Differences in the Surgical Treatment of Lower Back Pain Among Spine Surgeons in the United States

Lubelski, Daniel; Williams, Seth K.; O’Rourke, Colin; Obuchowski, Nancy A.; Wang, Jeffrey C.; Steinmetz, Michael P.; Melillo, Alfred J.; Benzel, Edward C.; Modic, Michael T.; Quencer, Robert M.; Mroz, Thomas E.

doi:10.1097/brs.0000000000001396

Cited by 46 publications

(30 citation statements)

References 16 publications

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“…Prior research has demonstrated a great degree of variation both in terms of indications for spine surgical intervention as well as the types of procedures performed for a wide range of similar spinal disorders [2,5,11,15,17,20,21]. Much of this variation involves the use of high-intensity, expensive surgical interventions such as instrumented interbody fusions [2,5,15,17,21].…”

Section: Introductionmentioning

confidence: 99%

Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System?

Schoenfeld

Makanji

Jiang

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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Background Whether compensation for professional services drives the use of those services is an important question that has not been answered in a robust manner. Specifically, there is a growing concern that spine care practitioners may preferentially choose more costly or invasive procedures in a fee-for-service system, irrespective of the underlying lumbar disorder being treated. Questions/purposes (1) Were proportions of interbody fusions higher in the fee-for-service setting as opposed to the salaried Department of Defense setting? (2) Were the odds of interbody fusion increased in a fee-for-service setting after controlling for indications for surgery? Methods Patients surgically treated for lumbar disc herniation, spinal stenosis, and spondylolisthesis (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014) were identified. Patients were divided into two groups based on whether the surgery was performed in the fee-forservice setting (beneficiaries receive care at a civilian facility with expenses covered by TRICARE insurance) or at a Department of Defense facility (direct care). There were 28,344 patients in the entire study, 21,290 treated in fee-for-service and 7054 treated in Department of Defense facilities. Differences in the rates of fusion-based procedures, discectomy, and decompression between both healthcare settings were assessed using multinomial logistic regression to adjust for differences in case-mix and surgical indication. Results TRICARE beneficiaries treated for lumbar spinal disorders in the fee-for-service setting had higher odds of receiving interbody fusions (fee-for-service Conclusions The preferential use of interbody fusion procedures was higher in the fee-for-service setting irrespective of the underlying diagnosis. These results speak to the existence of provider inducement within the field of spine surgery. This reality portends poor performance for surgical practices and hospitals in Accountable CareThis study was supported in part by a grant from the Henry M. Jackson Foundation of the Department of Defense (AHH). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. This work was performed at

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Section: Introductionmentioning

confidence: 99%

Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System?

Schoenfeld

Makanji

Jiang

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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“…Rather than patient level factors, geographic variations in MNT prior to spine surgery may stem in large part from the lack of consensus among providers surrounding the most efficacious nonoperative therapies or the optimal duration of conservative trial periods. In a study of 445 US spine surgeons given surveys designed to assess their treatment patterns of low back pain, Lubelski et al 27 found roughly 75% disagreement between providers on their treatment approach. This disagreement was most pronounced in the Southwest and weakest in the Midwest.…”

Section: Discussionmentioning

confidence: 99%

Regional Variation in Nonoperative Therapy Utilization for Symptomatic Lumbar Stenosis and Spondylolisthesis: A 2-Year Costs Analysis

Davison

Lilly

Moreno

et al. 2019

Global Spine Journal

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Study Design: Retrospective cohort study. Objectives: To characterize regional variations in maximal nonoperative therapy (MNT) costs in patients suffering from lumbar stenosis or spondylolisthesis. Methods: Medical records from patients with symptomatic lumbar stenosis or spondylolisthesis undergoing primary ≤3-level lumbar decompression and fusion procedures from 2007 to 2016 were gathered from a large insurance database. Geographic regions (Midwest, Northeast, South, and West) reflected the US Census Bureau definitions. Records were searchable by International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and insurance-specific generic drug codes. Utilization of MNT, defined as cost billed, prescriptions written, and number of units disbursed, within 2-years prior to index surgery was assessed. Results: A total of 27 877 patients underwent 1-, 2-, or 3-level lumbar decompression and fusion surgery. Regional breakdown of the study cohort was as follows: South 62.3%, Midwest 25.2%, West 10.4%, Northeast 2.1%. Regional variations in the number of patients using nonsteroidal anti-inflammatory drugs (NSAIDs) ( P < .0001), opioids ( P < .0001), muscle relaxants ( P < .0001), and lumbar steroid injections ( P < .0001) were detected. A significant difference was identified in the regional MNT failure rates ( P < .0001). The total cost associated with MNT prior to index surgery was $48 411 125 ($1736.60/patient), with the Midwest ($1943.83/patient) responsible for the greatest average spending. Despite comprising 62.3% of the cohort, the South was accountable for 67.5% of NSAID prescriptions, 64.6% of opioid prescriptions, and 71.2% of muscle relaxant prescriptions. Conclusions: Regional differences exist in the costs of MNT in patients with lumbar stenosis and spondylolisthesis prior to surgery. Future studies should focus on identifying patients likely to fail prolonged nonoperative management.

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“…Some of these instrumented techniques of fusion are; instrumented posterolateral fusion (PLF), anterolateral inter body fusion (ALIF), posterior inter body fusion (PLIF), Transforaminal inter body fusion (TLIF). [7][8][9][10] Asides the posterolateral fusion, the other techniques employ the use of interbody cages for interbody fusions. Instrumented Posterolateral fusions (PLF) can be done alone as a procedure and has been shown to be effective in treating such conditions or can be combined with the various types of interbody fusion techniques.…”

Section: Introductionmentioning

confidence: 99%

Postero-Lateral Fusion (PLF) for Degenerative Diseases of the Lumbosacral Spine in Jos Nigeria

Bundepuun¹

2018

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Degenerative diseases of the spine are a common presentation to the clinician, more so with an increase in the ageing population worldwide. Operative methods of treatment are employed following failure of conservative methods. Spine surgical procedures are expensive, and many different procedures are employed to treat these spinal conditions. Instrumented posterolateral fusion (PLF) is one of the options employed and has a reduced cost owing to the absence of the inter body cage used in inter body fusion techniques. The objective of this study was to assess posterolateral fusions in our center within a developing country with poor health insurance coverage as an effective treatment modality in degenerative lumbosacral spine disease, without the added cost of an interbody fusion cage. This was a retrospective study carried out in Jos, Nigeria covering a two year period from July 2015 to June 2017. Patients with degenerative spine diseases who had been on conservative methods of treatment for more than six months with no significant improvement were recruited for the study. Data was obtained from the case records of the patients the patients were assessed for the indications for the procedure, the number of levels of fusion, duration of surgery and transfusion requirement as well as outcome of procedure using the Numeric pain scale (11 point scale from 0 to 10) and the complications of the procedure. Data was analyzed using the epi info statistical software. 13 patients had Posterolateral fusion (PLF) within this period. The mean age was 61.4years ±10.7. A male female ratio of M:F 1:3.3. 8(61.5%) patients had multiple level disc degeneration and herniation, 2(15.4%) patients each had spinal canal stenosis and facet joint arthritis with instability and 1(7.7%) had degenerative spondylolisthesis. 9(69.2%) patients had 2 level fusion, 2 (15.4%) had 3 level fusion and 2(15.4%) had 1 level fusion. 6(46.2%) had a pain reduction by ≥ 8 points on the numeric pain scale, 6(46.2%) had reduction by 6-7 points and 1(7.7%) had reduction of 3-5 points. 92.6% of the patients had a pain reduction by more than 50%. Mean operative time was 203minutes, and mean transfusion requirement was 2.8 pints of blood. Complications noted were superficial surgical site infection 1 patient and dural tear 1 patient. Postero lateral fusion techniques are a safe and effective treatment modality in treating patients with degenerative lumbosacral spine disease. The non usage of the interbody fusion cage provides a cheaper alternative in posterolateral fusion and every modality to limit surgical site infection should be employed to limit increased cost from this complication.

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Differences in the Surgical Treatment of Lower Back Pain Among Spine Surgeons in the United States

Abstract: 3.

Cited by 46 publications

References 16 publications

Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System?

Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System?

Regional Variation in Nonoperative Therapy Utilization for Symptomatic Lumbar Stenosis and Spondylolisthesis: A 2-Year Costs Analysis

Postero-Lateral Fusion (PLF) for Degenerative Diseases of the Lumbosacral Spine in Jos Nigeria

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