A Motivating Factor for AHCPR Guidelines?

A recent study¹ took a hard look at the rates of surgery in the United States. The study revealed:

"From 1979-81 to 1988-90, in each sex, the rate of hospitalization with cervical spine surgery increased >45% with the rates for cervical fusion surgery increasing >70%. The rate of hospitalization with lumbar spine surgery increased >33% in each sex, with the rate for lumbar fusion surgery increasing >60% in each sex, the rate for lumbar disc surgery increasing 40% among males and 21% among females, and the rate for lumbar exploration/decompression surgery increasing >65% in each sex.

National survey data^2-7 indicate that from 1979 to 1990, spinal surgeries increased 137 percent, while the population older than 25 years (on whom almost all these operations are done) rose only 23 percent. The author concluded that "surgery rates are influenced by the ratio of surgeons to population."⁸ Between 1980 and 1990,1 the number of neurosurgeons and orthopedic surgeons increased by 24 percent. Of the all lumbar operations, 12-14 percent are repeat operations.^9-11

A second study¹² compared back surgery rates between the United States and the rest of the world. The authors found:

"The rate of back surgery in the United States was at least 40% higher than any other country and was more than five times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country."

In the United States, back surgery rates at HMOs were found to be "roughly half the rates for the states in which the HMOs were located and where fee-for-service practice and easy access to surgeons is the norm." The study suggests that differences in "financial incentives to perform surgery and in practice style philosophies" may explain why HMO back surgery rates are much lower.

While there has been no statement by the Agency for Health Care Policy and Research (AHCPR) to suggest so, these startling increases in surgery rates have to have been one of the primary motivating factors in the development of the low back guidelines. Now the question is, will spine surgeons respect the new guidelines or continue to operate as they have been?

References

1. Davis H. Increasing rates of cervical and lumbar spine surgery in the United States, 1979-1990. Spine 1994;19(10):1117-1124.

    

2. Graves EJ. Detailed diagnoses and procedures, National Hospital Discharge Survey, 1990. National Center for Health Statistics. Vital Health Stat, 1992;13(113).

    

3. Graves EJ. National Hospital Discharge Survey: annual summary, 1987, 1988, 1990. National Center for Health Statistics. Vital Health Stat, Series 13, Nos. 99, 106, 112, 1989: 1, 40-1; 1991: 1, 38-9, 44; 1992: 1, 9, 44-5, 51.

    

4. Graves EJ. Utilization of short-stay hospitals, United States, annual summary, 1982, 1983, 1984, 1985, 1986. National Center for Health Statistics. Vital Health Stat, Series 13, Nos. 78, 83, 84, 91, 96, 1984: 1, 40-1; 1985: 1, 38-9; 1986: 1, 40-1; 1987: 1, 40-1; 1988: 1, 40-1.

    

5. Graves EJ, Haupt BJ. Utilization of short-stay hospitals, United States, annual summary, 1981. National Center for Health Statistics. Vital Health Stat, Series 13, No. 72, 1983: 1, 46-7.

    

6. Graves EJ, Kozak LJ. National Hospital Discharge Survey: annual summary, 1989. National Center for Health Statistics. Vital Health Stat, Series 13, No. 109, 1992: 1, 34-5,40.

    

7. Haupt BJ. Utilization of short-stay hospitals, United States, annual summary, 1979, 1980. National Center for Health Statistics. Vital Health Stat, Series 13, Nos. 60, 64, 1981: 1, 45-6, 1982: 1, 42-3.

    

8. Wennberg J, Gittelsohn A. Variations in medical care among small areas. Sci Am 1982;246(4):120-34.

    

9. Bruske-Hohfeld I, Merritt JL, Onofrio BM, et al. Incidence of lumbar disc surgery: a population-based study in Olmstead County, Minnesota, 1950-1979. Spine 1990;15:31-5.

    

10. Frymoyer JW, Matteri RE, Hanley EN, et al. Failed lumbar disc surgery requiring second operation: a long-term follow-up study. Spine 1978;3:7-11.

     

11. Williams RW. Microlumbar discectomy: a surgical alternative for initial disc herniation. In: Cauthen JC, editor. Lumbar Spine Surgery: Indications, Techniques, Failures, and Alternatives. William & Wilkins, Baltimore, 1988:171-83.

     

12. Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G. An international comparison of back surgery rates. Spine 1994;19(11): 1201-1206.