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

Abstract

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.

Price elasticity of demand for new and recurring opioid prescriptions

“…Regional differences in opioid prescribing and consumption behavior for musculoskeletal pain have been observed in the United States (Jami et al, 2021; Davison et al, 2020), as have regional differences in non-narcotic treatments for pain, such as physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants (Machlin et al, 2011; Zimbelman et al, 2010). While the underlying reasons for these geographic patterns are unclear, together these studies suggest that preferences for treating pain may broadly track the current geo-cultural alignments in the United States – i.e., the divergence between the “coastal” (northeast and western) states and the central-southern states (Klaus & Romain, 2021).…”

“…Regional differences in opioid prescribing and consumption behavior for musculoskeletal pain have been observed in the United States (Jami et al, 2021;Davison et al, 2020), as have regional differences in non-narcotic treatments for pain, such as physical therapy, non-steroidal antiinflammatory drugs (NSAIDs), and muscle relaxants (Machlin et al, 2011;Zimbelman et al, 2010).…”

Practice Variation Within a Single Institution in Management of Degenerative Spondylolisthesis

“…The wide array of treatment options and intricacies of surgical decision-making for often elderly patients makes DS prone to practice variation like other degenerative spinal disorders 3–5. Although regional variation has been shown for DS, little is known about the variation among surgeons at the same institution 6,7. Differences in surgical training may lead to differing opinions on treatment strategies, which play a vital role in explaining practice variation 8.…”

“…[3][4][5] Although regional variation has been shown for DS, little is known about the variation among surgeons at the same institution. 6,7 Differences in surgical training may lead to differing opinions on treatment strategies, which play a vital role in explaining practice variation. 8 By omitting the geographic variability of incidence, demographics, and socioeconomic factors, more individualized drivers of practice variation can be identified when focusing on a single institution.…”