Two hundred and fifty-two patients provided consent to participate in this study, in which 171 patients (68%) completed both the HAPSQ and the RC-QOL. Fifty-three patients made no attempt to complete either questionnaire (
n = 13 Calgary patients and
n = 40 Edmonton patients) and were lost to follow-up. Twenty-eight patients submitted only partially completed questionnaires (
n = 17 Calgary patients and
n = 11 Edmonton patients), in which only demographic information (Page 1) was completed. Information from these questionnaires was not analyzed. The resulting response rates for Calgary and Edmonton were 76% (
N = 126) and 60% (N = 126), respectively. The main reasons for non-participation were time and effort. Patient demographics and clinical characteristics are presented in Table
3. Overall, the study analyzed 84 questionnaires from Group 1 patients and 87 from Group 2 patients. The mean age for the group was 58 years (SD: 10; range 27–78). The patient population was 61% men (
n = 104), 89% Caucasian (
n = 152), and 20% retired (
n = 35). Thirty-three percent (
n = 56) reported an annual household income over $100,000. The mean duration of symptoms was 3 years (SD: 5.0; range 0.1–34). Calgary and Edmonton patients were statistically similar in sex [χ
2(1) = 0.14,
p = 0.71], ethnicity [χ
2(1) = 7.2,
p = 0.41], income [χ
2(1) = 3.9,
p = 0.79], working status [χ
2(1) = 0.81,
p = 0.40], age [
t(171) = − 0.56,
p = 0.58], and duration of symptoms [
t(171) = 0.55,
p = 0.13].
Table 3
Patient demographics and clinical characteristics
Age, mean (SD) y | 58 (10) | 57 (10) | 58 (9) |
Age, range | 27–78 | 27–78 | 38–75 |
Male: n (%) | 104 (61) | 59 (62) | 44 (59) |
Caucasian: n (%) | 152 (89) | 83 (86) | 69 (92) |
Retired: n (%) | 35 (20) | 22 (23) | 13 (17) |
RC-QOL Score (0–100), mean (SD) | 42 (22) | 43 (21) | 42 (23) |
RC-QOL Score, range | 0–95 | 5–95 | 0–91 |
Duration of symptoms: n (%) |
< 1 year | 66 (38) | 42 (43) | 24 (32) |
1 to 2 years | 25 (15) | 12 (13) | 13 (17) |
2 to 5 years | 55 (32) | 26 (27) | 29 (39) |
> 5 years | 25 (15) | 16 (17) | 9 (12) |
Income: n (%) |
< $25,000 | 10 (6) | 6 (6) | 4 (5) |
$25,000–49,999 | 12 (7) | 6 (6) | 6 (8) |
$50,000 – 74,999 | 21 (12) | 14 (15) | 7 (9) |
$75,000 – 99,999 | 20 (12) | 12 (13) | 8 (11) |
> $100,000 | 56 (33) | 34 (35) | 22 (29) |
Prefer not to say | 52 (30) | 24 (25) | 28 (38) |
Treatment: n (%) |
Group 1 | 84 (49) | 51 (53) | 33 (44) |
Group 2 | 87 (51) | 45 (47) | 42 (56) |
Accessibility
Table
4 provides the mean and median (med) waiting times for all waiting periods.
Table 4
Actual, suggested, and ideal waiting times (days)
Diagnostic imaging |
| X-ray | | 6 (11) | 3 (6) | 1 | 0–30 | 4 (6) | 1 | 0–30 | 2 (5) | 0 | 0–23 |
Ultrasound | | 11 (13) | 28 (31) | 15 | 0–180 | 23 (29) | 14 | 0–180 | 38 (33) | 30 | 0–120 |
MRI public | | 25 (27) | 103 (100) | 82 | 2–611 | 108 (126) | 60 | 2–611 | 94 (75) | 90 | 7–300 |
MRI private | | 17 (35) | 8 (8) | 4 | 0–30 | 10 (9) | 7 | 2–30 | 4 (5) | 3 | 0–14 |
Physician visits |
Primary care | ER | | 1 (1)a | 3 (2) a | 2 | 0–8 | 2 (2) | 2 | 0–6 | 3 (2) | 2 | 0–8 |
GP/Family | 0–7 | 5 (8) | 6 (7) | 3 | 0–30 | 6 (8) | 3 | 0–30 | 5 (7) | 2 | 0–30 |
Specialist | Sport Med. | 0–14 | 13 (9) | 37 (48) | 21 | 3–180 | 41 (55) | 20 | 3–180 | 28 (25) | 21 | 7–90 |
Surgeon | 42–84 | 36 (39) | 172 (191) | 122 | 7–1430 | 175 (232) | 62 | 7–1430 | 169 (119) | 153 | 7–638 |
Surgery | 84 | | 162 (194) | 92 | 10–1280 | 137 (159) | 64 | 30–730 | 188 (223) | 121 | 10–1280 |
Total wait time | | | 264 (248) | 183 | 14–1491 | 250 (271) | 146 | 14–1491 | 282 (215) | 247 | 17–1308 |
Group 1 | | | 157 (133) | 119 | 14–700 | 142 (142) | 91 | 14–700 | 180(114) | 167 | 17–372 |
Group 2 | | | 370 (287) | 317 | 24–1491 | 378 (327) | 237 | 31–1491 | 362(242) | 366 | 24–1308 |
The mean waiting time for ambulatory care was 3 h (SD: 2, med: 2, range: 0–8). The mean waiting time for consultation by a surgeon was 172 days (SD: 191, med: 122, range: 7–1430). An analysis of variance showed that this waiting time was significantly different when compared to the other physician groups [F (3, 298) = 65.7, p < 0.001)]. Tukey HSD post hoc test for significance indicated that the mean waiting time to see a surgeon was significantly higher when compared to general practitioner/family physician (mean: 6 days, SD: 7, med: 3, range: 0–30) and sport medicine physician (mean: 37 days, SD: 48, med: 21, range: 3–180).
The mean waiting time for diagnostic imaging is also presented in Table
4. An analysis of variance showed that the mean waiting time for magnetic resonance imaging (MRI) received in the public healthcare system (mean: 103 days, SD: 100, med: 82, range: 2–611) was significantly different when compared to x-ray (mean: 3 days, SD: 6, med: 1, range: 0–30), ultrasound (mean: 28 days, SD: 31, med: 15, range: 0–180), and MRI obtained through a private diagnostic clinic (mean: 8 days, SD: 8; med: 4; range: 0–30) [F (3, 349) = 22.2,
p < 0.001)]. Tukey HSD post hoc test for significance indicated that the mean waiting time for public MRI was significantly higher when compared to all other diagnostic tests.
The total mean waiting time for all patients was 264 days (SD: 248, med: 183, range: 14–1491). Although patients in Edmonton had slightly longer waiting times over Calgary, this number was not found to be significantly different. In fact, a comparison of all mean waiting times did not result in any significant differences between the two cities. There was a significant difference in total mean waiting time for Group 1 patients (mean: 157 days, SD: 133, med: 119, range: 14–700) compared to Group 2 patients (mean: 370 days, SD: 287, med: 317, range: 24–1491); [t(171) = − 6.2, p < 0.001)].
Of the 96 patients that received care at the University of Calgary Sport Medicine Centre, 21 patients (22%) were not residents of the city of Calgary. Of these, 10 were from rural townships not within areas surrounding Calgary (e.g., Okotoks, Airdrie). Of the 75 patients that received care at the University of Alberta Glen Sather Sports Medicine Clinic, 20 patients (27%) were not residents of the city of Edmonton. Of these, 7 patients were from rural townships not within areas surrounding Edmonton (e.g., St. Alberta, Sherwood Park).
Acceptability
Patient satisfaction with respect to quality of care and waiting times are presented in Table
5. The mean patient satisfaction with respect to quality of care was lowest for emergency room physicians at 62% (SD: 33) and highest for surgeons at 90% (SD: 21). An analysis of variance demonstrated that patient satisfaction with respect to quality of care provided by a surgeon was significantly different between the other physician groups [F (3, 339) = 12.9,
p < 0.001). Tukey HSD post hoc test for significance demonstrated that patient satisfaction for surgeons was significantly higher than emergency room physicians (
p < 0.001) and general practitioners/family physicians (
p = 0.01). A comparison of patient satisfaction between Calgary and Edmonton with respect to quality of care did not reveal a significant difference.
Table 5
Mean patient satisfaction percentiles with respect to quality of care and waiting times
Diagnostic imaging |
| X-ray | | 78 (29) | | 76 (30) | | 81 (28) |
| Ultrasound | | 57 (33) | | 59 (32) | | 51 (38) |
| MRI public | | 46 (37) | | 45 (35) | | 47 (39) |
| MRI private | | 74 (37) | | 65 (43) | | 93 (11) |
Physician provider |
Primary care | ER | 62 (33) | 54 (37) | 67 (27) | 55 (30) | 59 (36) | 53 (42) |
GP/Family | 80 (27) | 73 (31) | 81 (26) | 75 (29) | 77 (29) | 70 (32) |
Specialist | Sport Med. | 80 (24) | 73 (28) | 82 (23) | 77 (25) | 75 (27) | 67 (34) |
Surgeon | 90 (21) | 60 (35) | 89 (23) | 61 (34) | 90 (18) | 59 (36) |
The mean patient satisfaction with respect to waiting time for physician consultation was also lowest for emergency room physician at 54% (SD: 37). Both general practitioners/family physicians and sport medicine physicians had a mean of 73% (SD: 31 and SD: 28 respectively). An analysis of variance demonstrated that patient satisfaction with respect to waiting time suggested a significant difference between the physician groups [F (3, 339) = 12.9, p = 0.001). Tukey HSD post hoc test for significance demonstrated that the mean patient satisfaction for surgeons (60%, SD: 35) was significantly lower than general practitioners/family physicians (p = 0.01) and sport medicine physicians (p < 0.001). No significant differences were found between Calgary and Edmonton.
The mean patient satisfaction with respect to waiting time for diagnostic services was lowest for public MRI (mean: 46%, SD: 37) and highest for x-ray (mean: 78%, SD: 29). An analysis of variance indicated a significant difference between types of diagnostic imaging [F (4, 356) = 19.2, p < 0.001). Tukey HSD post hoc test for significance demonstrated that the mean patient satisfaction for public MRI was significantly lower than x-ray (p < 0.001) and private MRI (mean: 74%, SD: 37, p = 0.03), but not for ultrasound (mean: 57%, SD: 33, p = 0.14).
Efficiency
Utilization of provincial healthcare services are presented in Table
6. The mean number of physicians seen by patients was 2.50 (SD: 0.77; range: 2–7). Patients in Calgary most frequently sought care from general practitioners/family physicians (mean: 3.70, SD: 4.18); whereas patients in Edmonton most frequently sought care from sport medicine physicians (mean: 4.00, SD: 4.72). Patients in Calgary and Edmonton receiving care for their RCD used approximately an equivalent amount of diagnostic and physician services. The utilization difference between the two cities was statistically significant in Edmonton regarding the use of public MRI (
p = 0.02).
Table 6
Utilization of provincial healthcare services by patients with rotator cuff disorders
X-ray | 1.74 (1.50) | 1.63 (1.69) | 1.90 (1.14) | 0.28 | 0.86 |
Ultrasound | 1.17 (0.92) | 1.08 (0.83) | 1.36 (1.07) | 0.95 | 0.79 |
MRI (public) | 0.50 (0.59) | 0.41 (0.59) | 0.61 (0.57) | 0.02* | 0.67 |
Emergency room visits | 1.13 (0.42) | 1.08 (0.52) | 1.15 (0.37) | 0.67 | 0.94 |
GP/Family physician clinical visits | 3.52 (3.78) | 3.70 (4.18) | 3.30 (3.24) | 0.55 | 1.12 |
Sport medicine physician clinical visits | 3.54 (3.28) | 3.32 (2.47) | 4.00 (4.72) | 0.62 | 0.83 |
Surgeon clinical visits | 2.67 (2.57) | 2.51 (2.93) | 2.87 (2.06) | 0.37 | 0.87 |
Table
7 summarizes the average costs incurred by patients presenting with RCD in Alberta. The total aggregate average cost per patient was $4541.19 (SD: 2953.23). The total aggregate average cost for the Calgary group per patient was $3832.05 (SD: 2284.83) compared to $5448.91 (SD: 3368.47) for the Edmonton group (
p = 0.001). The Calgary group thus incurred 70% of the total cost of the Edmonton group. No significant cost difference was found with respect to provincial healthcare costs ($2392.86 vs $2794.98) for Calgary and Edmonton, respectively. However, there was a significant difference in costs incurred by the patient ($284.80 vs $528.89) and private insurance companies ($1154.39 vs $2125.04). Specifically, patients in Edmonton purchased more complementary allied medical treatments and rehabilitation appliances (e.g., Therabands, cold packs, exercise equipment).
Table 7
Patient, provincial healthcare, and insurance costs for patients with rotator cuff disorders
Patient | 391.86 (642.36) | 284.80 (385.93) | 528.89 (822.02) | 0.02 | 0.54 |
Provincial healthcare | 2569.22 (1721.58) | 2392.86 (1715.65) | 2794.98 (1714.08) | 0.17 | 0.86 |
Private insurance companies | 1580.11 (2016.03) | 1154.39 (1357.91) | 2125.04 (2536.48) | 0.003 | 0.54 |
Total | 4541.19 (2953.23) | 3832.05 (2284.83) | 5448.91 (3368.47) | 0.001 | 0.70 |
Appropriateness
A comparison of actual waiting times, healthcare resource utilization, and clinical care pathways to ideal clinical standards of care with respect to diagnostic imaging was performed. Benchmark waiting times for physician consultation and diagnostic services were suggested by patients and are presented in Table
4. The suggested mean waiting time for emergency room physician was one hour (SD: 1). The suggested mean waiting time for surgical consultation was 36 days (SD: 39). The suggested mean waiting times for emergency room physician [
t(33) = 4.0,
p < .001)], sport medicine physician [
t(30) = 2.8,
p = 0.01)] and surgeon [
t(171) = 5.7,
p < 0.001)] were significantly different when compared with their actual mean waiting times. The suggested mean waiting times for diagnostic services ranged from 6 days (SD: 11) for x-ray to 25 days (SD: 27) for public MRI. The suggested mean waiting times for ultrasound [
t(117) = 7.3, p < .001)] and public MRI [
t(77) = 6.5, p = 0.01)] were significantly different when compared with their actual waiting times.
Eubank et al., 2016 recommended that all patients suffering chronic, full-thickness rotator cuff tears require the following standard shoulder x-rays: true anteroposterior, axillary, and trans-scapular lateral views [
33]. Sixteen patients (9%) reported that they had not received any x-rays. Additional recommendations included that an ultrasound be used as the most cost-effective investigation for diagnosing rotator cuff pathology, and that MRI only be ordered by a surgeon primarily for surgical planning purposes [
33]. Prior to seeing a surgeon, 77 patients (45%) received an MRI in the public system, and 19 patients (11%) paid out-of-pocket for a private MRI. Fifty-six patients (33%) received both an ultrasound and MRI.
Safety
Clinical pathways were analyzed for each patient and compared to ideal clinical pathway algorithms [
33]. In this comparison, 38 patients (22%) experienced indirect clinical pathways in which patient care was fragmented, and patients sought care from too many and often redundant healthcare professionals. Patient-reported waiting times were also compared to benchmark waiting times [
33]. For Group 1 patients, the ideal standard of care for non-operative patients is as follows: consultation with an expert trained and confident to assess and diagnose rotator cuff pathology within 2 weeks after the patient decides to seek medical care, followed by prescription of a 12 week home or supervised physical therapy program [
33]. Only 65% of Group 1 patients (54/84) had been received a non-operative program prior to being recruited for the study. Of these, only 24 patients (29%) had successfully completed 12 weeks of physical therapy. In this study, only one patient (1%) met the ideal standard of care for non-operative treatment. For Group 2 patients, the ideal waiting time from when the patient enters the primary healthcare system and surgery is between 12 to 22 weeks for an acute rotator cuff tear, and between 30 and 38 weeks for a chronic tear [
33]. Only 40 patients (46%) received surgery within the ideal timeframe. Although levels of satisfaction from these patients were low, no medical complications or harmful experiences were reported by patients during the study period.