News
Dartmouth Researchers Question Increase in Spinal Fusion Rates Nationwide
October 17, 2006
With variations in rates of the surgery as much as 20 times greater in some regions of the United States than in others, they call on the medical, academic, corporate and governmental communities to come together to support the necessary research into these conditions that affect millions of people each day.
The cost increase in spinal fusion has been more than 500 percent among Medicare patients alone, rising from $75 million in 1992 to $482 million in 2003. While other common procedures such as laminectomy and disectomy have actually decreased slightly in recent years, rates of lumbar fusion rose from 0.3 per 1,000 Medicare enrollees in 1992 to 1.1 per 1,000 in 2003. Lumbar or spinal fusion is a procedure designed to stabilize the spine by fusing bones together and theoretically providing protection and relief of back pain for degenerative joints in the back. Weinstein, a surgeon and Chair of the Department of Orthopaedics at DHMC and Professor of Orthopaedics at DMS, is also a member of the Center for the Evaluative Clinical Sciences (CECS) and Director of the Institute for Informed Patient Choice. He and his co-authors point to the lack of randomized clinical trials as the reason for the uncertainty about the procedure’s efficacy and effectiveness. "Left alone, practice variations will not go away. Expansion of the research agenda will require not only the early evaluation of new technologies and new theories about the use of current technologies, but also the ongoing evaluation of existing practice," they write. Addressing this problem will require the work of academic medical centers, physicians, and national funding and regulatory agencies, such as the NIH, CMS and FDA, they argue. In addition to variation between rates in the United States and the rest of the world, the study shows "striking" variation in regions within the United States. For example, in 2002, lumbar fusion was performed on 4.6 out of 1,000 Medicare patients in Idaho Falls, Idaho, while in cities such as Bangor, Maine; Covington, Kentucky; and Terre Haute, Indiana, an average of 1.0 patients per 1,000 underwent the procedure. Other regions with unusually high rates of the surgery included Missoula, Montana; Mason City, Iowa; Bradenton, Florida; and Casper, Wyoming. Reasons for the geographic variations internationally and nationally are not fully understood, but the authors suggest that "lack of scientific evidence, financial incentives and disincentives to surgical intervention, and difference in clinical training and professional opinion" are underlying causes. Co-authors of the paper, "United States' Trends and Regional Variations in Lumbar Spine Surgery: 1992-2003" are Jon D. Lurie, MD, MS; Patrick R. Olson, MD; Kristen K. Bronner, MS; and Elliott Fisher, Ph.D. Findings were based on analysis of Medicare claims and enrollment data for Medicare beneficiaries over age 65 in each of the 306 US Hospital Referral Regions between 1992 and 2003. A copy of the paper is available at http://www.spinejournal.com More information about CECS and the Dartmouth Atlas of Health Care may be found at http://www.dartmouth.edu/~cecs/ and at http://www.dartmouthatlas.org/, respectively. Information about the Department of Orthopaedics at DHMC can be found at http://www.dhmc.org/ortho/index.html. For more information, contact Sue Knapp at (603) 646-3661, sue.knapp@dartmouth.edu.
Lebanon, NH --
Rates of lumbar fusion in the United States have increased more than 250 percent over the past decade, according to a study appearing in the Nov. 1, 2006 edition of the journal, Spine. Yet, study authors from Dartmouth Medical School (DMS) and Dartmouth-Hitchcock Medical Center (DHMC) raise concerns that without scientific or clinical evidence to prove such procedures are effective for most low back conditions, there is no way of knowing if the increase is warranted.
Ratio of Rates of Lumbar Fusion to the U.S. Average by Hospital Referral Region (2002-03) 
"What’s most disquieting about these findings is that we really haven’t advanced our knowledge as to whether fusion, for several back conditions, works for our patients," said lead author James N. Weinstein, DO, MS. "Lumbar fusion now accounts from almost 50 percent of all back surgeries performed in the United States. Clearly, we are doing more and more of it, but we have not provided the scientific or clinical evidence to support these procedures."
