Where There's Back Pain There's Sure to be Profit

Back pain is endemic: It affects 8 out of every 10 people at one point in their lives. Americans spent some $86 billion in 2005 on doctor’s visits, surgery, imaging, and drugs to treat back and neck pain—and costs continue to rise each year. Despite being ubiquitous—and an enormous drain on medical resources—back pain continues to be poorly treated as well as over-treated. Recent research has shown that doctors consistently fail to follow accepted guidelines in treating their patients; ordering X-rays and MRIs when they aren’t useful, prescribing expensive prescription drugs when over-the-counter pain relievers would work just as well and resorting to surgery without evidence that it will actually relieve pain and disability.

The trend, unfortunately, is continuing. A new study published in this week’s issue of the Journal of the American Medical Association found that although the rate of lower-back surgery among older Americans had declined slightly between 2002 and 2007, the rate of the most complex, medically risky and most expensive type of lower back surgery increased 15-fold (from under 1% of operations to 14.6%) during this same time period. There is little upside to this increase in intervention: Besides driving up health care costs, the authors found that overuse of the expensive, risky technologies put patients at increased risk of death and life-threatening complications without providing a corresponding increase in pain relief or mobility.

First some background: The growth in spine surgery has been fueled in large part by its increased use to treat Medicare patients for a condition called spinal stenosis—a leading cause of pain and disability in this group. What happens is that as we age, degeneration of the vertebrae and associated ligaments can causes the spinal canal to narrow, putting pressure on nerves that then leads to serious back and leg pain and numbness. Over the last two decades, a surgical technique that alleviates this pressure on the nerves—called lumbar decompression—has improved so much that many older adults who undergo it have relatively good outcomes. The average hospital costs for simple decompression surgery is $23,724.

But the JAMA study found that increasingly, doctors are using far more complex procedures that involve spinal fusion and the use of expensive—and still experimental—bone grafts and implants to treat stenosis in their older patients. In a small minority of cases the severity of spinal degeneration and other anatomical problems makes it necessary to use such invasive procedures. But the researchers in the JAMA paper found that 50% of the new complex fusion operations were performed on people who did not have these problems. They would have had good outcomes from the simple decompression procedure. A companion editorial written by Eugene Carragee, director of the Orthopaedic Spine Center at Stanford University School of Medicine finds :

“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.”

Why are doctors choosing to perform complex surgeries for patients who would likely fare better with simple decompression procedures? Carragee chalks it up to “conflicting economic incentives:”

“[S]imple decompression operations rarely have well-funded advertising campaigns or well orchestrated promotions at professional meetings.

“The fact that lumbar decompression is well studied and highly effective in spinal stenosis does not mean that it is well-compensated. In the Medicare population studied by Deyo et al, surgeon reimbursement for a simple decompression for spinal stenosis is approximately US $600 to $800, whereas the reimbursement for a complex fusion may be 10-fold greater.”

Carragee also points out that in the simple decompression surgery there are no profits to be made from implants, devices or proprietary biological materials. In the complex surgeries, charges for implants alone can exceed $50,000. With Medicare footing the bill, doctors get paid more for the complex procedure, hospitals get paid more and medical device companies eagerly watch their profits grow. But there is another, more serious downside from the patient’s point of view:  According to the JAMA paper, the complex spinal surgeries carry greater risk of death, serious complications and long-term problems and so far have not proven to be more beneficial than simple decompression.

An article last year in the Journal of the American Board of Family Medicine documented enormous growth in tests and treatments targeting back pain including “a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates.” Despite the dramatic increase in interventions, there is little evidence that patients are reaping the benefits: the rate of disability from back pain was even higher in 2005 than in 1997.

In 2007, spinal surgery was number one on Consumer Reports’ list of the top 10 overused medical tests and treatments. “In 90 percent of cases, the pain goes away on its own within six weeks,” wrote the authors of the report.

Richard Deyo,  Kaiser Permanente professor of evidence-based family medicine at Oregon Health & Science University and lead author of both the new JAMA paper and the Family Medicine article told Newsweek last year:

"We seem to be doing more and more"… “[But] there's no evidence that people are getting more pain relief." He continues, "This suggests to me that we're overtreating a lot of people, and we're providing a lot of services that may not be very beneficial."

As the nation begins to implement health care reform it is imperative that we focus early on eliminating treatments and procedures that are not only costly but also ineffective and potentially dangerous. Action is clearly pending on the overuse of MRI for lower back pain—especially in the context of Medicare reform. This latest JAMA report raises important issues about spinal surgery and ultimately, money-driven medicine in general. It also highlights the unhealthy relationship that has developed between the medical device industry, doctors, and hospitals that ultimately drives over-treatment. It’s time to remove the financial incentives and market forces that favor more surgeries and more interventions at the expense of good patient care.

Comments

[masorteam]

30 year answer for chronic back pain, published and waiting for incentives. www.cottagepainclinic.com

[Ian G. Dorward]

Unfortunately you really don't know much about this article, or the topic at hand.

Importantly, the JAMA article reports on the rates of surgical procedures, their expense, and their complications. The article does not, in any way, evaluate outcomes beyond 30 days, and as such is wholly incomplete for informing any opinion about surgical results. The accepted standard for spinal surgery publications is to provide a minimum of 2 year follow-up; were this article to have been published in the spinal literature--or any publication without the anti-surgery bias of JAMA--it would have to have been accompanied by a disclaimer that it cannot, in any way, be used to reflect the ultimate value of the surgery from the standpoint of results.

We know that more extensive surgeries carry greater risk; this point stands to reason. It does not follow, however, that the surgery is not effective, or that the higher risk of complications is not worthwhile, if a more complex procedure results in improved outcomes long-term.

There are not randomized, controlled trials for most surgical procedures. Alas, this is the nature of surgery. Innovation outstrips exhaustive proof of efficacy. Also, surgeons are typically quite busy, and unlike Dr. Deyo do not have hours upon hours every week to dredge up reasons why patients shouldn't be cared for. They work to contribute to the literature, but the literature lags behind progress in patient care.

By the way, spinal stenosis (the topic of the JAMA article) is not back pain; please do not conflate the two if you purport to be some sort of expert on this subject.

Ian Dorward, M.D.

[Girl Gone Healthy]

Wow, that's an overwhelming discovery. With expense rising in every front, it's disturbing if it's actually a fact that these malpractices and irresponsible behaviour is prevalent in the industry.