Hospitals Waste Nearly $1 Billion on Low-Back Pain Treatment

The latest issue of Spine, the well-known chiropractic research journal, featured the paper, "Nonsurgical Hospitalization for Low-Back Pain: Is It Necessary?"¹ Authors Daniel Cherkin, PhD, and Richard Deyo, MD, MPH, analyzed three sources of data for the hospitalization and care of low-back pain patients in the state of Washington.

Dr. Cherkin is widely recognized for his studies on patient satisfaction (see "AHCPR Awards $979,751 for Comparison between Chiropractic and Physical Therapy for Low Back Pain" in the October 10, 1993 issue of "DC"). Both authors are part of the back pain outcomes assessment team for the Agency for Health Care Policy and Research (AHCPR), with Dr. Deyo acting as principal investigator (see "AHCPR Sponsors Back Pain Outcomes Assessment Team" in the March 27, 1992 issue of "DC").

The paper also reviewed related literature: "A recent analysis of Medicare data using appropriateness evaluation protocol estimated that 71 percent of admissions and 78 percent of hospital days for medical back problems (DRG 243) were inappropriate."² The study concluded:

"Although this study is limited by the lack of clinical detail and incompleteness of the NHDS (National Hospital Discharge Survey) data and by the availability of a relatively small number of medical records, the strengths of each data source complement the weaknesses of the other. The picture that emerges is consistent with the other published analyses of the appropriateness of hospitalizations for medical back problems, which suggested that 70 percent of hospitalizations and 80 percent of hospital days were inappropriate.^3,4 If these estimates apply to national data for 1988, approximately 235,000 hospitalizations and 1,500,000 hospital days would be considered inappropriate. At the 1989 average hospital cost of $637 per day⁴ this would represent, for a single year, almost one billion dollars in unnecessary hospital expenses alone. Although our study was not specifically designed to measure appropriateness, the findings suggest several opportunities for reducing the volume of medical back admissions."

One of the elements to blame for the excessive costs is the expense of hospitalizing patients for tests which could be conducted on an outpatient basis. The authors note:

"In spite of the numerous and consistent findings that outpatient myelography is safe and preferred by patients, influential leaders in orthopedic surgery continue to view myelography as an inpatient procedure.

"Hence, although the scientific literature and some major insurers and specialty organizations suggest that myelograms should, or even must, be performed as an outpatient procedure, other experts and professional organizations have recently recommended the opposite. Efforts to develop consistent guidelines for myelography are needed to address this apparent contradiction between expert opinion and scientific findings."

The study also noted that CT scans, MRIs, and other less costly diagnostic tests probably incurred unnecessary hospitalization. Various forms of treatment, including epidural steroid injections and bed rest, also included unnecessary inpatient care.

These points were driven home by recent decreases in hospitalization rates for "medical back problems" enjoyed by the state of Washington. A 47 percent decrease was achieved simply by imposing new utilization review criteria. In Michigan, the Chrysler Corporation "succeeded in reducing admissions by 64 percent" using a similar utilization review program.³

While this paper doesn't talk about the effectiveness of the treatment these patients received, it does speak directly to the incredible amount of unnecessary expense that has typified medical treatment of back problems. Every DC in the United States should consider this paper mandatory reading. This is a classic example of health care reform generated by scientific study.

A reprint of this complete paper may be ordered from:

Daniel C. Cherkin, PhD
Back Pain Outcome Assessment Team
University of Washington
JF-23
Seattle, WA 98195

References

1. Cherkin DC, Deyo RA: Nonsurgical hospitalization for low-back pain: Is it necessary? Spine 1993;18:1728-1735.

    

2. Payne MC: Targeting utilization review to diagnostic categories. Quality Review Bulletin 1987;13:394-404.

    

3. Maher WB: Controlling low back pain costs at Chrysler. Business and Health, May 1985, pp.20-23.

    

4. American Hospital Association. Hospital Statistics: 1990-91 Edition. American Hospital Association, Chicago, 1990, p.189.