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Complex Spine Procedures on Rise in Older Patients
By Todd Neale, Staff Writer, MedPage Today
Published: April 06, 2010
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner Earn CME/CE credit
for reading medical news
The rate of complex operations for spinal stenosis -- which are far more expensive and associated with more complications than simpler procedures -- increased 15-fold over a recent six-year period in a Medicare population, researchers found.
Overall rates of surgery for that condition declined slightly from 137.4 per 100,000 Medicare beneficiaries in 2002 to 135.5 per 100,000 in 2007, according to Richard Deyo, MD, MPH, of Oregon Health & Science University in Portland, and colleagues.
Although rates of decompression surgery and simple fusion likewise dropped slightly, the use of complex fusion increased from 1.3 to 19.9 per 100,000 beneficiaries, the researchers reported in the April 7 Journal of the American Medical Association.
Complex fusion accounted for less than 1% of operations for spinal stenosis in 2002, but 14.6% of those performed in 2007.Action Points
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Explain to interested patients that this study identified a massive increase in the use of complex and expensive spinal procedures in a Medicare population using claims data.
The rate of life-threatening complications was higher with complex operations compared with decompression surgery (5.6% versus 2.3%; OR 2.95, 95% CI 2.50 to 3.49). Mean hospital charges were likewise higher ($80,888 versus $23,724, P<0.05).
The reasons for the change are unclear. In an interview, Deyo said evidence generally does not show that complex operations are much more effective, if at all, although many surgeons believe otherwise.
Several forces might be contributing, he said, including effective marketing by device manufacturers touting the efficacy of complex operations using new surgical implants.
In addition, reimbursement is higher for more complex operations, contributing to financial pressures on surgeons and hospitals.
Finally, he said, surgeons generally want to use the latest techniques and devices to remain on the cutting edge of medicine.
But Deyo said that absent data showing clear superiority for more complex operations, surgeons and patients might want to identify the least invasive type of surgery that will yield good pain relief and functional outcomes.
"It's important for people to realize that when you match the right patient and the right operation, that surgery really does offer some substantial benefit for many patients that have spinal stenosis," he said.
Deyo and his colleagues noticed that surgery for spinal stenosis in older patients was becoming more aggressive, and they wanted to assess potential safety risks.
So they performed a retrospective cohort analysis of Medicare claims data for patients ages 65 and older with a primary diagnosis of lumbar spinal stenosis (98.2%) or spondylogenic compression of the lumbar spinal cord.
Patients were divided into three groups according to the type of surgery they received -- decompression alone, simple fusion of one or two disk levels using a single surgical approach, or complex fusion of more than two disk levels.
Although the overall procedure rate fell from 2002 to 2007, the rate of complex procedures increased substantially, accompanied by a 40% aggregate increase in hospital charges after adjustment for inflation.
In an accompanying editorial, Eugene Carragee, MD, of Stanford University, pointed out that about half of the complex fusions were performed in patients who had spinal stenosis without a complex deformity, such as spondylolithesis or scoliosis.
"Newer and more complex technologies are being used for patients with little specific indication for the approaches and for whom there is good evidence that simpler methods are highly effective," he wrote.
He focused on economic incentives as a likely explanation for the dramatic increase in complex procedures, noting that surgeon reimbursement for a simple decompression for spinal stenosis is $600 to $800, whereas that for complex fusion could be 10 times that much.
Charges for implants alone used in a complex fusion procedure could exceed $50,000, he said.
"These devices are aggressively marketed, so much so that their promotion may sometimes cross the line of professional conflict of interest among profession leaders and institutions," Carragee wrote.
Such financial pressures work against a careful assessment of different techniques for spinal stenosis before widespread use, he argued.
"When applied broadly across medical care in the U.S., the result is a formidable economic and social problem," he said.
Jeffrey Fischgrund, MD, an orthopedic surgeon at William Beaumont Hospital in Royal Oak, Mich., said financial pressures were a possible explanation to the rise in more complex procedures, but also pointed to the aging population.
The population of older patients who demand a more active lifestyle is growing, he said in an interview, and the availability of better tools today allows for more complex procedures to fix problems like spinal stenosis.
Although complex procedures might be overused, he said, there is little data to guide surgeons in choosing appropriate patients.
"I think overall there probably is too much fusion happening at this point," said Fischgrund, editor-in-chief of the Journal of the American Academy of
Orthopaedic Surgeons. "But it's probably all in an effort to do what people think is the best for the patient."
Deyo and his colleagues acknowledged some limitations of the study, including the possibility of miscoding of diagnoses and procedures in claims data, incomplete information on use of implants, the possibility that complications are not consistently recorded, the lack of information on severity or extent of anatomic changes, patient symptoms, or functional status, and the use of hospital charges, rather than actual resource costs or reimbursements. |
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发表于 2010-5-20 21:57:19