April 6, 2010
Complex back surgeries in older adults surged 15-fold from 2002 to 2007, driving up medical costs and the risk that patients may develop life-threatening complications, a study found.
The operation, complex spinal fusion, accounted for 14.6 percent of all back surgeries for Medicare patients in 2007, up from less than 1 percent in 2002, researchers said today in the Journal of the American Medical Association. Patients who underwent the procedure had more than double the rate of life- threatening complications, 5.6 percent, compared with 2.3 percent for a simpler back surgery called decompression. The more complicated surgery generated average hospital charges of $80,888 compared with an average of $23,724 for the simpler operation, said the lead researcher, Richard Deyo, in the article.
The study is the first to look at the rate of spinal surgery and its complications and cost in a large group of Medicare patients, Deyo said. About 660,000 back surgeries, some of which use devices made by Medtronic Inc. and Zimmer Holdings Inc., were performed in the U.S. in 2009, according to Millennium Research Group, a medical market research company in Toronto.
“This is an example where lower-cost procedures are just as good and safer, as well as being less expensive,” Deyo, a researcher at Oregon Health & Science University in Portland, Oregon, said in a telephone interview.
The large increase in spinal fusions came amid a decline of 1.4 percent in the overall number of lower back surgeries for patients on Medicare, the U.S. health program for the disabled and people ages 65 and older, the researchers said.
For purposes of the study, the researchers grouped back surgeries into the categories of simple decompression, simple fusion and complex fusion. The large increase was seen in complex fusion surgery.
It is “unclear” why the rate of complex back operations rose 15-fold in six years, Deyo and colleagues wrote in the study. Possible explanations include marketing of new surgical products by medical device makers and promotion of new techniques by medical “opinion leaders,’ the authors wrote.
Improvements in surgical technique, anesthesia and after- surgery care “may make more invasive surgery feasible when risks formerly would have been prohibitive,” the authors wrote.
The study relied on “very coarse” data from patient records “not designed to answer therapeutic questions,” said Ray Baker, a pain medicine specialist in Bellevue, Washington, and president of the North American Spine Society based in Burr Ridge, Illinois. Still, the spine society “is gravely concerned about overutilization of precious resources that may in fact be injurious to patients,” he said in an e-mail. Most physicians are not consciously making decisions to do riskier, costlier surgeries, “but I do think you have a misalignment of incentives that could be a problem,” he said.
Physicians’ fees may be 10 times higher for fusion surgeries than for the simpler decompression operation for back pain, according to the study.
In decompression, surgeons remove some bone and tissue inside the spinal cord to relieve pressure on nerves that can cause shooting pain in the back, buttocks and legs. For fusion procedures, surgeons may use metal rods, screws and bone grafts to stabilize two or more bones in the spine to ease pain or correct a deformity. Patients stayed in the hospital about two days longer for the complex fusion operation than the decompression procedure.
The spine society adopted guidelines in 2008 that said the simpler back operation is effective 80 percent of the time for patients who don’t have more serious spine defects or injuries. The guidelines say “there is no evidence to support” fusion surgeries in patients who don’t have a slippage of the spine, known as spondylolisthesis, or spinal instability, according to Baker.
The study found that half of the complex fusion operations were done in patients who didn’t have spondylolisthesis or a back deformity.
“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,” wrote Eugene Carragee, chief of spinal surgery at Stanford University School of Medicine near Palo Alto, California, in an accompanying editorial.
The increase in spinal fusion procedures can be explained by patients who are living longer, improvements in surgical devices and “better patient selection,” Marybeth Thorsgaard, a Medtronic spokeswoman, said today in an e-mail about the study.
“The combination of these factors has led to a natural evolution in the increase of spine stabilization procedures as people are living healthier longer, and want to continue their active lifestyles,” Thorsgaard said. Medtronic had $3.4 billion in sales from its spinal business for the year ended April 24.
“I don’t think guys in the community are acting maliciously,” said Carragee, the editorial writer, referring to doctors. “But if leaders in the field who are very heavily industry sponsored get up at professional meetings and say, ‘These are the latest and greatest things and we should be doing these blue plate specials,’ doctors say, ‘Gee, I don’t want to be in the Stone Age.’”
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