Do the number of visits and the cost of musculoskeletal care improve outcomes? More may not be better

Key points

1. 01This was a secondary analysis of a 104-patient randomized trial of corticosteroid injection versus manual therapy plus exercise for subacromial pain syndrome, with 98 patients in the final analysis.
2. 02Patients were grouped into high responders (n=38) and low responders (n=60) based on 1-year change in the Shoulder Pain and Disability Index (SPADI).
3. 03Neither the number of shoulder visits nor the total cost of shoulder care was significantly associated with how much patients improved.
4. 04High responders got far more value: they spent 74% less per point of improvement and gained nearly 10 more SPADI points per visit than low responders.
5. 05More care is not necessarily better; many factors beyond the amount of care contribute to a good outcome.

How it was conducted

Design

Secondary analysis of a randomized clinical trial, using a fixed 2-group, 2-step cluster analysis

Participants

98 patients with subacromial pain syndrome treated at a US military hospital between June 2010 and March 2012

Groups

High responders (n=38, 38.8%) and low responders (n=60, 61.2%), grouped by 1-year SPADI change

Health care data

Shoulder-related visit counts and costs over 1 year, abstracted from the Military Health System data repository (military clinics only)

Primary outcome

Association of shoulder visits and cost with 1-year SPADI change, plus value (change per dollar and per visit)

Analysis

Negative binomial regression for visit counts and gamma generalized linear models for costs, unadjusted and adjusted for comorbidities and demographics

What they found

• Mean 1-year SPADI change across the full sample was 23.19 points; high responders changed 46.83 (SD 12.28) points versus 8.21 (SD 19.66) points for low responders.
• Shoulder visits did not differ significantly: 5.89 visits (95% CI: 4.35, 7.44) for high responders versus 6.30 visits (95% CI: 5.14, 7.46) for low responders.
• Shoulder care costs did not differ significantly: $1404.86 (95% CI: $1109.34, $1779.09) for high responders versus $1679.26 (95% CI: $1391.54, $2026.48) for low responders.
• Cost per 1-point SPADI change was $31.63 (95% CI: $24.21, $41.32) for high responders versus $120.85 (95% CI: $94.01, $155.36) for low responders, about 74% less for high responders.
• SPADI point change per shoulder visit was 12.23 (95% CI: 9.62, 14.84) for high responders versus 2.33 (95% CI: 0.25, 4.40) for low responders.
• High responders were significantly older (mean age 44.26, SD 11) than low responders (38.53, SD 11.53; P = .02); no other baseline characteristic differed significantly between groups.

Limitations

• The entire cohort was combined for analysis even though patients received 2 distinct treatments (corticosteroid injection or physical therapy), which may have different patterns of use.
• Changes were not captured at each session, so the study could not identify the point at which care reached a plateau or determine optimal dosing.
• The exact nature of each visit and the specific care delivered were unknown, limiting granular conclusions about which treatments and doses are best.
• This was a secondary analysis of a single trial in a military population, and patterns of use in a research study may differ from routine care.

Why it matters

For patients

For shoulder pain, more appointments or higher spending will not necessarily make you recover better, so quality and the right care matter more than quantity.

For clinicians

Track value, not just volume, when managing subacromial pain, since equal amounts of care can produce very different outcomes and added visits past a plateau may add cost without benefit.

For readers

This study reframes care around value (change per dollar and per visit) rather than the sheer amount of health care used.