Thursday, April 8, 2010

A Handy Summary & Insights From the JAMA Article on Simple and Complex Lumbar Surgery. Shared Decision Making Anyone?

Whew! After reading (for example, the New York Times) about a recent JAMA report on back surgeries, the Disease Management Care Blog was ready agree with some of its sister blogs that the nation's spinal surgeons have run amok. If you accept what the media has to say, the rate of complicated and expensive spinal surgeries are going up, up up, leading to patient harm and national bankruptcy.

In the meantime, primary care physicians have been working tirelessly to shield patients with chronic low back pain from the allure of quick surgical fix. We know that once a patient falls into an orthopedists' orbit, there is no turning back from the toss-up proposition: in exchange for a back scar, there is a good chance the symptoms will get better, but there is also a chance of developing the dreaded failed back syndrome. 'Go home,' said the DMCB to many of its fragile and high risk patients, 'and let me help you learn to live with your symptoms.'

Which is why DMCB decided to not take the media's word for it and read the JAMA article for itself.

Richard Deyo, Sohail Mirza, Brook Martin, William Kreuter, David Goodman and Jeffrey Jarvik tapped the Medicare payment claims databases to compare 2007's spinal surgeries to prior years. Insurance claims are an important tool for researchers, because Medicare and other health insurers not only record the amount of money paid, but other information including the type of surgery, the type of patient and other medical expenses arising from complications.

Their analysis focused on patients with 'lumbar stenosis' (information on what that is is here and here but bascially, it's a form of arthritis that causes back pain and pinches nerves) and divided the myriad surgery types into three broad categories: 1) decompression (if something is pressing on something causing pain or numbness, it is cut or chiseled out), 2) simple fusion (which is what it sounds like: joining parts of the bones of the spine together) or 3) complex fusion (a more complete joining of the spinal bones or doing it to multiple bones). The complex surgery is relatively new and typically involves use use of hardware. In addition to counting the three types of surgery, they also looked at concurrent diagnoses and complications.

In 2007, Medicare paid $1.65 billion for over 37,000 spinal stenosis operations. Compared to previous years, the overall rate of surgery was unchanged, i.e. about 135 per 100,000 Medicare beneficiaries. However, within that number, the percent of decompression and simple fusion surgeries declined and the percent of complex surgery proportionately increased in 2007 from about 1 per 100,000 in 2002 to 19 per 100,0000.

Complications occured in 3.1% of all patients and the death rate within 30 days was 0.4%. Complex fusion operations had a 5.2% complication rate compared to 4.7% for simple and 2.1% for decompression. When the authors statistically neutralized the impacts of age, gender, co-morbid conditions, other back problems and previous hospitalization rates, the odds of a wound complication, prolonged hospitalization stay, high hospital charges and a readmission within 30 days remained stastically higher in the complex surgery group group.

The DMCB's first instinct was to ask 'what's the big deal?' Despite an aging population, spinal surgery rates are flat and a big majority (85%) are still decompressive or simple. The death rate is less than 1% and complication rates are in the single digits. We could do better, but this is not a disaster.

As for the increase in complex surgeries, the DMCB's second instinct was to recall this past landmark article published in the New England Journal of Medicine. While the topic was "sciatica" (which is frequently but not always caused by spinal stenosis), it demonstrates two key insights about modern back surgery:

1) if patients are willing to wait up to a year, they may not need any surgery and

2) there are an increasing array of other invasive treatment options that deal with back pain, including various types of nerve blocks, injections and percutaneous microsurgeries.

That's important because it is possible that spinal stenosis patients who would have gotten the decompression or simple surgery years ago may, in 2007, be getting 1) rest or 2) the other types of treatments. That could account for some of the decline in the simpler types of surgery reported in the JAMA article. In addition, the recent increasing availability surgeons capable of performing new complicated surgeries could have attracted the kind of high risk patient that, years ago, would have been advised by the DMCB-type primary care physicians to go home. What's more, because they're sicker and have worse back pain, they can be expected to experience greater complications anway. Between the pull of old candidate patients away from the low intensity surgeries and the push of new patients to the high risk surgeries, the DMCB wondered if the results of Deyo et al were biased.

Not exactly, says an accompanying JAMA editorial by Eugene Carragee. He notes the accepted indications for the complex surgery includes spinal stenosis with "deformities" (for example, scoliosis) and that the JAMA research shows about half of the complex surgery group appeared to have "simple" spinal stenosis. Ignoring the "pull/push" bias described above, that's about half of the 19 per 100,000 Medicare enrollees (or 10/100K) who appeared to have unjustified complex surgery. Lacking any other explanation, it's possible that the economics are playing a role, i.e., complex surgery and the use of hardware is more remunerative to the hospital and surgeon, giving them an incentive to do more with more risk when less with less risk will do.

What does the DMCB think?

1) It's not THAT bad. The majority of spinal stenosis surgeries are not complex. Of the ones that are complex, only about half or 7% of the total seem to be for questionable indications.

2) Despite an aging population and significant health care inflation, the overall rate of spinal stenosis surgeries are flat from year to year and many patients that would have gotten surgery years ago are probably being treated with less invasive, safter and cheaper alternative care options.

3) Medicare's ability and track record in dealing with a 7% problem in spinal stenosis surgery is not good, so the likelihood of a solution is distant at best. In managed care, however (and that includes Medicare Advantage) the solution is unfortunately simple: ask the surgeon to justify the medical necessity of the complex surgery ahead of time - or no payment. It's a hassle, but it works.

4) The other approach is retrospective audit, which has been used by Medicare in other circumstances. Unfortunately, the science of complex spinal surgeries is complex and once you get into the medical charts, it's not as simple as Deyo et al would suggest.

5) Which brings us back to shared decision making, which was written into the health reform legislation. In the opinion of the DMCB (and this writer in the NYT), this holds the best promise of tempering out fancy for really big surgeries, because 1) sharing the insights above in an unbiased and patient-friendly way and 2) then letting the patient decide based on his or her own symptoms and values may be the best tool in addressing how and when Medicare covers surgery.

Here's to hoping that we get there soon.

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