Introduction

Rotator cuff (RC) disease is frequent and represents a common source of shoulder pain [1, 2]. Each year in the USA, approximately 4.5 million patient visits related to shoulder pain occur, and the majority of them are due to RC problems [3, 4].

Patients with RC pathology may complain of symptoms ranging from minimal discomfort without functional deficits to severe pain, weakness and marked disability [5, 6]. Surgical repair of RC tears is a well-documented therapeutic option in these patients [7,8,9,10,11].

Geographical variation in the number of RC surgical procedures performed in the USA and variations in what surgeons deemed to be indications for RC surgery has been studied [12, 13]. Several reports have highlighted the apparent broadening of indications for RC surgery [12, 14,15,16], showing a considerable variation in the treatment of RC disease and the conditions requiring surgical repair. Incidence of RC surgery is rapidly increasing in selected patient cohorts [17], but nationwide incidence rates have been reported only for Finland [18] and Italy [19].

One of the founding principles of the Italian National Health Service (NHS) is fairness in access to health care, being free to every patient at the point of use.

Data from the Italian registry showed that 68.1% of RC repairs were performed in the North from 2001 to 2014, 19.1% in the Centre and 12.8% in the South. Data on domicile of the patient showed that 63.3% patients undergoing RC repairs came from the North, 20.2% from the Centre and 16.5% from the South and Islands. These data implicated significant differences in incidence of operations. Considering the Italian population of the 3 different regions of Italy (North, Centre and South), from 2001 to 2014, the incidence of operations was 77.7 per 100,000 person-years in the North, 35.5 per 100,000 person-years in the Centre, and 22.2 per 100,000 person-years in the South. [19].

This study aimed to explore geographical variation in equity in access to RC surgery among regions of Italy from 2001 to 2014, based on the official information source of hospitalization records provided by the Italian Ministry of Health.

Materials and Methods

An analysis of the National Hospital Discharge records (SDO) maintained at the Italian Ministry of Health concerning the 14 years of our survey (2001 through 2014) was performed. This archive collects information concerning all hospitalizations occurring in Italian public and private care settings. These data are anonymous and include patient’s age, sex, domicile, region of hospitalization, length of hospitalization and type of reimbursement (public or private). National and regional population data were obtained from the National Institute for Statistics (ISTAT) for each year. RC repair was defined by the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) major diagnosis code: 83.63 (rotator cuff repair).

Epidemiology of RC repairs based on Italian geographical macroregions has already been reported [19]. This article reports details of patients’ domicile, region of hospitalization and region where the surgery was performed. These data aim to highlight potential disparities in access to health care in Italy and patients’ necessity to migrate among regions in order to obtain it.

We distinguished patients by their regional domicile, thus defining them “regional populations”. Moreover, we distinguished for each region the origin of patients who underwent surgery. Procedures performed on patients residing in the same region of hospitalization were defined as “regional surgeries”. Procedures performed on patients not residing in the same region of hospitalization were defined “extra-regional surgeries”.

Descriptive statistics was performed.

Results

Demographics

During the 14-year study period, 390,001 RC repairs were performed in Italy, which represented a mean incidence of 62.1 RC procedures for every 100,000 Italian inhabitants. Nevertheless, the mean incidence is very different if every single regional population is considered individually.

Of 390,001 RC repairs performed in Italy during the study period, patients’ domicile data were not available for 244 RC repairs, thus resulting in a total of 389,757 RC repairs for which patients’ domicile data were available (Table 1). Only 5 over 21 regional populations (Patients from Aosta Valley, Veneto, Lombardy, Autonomous Province of Trento and Emilia Romagna) had an incidence greater than the national one. Seven over 21 regional populations (Patients from Basilicata, Molise, Apulia, Calabria, Sicily, Sardinia, Campania) had less than half the incidence than the national one. Patients from Campania resulted to be the ones with the lowest incidence of RC repair in Italy (13.39 RC procedures for every 100,000 inhabitants). Further details about the incidence of surgeries performed for each regional population are reported in Fig. 1 and Table 2.

Table 1 Regional migration summary, 2001–2014 time span
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Fig. 1
figure 1

Classification by RC procedures performed per 100.000 inhabitants

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Table 2 Classification by surgeries per 100.000 inhabitants
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Region of hospitalization and domicile of the patients

Regarding regional distribution of surgeries, the majority of patients underwent surgery in their own region of domicile. Lombardy resulted to have the highest number of surgeries during the 14-year study period, with 27.95% (108,954) of the total national procedures performed in the 2001–2014 time span. More than half the surgeries (52.00%) were performed in only 3 regions of northern Italy (Lombardy, Emilia Romagna, Veneto). Lombardy also performed the highest number of extra-regional surgeries (19,791). Umbria resulted instead the region with the highest percentage of extra-regional surgeries (47.7%). Patients from the Autonomous Province of Bolzano resulted to be the only regional population from the Northern part of Italy to have an incidence of RC repair below the national one. Further details about the number of surgeries performed in each region are reported in Fig. 2. A number of regional and extra-regional surgeries are reported in Fig. 2 and Table 2. Specifics on regional migration in the 2001–2014 time span are summarized in Table 1.

Fig. 2
figure 2

Classification by total RC procedures performed for each region of Italy

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Discussion

The most important finding from our registry study is that severe geographical variations in RC repair rates were present among regions of Italy. The majority of RC procedures were performed in the northern part of Italy, with more than half the surgeries (52.00%) performed in only 3 regions (Lombardy, Emilia Romagna, Veneto).

Regions from the southern part of Italy were characterized both by a lower number of regional and extra-regional surgeries. Regional populations of the southern regions of Italy had significantly lower rate of surgeries per 100.000 inhabitants compared to the ones of the northern part of Italy. Patients from Campania resulted to be by far the ones with the lowest incidence in Italy.

Oddly, patients from the Autonomous Province of Bolzano resulted to be the only regional population from the Northern part of Italy to have an incidence of RC repair below the national one: this may reveal an international migration of such patients to the adjoining Austria and Switzerland.

It is not possible to discriminate whether these differences reflect variations in need or in clinical practice because data on prevalence, incidence, severity of RC tears and information regarding clinicians’ and patients’ attitudes to RC surgery are not available [20]. They may also indicate differing amounts of resources available to provide RC surgery.

In view of the Government and the Italian Ministry of Health focus on reducing health inequalities, this massive difference in RC surgeries incidence among regions of Italy highlights a topic that absolutely needs further investigation.

It is possible that these differences reflect real geographical variation in need or patient consent to surgery. However, some studies have suggested that need is greater among the most deprived groups, and that education and income are unrelated to willingness to undergo surgery [21]. If so, this would imply inequity in the provision of RC surgery. A nationwide registry study in Finland showed higher incidence rate (from 44 to 131 per 100,000 adults per year) compared to rates in Italy [18].

This study has some limitations. It relied upon administrative data, and thus, there is the possibility that changes in coding practices could have impacted our results. That said, we are unaware of any systematic changes in the coding of RC repair that would have significantly impacted our findings. Significant regional variations were found in our study, confirming an inequity. This may express unmet needs in the low RC repair rate areas, or else over-indication in the high RC repair rate areas. So, part of this variability may be related to patients and to surgeons, and this cannot be clarified from the database analysis.

Thirdly, a limitation of this registry study is that we are unable to evaluate potential inaccuracies in diagnoses or procedures coding. Fourthly, the diagnosis and procedure coding used during the study period did not allow differentiation between open and arthroscopic procedures, or between partial and full-thickness tears. That said, this does not represent a major issue, since we focused in this article on geographical disparities in access to health care.

Conclusions

In conclusion, this study confirms the existence of a geographical disparity in access to health care and patients’ necessity to migrate among regions in order to obtain it. Regions from the southern part of Italy are characterized by a lower number of surgeries. Patients residing in southern regions of Italy had significantly lower incidence of surgeries compared to the ones of the northern part of Italy.

We found evidence of a concentration of RC procedures in the north of Italy. Our results give pause over whether efforts on regionalization of RC repair should turn towards improving quality in hospitals in the South of Italy. There is evidence of inequity in access to RC surgeries across macroregions of Italy. Today’s levels of RC surgery are below the expected maximum incidence, and we expect a continued annual increase in the total number of RC repair performed. Policy makers should examine factors to understand the determinants of inequitable provision.