There are regional variations in spine surgery, and a new article in The Spine Journal addresses the challenges and solutions that could lead to more uniform utilization in the future.
1. The variation in spine surgery across the country is longstanding, with Cherkin et al. finding in 1994 that the lumbar spine surgery frequency was 40 percent to 400 percent greater than in other countries, depending on the region. Spine surgery rates have only increased since then, but at the same time the back and neck problems in the country have worsened.
2. The Spine Patient Outcomes Research Trial examined spinal stenosis, degenerative spondylolisthesis and intervertebral disc herniation treatment, finding surgery for all three cost-effective:
• Spinal stenosis: $59,400/QALY
• Degenerative spondylolisthesis: $64,300/QALY
• Intervertebral disc herniation: $20,600/QALY
However, there were key differences in the SPORT trial than in the general population, including clearly defined inclusion criteria and strict guidelines for surgery. Specific guidelines and protocol don't exist on a national level.
3. The Choosing Wisely campaign includes specific guidelines for back pain imaging and non-surgical treatment. But there are some back pain conditions that do respond to surgical management, according to the report, and it's not yet clear which cases will respond best. Many current guidelines allow for surgeon preferences and interpretation.
4. Patients often defer to their physicians and surgeons for the best treatment options, but studies show patients make different decisions when they are well-informed. Patients working with physicians to make treatment decisions could improve healthcare quality and consumption, according to the report
5. Insurance companies are moving from the fee-for-service models to the pay-for-performance models and seeking cost containment, which could address spine surgery variation. Risk-based payments may also limit surgeries to just the patients who would clearly benefit most.
"Large-scale databases for the robust collection and analysis of relevant practice data are essential for better understanding practice variations and their cause," concluded the article authors.