What's Driving Overuse of Complex Spinal Surgery?

An important paper in the current issue of JAMA:
http://jama.ama-assn.org/cgi/content/full/303/13/1259?home
(at least for now the journal seems to be providing free access to this article)--looks at Medicare billing data for various forms of surgery for spinal stenosis from 2002 to 2007. The chief author, Dr. Richard A. Deyo of Oregon Health and Science University, might well be dubbed "Doctor Back Pain" for his many publications on that topic, many of which demonstrating conclusively that more conservative and cheaper treatments for back pain work as well as more invasive and expensive ones.

The focus of the present article is on the very common condition of spinal stenosis, which basically means a narrowing of a bony canal through which nerve roots come, resulting in pain due to compressed (pinched) nerves. This type of back pain usually does not get better without surgery. The available research data show that the simplest and least invasive surgery, scrounging out the edges of the bony canal to decompress the nerve, works as well as more complex surgeries that involve fusing one or more vertebrae together. (At least, there are no good data today to demonstrate a clear superiority to the more complex surgical techniques.)

Deyo and colleagues showed that from 2002 to 2007, while the overall rate of surgery for spinal stenosis did not increase, the percentage of cases in which the complex procedures were used climbed from 1.3% to 19.9%. The use of more complex surgical approaches was correlated with a higher rate of complications, a greater risk of death, and more than three times greater hospital charges. In short, a type of surgery that has no proof of added benefit went from a tiny blip on the radar to nearly one-fifth of all surgeries of that type, adding to patient risk and greatly padding the total Medicare bill.

What caused this? Deyo and colleagues are reticent, as is appropriate as just staring at sheets of Medicare data cannot answer cause-and-effect questions. But they mention among the possibilities first, the fact that medical device makers have heavily promoted the implants, cement, and other paraphernalia required for the more complex surgeries (the price for which can add up to as much as $50,000 per operation), and second, that surgeons get paid a good deal more for the complex procedures. (This reminds us of George Bernard Shaw's classic statement in The Doctor's Dilemma in 1911, that if you pay a surgeon to cut off your leg, and don't pay him not to cut it off, don't be surprised if the fellow cuts off your leg.)

A bit of further insight is added in an accompanying editorial:
http://jama.ama-assn.org/cgi/content/full/303/13/1309?home
--by Dr. Eugene J. Carragee of Stanford. Dr. Caragee notes that the difference in surgical fees between the simple decopmpression operation and the more complex surgeries may be on a ten-fold scale. He also notes that there are times when it is technically harder to do the simpler than the more complex surgery--to go in and scrounge out the bone without disrupting the stability of the vertebra or the ligaments may be more difficult than simply slapping on an implant or a graft. So today, he suggests, we are actually paying back surgeons less to do the more difficult (but often more desirable) procedure.

The whole story here is complicated but seems to typify how drug or device industry marketing seldom operates in a vacuum. In this case the heavy promotion of expensive devices interacts with a perverse incentive structure to produce outcomes that cost us all a lot of money and that expose patients to unneeded risk.

Finally, one has to note the apparent lack of interest of the average medical specialist in basic epidemiology. In HOOKED I cited psychiatrist David Healy on this matter. As drug companies promoted the newer generation of antidepressant drugs aggressively in the 1990s, the diagnosis of depression became so much more common that eventually the WHO announced that depression was the second largest cause of disability among all diseases. Psychiatrists greeted that news with great joy, as if making depression that common made them that much more important. Healy noted their apparent disinterest in the basic question--just what made that many people so much more depressed all at once? How does one scientifically account for the diagnosis of depression growing by leaps and bounds? Similarly, if Deyo et al. are correct, the back surgery community as apparently been very little interested in or concerned about whatever made the complex (and more remunerative) forms of back surgery so much more necessary in 2007 than they were in 2002.