I.Q. -- Interesting Quotes

By Editorial Staff

Lumbar Spinal Fusion

The December 1993 issue of Research Activities published by the U.S. Agency for Health Care Policy and Research (AHCPR), included a report¹ that states: "Indications for this procedure are not scientifically established, according to a recent meta-analysis by the AHCPR-funded Back Pain Outcomes Assessment Team."

Noted health care researcher, Richard A.

Deyo, MD, of the University of Washington, led the team which found: "... most studies of patients with herniated discs failed to show an advantage of fusion surgery over discectomy, which is the surgical removal of a vertebral disc without fusion."

The report also correlated relevant studies:

"In a related investigation, Dr. Deyo reviewed three studies comparing the differences in morbidity, mortality, and reoperation rates following different surgical procedures on the lumbar spine. All three studies suggest that lumbar spinal fusion, when compared to surgery without fusion, is associated with substantially more complications, death, and health resource use. Complications of spinal fusion are relatively common and range from deep vein thrombosis (3.7 percent) and neurological injury (2.8 percent) to chronic donor-site pain (8.7 percent). Moreover, fusion does not reduce the need for future back surgery and usually results in high short-term medical and financial costs."

This is information that all patients who are being told they need spinal fusion should consider. Let their surgeon argue with the scientific literature.

Reference:

1. Lumbar spine fusion remains controversial. Research Activities, Dec. 1993.

I.Q. -- Who You See Is What You Get

A recent study published in Arthritis and Rheumatism¹ revealed a serious lack of consensus regarding diagnostic tests for low back pain. A survey of approximately 1,100 medical physicians resulted in the following comments:

"Even within specialties, physicians are often divided about ordering specific tests. Thus, there is poor consensus on the use of these tests both within and among specialties. These findings lend support to the hypothesis that much of the geographic variation in medical care for low back pain may be due to physician uncertainty, rather than to differences in patient characteristics."²
"If these findings reflect actual physician behavior, then inappropriate use of diagnostic tests for low back pain is a significant problem in the US, with major implications for both the costs and the quality of care. The absence of clear and widely accepted guidelines for test ordering may explain the apparently large practice variation and inappropriate use of tests. Our data support the need for guidelines such as those scheduled for release in 1994 by the Agency for Health Care Policy and Research. Whether the mere availability of guidelines will reduce the inappropriate use of tests remains to be seen."

The authors' call for guidelines development by the Agency for Health Care Policy and Research (AHCPR) appears to be the accepted method of addressing provider uncertainty. These guidelines will need to include all providers regardless of specialty.

The inappropriate use of tests suggests significant unnecessary costs. The authors conclude:

"There is little consensus, either within or among specialties, on the use of diagnostic tests for patients with back pain. Thus, the diagnostic evaluation depends heavily on the individual physician and his or her specialty, and not just the patient's symptoms and findings. Furthermore, many physicians may be ordering imaging studies too early and for patients who do not have the appropriate clinical indications. These results suggest a need for additional clinical guidelines as well as better adherence to existing guidelines."

References

Cherkin DC, Deyo RA, Wheeler K, Ciol MA: Physician variation in diagnostic testing for low back pain. Arthritis Rheum 37:15-22, 1994
Wennberg JE, Barnes BA, Zubkoff M: Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med 16:811-824, 1982.