TY - JOUR
T1 - How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers' compensation systems
AU - Martin, Brook I.
AU - Franklin, Gary M.
AU - Deyo, Richard A.
AU - Wickizer, Thomas M.
AU - Lurie, Jonathan D.
AU - Mirza, Sohail K.
N1 - Funding Information:
Funding for this project was provided by grants P60AR062799 and R01AR054912–01A (National Institute of Arthritis, Musculoskeletal, and Skin Diseases) , HS018405 (Agency for Healthcare Research and Quality) , and 1RC1AG036268 (National Institute of Aging) . The findings and conclusions expressed are solely those of the authors and do not necessarily represent the views of any agency of the federal government. The funding agencies had no role in the design, collection, analysis, and interpretation of the data, or with the manuscript preparation. The corresponding author confirms that he had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis as well as the decision to submit for publication.
PY - 2014/7/1
Y1 - 2014/7/1
N2 - Background context In response to increasing use of lumbar fusion for improving back pain, despite unclear efficacy, particularly among injured workers, some insurers have developed limited coverage policies. Washington State's workers' compensation (WC) program requires imaging confirmation of instability and limits initial fusions to a single level. In contrast, California requires coverage if a second opinion supports surgery, allows initial multilevel fusion, and provides additional reimbursement for surgical implants. There are no studies that compare population-level effects of these policy differences on utilization, costs, and safety of lumbar fusion. Purpose The purpose of this study was to compare population-level data on the use of complex fusion techniques, adverse outcomes within 3 months, and costs for two states with contrasting coverage policies. Study design and setting The study design was an analysis of WC patients in California and Washington using the Agency for Healthcare Research and Quality's State Inpatient Databases, 2008-2009. Patient sample All patients undergoing an inpatient lumbar fusion for degenerative disease (n=4,628) were included the patient sample. Outcome measure(s) Outcome measures included repeat lumbar spine surgery, all-cause readmission, life-threatening complications, wound problems, device complications, and costs. Methods Log-binomial regressions compared 3-month complications and costs between states, adjusting for patient characteristics. Results Overall rate of lumbar fusion operations through WC programs was 47% higher in California than in Washington. California WC patients were more likely than those in Washington to undergo fusion for controversial indications, such as nonspecific back pain (28% versus 21%) and disc herniation (37% versus 21%), as opposed to spinal stenosis (6% versus 15%), and spondylolisthesis (25% versus 41%). A higher percentage of patients in California received circumferential procedures (26% versus 5%), fusion of three or more levels (10% versus 5%), and bone morphogenetic protein (50% versus 31%). California had higher adjusted risk for reoperation (relative risk [RR] 2.28; 95% confidence interval [CI], 2.27-2.29), wound problems (RR 2.64; 95% CI, 2.62-2.65), device complications (RR 2.49; 95% CI, 2.38-2.61), and life-threatening complications (RR 1.31; 95% CI, 1.31-1.31). Hospital costs for the index procedure were greater in California ($49,430) than in Washington ($40,114). Conclusions Broader lumbar fusion coverage policy was associated with greater use of lumbar fusion, use of more invasive operations, more reoperations, higher rates of complications, and greater inpatient costs.
AB - Background context In response to increasing use of lumbar fusion for improving back pain, despite unclear efficacy, particularly among injured workers, some insurers have developed limited coverage policies. Washington State's workers' compensation (WC) program requires imaging confirmation of instability and limits initial fusions to a single level. In contrast, California requires coverage if a second opinion supports surgery, allows initial multilevel fusion, and provides additional reimbursement for surgical implants. There are no studies that compare population-level effects of these policy differences on utilization, costs, and safety of lumbar fusion. Purpose The purpose of this study was to compare population-level data on the use of complex fusion techniques, adverse outcomes within 3 months, and costs for two states with contrasting coverage policies. Study design and setting The study design was an analysis of WC patients in California and Washington using the Agency for Healthcare Research and Quality's State Inpatient Databases, 2008-2009. Patient sample All patients undergoing an inpatient lumbar fusion for degenerative disease (n=4,628) were included the patient sample. Outcome measure(s) Outcome measures included repeat lumbar spine surgery, all-cause readmission, life-threatening complications, wound problems, device complications, and costs. Methods Log-binomial regressions compared 3-month complications and costs between states, adjusting for patient characteristics. Results Overall rate of lumbar fusion operations through WC programs was 47% higher in California than in Washington. California WC patients were more likely than those in Washington to undergo fusion for controversial indications, such as nonspecific back pain (28% versus 21%) and disc herniation (37% versus 21%), as opposed to spinal stenosis (6% versus 15%), and spondylolisthesis (25% versus 41%). A higher percentage of patients in California received circumferential procedures (26% versus 5%), fusion of three or more levels (10% versus 5%), and bone morphogenetic protein (50% versus 31%). California had higher adjusted risk for reoperation (relative risk [RR] 2.28; 95% confidence interval [CI], 2.27-2.29), wound problems (RR 2.64; 95% CI, 2.62-2.65), device complications (RR 2.49; 95% CI, 2.38-2.61), and life-threatening complications (RR 1.31; 95% CI, 1.31-1.31). Hospital costs for the index procedure were greater in California ($49,430) than in Washington ($40,114). Conclusions Broader lumbar fusion coverage policy was associated with greater use of lumbar fusion, use of more invasive operations, more reoperations, higher rates of complications, and greater inpatient costs.
KW - Coverage and reimbursement
KW - Degenerative disease
KW - Lumbar spine fusion
KW - Readmission
KW - Safety and quality
KW - Workers' compensation
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U2 - 10.1016/j.spinee.2013.08.018
DO - 10.1016/j.spinee.2013.08.018
M3 - Article
C2 - 24210578
AN - SCOPUS:84902655980
SN - 1529-9430
VL - 14
SP - 1237
EP - 1246
JO - Spine Journal
JF - Spine Journal
IS - 7
ER -