Abstract
Purpose
To determine epidemiological trends, demographic variation, and indications for shoulder arthroscopy in the United States (US).
Methods
We queried the TriNetX database to identify patients undergoing shoulder arthroscopy in the US. The sample was stratified by indication, location, age, sex, race, BMI, and two-year intervals. Comparisons were performed using incidence rates and incidence rate ratios. 95% confidence intervals were calculated assuming a Poisson distribution. P-values<0.05 were considered significant.
Results
We identified 191,549 patients who underwent shoulder arthroscopy from 2014–2024. Approximately 55% of patients were male. Most were white (73%), and the Northeast (39%) and South (34%) had the greatest representation among geographic regions. Overall incidence rate was 238.59 procedures per 100,000 patients (95% CI: 237.52–239.66). Patients aged 50–54 years had the greatest incidence rate (589.72 per 100,000). Incidence rates increased significantly with BMI (P < 0.000001) except for BMI>40.0. Rotator cuff repair was the most common indication (65.1%) followed by DCR (26.1%) and biceps tenodesis (22.3%).
Conclusion
Patients undergoing shoulder arthroscopy in the US are primarily older, white, male adults. Rotator cuff repair remains the most common indication. Persistent disparities in utilization exist among racial groups, sexes, and locations. Those with greater BMIs are generally more likely to undergo shoulder arthroscopy.
Keywords: Shoulder arthroscopy, epidemiology, indications, risk factors
Introduction
Over the past four decades, shoulder arthroscopy has become one of the most common orthopaedic procedures.1–3 While open repair was once the standard for treating shoulder instability, more recent studies have demonstrated that nearly 90% of shoulder stabilization surgeries were performed arthroscopically in the United States, and rates of arthroscopic repair are increasing at a faster rate than open procedures.3–5 This is due to a number of advantages arthroscopy offers over open surgery, including a less invasive approach, improved operative visualization, and a lower risk of postoperative complications and pain.6,7 Moreover, shoulder arthroscopy has a variety of indications, including tears of the biceps tendon or labrum, removal of loose bodies, primary osteoarthritis, chondral injury, and shoulder instability.8,9 Past demographic studies of shoulder arthroscopy have found that the patients are most commonly men between middle and old age. 10 However, multiple studies have also demonstrated that rates of shoulder arthroscopy have increased significantly in recent years due to its expanding indications.9,11,12 Thus, there exists a need for more recent analysis of this expanded patient population and changes in their indications for shoulder arthroscopy.
Generally, there is a paucity of recent data regarding the demographics, indications, and geographic regions associated with shoulder arthroscopy in the United States (US). A more current epidemiological study of these procedures can help identify patient risk factors and establish a consensus regarding their indications. Thus, this study aims to evaluate trends in shoulder arthroscopy in a nationwide sample from 2014 to 2024. Moreover, we determine the relative rates of indications for arthroscopy and compare incidences between sexes, ethnicities, racial groups, and age groups.
Methods
Study design
This was a retrospective, multi-center study evaluating epidemiological trends of shoulder arthroscopy in the United States between 2014 and 2024. Data was collected using the TriNetX U.S. Collaborative Research Platform (Cambridge, Massachusetts, United States; www.trinetx.com), which has access to over 70 healthcare organizations (HCOs) and 121 million electronic patient records. This platform consists of a diverse patient population, including representation from all major United States geographical regions, varying insurance statuses, and a variety of different hospital systems representing almost a third of the United States population. Data on the platform is de-identified in accordance with §164.514(b)(1) of the HIPAA Privacy Rule through expert-certified methods such as obfuscation and minimum thresholds, guaranteeing that each query includes at least 10 individuals. As a result, it does not qualify as Protected Health Information (PHI) and is not subject to HIPAA or IRB regulations.
Cohort creation
All patients who had undergone shoulder arthroscopy between the years of 2014 and 2024 were identified using the Common Procedural Terminology (CPT) code 1005614. Patients were then stratified by indications for shoulder arthroscopy, including capsulorrhaphy (CPT 29806), superior labrum anterior posterior (SLAP) lesion repair (CPT 29807), removal of foreign body (CPT 29819), rotator cuff repair (CPT 29827), biceps tenodesis (CPT 29828), synovectomy (CPT 29820 and 29821), lysis of adhesions (CPT 29825), and distal clavicular resection (DCR; CPT 29824). The shoulder arthroscopy cohort was also stratified by age, sex, race, ethnicity, body mass index (BMI), and geographic location. All overall cohort trends were assessed as well as trends at every two-year interval.
Outcome measures and statistical analysis
The primary epidemiological outcome evaluated was the incidence rate (IP) which was defined as the number of new shoulder arthroscopy cases within a cohort in a given time interval over all patients at risk in the TriNetX database during that time interval. This calculation was performed by the IP tool within the TriNetX platform and represented as the number of procedures per a hundred thousand patients at risk. Incidence rate ratios were used to compare subgroups to their respective reference groups. A 95% confidence interval (CI) for both IP and incidence rate ratios was calculated assuming a Poisson distribution. A P-value less than 0.05 was considered statistically significant.
Results
Shoulder arthroscopy patients
A total of 191,549 patients were identified as having undergone shoulder arthroscopy between 2014 and 2024. The mean age of the cohort was 52.1 ± 15.6 years. Males comprised the majority of the cohort, approximately 55%, while females accounted for about 39%. The racial distribution showed that most patients were White (73%), followed by Black patients (9.34%). The mean patient BMI was 30 ± 6.48. Geographically, the highest proportion of procedures occurred in the Northeast (39%), followed closely by the South (34%). A more detailed breakdown can be found in Table 1.
Table 1.
Demographic information and incidence rate.
| Shoulder arthroscopy patients, N (%) | Incidence rate* | 95% confidence interval | Incidence rate** ratio | 95% confidence interval | P-Value | |
|---|---|---|---|---|---|---|
| Overall cohort | 191,549 | 238.59 | (237.52, 239.66) | NA | NA | NA |
| Characteristic | ||||||
| Age mean (standard deviation) | 52.1 ± 15.6 | |||||
| 15–19 | 6445 (3.36) | 121.21 | (118.25, 124.17) | 0.21 | (0.20, 0.21) | < 0.000001 |
| 20–24 | 5697 (2.97) | 104.74 | (102.02, 107.46) | 0.18 | (0.17, 0.18) | < 0.000001 |
| 25–29 | 7127 (3.72) | 139.60 | (136.36, 142.84) | 0.24 | (0.23, 0.24) | < 0.000001 |
| 30–34 | 9708 (5.07) | 203.86 | (199.80, 207.92) | 0.35 | (0.34, 0.35) | < 0.000001 |
| 35–39 | 13,098 (6.84) | 310.98 | (305.65, 316.31) | 0.53 | (0.52, 0.54) | < 0.000001 |
| 40–44 | 19,950 (10.42) | 452.27 | (445.99, 458.55) | 0.77 | (0.75, 0.78) | < 0.000001 |
| 45–49 | 25,613 (13.37) | 551.10 | (544.35, 557.85) | 0.93 | (0.92, 0.95) | < 0.000001 |
| 50–54 | 30,041 (15.68) | 589.72 | (583.05, 596.39) | 1.00 | (0.98, 1.02) | 1.00 |
| 55–59 | 27,205 (14.20) | 546.08 | (539.59, 552.57) | 0.93 | (0.91, 0.94) | < 0.000001 |
| 60–64 | 19,011 (9.92) | 435.95 | (429.75, 442.15) | 0.74 | (0.73, 0.75) | < 0.000001 |
| 65–69 | 10,345 (5.40) | 291.49 | (285.87, 297.11) | 0.49 | (0.48, 0.51) | < 0.000001 |
| 70–74 | 4092 (2.14) | 160.86 | (155.93, 165.79) | 0.27 | (0.26, 0.28) | < 0.000001 |
| 75–79 | 1159 (0.61) | 63.73 | (60.06, 67.40) | 0.11 | (0.10, 0.11) | < 0.000001 |
| 80–84 | 263 (0.14) | 22.97 | (20.19, 25.75) | 0.04 | (0.03, 0.04) | < 0.000001 |
| Sex | ||||||
| Female | 73,950 (38.61) | 177.95 | (176.67, 179.23) | 1.00 | (0.98, 1.02) | 1.00 |
| Male | 105,549 (55.10) | 292.07 | (290.31, 293.83) | 1.63 | (1.63, 1.66) | < 0.000001 |
| Unspecified | 12,050 (6.29) | 465.50 | (457.19, 473.81) | 2.62 | (2.57, 2.67) | < 0.000001 |
| Race | ||||||
| American Indian or Alaska Native | 604 (0.32) | 225.66 | (207.66, 243.66) | 0.74 | (0.69, 0.80) | < 0.000001 |
| Asian | 5713 (2.98) | 158.76 | (154.64, 162.88) | 0.52 | (0.51, 0.54) | < 0.000001 |
| Black or African American | 17,882 (9.34) | 162.50 | (160.12, 164.88) | 0.54 | (0.53, 0.54) | < 0.000001 |
| Native Hawaiian or Other Pacific Islander | 1507 (0.79) | 238.39 | (226.35, 250.43) | 0.79 | (0.75, 0.83) | < 0.000001 |
| Unknown Race | 21,952 (11.46) | 155.41 | (153.35, 157.47) | 0.51 | (0.51, 0.52) | < 0.000001 |
| White | 139,121 (72.63) | 303.36 | (301.77, 304.95) | 1.00 | (0.98, 1.02) | 1.00 |
| Other Race | 4770 (2.49) | 99.42 | (96.60, 102.24) | 0.33 | (0.32, 0.34) | < 0.000001 |
| Ethnicity | ||||||
| Hispanic or Latino | 11,760 (6.14) | 143.53 | (140.94, 146.12) | 1.00 | (0.98, 1.02) | 1.00 |
| Not Hispanic or Latino | 132,821 (69.34) | 282.11 | (280.59, 283.63) | 1.97 | (1.93, 2.00) | < 0.000001 |
| Unspecified Ethnicity | 46,968 (24.52) | 187.79 | (186.09, 189.49) | 1.31 | (1.28, 1.34) | < 0.000001 |
| Body mass index mean (standard deviation) | 30 ± 6.48 | |||||
| <18.5 | 4448 (2.32) | 117.42 | (113.97, 120.87) | 1.00 | (0.98, 1.02) | 1.00 |
| 18.5–24.9 | 41,284 (21.55) | 287.24 | (284.47, 290.01) | 2.45 | (2.37, 2.52) | < 0.000001 |
| 25.0–29.9 | 67,713 (35.35) | 532.57 | (528.56, 536.58) | 4.54 | (4.40, 4.68) | < 0.000001 |
| 30.0–34.9 | 53,533 (27.95) | 651.29 | (645.77, 656.81) | 5.55 | (5.38, 5.72) | < 0.000001 |
| 35.0–39.9 | 29,472 (15.39) | 767.67 | (758.91, 776.43) | 6.54 | (6.34, 6.75) | < 0.000001 |
| 40.0< | 17,183 (8.97) | 544.95 | (536.80, 553.10) | 4.64 | (4.49, 4.80) | < 0.000001 |
| Geographic location | ||||||
| Northeast | 74704 (39.00) | 383.97 | (381.22, 386.72) | 1.00 | (0.98, 1.02) | 1.00 |
| Midwest | 26817 (14.00) | 240.18 | (237.31, 243.05) | 0.63 | (0.62, 0.63) | < 0.000001 |
| South | 65127 (34.00) | 297.96 | (295.67, 300.25) | 0.78 | (0.77, 0.78) | < 0.000001 |
| West | 17239 (9.00) | 167.28 | (164.78, 169.78) | 0.44 | (0.43, 0.44) | < 0.000001 |
| Unknown | 5746 (3.00) | 19.78 | (19.27, 20.29) | 0.05 | (0.05, 0.05) | < 0.000001 |
| Year | ||||||
| 2014–2016 | 36,760 (19.19) | 84.13 | (83.27, 84.99) | 1.00 | (0.98, 1.02) | 1.00 |
| 2016–2018 | 58,116 (30.34) | 109.94 | (109.05, 110.83) | 1.31 | (1.29, 1.32) | < 0.000001 |
| 2018–2020 | 68,268 (35.64) | 118.91 | (118.02, 119.80) | 1.41 | (1.40, 1.43) | < 0.000001 |
| 2020–2022 | 68,413 (35.72) | 115.19 | (114.33, 116.05) | 1.37 | (1.35, 1.39) | < 0.000001 |
| 2022–2024 | 68,661 (35.85) | 130.58 | (129.60, 131.56) | 1.55 | (1.53, 1.57) | < 0.000001 |
*The incidence rate per 100,000 persons.
** The reference group utilized in the rate ratio comparison.
Incidence proportion of shoulder arthroscopy in the United States
The overall IP of shoulder arthroscopy in the United States is 238.59 procedures per hundred thousand patients (95% CI: 237.52–239.66) from 2014 to 2024. Over the past decade, the IP increased from 84.13 procedures per hundred thousand patients during 2014–2016 to 118.91 procedures per hundred thousand patients in 2018–2020. It then experienced a slight decline to 115.19 procedures per hundred thousand patients in 2020–2022, followed by a sharp rise to 130.58 procedures per hundred thousand patients in 2022–2024 (Figure 1). When stratified by sex, males underwent a higher rate of shoulder arthroscopy procedures with an IP of 292.07 (95% CI: 290.31–293.83) compared to females who experienced a rate of 177.95 (95% CI: 76.67–179.23) procedures per hundred thousand patients. The incidence proportion ratio between males and females was 1.63 (95% CI: 1.63–1.66; P < 0.000001). Among all age groups, patients aged 50 to 54 years had the highest rate of shoulder arthroscopy procedures, with an incidence of 589.72 per 100,000 patients (95% CI: 583.05–596.39). Overall, the incidence pattern by age followed a roughly normal distribution, with higher procedure rates observed in age cohorts near the 50–54 range. In contrast, both younger patients (15–19 years) and older patients (80–84 years) had substantially lower rates of shoulder arthroscopy (121.21 and 22.97 cases per hundred thousand patients respectively; P < 0.0001).
Figure 1.
Trends in incidence rates of shoulder arthroscopy in the US Collaborative TriNetX database from 2014 to 2024.
White Americans experienced the highest rate of shoulder arthroscopy procedures with an IP of 303.36 (95% CI: 301.77–304.95) cases per hundred thousand patients. Although Black Americans accounted for the second highest number of shoulder arthroscopy procedures (9.34%), Native Hawaiian or Other Pacific Islander Americans had the second highest incidence rate, with an IP of 238.39 cases per 100,000 patients (95% CI: 226.35–250.43). Asian Americans experienced the lowest rate of shoulder arthroscopy procedures with an IP of 158.76 (95% CI: 154.64–162.88) cases per hundred thousand patients.
Overall trends based on BMI show that IP of shoulder arthroscopy procedures increases at a significant rate (P < 0.000001) as BMI increases; however, patients with a BMI of greater than 40.0 experienced a lower IP compared to patients with a BMI of 35.0–39.9 and 30.0–34.9. Patients with a BMI between 35.0 and 39.9 experienced the highest IP of 767.67 (95% CI: 758.91–776.43) cases per hundred thousand patients while patients with a BMI lower than 18.5 experienced the lowest IP of 117.42 (95% CI: 113.97–120.87) cases per hundred thousand patients.
Geographic trends show that shoulder arthroscopy procedures were primarily performed at HCOs located in the Northeast with an IP of 383.97 (95% CI: 381.22–386.72) cases per hundred thousand patients followed by HCOs located in the South with an IP of 297.96 (95% CI: 295.67–300.25) cases per hundred thousand patients. Health care organizations in the West experienced the lowest IP of shoulder arthroscopy procedures with an IP of 167.28 (95% CI: 164.78–169.78) cases per hundred thousand patients.
Indications of shoulder arthroscopy
When examining overall trends, the most common indication for shoulder arthroscopy was rotator cuff repair (65.09% of the cohort) followed by DCR (26.08%) and biceps tenodesis (22.30%) (Table 2). These trends held at individual two-year intervals as well besides 2022–2024 where biceps tenodesis was more commonly performed than DCR (23.22 vs 22.12% respectively). The least common indication was removal of a foreign body making up only 2.07% of the overall cohort (Figure 2).
Table 2.
Indications for shoulder arthroscopy.
| Year | Capsulorrhaphya, N (%) | SLAP lesion repairb, N (%) | Removal of foreign bodyc, N (%) | Rotator cuff repaird, N (%) | Biceps tenodesise, N (%) | Synovectomyf, N (%) | Lysis of adhesionsg, N (%) | DCRh, N (%) |
|---|---|---|---|---|---|---|---|---|
| Overall | 27,362 (14.28) | 16,481 (8.60) | 3972 (2.07) | 124,682 (65.09) | 42,722 (22.30) | 5105 (2.67) | 8632 (4.51) | 49,954 (26.08) |
| 2014–2016 | 5235 (20.20) | 3405 (13.98) | 877 (3.25) | 19,127 (89.16) | 4954 (28.20) | 2176 (5.24) | 1508 (7.00) | 8904 (38.53) |
| 2016–2018 | 7424 (14.11) | 5140 (9.84) | 1195 (2.44) | 32,776 (70.51) | 10,367 (24.28) | 1926 (2.25) | 2572 (5.12) | 14,163 (29.24) |
| 2018–2020 | 8203 (12.02) | 5717 (8.37) | 1418 (2.08) | 40,976 (60.02) | 14,109 (20.67) | 1309 (1.92) | 2975 (4.36) | 16,993 (24.89) |
| 2020–2022 | 8496 (12.42) | 5217 (7.63) | 1206 (1.76) | 42,197 (61.68) | 14,471 (21.15) | 1310 (1.91) | 3132 (4.58) | 16,050 (23.46) |
| 2022–2024 | 9128 (13.29) | 4548 (6.62) | 1018 (1.48) | 44,247 (64.44) | 15,946 (23.22) | 681 (0.99) | 2223 (3.24) | 15,186 (22.12) |
CPT 29806.
Superor Labrum Anterior and Posterior Lesion (CPT 29807).
CPT 29819.
CPT 29827.
CPT 29828.
CPT 29820 and 29821.
CPT 29825.
Distal Clavicular Resection (CPT 29824).
Figure 2.
Indications for shoulder arthroscopy in the US Collaborative TriNetX database from 2014 to 2024.
Discussion
Shoulder arthroscopy has become increasingly common in the United States in recent years, offering a less invasive approach, better visualization, and lower rates of complications than open repair.3,6,7 This trend was confirmed in our own sample as the incidence rate ratio increased time interval between 2014 and 2024. Previous epidemiological studies have found that shoulder arthroscopies are most commonly performed on older adult males, and our results generally agree with these trends. 13 However, other characteristics, including race, BMI, and surgical indications demonstrated more variation than previously described. We are also unaware of any recent studies that have confirmed the epidemiology of shoulder arthroscopies in a large, nation-wide sample.
In a study of musculoskeletal upper extremity ambulatory surgeries in the United States, Jain et al. found that shoulder arthroscopy was most common in those aged 45 to 64 years. 13 Our results agree with this range as age intervals within these years demonstrated significantly greater incidence rates than all other groups, peaking with patients aged 50 to 54 years. However, this group within our sample demonstrated an incidence rate of 589.72 per 100,000 persons compared to 17.1 per 10,000 persons, likely reflecting broader increases in indications and rates of arthroscopy in recent years.1,2,9,11 Shoulder arthroscopy was particularly rare in young and elderly adults with age intervals less than 30 years and greater than 70 years each demonstrating incidence rate ratios 0.27 compared to the reference group (Table 1). These results generally reflect past studies of outcomes for these age groups. For example, Feng et al. found that high rates of instability recurrence 24 patients aged 13 to 19 years and 34 patients aged 20 to 35 years following arthroscopic Bankart repair (41.7% vs 11.8%, respectively). 14 Rubenstein et al. also determined that age above 80 years was a significant risk factor for adverse events following shoulder arthroscopy in a sample of 7867 patients. 10 Conversely, Burns et al. found favorable that 95% of shoulders achieved favorable postoperative results in a study of 37 patients with mean age 43.7 years at minimum 3-year follow-up. 15
Like past studies of shoulder arthroscopy utilization, males in our sample demonstrated a significantly greater incidence rate than females. For example, Rudisill et al. found that 57.7% of individuals were male in a sample of 42,443 arthroscopic rotator cuff patients between 2010 and 2019, and our sample was 55.1% male. 16 Moreover, we found that the incidence rate was 1.63 times greater in males than females. Interestingly, females have been shown to demonstrate greater rates of shoulder instability and generalized joint instability despite lower rates of arthroscopy.16–18 However, Cannizzaro et al. found that males may demonstrate greater rates of recurrence following arthroscopic anterior shoulder stabilization in a systematic review of 7102 patients, potentially contributing to the disparity seen within our sample. 19
The majority of patients in our sample were white (72.6%), and white patients also demonstrated the greatest incidence rate of all racial groups. Past studies describe even greater disparities. For example, in a sample of 42,443 arthroscopic rotator cuff repairs, Linker et al. found that 38,090 (89.7%) were white. 20 The remaining 4353 patients were Black or African American. Other racial groups found within our sample, including Asians, American Indians or Alaskan Natives, and Native Hawaiians or Pacific Islanders, are generally unrepresented in existing studies. These disparities extend beyond utilization to outcomes following shoulder arthroscopy. Linker et al. demonstrated that Black patients experienced significantly longer operative times and time from operation to discharge. 20 Ziedas et al. found that Black race was significantly associated with worse function and pain outcomes following rotator cuff repair in a sample of 338 patients. 21
Incidence rates of shoulder arthroscopy increased significantly with each BMI range with the exception of those with BMIs greater than 40.0. In addition to a greater likelihood of undergoing arthroscopy, increased BMI is associated with greater rates of complications and readmission.22–25 Nicolay et al. determined that diabetic patients with class III obesity are at higher risk of morbidity and readmission following all forms of arthroscopy in a sample of 141,335 patients at 30-day follow-up. 22 Similarly, Warrender et al. found that obesity had a negative impact on operative time, length of hospitalization, and functional outcomes following arthroscopic rotator cuff repair in a sample of 149 repairs. 24 Despite greater utilization of arthroscopy among those with greater BMIs found within our sample, outcomes appear to be worsen as BMI increases.
The Northeast demonstrated a significantly greater incidence rate than the South, Midwest, and West. Jain et al. also found significant geographic variation in patients undergoing shoulder arthroscopy, rotator cuff repair, and knee arthroscopy in a sample of 4,856,385 records. In line with our results, patients in Kentucky and Maine had significant increases in shoulder arthroscopy, and patients in Florida, Kentucky, Maine, New York, New Jersey, North Carolina, Utah, and Vermont had significant increases in arthroscopic rotator cuff repair. 9 However, Zhang et al. determined that arthroscopic SLAP repair was significantly more common in the West and South than the Midwest and Northeast. 26
Few studies have analyzed relative rates of indications for shoulder arthroscopy within a large, nation-wide sample. We found that rotator cuff repair was the most common indication at each time interval followed by DCR and biceps tenodesis. Synovectomy, removal of a foreign body, and lysis of adhesions were the least prevalent indications. Despite ever-expanding technologies and indications for shoulder arthroscopy, diffusion of these techniques appears to be gradual as the proportion of procedures indicated by rotator cuff repaired has remained above 60% since 2018 within our sample, and other indications have changed modestly within this time frame. 27
Limitations of this study are characteristic of other large database analyses. For example, utilization of ICD-10 and CPT codes limits understanding of detailed clinical information and patient characteristics within our sample. For example, we were unable to determine whether procedures were indicated for correction of pain or instability. Moreover, changes in patient satisfaction and functional outcomes over time remain unclear. Reliance on the TriNetX database also likely biases our patient selection due to representation only of hospitals participating within this system. It also limits our ability to analyze geographic trends in areas more specific than the US census region, and we were unable to describe indications rarer than those identifiable within the TriNetX database. Regardless, this study offers a robust, national-level analysis of the epidemiology and indications associated with shoulder arthroscopy in the United States.
Conclusion
Shoulder arthroscopy has become increasingly common the last decade. These were most frequently performed on those aged 50 to 54 years and males. White patients were also considerably more likely to undergo arthroscopy, reflecting persistent disparities in utilization among racial groups. Incidence also increased with BMI with the exception of those with BMI greater than 40.0. Of US census regions, the Northeast demonstrated significantly greater rates of arthroscopy than the South, West, and Midwest. Rotator cuff repair was the most common indication at each time interval despite expanding indications and technologies for shoulder arthroscopy.
Footnotes
ORCID iD: Rayyan Abid https://orcid.org/0009-0008-2278-915X
Ethical approval: Data on the TriNetX platform is de-identified in accordance with §164.514(b)(1) of the HIPAA Privacy Rule through expert-certified methods such as obfuscation and minimum thresholds, guaranteeing that each query includes at least 10 individuals. As a result, it does not qualify as Protected Health Information (PHI) and is not subject to HIPAA or IRB regulations.
Informed consent: Informed consent was not sought for the present study because data was obtained from a large, de-identified database exempt from HIPAA and IRB regulations.
Author contributions: RA, RJB, GD, PS, AJM, and JMA were responsible for data collection, statistical analysis, and drafting the original manuscript. JEV, MJS, JMA, and JGC were responsible for study design, data interpretation, study resources, manuscript drafting and editing, and supervision. All authors made substantial contributions to the work, participated in critical revision, approved the final manuscript, and agree to be accountable for all aspects of the work.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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