Spine Surgeons Respond to Martin-Deyo Study in JAMA

It's a mystery.

Millions of people in the U.S. suffer from neck and back pain every year. Unfortunately for many, their pain cannot be clearly identified and diagnosed. This creates uncertainties for payers who aren't sure what to pay for and confusion for patients who don't know who to trust to treat their pain.

This uncertainty also creates an environment where a study published in the Journal of the American Medical Association (February 13, 2008; Vol. 299, No. 6) is spread at the speed of light―a study claiming that we are spending more on back pain and getting less relief. We stopped counting media references at 55. Forbes had a typical headline: "Back Pain, No Gain."

The study, "Expenditures and Health Status Among Adults With Back and Neck Problems," concluded that "spine-related expenditures have increased substantially from 1997 to 2005, without evidence of corresponding improvement in self-assessed health status."

The authors of the study are our well-known friends at the University of Washington who have been highly critical of the number of spine surgeries performed in the U.S., as well as the relationships between spine surgeons and spine industry device manufacturers. The lead authors were Brook I. Martin, MPH; Richard A. Deyo, M.D., MPH; Sohail K. Mirza, M.D., MPH; and others.

But this is no time to shoot the messengers. They brought data published in a peer-reviewed journal that is worth considering.

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The Study: Higher Cost—Lower Health

The authors examined changes in expenditures related to back and neck problems based on Medical Expenditure Panel Survey (MEPS) descriptions and International Classification of Disease (ICD-9-CM) definitions. They could not distinguish among cervical, thoracic, and lumbar spine problems, and some spine-related diagnoses were not included in their definition because they could not be distinguished from nonspine-related diagnoses. Additional limitations of using ICD codes were cited because the codes do not identify a back or neck problem as a cause of hospitalization. The authors also noted that some persons have co-morbid conditions related to their back or neck problems that are not recorded with spine-related ICD codes.

The most common ICD-9-CM diagnoses were other and unspecified disorders of the back (52.9%), followed by intervertebral disk disorders (15.9%) and sprains and strains of the back (9.3%).

The authors didn't cull out spine surgery from the entire neck and back pain management continuum of treatment options, and therefore they had no opportunity to cite the SPORT study, which confirmed the proven health status of patients undergoing surgery for indications evaluated in that study.

Their data was based on annual samples of surveys of about 22,000 respondents with and without self-reported spine problems from 1997 through 2005. The survey asked participants to report all health problems, including "physical conditions, accidents, or injuries that affect any part of the body as well as mental or emotional health conditions, such as feeling sad, blue, or anxious about something."

In 1997, the mean age- and sex-adjusted medical costs for respondents with spine problems were $4,695 compared with $2,731 among those without spine problems.

In 2005 those numbers rose to $6,096 for respondents with spine problems and to $3,516 for those without spine problems.

After adjusting for inflation, the study said expenditures in the U.S. for the spine group increased 65% from 1997 to 2005 for a total of $86 billion, a more rapid rise than experienced over the same time frame for overall health expenditures. That's the spending part.

The estimated proportion of persons with back or neck problems who self-reported physical functioning limitations increased from 20.7% to 24.7% from 1997 to 2005, respectively. As a result, say the authors, "Age- and sex-adjusted self-reported measures of mental health, physical functioning, work or school limitations, and social limitations among adults with spine problems were worse in 2005 than in 1997."

A Question of Medical Waste

The authors said, "An increase in expenditures without improvement in health status, however, would raise questions of medical waste."

We weren't seeking to challenge the study's methodology or data, but this raising of the issue of medical waste caught our attention and made us wonder what the implications were for patients seeking treatment and policymakers making decisions about reimbursement.

The largest increase of expenditures was for outpatient visits, and the greatest increase among expenditure categories was observed for medications. Other increases were attributed to medical imaging, diagnostic tests and spinal injections.

Surgeons Respond

We talked to the spine societies, private industry consultants and analysts for their take on this study.

Charlie Ray, M.D., is a past President of the Spine Arthroplasty Society (SAS) and is about as well-known as you can get in the spine profession. Dr. Ray gave us his thoughts about the study.

He said the study was interesting and quite informative, but he found several details disquieting. These include:

  • There was a substantial cultural change in the U.S. over the eight-year reporting period, causing unknown influences on the data.
  • Self-assessment is a moving target and loaded with uncertainty—even though with the study design, it's apples to apples.
  • ICD-9-CM is an iffy coding problem for many diagnoses with too many lumped together—even though it is the best we have at present.
  • Subjects reported all health “problems” including “feeling blue”—a trait difficult to relate to back problems.
  • Back and neck “problems” contain a bag of worms, impossible to clarify and to correlate with costs in this study.
  • Drug payments for non-medical items (nutrition, vitamins, liniments, Ice Heat pads, massage, heat lamps, etc.) and non-prescription medication (Tylenol, sleepers, etc.) were not included.
  • There was no breakout for surgical procedures, which is of greater interest to spine surgeons.
  • Some reported categories did not worsen but improved over the period, such as sprains and strains of the back, and some were about neutral.
  • The sampling (22,258 adults) was on the one hand good, and on the other hand, poor (out of 230 million citizens).
  • The increases in expenditures for some categories (especially for drugs and chiropractic) were greater than for other categories of treatment, and it's likely if surgery had been culled out of the study, the categories with greater increases would have topped the list regarding rises in costs.
  • Surprisingly, workers’ compensation costs went down, but why?
  • There's a worry about politicians looking only at the overall conclusion. Namely, medical expenditures for back problems went up while self-assessed health status didn't, and at a time when there was only a modest increase in the number of citizens with reported back and neck problems.
  • The total expenditure given for spine care (but where is surgery in the formula?) in 2005 was about $86 billion, only 9% of total healthcare expenditures in the U.S. (compared to diabetes at $98 billion and vascular heart/stroke at a whopping $258 billion).
  • In closing, the authors aptly state, "The health status results should be interpreted cautiously.” Further, "The data suggest that spine problems are expensive, due to both large numbers of affected persons and to high costs per person."

Dr. Ray said he feels "futility in a statement that the authors suggest that such studies will help to find ways to reduce healthcare costs—I'm afraid that such studies alert us to a portion of our overall poor U.S. financial status but I do not see any part of this work that suggests what to do about it, even regarding the spine. That was not a part or intent of the study—it is an important awareness report and not much more. Nonetheless, useful to indicate magnitudes.”

Patient Access

In line with Ray's thoughts about focusing only on the study's overall conclusion, the President of the North American Spine Society (NASS), Tom Faciszewski, M.D., said, "NASS wants patients to know that there are many good treatments, surgical and nonsurgical, for significant spine disorders."

He said some back pain (up to 30%) can't be diagnosed. But, as the SPORT study confirmed (and as surgeons have known for years), when patients and physicians work together on clear diagnosed sources of pain, patients can be treated with appropriate therapies. Said Faciszewski, "Good treatments are out there, and NASS is committed to fostering quality spine care for patients and will endeavor to help those with spinal disorders."

As a physician in a small community, Faciszewski doesn't want to see patients with specific diagnosable spinal pain and injuries miss out on effective treatments because they read stories in the media about treatments that don't show patient satisfaction.

Pay For Proven Success

Hansen Yuan, M.D., current President of the Spine Arthroplasty Society (SAS) and Editor-in-Chief of the SAS Journal, said he agrees with Charlie Ray's assessment. "We should embrace this study as a general alert to us all on the huge cost in non-substantiated benefits such as chiropractic care, physical therapy without proper diagnosis, and pain management (blocks) without appropriate indications. These are modalities that are not substantiated by RCT (randomized clinical trials) to indicate benefits for general run-of-the mill neck and back pain."

Appropriate evaluation and diagnosis should be done by spinal experts, says Yuan. "Then proper management even with some of these modalities for an appropriate period of time can be beneficial. Management and prescriptions by someone not skilled in spinal care can add significantly to the cost of care."

For example, Yuan said, "If a patient has a herniated disc with classic back and leg pain he will go to his family doctor and go through conservative treatments for weeks to a couple of months. This adds up to several thousand dollars. Then he may go see a pain specialist who prescribes up to three epidural blocks, and again end up spending thousands of dollars. By the time you get through those two phases and still don't want surgery, the patient may go see a chiropractor for several months. So the patient may be six months down the road in non-operative care before he sees a surgeon. The surgeon then does the definitive procedure. If you add up all the pre-surgery costs you are certainly into tens of thousands of dollars of care. At most, the surgeon charges up to $1,400."

"What we're saying is that there can be a lot of waste in the treatment program, and appropriate and correct management and diagnosis should be handled by an expert in the field based on evidence-based medicine," concluded Yuan.

Embrace Evidence-Based Medicine

Marcy T. Rogers, President and CEO of SpineMark Corporation, said the study points out the critical need to refine and improve how spine care is delivered. "The medical community needs to continue to drive an increase in the practice of evidenced-based medicine and the collection of outcomes to determine the most efficacious clinical pathways for patients with musculoskeletal and spine problems.”

She notes with interest that outpatient care comprises 92% of the healthcare dollars spent on back and neck problems. This, says Rogers, correlates with the sites of service for interventional pain management, diagnostic and therapeutic procedures, diagnostics, conservative alternative medicine modalities, and minimally invasive spinal procedures. "Again, this supports the need for an integrated team approach and delivery system using evidence-based protocols and outcomes to measure efficacy, functional gains, return to work, cost of care, and patient satisfaction."

Matt Menze, a senior analyst with PearlDiver said, "With respect to the increases in outpatient charges noted in the study, MIS technology has enabled many spine surgeries to be performed on an outpatient basis that were formerly inpatient procedures. The increase in charges may be representative of a shift in sites of care, which speaks to the success of emerging technologies in spine, as opposed to rampant cost increases."

"Expenditures on spine patients may be higher due to co-morbidities often seen in spine patients. The PearlDiver database cites obesity, hypertension, and diabetes as common co-morbidities in spine patients. There is not a breakdown in the study with respect to the amount that medications related to these co-morbidities contribute to the increasing cost," concluded Menze.

The authors of the study might be a little surprised at the positive reception to their study by our spine surgeons. If their suggestion of wasted money for neck and back pain is valid, then those procedures and treatments which are clinically proven and evidence-based will win out over the fastest rising expenditures cited in the study, which are not proven through rigorous RCTs.

That’s no mystery.

Written by Walter Eisner
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