Variation in Utilization of Physical Therapist and Occupational Therapist Services After Rotator Cuff Repair: A Population-Based Study

Abstract

Objective

The objective of this study was to describe the utilization of physical therapist and occupational therapist services after rotator cuff repair (RCR) and examine variation in rehabilitation characteristics by profession.

Methods

This retrospective cohort study used the IBM MarketScan Commercial Claims and Encounters database. Eligible patients were 18 to 64 years old and had undergone outpatient RCR between 2017 and 2020. Physical therapist and occupational therapist services were identified using evaluation and treatment codes with profession-specific modifiers (“GP” or “GO”). Factors predicting utilization of formal rehabilitation and physical therapist versus occupational therapist services were examined; and univariable and multivariable analyses of days to initiate therapy, number of visits, and episode length by profession were completed.

Results

Among 53,497 patients with an RCR, 81.2% initiated formal rehabilitation (93.8% physical therapist, 5.2% occupational therapist, 1.0% both services). Patients in the Northeast and West (vs the South) were less likely to receive rehabilitation (odds ratio [OR] = 0.67 to 0.70) and less likely to receive occupational therapist services (OR = 0.39). Patients living in the Midwest (versus the South) were less likely to receive rehabilitation (OR = 0.79) but more likely to receive occupational therapist services (OR = 1.51). Similarly, those living in a rural (versus urban) area were less likely to utilize rehabilitation (OR = 0.89) but more likely to receive occupational therapist services (OR = 2.21). Additionally, receiving occupational therapist instead of physical therapist services was associated with decreased therapist visits (−16.89%), days to initiate therapy (−13.43%), and episode length (−13.78%).

Conclusion

Most patients in our commercially insured cohort utilized rehabilitation services, with a small percentage receiving occupational therapist services. We identified profession-specific variation in utilization characteristics that warrants further examination to understand predictors and associated outcomes.

Impact

Variation in rehabilitation utilization after RCR, including profession-specific and regional differences, may indicate opportunities to improve standardization and quality of care.

Introduction

Rotator cuff pathology is a prevalent condition, resulting in pain and functional limitations that may benefit from rotator cuff repair (RCR) to improve quality of life and reduce societal burden.^1,2 Rates of RCR surgery are increasing,^3–6 with implications for health care costs. Formal rehabilitation is a substantial driver of episode costs after RCR,⁷ warranting attention in the context of value-based initiatives. There is debate about the need for formal rehabilitation services versus self-directed programs after RCR.^8–11 Compared to physical therapists, orthopedic surgeons are less likely to endorse the need for formal rehabilitation and more likely to perceive a decreased role for rehabilitation with technological advances and shifting reimbursement patterns.¹² There is also limited consensus on the specific characteristics of rehabilitation after RCR, such as frequency and timing of initiating mobilization,^12–14 which may result in substantial variation in service delivery. Variation has previously been documented in other non-RCR upper extremity conditions by factors such as geographic region, year, facility type, and referring physician characteristics.^15–18

Adding to the complexity of variation in RCR rehabilitation utilization is the potential involvement of both physical and occupational therapists. Although physical therapists are the dominant musculoskeletal rehabilitative providers, certified hand therapists who provide specialty rehabilitative care to the upper extremity (ie, including the shoulder girdle) are primarily occupational therapists.¹⁹ Within hand therapy, the complementary expertise of each parent profession is merged, with physical and occupational therapists addressing similar treatment goals and providing similar interventions.²⁰ Better understanding of profession-specific utilization patterns can guide standardization of care within and between professions. Similarly, utilization has been examined for orthopedic surgeons versus neurosurgeons in the spine surgery context²¹; podiatrists versus orthopedic surgeons in the foot and ankle surgery context²²; and orthopedic, general, and plastic surgeons in the hand surgery context.²³

We therefore aimed to describe utilization of formal rehabilitation after RCR, including specifically receipt of physical therapist versus occupational therapist services, in a national cohort of adults who were commercially insured. Additionally, we aimed to examine variation in characteristics of rehabilitation utilization by profession, including number of therapist visits, days to initiate therapy, and episode length.

Methods

Design and Cohort

For this retrospective cohort study, we used the IBM MarketScan Commercial Claims and Encounters database, which includes data from patients with commercial insurance. The full cohort included adults who were 18 to 64 years old, had undergone outpatient RCR in 2017 to 2020, and had continuous enrollment in the insurance database for 12 months before and after their RCR surgery (Figure). Both inpatient and outpatient claims were searched for an RCR to ensure identification of the first surgery per patient in the study time frame (with a 12-month look back into 2016 for patients with an index surgery in 2017), but only patients with an index outpatient RCR were included in the cohort. Inpatient RCRs were excluded as they are far less common in this age group⁴ and may reflect clinical complexity that would warrant variation in rehabilitation characteristics. Surgical procedures were identified using International Classification of Diseases, Tenth Revision (ICD-10), procedure codes and Current Procedural Terminology (CPT) codes based on a previous RCR study using MarketScan data²⁴ (Suppl. Tab. 1). Patients had to have an accompanying ICD-10 diagnosis code on the surgery date reflecting a rotator cuff tear (Suppl. Tab. 2). To examine profession-specific variation, we also created a “broad rehabilitation cohort” and a “strict rehabilitation cohort,” which were limited to patients who initiated either physical therapist or occupational therapist services (but not both) within 90 days of the RCR. These cohorts differed on the basis of how rehabilitation was identified in the dataset as described in the following section (Figure). We used the Strengthening the Reporting of Observational Studies in Epidemiology statement to guide reporting.²⁵

Variables of Interest

All dates of service with formal rehabilitation within 0 to 365 days after surgery were identified in outpatient claims using rehabilitation CPT codes accompanied by a relevant shoulder-related diagnosis code (Suppl. Tabs 3 and 4). If both physical therapist and occupational therapist services were identified on the same date of service, those dates of service were not extracted (<1% of dates of service with rehabilitation codes). Patients are unlikely to receive dual services for the same condition on the same date, suggesting a coding error. Additionally, that visit could not be categorized as either physical therapy or occupational therapy for our analyses. To increase confidence that the rehabilitation services were associated with the index RCR, the first date of service had to be within 90 days of the surgery. If a break of ≥45 days was noted between dates of service, the last date before that break was considered the end of the episode of care.

For the full cohort and broad rehabilitation cohort, physical therapist and occupational therapist services were identified using profession-specific evaluation codes regardless of CPT modifiers or treatment CPT codes limited to those with accompanying “GP” (ie, physical therapy) and “GO” (ie, occupational therapy) modifiers to distinguish between the professions. A broader definition of physical and occupational therapy was used here to better estimate the actual proportion of patients with RCR receiving any rehabilitation services in the population. For the strict rehabilitation cohort, physical therapist and occupational therapist services were identified using the same evaluation and treatment CPT codes, but all codes (including evaluation) were limited to those with “GP” or “GO” modifiers. The variables of interest in the strict rehabilitation cohort were therapist visits (ie, number of unique dates of service with rehabilitation-related codes in the episode of care), days to initiate therapy (ie, days between the RCR surgery date and first therapist visit), and episode length (ie, number of days between the first and last therapist visit). The use of a stricter definition of physical therapy and occupational therapy to examine the more granular rehabilitation characteristics was supported by the data. Using the broader rehabilitation definition, 44.5% of patients were classified as receiving a single visit, whereas only 5.9% of patients were classified as receiving a single visit using the stricter rehabilitation cohort. The former estimate is likely not reflective of clinical practice patterns, instead reflecting cases where profession-specific CPT modifiers were not documented in the claims data. In such instances, only the dates of service where evaluation (but not treatment) codes were billed were extracted, inflating the proportion of single visits and underestimating the episode length if using the broad rehabilitation definition.

Demographic variables included age group (18–34, 35–44, 45–54, and 55–64 years), sex (male and female), health insurance (preferred provider organization, health maintenance organization, consumer-driven health plan, high-deductible health plan, point of service, and other), geographic region of the beneficiary’s residence as categorized in the database (Northeast, Midwest, South, and West), and rural area of the beneficiary’s residence based on a listing for a nonmetropolitan statistical area in the database.²⁶ Clinical covariates included open versus arthroscopic surgery (Suppl. Tab. 1), year of the RCR surgery, and Charlson-Deyo Comorbidity Index,²⁷ smoking,²⁸ and obesity²⁹ as defined on the basis of ICD-10 diagnosis codes within 12 months before the RCR surgery claim (Suppl. Tab. 5).

Data Analysis

Within the full cohort, we summarized the proportion of patients who initiated formal rehabilitation, including the proportion initiating physical therapist services, occupational therapist services, or both. Sociodemographic and clinical factors were compared on the basis of the initiation of formal rehabilitation (yes/no) in the full cohort as well as between those who received occupational therapist versus physical therapist services in the broad and strict rehabilitation cohorts. Standardized differences (STDs) with a threshold of >0.100 reflecting significant between-group differences were used instead of P values because of the large sample size in which statistical significance can easily be reached.³⁰ Within the strict rehabilitation cohort, we summarized the number of visits, days to initiate therapy, and episode length in days using medians and interquartile ranges (IQRs) because of positively skewed variables and completed univariable comparisons by profession using STDs.

Using a multivariable logistic regression model, we examined the association between demographic and clinical factors and utilization of any rehabilitation services (yes/no) in the full cohort and utilization of occupational therapist versus physical therapist services in both the broad rehabilitation (primary) and the strict rehabilitation (secondary) cohorts. We report adjusted point estimates, including odds ratios (ORs) and 95% CIs as well as predicted probabilities (predictive margins with 95% CIs using the Margins macro; SAS Institute, Cary, NC, USA). In the strict rehabilitation cohort, we used a generalized linear model with a γ distribution and a log link to address positively skewed data and examine the adjusted associations between profession and number of visits, days to initiate therapy, and episode length. We report percent differences and 95% CIs as well as adjusted means (predictive margins with 95% CIs using the Margins macro). We also examined the interaction between profession and region in the multivariable generalized linear models but only retained that more complex model if the interaction was significant. A 2-tailed P value threshold of <.05 indicated statistical significance in the multivariable models. In the multivariable models, observations were deleted with missing covariates, and no imputation was performed secondary to a small amount of missing data (<2%). All statistical analyses were performed using SAS v9.4 (SAS Institute, Cary, NC, USA).

We completed 2 sensitivity analyses with the strict rehabilitation cohort. The first sensitivity analysis limited the cohort to those with an RCR surgery from January 1, 2017 to March 31, 2019, to avoid potential effects of COVID-19 during the 12-month follow-up period that could introduce bias. Specifically, we summarized the number of visits, days to initiate therapy, and episode length using medians and IQRs in this time-restricted cohort. Univariable and multivariable analyses were only planned if these descriptive statistics were qualitatively different from those in the original rehabilitation cohort. The second sensitivity analysis examined the adjusted associations between profession and number of visits, days to initiate therapy, and episode length in a propensity score–matched cohort secondary to a large imbalance in the group sizes. Specifically, we matched 1 patient receiving occupational therapist services with up to 3 patients receiving physical therapist services on all demographic and clinical variables.

Results

Initiation of Any Formal Rehabilitation

The full cohort included 53,497 patients with an RCR, of whom 81.2% (n = 43,462) initiated formal rehabilitation services. Of the patients who initiated rehabilitation, 93.8% received physical therapist services only, 5.2% received occupational therapist services only, and 1.0% received both physical therapist and occupational therapist services during the episode of care. In univariable analyses, patients who initiated rehabilitation differed in their health insurance (STD = 0.142) and geographic region (STD = 0.145) from those who did not initiate rehabilitation (Tab. 1). In multivariable analyses, older age was associated with increased utilization of rehabilitation compared to those who were 18 to 34 years old (OR = 1.43 to 1.57 [P < .001; 4- to 6-point difference in probabilities]) (Tab. 2). Having health maintenance organization or point-of-service insurance was associated with decreased utilization of rehabilitation compared to having preferred provider organization insurance (OR = 0.70 to 0.78 [P < .001; 4- to 6-point difference in probabilities]). Those living in the Northeast, Midwest, and West (vs the South) had decreased odds of receiving formal rehabilitation (OR = 0.67 to 0.79 [P < .001; 4- to 6-point difference in probabilities]). Additionally, living in a rural region was associated with decreased rehabilitation utilization (OR = 0.89 [95% CI = 0.85 to 0.94; P < .001; 2-point difference in probabilities]). Surgery in 2019 or 2020 (vs 2017) was associated with increased odds of rehabilitation (OR = 1.15 to 1.17 [P < .001; 1- to 2-point difference in probabilities]). Similarly, arthroscopic versus open surgery was associated with increased rehabilitation utilization (OR = 1.26 [95% CI = 1.18 to 1.33; P < .001; 4-point difference in probabilities]). Finally, more comorbidities or smoking was also associated with decreased utilization of rehabilitation (OR = 0.80 to 0.93 [P = .01 to P < .001; 1- to 4-point difference in probabilities]) (Tab. 2).

Utilization of Occupational Therapist Versus Physical Therapist Services

The broad rehabilitation cohort included 43,033 patients, of whom 94.7% (n = 40,763) received physical therapist services and 5.3% (n = 2270) received occupational therapist services. In univariable analyses, health insurance (STD = 0.104), geographic region (STD = 0.434), rural area (STD = 0.362), and procedure type (STD = 0.131) differed significantly between patients receiving occupational versus physical therapist services (Tab. 1). In multivariable analyses, male patients were less likely to receive occupational therapy (OR = 0.89 [95% CI = 0.81 to 0.97; P = .01; 1-point difference in probabilities]) (Tab. 3). Compared to those with a preferred provider organization insurance plan, those with a health maintenance organization (OR = 0.76 [95% CI = 0.65 to 0.88; P = .001]) or consumer-driven health plan (OR = 0.80 [95% CI = 0.70 to 0.91; P = .001]) had decreased utilization of occupational therapist versus physical therapist services (1-point difference in probabilities). Compared to the South, the Northeast (OR = 0.39 [95% CI = 0.33 to 0.47; P < .001]) and West (OR = 0.39 [95% CI = 0.32 to 0.47; P < .001]) was associated with significantly decreased odds of utilizing occupational therapist versus physical therapist services (4-point difference in probabilities). In contrast, the Midwest (vs the South) was associated with significantly increased odds of utilizing occupational therapist versus physical therapist services (OR = 1.51 [95% CI = 1.37 to 1.66; P < .001; 2-point difference in probabilities]). Additionally, patients living in rural areas were more likely to receive occupational therapist services (OR = 2.21 [95% CI = 2.02 to 2.41; P < .001; 5-point difference in probabilities]). In contrast, those with an arthroscopic versus open RCR had decreased occupational therapist service utilization (OR = 0.75 [95% CI = 0.67 to 0.85; P < .001; 2-point difference in probabilities]). A Charlson–Deyo Comorbidity Index score of 3+ (vs 0; OR = 1.18 [95% CI = 1.01 to 1.37; P = .04])) and smoking (OR = 1.16 [95% CI = 1.01 to 1.34; P = .04]) were associated with increased odds of occupational therapist versus physical therapist services (1-point difference in probabilities) (Tab. 3). Findings for utilization of occupational therapist and physical therapist services were overall similar in the strict rehabilitation cohort (n = 22,250; 94.3% physical therapist and 5.7% occupational therapist services). However, there was also a significant univariable difference in Charlson–Deyo Comorbidity Index score by profession (STD = 0.115) (Suppl. Tab. 6), there was no longer a significant adjusted association for sex, and the only significant adjusted association for insurance was high-deductible health plan versus preferred provider organization (Suppl. Tab. 7).

Differences in Characteristics of Rehabilitation Utilization by Profession

In the strict rehabilitation cohort, the median number of therapist visits for both professions combined was 19 (IQR = 10 to 28), median days to initiate therapy was 16 (IQR = 7 to 31), and the median episode length was 85 days (IQR = 54 to 120). The number of physical therapist visits ranged from 1 to 133, with 5.7% (n = 1190) of patients receiving a single visit only. The number of occupational therapist visits ranged from 1 to 82, with 9.2% (n = 116) of patients receiving a single visit only. Additionally, number of therapist visits (STD = 0.264), days to initiate therapy (STD = 0.194), and episode length (STD = 0.251) differed significantly by profession (Tab. 4). In the sensitivity analysis limited to surgeries from January 2017 to March 2019 (n = 11,590), characteristics of rehabilitation utilization were qualitatively similar to those in the full time frame (Suppl. Tab. 8).

In multivariable models, number of therapist visits, days to initiate therapy, and episode length all significantly differed by profession in multivariable models (Tab. 5). Specifically, those receiving occupational therapist services had fewer visits (−16.89% [95% CI = −20.56 to −13.06; P < .001]), fewer days to initiate therapy (−13.43% [95% CI = −19.62 to −6.77; P < .001]), and a shorter episode length (−13.78% [95% CI = −17.58 to −9.81; P < .001]).

There was a significant interaction between profession and region for days to initiate therapy (P < .001). On average, time to initiate therapy was shorter for occupational therapy versus physical therapy in the Midwest and the West, similar in the South, and slightly longer in the Northeast. There was also a significant interaction between profession and region for episode length (P = .049). Although average episode length was shorter for occupational therapy in all regions, this profession-specific difference was smallest for the West (−6.84 days) and largest for the Northeast (−24.29 days). The sensitivity analysis using the propensity score–matched cohort (n = 5760) identified a similar pattern of findings between profession and characteristics of rehabilitation utilization (Suppl. Tab. 9).

Discussion

This study investigated utilization of formal rehabilitation after outpatient RCR, including receipt of occupational therapist versus physical therapist services. Most patients in our cohort initiated formal rehabilitation services. The current estimate of 81.2% of patients initiating formal rehabilitation within 90 days after RCR is comparable to a previous estimate of 79.6% to 81.6% in a commercially insured cohort in 2007 to 2010.³¹ Additionally, only a small percentage of our cohort had a single therapist visit, suggesting that most patients received formal services that extended beyond instruction in an independent home program. Given the postoperative context, it is likely that most of our patients who received formal rehabilitation began the episode through an orthopedic surgeon referral versus other pathways (eg, direct access). A consensus statement in the American Academy of Orthopaedic Surgeons clinical practice guidelines supports formal rehabilitation compared to independent exercise in “some patients” after RCR.¹¹ Although no specific guidance is provided as to who should receive formal rehabilitation, our finding of >75% incidence of initiating formal rehabilitation may reflect greater referral at the population level than suggested per expert recommendation. Simultaneously, the finding of decreased odds of utilizing formal rehabilitation in those with increased comorbidities may reflect an unmet need for services in some patient subgroups, given overall increased complications and slower recovery in patients with various medical comorbidities.^32,33 Similarly, decreased utilization of formal rehabilitation in rural areas may reflect barriers to access in some patients.

Among those receiving formal rehabilitation, most services in this cohort were provided by physical therapists, which is not unexpected. In the United States, there are more than 1.5 times the number of physical versus occupational therapists.^34,35 Additionally, there is a high percentage of physical therapists practicing in orthopedics and sports per membership in the related academies of the American Physical Therapy Association.³⁶ Similarly, physical therapist board certification in orthopedics dominates certification in other specialties.³⁷ In contrast, musculoskeletal rehabilitation is not a dominant specialty in occupational therapy. Only 13% of occupational therapists report primary employment in free-standing outpatient settings, which would be the most common setting for hand therapist practice and subsequently RCR rehabilitation.³⁸ The finding that 1.0% of patients utilized both physical therapist and occupational therapist services on separate dates of service within a single episode may reflect care delivered specifically in hand therapy clinics. These clinics may switch patients between professions from session to session on the basis of therapist availability because of shared treatment goals and plans.

Although utilization of occupational therapist services had a low incidence in our cohort, it was still present in this population. This incidence should be considered when defining, identifying, and labeling postoperative shoulder rehabilitation in administrative claims studies where profession may be challenging to discern. Specifically, labeling services as physical therapy with CPT codes that are not profession-specific can be problematic.³⁹ Additionally, although hand therapists report treating (vs screening and/or referring) 72% of shoulder girdle patients they see in the clinic, which reflects comfort with management, they only report spending 17% of their direct patient care time treating the shoulder.²⁰ This pattern combined with our findings likely reflects limited shoulder referrals to hand therapy, which is dominated by occupational therapists.¹⁹ There is likely an opportunity to increase awareness among sports medicine, shoulder and elbow, and general orthopedic surgeons of the role of the hand therapy specialty and its parent profession of occupational therapy in shoulder rehabilitation. Although receipt of occupational therapist versus physical therapist services was already higher in our cohort for patients residing in rural areas, further flexibility in referrals to physical therapist or occupational therapist services after surgery may increase access for patients in geographic areas with limited rehabilitation providers.

We identified regional variation both in who initiated formal rehabilitation and who specifically utilized physical therapist versus occupational therapist services. At the profession level, workforce availability may not explain this pattern alone since there is overall similar geographic distribution of physical therapists and occupational therapists.^34,35 The Midwest (vs the South) may have a higher proportion of certified hand therapists per population, which may partially explain the pattern of increased odds of utilizing services from an occupational therapist (who comprise the majority of certified hand therapists¹⁹). However, the Northeast and West do not appear to have a lower proportion of certified hand therapists per population compared to the South, which could have explained the pattern of decreased odds of utilizing occupational therapy.⁴⁰ Further examination of regional variation in rehabilitation utilization after RCR is warranted, particularly as it relates to surgeon specialty concentration and referral patterns.

Additionally, we identified profession-specific variation in rehabilitation utilization characteristics of number of therapist visits, days to initiate therapy, and episode length. Although these differences persisted in multivariable analyses, we cannot determine if these reflect warranted or unwarranted variation given lack of clinical nuance (eg, range of motion, patient-reported outcome measures) in the administrative claims data.⁴¹ Additionally, although occupational therapist services tended to occur earlier and for a shorter period of time, we cannot determine from these analyses whether these patterns reflect better or poorer quality of care delivery. However, the presence of variation may signal care that could be improved through standardization, such as via enhanced clinical practice guidelines. If there are opportunities to standardize care, multiple clinical decision-makers likely need to targeted.⁴² Some utilization characteristics, such as time to initiate therapy, likely are more directly affected by surgeon decision-making. In contrast, number of therapist visits or episode length likely are more directly affected by therapist decision-making. Disparate views between surgeons and therapists on optimal postoperative RCR rehabilitation characteristics may challenge standardization.¹²

These interpretations should be considered in the context of several limitations. Our findings for adults who were 18 to 64 years old and were commercially insured likely cannot be generalized to people who receive worker’s compensation, Medicare, or Medicaid or those who are uninsured because of both payer-related and patient-related differences.^31,43 We may also have over-attributed rehabilitation to the index RCR since it is possible that some therapist utilization was related to a contralateral shoulder condition. Additionally, our conclusions are reliant on accuracy of coding in the database, which is a recognized challenge for claims analyses.⁴⁴ Limiting rehabilitation claims to those with modifiers “GP” or “GO,” although necessary for our study aim, may have underrepresented utilization of rehabilitation services. The database only had 1 field available for the CPT modifier, limiting reporting of the profession-specific modifiers. Several rehabilitation CPT code combinations require application of modifier “59” to 1 of the codes per National Correct Coding Initiative Edits⁴⁵ to indicate provision of separate and distinct services. Therefore, even if the profession-specific modifier had been applied by the provider, modifier “59” may have replaced the “GP” and “GO” in the single available field. However, since modifier “59” is only applied to 1 of the codes in the eligible pair, the profession-specific modifier was likely present for at least 1 code in the claim on the date of service, increasing confidence in interpretations about number of therapist visits. Because of these challenges with code modifiers, we were unable to perform meaningful analyses of the number of units per session or proportion of types of codes billed (eg, physical agent modalities vs exercise/activity). Examining variation in these additional rehabilitation characteristics would be of interest to understand profession-specific service variation on a more granular level. Additionally, future research should consider aspects of patient financial burden (eg, copayments) and potential differences in covered visits or prior authorization procedures that may vary for physical therapist versus occupational therapist services and may contribute to between-profession differences in care delivery.

In conclusion, we identified a high rate of formal rehabilitation utilization at the population level after RCR, with approximately 5% of patients who received rehabilitation utilizing occupational therapist versus physical therapist services. We also identified variation in characteristics of rehabilitation utilization after RCR—including both profession-specific and regional differences—that may indicate opportunities to improve standardization and quality of care. Follow-up research that aims to better understand predictors and outcomes of variation in postoperative RCR rehabilitation is warranted.

Author Contributions

Conceptualization: B. Z. Stern, S. G. Anthony, J. N. Gladstone, J. Poeran

Formal analysis: B. Z. Stern, N. Zubizarreta

Writing – Original Draft: B. Z. Stern

Writing – Review and Editing: N. Zubizarreta, S. G. Anthony, J. N. Gladstone, J. Poeran

Supervision: J. N. Gladstone, J. Poeran

Funding

There are no funders to report for this study.

Ethics Approval

The data we used were deidentified, and this study did not require review from the Institutional Review Board at the institution where it was conducted.

Disclosures and Presentations

Dr Stern, Ms Zubizarreta, and Dr Poeran declare no conflicts of interest. Dr Anthony reports consulting fees from Smith & Nephew and Miach Orthopaedics, support for education from Gotham Surgical Solutions & Devices and Arthrex, and equity from the Manhattan Surgery Center outside of this submitted work. Dr Gladstone reports consulting fees from Depuy Synthes Sports Medicine and Trice Medical, stock options from Trice Medical, and royalties from Springer Verlag outside of this submitted work.

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no other conflicts of interest.

Preliminary findings of this study were presented at: the American Society of Hand Therapists Annual Meeting; October 13–16, 2022; Washington, DC.

References