ChiroACCESS Article

Money and Spinal Surgery: What Happened to the Patient?

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ChiroACCESS Editorial Staff



Published on

April 8, 2010

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There is a lack of evidence-based support for the efficacy of complex fusion surgeries over conservative surgical decompression for elderly stenosis patients.  There is, however, a significant financial incentive to both hospitals and surgeons to perform the complex fusions.  Spinal stenosis is the most frequent cause for spinal surgery in the elderly.  There has been a slight decrease in these surgeries between 2002 and 2007.  However, there has also been an overall 15 fold increase in the more complex spinal fusions (360 degree spine fusions).  Deyo et. al. in yesterday’s issue (April 7, 2010) of the Journal of the American Medical Association concludes that  “It is unclear why more complex operations are increasing. It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just 6 years.  The introduction and marketing of new surgical devices and the influence of key opinion leaders may stimulate more invasive surgery, even in the absence of new indications…financial incentives to hospitals and surgeons for more complex procedures may play a role…”  There is a significant difference in mean hospital costs for simple decompression versus complex surgical fusion.  The cost of decompression is $23,724 compared to an average of $80,888 for complex fusion.  Despite the much higher cost, there is no evidence of superior outcomes and there is greater morbidity associated with the complex fusion.  The surgeon is typically reimbursed only $600 to $800 for simple decompression and approximately ten times more, $6,000 to $8,000 for the complex fusion.

SurgeryIn a JAMA editorial that accompanied this study and was written by Dr. Carragee of Stanford University School of Medicine, the following comment was made “In 2007, the final year of data reported in the study by Deyo et al, Consumer Reports rated spinal surgery as number 1 on its list of overused tests and treatments. This was a harsh rebuke given the benefit associated with many common spinal surgeries. However, the findings from the study by Deyo et al should not only remind patients, surgeons, and payors that the efficacy of basic spinal techniques must be assessed carefully against the plethora of unproven but financially attractive alternatives, but also should serve as an important reminder that as currently configured, financial incentives and market forces do not favor this careful assessment before technologies are widely adopted. When applied broadly across medical care in the United States, the result is a formidable economic and social problem.”

These studies reflect much of what is plaguing our broken health care system.  Third party payors, including the government, fail to hold all health professionals to the same evidence-based standards.  There is little or no accountability when significantly more expensive surgery, with no evidence of superior effectiveness, is routinely reimbursed.  There is discrimination of health care providers and the needs and desires of the patient are secondary to matters of finance and politics.

Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults.

JAMA. 2010 Apr 7;303(13):1259-65.

Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG.
Department of Family Medicine, Mail Code FM, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.

CONTEXT: In recent decades, the fastest growth in lumbar surgery occurred in older patients with spinal stenosis. Trials indicate that for selected patients, decompressive surgery offers an advantage over nonoperative treatment, but surgeons often recommend more invasive fusion procedures. Comorbidity is common in older patients, so benefits and risks must be carefully weighed in the choice of surgical procedure.

OBJECTIVE: To examine trends in use of different types of stenosis operations and the association of complications and resource use with surgical complexity.

DESIGN, SETTING, AND PATIENTS: Retrospective cohort analysis of Medicare claims for 2002-2007, focusing on 2007 to assess complications and resource use in US hospitals. Operations for Medicare recipients undergoing surgery for lumbar stenosis (n = 32,152 in the first 11 months of 2007) were grouped into 3 gradations of invasiveness: decompression alone, simple fusion (1 or 2 disk levels, single surgical approach), or complex fusion (more than 2 disk levels or combined anterior and posterior approach).

MAIN OUTCOME MEASURES: Rates of the 3 types of surgery, major complications, postoperative mortality, and resource use.

RESULTS: Overall, surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 beneficiaries. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50-3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80,888 compared with US $23,724 for decompression alone.

CONCLUSIONS: Among Medicare recipients, between 2002 and 2007, the frequency of complex fusion procedures for spinal stenosis increased while the frequency of decompression surgery and simple fusions decreased. In 2007, compared with decompression, simple fusion and complex fusion were associated with increased risk of major complications, 30-day mortality, and resource use.

The increasing morbidity of elective spinal stenosis surgery: is it necessary?

JAMA. 2010 Apr 7;303(13):1309-10.

Carragee EJ.

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·  JAMA. 2010 Apr 7;303(13):1259-65.
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