It is clear that small area variation exists in orthopedics, but there is still much to learn. Given the many unanswered questions regarding area variation, regulatory policy at this time would be premature. The biggest piece of the puzzle that needs to be solved is the influence of disease prevalence and severity. While it seems unlikely this will explain all of the variation, it is equally unlikely that musculoskeletal diseases are distributed evenly across geopolitical boundaries, hence, it likely accounts for some of the observed variation. More patient-level studies need to be conducted in non-Medicare populations. For example, the extent to which area variation exists in sports medicine and knee surgery for younger patients is unknown. Profiling is likely here to stay. In accord, it should be exploited by the orthopedic community for its strengths while keeping in mind its limitations. Orthopedic surgeons should be at the forefront of this research and consequently influential in its evolution rather than have the managed care industry or government dictate policy.
