JAMA Article: Trends, Major Medical Complications, and Charges Associated With Surgery for Lumbar Spinal Stenosis in Older Adults
Tuesday, April 6, 2010 at 11:55PMFollowing is an abstract from a recent article in the Journal of the American Medical Association (JAMA). It is very interesting, especially in light of all of the ongoing healthcare debate and resource use. A link to the full text article is located at the bottom of the page.
Richard A. Deyo, MD, MPH; Sohail K. Mirza, MD, MPH; Brook I. Martin, MPH; William Kreuter, MPA; David C. Goodman, MD, MS; Jeffrey G. Jarvik, MD, MPH
JAMA. 2010;303(13):1259-1265.
Context In recent decades, the fastest growth in lumbar surgery occurred in older patients with spinal stenosis. Trials indicate that for selected patients, decompressive surgery offers an advantage over nonoperative treatment, but surgeons often recommend more invasive fusion procedures. Comorbidity is common in older patients, so benefits and risks must be carefully weighed in the choice of surgical procedure.
Objective To examine trends in use of different types of stenosis operations and the association of complications and resource use with surgical complexity.
Design, Setting, and Patients Retrospective cohort analysis of Medicare claims for 2002-2007, focusing on 2007 to assess complications and resource use in US hospitals. Operations for Medicare recipients undergoing surgery for lumbar stenosis (n = 32 152 in the first 11 months of 2007) were grouped into 3 gradations of invasiveness: decompression alone, simple fusion (1 or 2 disk levels, single surgical approach), or complex fusion (more than 2 disk levels or combined anterior and posterior approach).
Main Outcome Measures Rates of the 3 types of surgery, major complications, postoperative mortality, and resource use.
Results Overall, surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100 000 beneficiaries. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50-3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80 888 compared with US $23 724 for decompression alone.
Conclusions Among Medicare recipients, between 2002 and 2007, the frequency of complex fusion procedures for spinal stenosis increased while the frequency of decompression surgery and simple fusions decreased. In 2007, compared with decompression, simple fusion and complex fusion were associated with increased risk of major complications, 30-day mortality, and resource use.
Full Text at: http://jama.ama-assn.org/cgi/content/full/303/13/1259
Following is an interview with Dr. Deyo regarding this study: http://www.npr.org/templates/story/story.php?storyId=125627307
Following is a portion of a letter to the editor from reknowned Dr. Carragee commenting on this article:
"In 2007, the final year of data reported in the study by Deyo et al, Consumer Reports rated spinal surgery as number 1 on its list of overused tests and treatments. This was a harsh rebuke given the benefit associated with many common spinal surgeries. However, the findings from the study by Deyo et al should not only remind patients, surgeons, and payors that the efficacy of basic spinal techniques must be assessed carefully against the plethora of unproven but financially attractive alternatives, but also should serve as an important reminder that as currently configured, financial incentives and market forces do not favor this careful assessment before technologies are widely adopted. When applied broadly across medical care in the United States, the result is a formidable economic and social problem." [JAMA. 2010;303(13):1309-1310.]
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