Update of Utilization Patterns of Facet Joint
Interventions in Managing Spinal Pain from
2000 to 2018 in the US Fee-for-Service Medicare
Population

Manchikanti, Laxmaiah; Sanapati, Mahendra R; Pampati, Vidyasagar; Soin, Amol; Atluri, Sairam; Kaye, Alan D.; Subramanian, Joysree; Hirsch, Joshua A

doi:10.36076/ppj.2020/23/e133

Cited by 30 publications

(33 citation statements)

References 22 publications

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“…From 2009 to 2018, to the contrary, the Medicare population had rapid growth of 3% for a total increase of 30%. It should be noted that these decreases are larger than the declines of overall interventional techniques, but are nevertheless similar to adhesiolysis procedures, which have reduced at an annual rate of 12.3% from 2009 to 2018 for an overall total of 69.2% (67)(68)(69)(70)(71)(72)(73). One can compare this, by contrast, to the overall decrease in the use of interventional techniques from 2009 to 2018 of only 6.7% with an annual decline of only 0.8% per 100,000 FFS Medicare population (67)(68)(69)(70)(71)(72)(73).…”

Section: Discussionmentioning

confidence: 89%

“…Consequently, multiple measures have been developed to continue interventional pain management and provide appropriate care to chronic pain patients (63)(64)(65)(66). Thus, COVID-19's pandemic and simultaneous revival of the opioid epidemic, in conjunction with reduced access, have caused significant declines in utilization patterns, as well as expenditures of many interventional procedures (53,54,(63)(64)(65)(66) compared to epidural interventions, facet joint interventions, and spinal cord stimulators (53,54,(67)(68)(69)(70)(71)(72)(73)(74).…”

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confidence: 99%

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Utilization and Expenditures of Vertebral Augmentation Continue to Decline: An Analysis in Fee-For-Service (FFS) Recipients from 2009 to 2018

et al. 2021

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BACKGROUND: Despite the high prevalence of vertebral compression fractures (VCFs) associated with refractory pain, deformity, or progressive neurological symptoms, minimally invasive vertebral augmentation procedures, including vertebroplasty and kyphoplasty, have been declining in their relative utilization, along with expenditures. OBJECTIVES: This investigation was undertaken to assess utilization and expenditures for vertebral augmentation procedures, including vertebroplasty and kyphoplasty, in the fee-for-service (FFS) Medicare population from 2009 to 2018. STUDY DESIGN: The present study was designed to assess utilization and expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript: • A patient was described as receiving vertebral augmentation over the course of the year. • An episode was considered as one treatment per region per day utilizing primary codes only. • Services or procedures were considered to be procedures including multiple levels. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted for inflation to 2018 US dollars. RESULTS: In 2009, there were 76,860 episodes of vertebral augmentation with a rate of 168 per 100,000 Medicare population, which declined to 58,760, or 99 per 100,000 population for a total decline of 41%, or an annual rate of decline of 5.7% per 100,000 Medicare population. Vertebroplasty interventions declined more dramatically than kyphoplasty from 2009. Total episodes of vertebroplasty were 27,380 with an annual rate of 60 per 100,000 Medicare population, decreasing to 9,240, or 16 per 100,000 Medicare population, a 66% decline in episodes and a 74% decline in overall rate with an annual decline of 11.4% and 13.9%. In contrast, kyphoplasty interventions were 49,480, for a rate per 100,000 population of 108 in 2009 compared to 49,520 in 2018 with a rate of 83, for a decrease of 23% and 2.9% annual decrease. Evaluation of expenditures showed a net decrease of $30,102,809, or 8%, from $378,758,311 in 2009 to $348,655,502 in 2018. However, inflation-adjusted expenditures decreased overall by 21% and 3% annually from $443,147,324 in 2009 to $345,655,502 in 2018. In addition, inflation-adjusted total expenditures per 100,000 Medicare population decreased from $967,549 to $584,992, for an overall decrease of 40%, or an annual decrease of 5%. Per patient expenditures decreased 2% overall with 0% decrease per year. LIMITATIONS: Vertebral augmentation procedures were assessed only in the FFS Medicare service population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans. CONCLUSIONS: This study shows a significant decline in relative utilization patterns of vertebroplasty and kyphoplasty procedures, along with reductions in overall expenditures. The inflation-adjusted total expenditures of kyphoplasty and vertebroplasty decreased 21% with an annual decline of 3%. The inflation-adjusted expenditures per 100,000 of Medicare population decreased 40% overall and 5% per year. In addition, vertebroplasty has seen substantial declines in utilization and expenditure patterns compared to kyphoplasty procedures, which showed trends of decline. KEY WORDS: Osteoporosis, osteoporotic compression fracture, vertebroplasty, kyphoplasty, vertebral augmentation, expenditures, inflation-adjusted, utilization

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Section: Discussionmentioning

confidence: 89%

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confidence: 99%

Utilization and Expenditures of Vertebral Augmentation Continue to Decline: An Analysis in Fee-For-Service (FFS) Recipients from 2009 to 2018

et al. 2021

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“…Utilization of pharmacological and nonpharmacological modalities including surgical and nonsurgical interventions have been escalating for the treatment of chronic pain, specifically spinal pain including interventional techniques and surgical interventions, despite the decline noted for some interventions (1)(2)(3)(4)(38)(39)(40)(41)(42). Among these, surgical interventions and interventional techniques also have increased with an associated failure rate over the years (1)(2)(3)(4)(38)(39)(40)(41)(42).…”

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confidence: 99%

Spinal Cord Stimulation Trends of Utilization and Expenditures in Fee-For-Service (FFS) Medicare Population from 2009 to 2018

et al. 2021

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BACKGROUND: Spinal cord stimulation has been utilized with increasing frequency in managing chronic intractable spinal pain and complex regional pain syndrome (CRPS) in addition to other neuropathic pain states. The literature has shown the effectiveness of spinal cord stimulation in managing chronic pain with improvement in quality of life and cost utility. There have not been any reviews performed in the fee-for-service (FFS) Medicare population in reference to utilization and expenditure patterns of spinal cord stimulators. OBJECTIVES: This investigation was undertaken to assess the utilization and expenditures for spinal cord stimulation in the FFS Medicare population from 2009 to 2018. STUDY DESIGN: The present study was designed to assess the utilization patterns and expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars only trials and implants were included. RESULTS: Utilization patterns showed that spinal cord stimulation trials increased from 12,680 in 2009 to 36,280 in 2018, a 186% increase with an annual increase of 12.4%. The rate of trials per 100,000 population increased from 28 in 2009 to 61 in 2018 with a 120% increase, or an annual increase of 9.1%. The pulse generator implants increased from 7,640 in 2009 to 22,960 in 2018, an increase of 201%, with an annual increase of 13%. In addition, percutaneous placement with pulse generator implants increased from 4,080 in 2009 to 14,316 in 2018, a 252% increase, or 15% annual increase. In contrast, implantation of neurostimulator electrodes with paddle leads with laminectomy and placement of spinal pulse generator increased from 3,560 in 2009 to 8,600 in 2018, a 142% increase or an annual increase of 10.3%. Analysis of expenditures showed total inflation-adjusted expenditures increased from $292,153,701 in 2009 to $1,142,434,137 in 2018, a 291% increase from 2009 to 2018 and 16.4% annual increase. These expenditures were 125% higher than facet joint interventions and 138% higher than epidural interventions in 2018. In contrast, these expenditures were 55% below the expenditures of facet joint interventions and 66% lower than epidural injections in 2009. Trial to implant ratio improved from 42.5% in 2009 to 63.6% in 2018. An overwhelming majority of trials (90%) were performed by nonsurgical physicians, whereas, 56% of implants were performed by non-surgeons. LIMITATIONS: This assessment includes only FFS Medicare population, thus eliminating approximately 30% of the population with Medicare Advantage plans. In addition, this study has not taken into consideration various revisions not included in 3 specific codes. CONCLUSIONS: The analysis of spinal cord stimulators in the FFS Medicare population from 2009 to 2018 showed explosive increases of trials, implants and overall costs. KEY WORDS: Chronic pain, spinal pain, spinal cord stimulation, spinal cord stimulation trial, pulse generator implant, paddle leads with laminectomy, utilization trends of expenditures

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“…L L ow back and neck pain continue to be the most frequently encountered disabling spinal conditions with an annual expenditure of $134.5 billion in 2016 increased from $89.2 billion in 2013 in the United States (1,2). Opioids and epidural injections are the most commonly utilized nonsurgical modalities in managing chronic spinal pain (3)(4)(5)(6)(7)(8)(9)(10)(11). The utilization patterns of epidural injections have shown significant increases over the years, even though a decline with reversal of growth patterns has been noted from 2009 to 2016 (3)(4)(5)(6)(7)(8)(9).…”

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confidence: 99%

“…Opioids and epidural injections are the most commonly utilized nonsurgical modalities in managing chronic spinal pain (3)(4)(5)(6)(7)(8)(9)(10)(11). The utilization patterns of epidural injections have shown significant increases over the years, even though a decline with reversal of growth patterns has been noted from 2009 to 2016 (3)(4)(5)(6)(7)(8)(9). Epidural injections with local anesthetics have been extensively utilized since 1901 (12)(13)(14)(15)(16)(17)(18), whereas steroids were not used until 1952 (12,19,20).…”

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confidence: 99%

Is Epidural Injection of Sodium Chloride Solution a True Placebo or an Active Control Agent? A Systematic Review and Meta-Analysis

et al. 2020

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BACKGROUND: Epidural injections have been extensively used since their description in 1901, and steroids since their first utilization in 1952. Multiple randomized controlled trials and systematic reviews have reached discordant conclusions regarding the effectiveness of sodium chloride solution and steroids in managing spinal pain. True placebo-controlled trials with the injection of an inactive substance to unrelated structures have been nonexistent. Consequently, the discussions continue to escalate, seemingly without proper discourse. In this review, we sought to assess the true placebo nature of saline and the effectiveness of steroids. OBJECTIVES: This assessment of sodium chloride solution is undertaken to assess if it is a true placebo when injected into the epidural space, is effective alone, and whether steroids are effective when injected with sodium chloride solution rather than local anesthetic in managing spinal pain. STUDY DESIGN: A systematic review of randomized controlled trials utilizing sodium chloride solution alone, steroids alone, or sodium chloride solution with steroids in managing spinal pain secondary to disc herniation or spinal stenosis. METHODS: The systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Cochrane review criteria and Interventional Pain Management techniques--Quality Appraisal of Reliability and Risk of Bias Assessment (IPM–QRB) was used to assess the methodological quality assessment. Qualitative analysis was performed by utilizing best evidence synthesis principles, and quantitative analysis was performed utilizing meta-analysis with conventional methodology and single-arm meta-analysis. PubMed, Cochrane Library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through December 2018. The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Outcome measures for the present analysis, 20% improvement from the baseline pain scores or disability scores was considered clinically significant. Effectiveness was determined short-term if it was less than 6 months, whereas longer than 6 months was considered to be long-term. RESULTS: Of the 8 trials meeting inclusion criteria, 2 trials utilized fluoroscopic imaging and one study utilized ultrasound. All other studies performed the procedure without fluoroscopy. With dual-arm meta-analysis, there was no significant difference between epidural sodium chloride solution and epidural steroids with sodium chloride solution. Utilizing single-arm analysis, both epidural saline and epidural steroids with saline were effective in reducing 20% of pain, however, only reducing disability scores by 10% to 12%. Based on the qualitative analysis, epidural saline and epidural steroids with saline showed effect beyond placebo and showed level I, or strong evidence, that neither epidural saline, nor epidural steroids with saline are placebo and that both are effective. LIMITATIONS: Despite 8 randomized controlled trials, only 2 of them utilized fluoroscopy. Overall evidence is considered less than optimal and further studies elucidating these actions are strongly recommended. CONCLUSIONS: The findings of this systematic review and meta-analysis show that epidurally administered sodium chloride solution and sodium chloride solution with steroids may be effective in managing low back and lower extremity pain. Consequently, the findings of this review provide information that epidurally administered sodium chloride solution is not a true placebo. KEY WORDS: Chronic low back pain, epidural injections, local anesthetic, sodium chloride solution, steroids, placebo effect

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Update of Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain from 2000 to 2018 in the US Fee-for-Service Medicare Population

Cited by 30 publications

References 22 publications

Utilization and Expenditures of Vertebral Augmentation Continue to Decline: An Analysis in Fee-For-Service (FFS) Recipients from 2009 to 2018

Utilization and Expenditures of Vertebral Augmentation Continue to Decline: An Analysis in Fee-For-Service (FFS) Recipients from 2009 to 2018

Spinal Cord Stimulation Trends of Utilization and Expenditures in Fee-For-Service (FFS) Medicare Population from 2009 to 2018

Is Epidural Injection of Sodium Chloride Solution a True Placebo or an Active Control Agent? A Systematic Review and Meta-Analysis

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