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Archive for April, 2010

Hidden Costs

The collection of stories assembled by the Kaiser Health News on April 7, 2010 on the rising cost and complexity of back surgeries provides a case study for the question of whether or not “more” and “more expensive” care equals “better” care. The question is obviously not new (since even we have blogged about it already here).  What’s interesting about the research on back surgery outcomes (summarized below) is how the quality/cost equation finds real physical and financial expression.

Ruptured disc, spinal stenosis or degenerating spinal joints? See three common and chronic spine problems. (Graphic: NPR)

NPR: “Too many complex back surgeries are being done and people are suffering as a result, according to a study in the current issue of the Journal of the American Medical Association. The general tendency noted in the study — that many patients and doctors think more medical care is always better — has implications for the new health overhaul law. Back pain associated with aging can be treated in one of numerous ways: rest and physical therapy, surgery to remove the bony growths that can push on nerves, fusing two vertebrae together, or fusing many vertebrae together.” But several studies have not shown an advantage for surgery so this study examined Medicare billing records to see whether the number of back surgeries had been reduced as a result.

“They found the number of surgeries has gone down very slightly. But when they looked specifically at complex surgeries, they found a big difference. ‘The most complex type of back surgery has increased dramatically between 2002 and 2007, with a 15-fold increase,’ says co-author Richard Deyo. … Deyo and his colleagues also checked the rate of complications. ‘This more complex form of surgery is associated with a higher risk of life threatening complications,’ he says” (Silberner, 4/6).

The Associated Press: “A study of Medicare patients shows that costlier, more complex spinal fusion surgeries are on the rise — and sometimes done unnecessarily — for a common lower back condition caused by aging and arthritis. … ‘This is exactly what the health care debate has been dancing around,’ said Dr. Eugene Carragee of Stanford University Medical Center. ‘You have one kind of operation that could cost $20,000 and another that could cost $80,000 and there’s not good evidence the expensive one is being used appropriately in the majority of cases,’ Carragee said. Add to that the expense for patients whose problems after surgery send them back to the hospital or to a nursing home and ‘that’s not a trivial amount of money’ for Medicare, said Carragee. … The cost to Medicare, just for the hospital charges for the three types of back surgery reviewed is about $1.65 billion a year, according to the researchers” (Johnson, 4/6).

HealthDay News/Modern Medicine: “After adjustment for age, comorbidity and previous spinal surgery, the odds ratio of life-threatening complications was 2.95 for complex fusion compared with decompression. Also, for complex fusion versus decompression only, 30-day mortality was 0.6 versus 0.3 percent, the mean hospital charge was $80,888 versus $23,724, and the 30-day rehospitalization rate was 13 versus 7.8 percent” (4/6).

MedPage Today: “Complex fusion accounted for less than 1% of operations for spinal stenosis in 2002, but 14.6% of those performed in 2007.” Researchers were unclear about the reason for a spike in complex surgeries: “Several forces might be contributing, [Deyo] said, including effective marketing by device manufacturers touting the efficacy of complex operations using new surgical implants” (Neale, 4/6).

David Leonhardt in the New York Times also takes on over-treatment this week. He argues that the low-hanging fruit for managing healthcare costs is to say “no” to unnecessary care:

Advocates for less intensive medicine have been too timid about all this. They often come across as bean counters, while the try-anything crowd occupies the moral high ground. The reality, though, is that unnecessary care causes a lot of pain and even death.

The (partial) cure may be found in patient education, he suggests:

When patients are given information about potential benefits and risks, they seem to choose less invasive care, on average, than doctors do, according to early studies. Some people, of course, decide that aggressive care is right for them …. They are willing to accept the risks and side effects that come with treatment. Many people, however, go the other way once they understand the trade-offs.

The causes and effects of “too much care” are  clearly amplified by practice pattern variation. (But that’s a topic for another posting.)

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