg J E. Understanding of regional variation in the use of surgery. Lancet 2013; 382: 1121-9. doi: 10.1016\/S0140-6736(13)61215-5.","DOI":"10.1016\/S0140-6736(13)61215-5"},{"key":"76476","doi-asserted-by":"crossref","unstructured":"Blom A W, Donovan R L, Beswick A D, Whitehouse M R, Kunutsor S K. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021; 374: n1511. doi: 10.1136\/bmj.n1511.","DOI":"10.1136\/bmj.n1511"},{"key":"76477","doi-asserted-by":"crossref","unstructured":"Karjalainen T V, Jain N B, Heikkinen J, Johnston R V, Page C M, Buchbinder R, et al. Surgery for rotator cuff tears. Cochrane Database Syst Rev 1996; 2019. doi: 10.1002\/14651858.CD013502.pub2.","DOI":"10.1002\/14651858.CD013502"},{"key":"76478","doi-asserted-by":"crossref","unstructured":"Karjalainen T V, Jain N B, Page C M, L\u00e4hdeoja T A, Johnston R V, Salamh P, et al. Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev 2019; 1(1): CD005619. doi: 10.1002\/14651858.CD005619.pub3.","DOI":"10.1002\/14651858.CD005619.pub3"},{"key":"76479","doi-asserted-by":"crossref","unstructured":"Sihvonen R, Paavola M, Malmivaara A, It\u00e4l\u00e4 A, Joukainen A, Nurmi H, et al. Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Ann Rheum Dis 2018; 77: 188. doi: 10.1136\/annrheumdis-2017-211172.","DOI":"10.1136\/annrheumdis-2017-211172"},{"key":"76480","doi-asserted-by":"crossref","unstructured":"Sihvonen R, Paavola M, Malmivaara A, It\u00e4l\u00e4 A, Joukainen A, Nurmi H, et al. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med 2013; 369: 2515-24. doi: 10.1056\/NEJMoa1305189.","DOI":"10.1056\/NEJMoa1305189"},{"key":"76481","doi-asserted-by":"crossref","unstructured":"Ochen Y, Peek J, van der Velde D, Beeres F J P, van Heijl M, Groenwold R H H, et al. Operative vs nonoperative treatment of distal radius fractures in adults: a systematic review and meta-analysis. JAMA Network Open 2020; 3: e203497-e203497. doi: 10.1001\/jamanetworkopen.2020.3497.","DOI":"10.1001\/jamanetworkopen.2020.3497"},{"key":"76482","doi-asserted-by":"crossref","unstructured":"Huttunen T T, Kannus P, Rolf C, Fell\u00e4nder-Tsai L, Mattila V M. Acute achilles tendon ruptures: incidence of injury and surgery in Sweden between 2001 and 2012. Am J Sports Med 2014; 42: 2419-23. doi: 10.1177\/0363546514540599.","DOI":"10.1177\/0363546514540599"},{"key":"76483","doi-asserted-by":"crossref","unstructured":"Huttunen T T, Launonen A P, Berg H E, Lepola V, Fell\u00e4nder-Tsai L, Mattila V M. Trends in the incidence of clavicle fractures and surgical repair in Sweden: 2001\u20132012. J Bone Joint Surg Am 2016; 98: 1837-42. doi: 10.2106\/JBJS.16.00027.","DOI":"10.2106\/JBJS.15.01284"},{"key":"76484","doi-asserted-by":"crossref","unstructured":"Huttunen T T, Launonen A P, Pihlajam\u00e4ki H, Kannus P, Mattila V M. Trends in the surgical treatment of proximal humeral fractures: a nationwide 23-year study in Finland. BMC Musculoskelet Disord 2012; 13: 261. doi: 10.1186\/1471-2474-13-261.","DOI":"10.1186\/1471-2474-13-261"},{"key":"76485","doi-asserted-by":"crossref","unstructured":"Karelson M C, Jokihaara J, Launonen A P, Huttunen T, Mattila V M. Lower nationwide rates of arthroscopic procedures in 2016 compared with 1997 (634925 total arthroscopic procedures): has the tide turned? Br J Sports Med 2020; 55: 1018-23. doi: 10.1136\/bjsports-2020-102569.","DOI":"10.1136\/bjsports-2019-101844"},{"key":"76486","doi-asserted-by":"crossref","unstructured":"Mattila V M, Huttunen T T, Haapasalo H, Sillanp\u00e4\u00e4 P, Malmivaara A, Pihlajam\u00e4ki H. Declining incidence of surgery for Achilles tendon rupture follows publication of major RCTs: evidence-influenced change evident using the Finnish registry study. Br J Sports Med 2015; 49: 1084-6. doi: 10.1136\/bjsports-2014-094379.","DOI":"10.1136\/bjsports-2013-092756"},{"key":"76487","doi-asserted-by":"crossref","unstructured":"Mattila V M, Huttunen T T, Sillanp\u00e4\u00e4 P, Niemi S, Pihlajam\u00e4ki H, Kannus P. Significant change in the surgical treatment of distal radius fractures: a nationwide study between 1998 and 2008 in Finland. J Trauma 2011; 71: 939-43. doi: 10.1097\/TA.0b013e31821e4a4d.","DOI":"10.1097\/TA.0b013e3182231af9"},{"key":"76488","doi-asserted-by":"crossref","unstructured":"Mattila V M, Sihvonen R, Paloneva J, Fell\u00e4nder-Tsai L. Changes in rates of arthroscopy due to degenerative knee disease and traumatic meniscal tears in Finland and Sweden. Acta Orthop 2016; 87: 5-11. doi: 10.1080\/17453674.2015.1121707.","DOI":"10.3109\/17453674.2015.1066209"},{"key":"76489","doi-asserted-by":"crossref","unstructured":"Poolman R W, Petrisor B A, Marti R K, Kerkhoffs G M, Zlowodzki M, Bhandari M. Misconceptions about practicing evidence-based orthopedic surgery. Acta Orthop 2007; 78: 2-11. doi: 10.1080\/17453670610013483.","DOI":"10.1080\/17453670610013358"},{"key":"76490","doi-asserted-by":"crossref","unstructured":"Dijkman B G, Kooistra B W, Pemberton J, Sprague S, Hanson B P, Bhandari M. Can orthopedic trials change practice? A survey of 796 orthopedic surgeons on the possible findings of a hip fracture trial. Acta Orthop 2010; 81: 122-5. doi: 10.3109\/17453671003587082.","DOI":"10.3109\/17453671003587093"},{"key":"76491","doi-asserted-by":"crossref","unstructured":"M\u00e4ntym\u00e4ki H, Ponkilainen V T, Huttunen T T, Mattila V M. Regional variations in lumbar spine surgery in Finland. Arch Orthop Trauma Surg 2021: 1-8. doi: 10.1007\/s00402-021-03895-8.","DOI":"10.1007\/s00402-021-04313-0"},{"key":"76492","doi-asserted-by":"crossref","unstructured":"Sund R. Quality of the Finnish Hospital Discharge Register: a systematic review. Scand J Public Health 2012; 40: 505-15. doi: 10.1177\/1403494812456637.","DOI":"10.1177\/1403494812456637"},{"key":"76493","unstructured":"Official Statistics Finland. Population structure statistics; 2024. Available from: https:\/\/pxdata.stat.fi\/PxWeb\/pxweb\/en\/StatFin\/StatFin__vaerak\/statfin_vaerak_pxt_11rd.px\/"},{"key":"76494","unstructured":"NOMESCO Classification of Surgical Procedures (NCSP), Version 1.14; 2009. Available from: https:\/\/norden.diva-portal.org\/smash\/get\/diva2:970548\/FULLTEXT01.pdf"},{"key":"76495","doi-asserted-by":"crossref","unstructured":"O\u2019Connor D, Johnston R V, Brignardello-Petersen R, Poolman R W, Cyril S, Vandvik P O, et al. Arthroscopic surgery for degenerative knee disease (osteoarthritis including degenerative meniscal tears). Cochrane Database Syst Rev 1996; 2022. doi: 10.1002\/14651858.CD014960.pub2.","DOI":"10.1002\/14651858.CD014328"},{"key":"76496","doi-asserted-by":"crossref","unstructured":"Karjalainen V-L, Harris I A, R\u00e4is\u00e4nen M, Karjalainen T. Minimal invasions: is wrist arthroscopy supported by evidence? A systematic review and meta-analysis. Acta Orthop 2023; 94: 200. doi: 10.2340\/17453674.2023.1321.","DOI":"10.2340\/17453674.2023.11957"},{"key":"76497","doi-asserted-by":"crossref","unstructured":"Glazebrook M A, Ganapathy V, Bridge M A, Stone J W, Allard J-P. Evidence-based indications for ankle arthroscopy. Arthroscopy 2009; 25: 1478-90. doi: 10.1016\/j.arthro.2009.04.082.","DOI":"10.1016\/j.arthro.2009.05.001"},{"key":"76498","doi-asserted-by":"crossref","unstructured":"Linnanm\u00e4ki L, Hevonkorpi T, Repo J, Karjalainen T. Anterior locking plate versus non-operative treatment in different age groups with distal radial fractures: a systematic review and meta-analysis. J Hand Surg Eur 2023; 48: 532-43. doi: 10.1177\/17531934231163889.","DOI":"10.1177\/17531934221143636"},{"key":"76499","unstructured":"Statistics Finland. Available from: https:\/\/stat.fi\/index_en.html,StatisticsFinland,Helsinki"},{"key":"76500","doi-asserted-by":"crossref","unstructured":"Ulm K. Simple method to calculate the confidence interval of a standardized mortality ratio (SMR). Am J Epidemiol 1990; 131: 373-75. doi: 10.1093\/oxfordjournals.aje.a115507.","DOI":"10.1093\/oxfordjournals.aje.a115507"},{"key":"76501","doi-asserted-by":"crossref","unstructured":"Ponkilainen V T, Uimonen M, Sihvonen R, Partio N, Paloneva J, Mattila V M. Evaluation of the changes in incidence and patient age of knee arthroscopy along with changes in time between knee arthroscopy and arthroplasty between 1998 and 2018: a nationwide register study. Knee Surg Relat Res 2023; 35: 19. doi: 10.1186\/s43019-023-00191-2.","DOI":"10.1186\/s43019-023-00194-2"},{"key":"76502","doi-asserted-by":"crossref","unstructured":"Paloneva J, Lepola V, \u00c4\u00e4rimaa V, Joukainen A, Ylinen J, Mattila V M. Increasing incidence of rotator cuff repairs: a nationwide registry study in Finland. BMC Musculoskelet Disord 2015; 16: 1-6. doi: 10.1186\/s12891-015-0727-9.","DOI":"10.1186\/s12891-015-0639-6"},{"key":"76503","unstructured":"Haukka J. mapsFinland: A data set containing map of Finland with hospital district (sairaanhoitopiiri) boundaries; 2024. Available from: https:\/\/cran.r-project.org\/web\/packages\/mapsFinland\/mapsFinland.pdf"},{"key":"76504","doi-asserted-by":"crossref","unstructured":"Poolman R W, Verheyen C C, Kerkhoffs G M, Bhandari M, Sch\u00fcnemann H J. From evidence to action: understanding clinical practice guidelines. Acta Orthop 2009; 80: 113-18. doi: 10.1080\/17453670902807408.","DOI":"10.1080\/17453670902807458"},{"key":"76505","doi-asserted-by":"crossref","unstructured":"Sajid I M, Parkunan A, Frost K. Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ Open Qual 2021; 10. doi: 10.1136\/bmjoq-2020-001253.","DOI":"10.1136\/bmjoq-2020-001287"},{"key":"76506","doi-asserted-by":"crossref","unstructured":"van Oudenaarde K, Swart N M, Bloem J L, Bierma-Zeinstra S M A, Algra P R, Bindels P J E, et al. General practitioners referring adults to MR imaging for knee pain: a randomized controlled trial to assess cost-effectiveness. Radiology 2018; 288: 170-6. doi: 10.1148\/radiol.2018172877.","DOI":"10.1148\/radiol.2018171383"},{"key":"76507","doi-asserted-by":"crossref","unstructured":"van Schie P, van Bodegom-Vos L, Zijdeman T M, Nelissen R, Marang-van de Mheen P J. Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial. BMJ Qual Saf 2023; 32: 34-46. doi: 10.1136\/bmjqs-2021-014062.","DOI":"10.1136\/bmjqs-2021-014472"}],"container-title":["Acta Orthopaedica"],"original-title":[],"link":[{"URL":"https:\/\/actaorthop.org\/actao\/article\/download\/41930\/47686","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/actaorthop.org\/actao\/article\/download\/41930\/47742","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/actaorthop.org\/actao\/article\/download\/41930\/47743","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/actaorthop.org\/actao\/article\/download\/41930\/47686","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,12,19]],"date-time":"2024-12-19T02:03:30Z","timestamp":1734573810000},"score":1,"resource":{"primary":{"URL":"https:\/\/actaorthop.org\/actao\/article\/view\/41930"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,9,20]]},"references-count":36,"URL":"https:\/\/doi.org\/10.2340\/17453674.2024.41930","relation":{},"ISSN":["1745-3682","1745-3674"],"issn-type":[{"type":"electronic","value":"1745-3682"},{"type":"print","value":"1745-3674"}],"subject":[],"published":{"date-parts":[[2024,9,20]]}}}