A study of Medicare patients shows that doctors are increasingly performing costlier, more complex spinal fusion surgeries, sometimes unnecessarily, for stenosis, a common lower back condition caused by aging and arthritis.
Even more disturbing is that the findings suggest these more challenging operations are riskier, leading to more complications and even deaths.
According to surgeons, a simpler and less risky operation could cost $20,000 and the more complex one $80,000 without any good evidence the expensive one is being used appropriately in the majority of cases.
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.
All the patients in the study had stenosis in their lower backs, a painful squeezing in the spine that's most common in people over 50. The researchers compared the risks for three different types of surgery for the condition: decompression, simple fusion and complex fusion.
There's little agreement about the best way to treat chronic lower back pain, and much depends on what's causing the pain.
Many times steroid injections and physical therapy provide relief, and a simple decompression procedure is as helpful as a spinal fusion and with less risk.
In a decompression procedure, the simplest method in the Medicare study, a surgeon cuts away part of the bone that's painfully pressing on nerves. It can cost about $30,000 in hospital and surgeon fees.
For a fusion, a surgeon binds two or more vertebrae together using a bone graft, with or without plates and screws. The researchers defined a complex fusion as one involving three or more vertebrae or more than one side of the spine. Fusions cost $60,000 to $90,000.
The researchers analyzed data on more than 32,000 Medicare patients who had one of the three types of surgeries in 2007.
About 5 in 100 patients who had simple or complex fusions suffered major complications such as stroke compared to 2 in 100 with decompressions. The risk of death within 30 days after surgery was different too: 6 in 1,000 for complex fusions compared with 5 in 1,000 for simple fusions and 3 in 1,000 for decompressions.
More than half the patients who had complex fusions had a simple stenosis, which usually calls for decompression alone. They did not have curvature of the spine or a slipped vertebra which might suggest a fusion is needed.
Rates of complex fusions in Medicare patients rose 15-fold from 2002 to 2007, while decompressions and simple fusions declined, the study found. Although the overall procedure rate fell, hospital charges grew 40 percent.
Aggressive marketing of devices used in complex fusions is likely playing a role in the increase according to researchers. The marketing includes ads in medical journals and lectures by surgeons on the payroll of device manufacturers.
Allegations of kickbacks to spine surgeons for using products and questionable financial arrangements to doctors as consultants have abounded in the industry. One company, Medtronic Inc., reached a $40 million settlement with the U.S. Justice Department in a whistleblower case that included allegations the company paid doctors to use its spine surgery products. The company denied any wrongdoing.
A provision in the new health care law requires device makers and others to file annual reports to the government on their financial ties to doctors. Patients will be able to look up possible conflicts in a government database.