Going About Spine Care The Wrong Way

Spine care "bass-ackwards."
By ANTHONY ROSNER, PhD, LLD [Hon.], LLC

Let's start this discussion with a revealing quote from Mark Schoene, editor of an international spine research newsletter from Georgetown University, who recently declared, "Spinal medicine in the U.S. is a poster child for inefficient spine care."1

And small wonder when you consider spine researchers have stated that medical primary care physicians are inept in their training for MS disorders.2Add to this the facts that (1) primary care physicians are prone to ignore recent guidelines that do not recommend narcotics;3 and (2) primary care physicians are more likely to suggest spine surgery than surgeons themselves.4

Dollars and Nonsense?

In addition, consider a recent Medical Expenditure Panel Survey that revealed the prevalence of low back pain in the U.S. increased by 29 percent from 2000-2007. Forchronic low back pain, the figure was much worse: 64 percent. When it comes to dollars and cents, you are looking at a staggering 129 percent increase, from $15.6 billion to $35.7 billion over the same period.5

Total expenditures for back pain were even more mind-numbing, pegged at $85.9 billion in 2005,6 exceeded only by the 2007 outlay for cancer ($89.0 billion),7 2002 cost of diabetes ($98.1 billion)8 or 2005 tab for heart disease and stroke ($257.6 billion).9

In a study published in 2008, Martin, Deyo and others concluded that the average total health expenditure per person with spine problems in the United States was 73 percent greater than for individuals in other countries.6

Particularly unsettling is the fact that, back in 1998, the costs of prescription drugs for treating back pain was just over 15 percent of the total expenditures for this condition, representing an increase more rapid than any of the other health service expenditures (inpatient, outpatient, office-based, emergency room, and home health).10 In fact, most of the 65 percent increase in spine care costs from 1997-2005 could be attributed to drugs, representing a 188 percent increase.6

The surgery picture isn't pretty, either: a whopping 77 percent increase in spinal fusions in the U.S. from 1996-2001, with the average cost per operation pegged at $34,000, excluding professional fees.11 Complications and reoperations only add to the problem. When compared to any operations without fusion, there's a doubling of the risk of complications accompanied by a doubling of the risk of postoperative mortality at six weeks.12

Complications at the bone-donor site (usually the iliac crest) involve infection and chronic pain, and occur in 11 percent of cases.13 Add to this the fact that, as far back as 1992, the Congressional Committee on Interstate and Foreign Commerce concluded that 17.6 percent of all surgeries in the U.S. were unnecessary.14

As my high-school band director (or any barkeeper) might have suggested if a dispute began to get out of hand: Let's take it outside. In this case, take a look at the total U.S. health care costs. Start with the fact that the third most common reason people in the U.S. visit their doctor is for back problems.15 Add to this the fact that medical care costs have shown the greatest increase in inflation among the eight subcomponents [food and beverage, apparel, housing, transportation, medical care, recreation, education and communication, other goods and services] that make up the Consumer Price Index.16

Against an international profile ranking quality of health care, the U.S. placed 37th on a list of 191 countries not so long ago.17 According to Uwe Reinhardt, a health economist at Princeton University, "While good at expensive, heroic care, Americans are very poor at low-cost preventive care that keeps Europeans healthy."18

Turning Things Around

So, how does one begin to bail out this sorry state of affairs? Consider a number of studies that identify factors leading to spinal surgery and how these might be bypassed:

• An early risk identification study cohort examined early predictors of lumbar spine surgery within three years among Washington state workers with new worker's compensation temporary total disability claims for back injuries. Of 1,885 workers, 42.7 percent of workers who saw a surgeon first had surgery, but just 1.5 percent of those who first consulted a chiropractor had surgery. The breadth of this margin suggests that simply having chiropractors as first-contact providers could produce major cost savings without a sacrifice on health.19
• A managed care organization in Michigan required that all spine patients who were heading for nonurgent surgical consultation first have one session with a physiatrist. After this policy was implemented, there was a 48 percent decrease in surgical referrals, a 25 percent reduction in spine operations and a 25.1 percent drop in surgical costs.20
• The University of Pittsburgh Medical Center Health Plan, recognizing back pain as the third most costly health condition treated, as mentioned earlier, five years ago started educating doctors about using less medication, imaging and surgery while increasing referral rates to DCs and PTs. Because this initiative did not show a significant impact, plan administrators subsequently mandated that patients with chronic back pain undergo a minimum of three months of chiropractic and/or physical therapy before any spine surgery is approved.21

Considering how significant cost savings and the potential for fewer side effects (with fewer associated costs) can be realized with conservative interventions such as chiropractic as a first alternative in managing back pain, there should be little doubt as to which direction treatment of this widespread and costly condition should take. It certainly would eradicate the current "bass-ackwards" element from the choice of interventions for back pain resolution.

References

1. Editorial, The BACKLetter, November 2012;27(11).
2. Joy EA, van Hala S. Musculoskeletal curricula in medical education - filling in the missing pieces. Phys Sports Med, 2004;32(11).
3. Bishop PB, et al. The C.H.I.R.O (Chiropractic Hospital-Based Interventions Research Outcomes) part I: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. Presented at the annual meeting of the International Society for the Study of the Lumbar Spine, Hong Kong, 2007, an at annual meeting of the North American Spine Society, Austin, Texas, 2007.
4. Bederman SS, Mahomed NN, Kreder HJ, Mcisaac WG, Coyte PC, Wright JG. The eye of the beholder: preferences of patients, family physicians, and surgeons for lumbar spinal surgery. Spine, 2010;135(1):108-115.
5. Smith M, Davis MA, Stano M, Whedon JM. Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Survey data for years 2000 to 2007. JMPT, 2013;36(1):2-11.
6. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingsworth W, Sullivan SD. Expenditures and health status among adults with back and neck problems. JAMA, 2008;299(6):656-664.
7. NHLBI Fact Book: Direct and indirect costs of illness by major diagnosis, U.S. 2006: National Heart and Lung Institute Web site.
8. Hogan P, Dall T, Nikolov P. American Diabetes Association. Economic costs of diabetes in the U.S. in 2002. Diabetes Care, 2003;26(3):917-932.
9. American Heart Association. Heart Disease and Stroke Statistics-2005 Update. Dallas, TX. American Heart Association, 2005.
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11. Agency for Health Care Research and Quality: Health Cost and Utilization Project, HCUPnet.
12. Deyo RA, Ciol MA, Cherkin DC, Loesser JD. Bigos SJ. Lumbar spinal fusions from a cohort study of complications, reoperations, and resource use in the Medicare population. Spine, 1993;18:1463-1470.
13. Turner JA, Ersek M, Herron I, Haselkom J, Kent D, Ciol MA, Deyo R. Patient outcomes after lumbar spinal fusions. JAMA, 1992;268(7):907-911.
14. Leape LL. Unnecessary surgery. Annual Rev Public Health, 1992;13:363-383.
15. St Sauver JL, Warner DO, Yawn BP, Jacobson DJ, McGree ME, Pankratz JJ, Melton LJIII, Roger VL, Ebbert JO, Cocca WA. Why patients visit their doctors: assessing the most prevalent conditions in a defined American population. Mayo Clinic Proceed, 2013;88(1):56-67.
16. Short D. "What Inflation Means to You: Inside the Consumer Price Index."AdvisorPerspectives.com, Oct. 30, 2013.
17. Feachem RG. Health system: more evidence, more debate [Editorial]. Bulletin World Health Org, 2000;78(6):715.
18. The Week in Chiropractic, June 26, 2000;6(36):1.
19. Keeney B, Fulton-Kehoe D, Turner J. Wickizer TM, Chan KC, Franklin GM. Early predictors of spine surgery after occupational back injury: results from a prospective study of workers in Washington State. Spine, 2013;38(11):953-964.
20. Fox J, Haig AJ, Todey B, Challa S.. The effect of required physiatrist consultation on surgery rates for back pain. Spine, 2013;38(3):e178-e184.
21. "DC Receives Federal Grant to Study Nonsurgical Alternatives to Surgery for Spinal Stenosis: Interview With Michael Schneider, DC, PhD." Health Insights Today, March 2013.