Ask 2 spine surgeons for a recommendation on what kind of spine surgery to have for low back pain (LBP)—or whether to have surgery at all—and you're likely to get 2 different answers, according to results of a new survey that found high rates of disagreement, with some significant regional variability.
In an article published recently in Spine (abstract only available for free), researchers shared results of a study in which 445 spine surgeons across the US (75% orthopedic surgeons, 25% neurological surgeons) were asked to respond to 2 case scenarios and related imaging. Scenario 1 described a 44-year-old man with mechanical LBP refractory to conservative management, no leg pain, and discogram at L4-5 causing concordant pain; L3-4 and L5-S1 were negative controls. Scenario 2 presented the same patient, but with discogram at L4-5 and L5-S1 causing concordant pain, and L3-4 a negative control. The surgeons were instructed to provide their recommendation by choosing 1 of 4 fusion surgeries, or no surgery at all.
Authors analyzed the results by geographic region, practice setting, years of experience, and other factors. Here's what they found:
Overall disagreement on how to proceed was 75%-76%, with significant geographic variation. Even in the regions and scenarios with the highest rate of agreement—scenario 1 in the Midwest, and scenario 2 in the Southeast—more than 2 out 3 surgeons (69%) provided differing recommendations. The highest rates of disagreement occurred in the Southwest for both scenarios, with disagreement rates of 82% for scenario 1 and 85% for scenario 2.
The rates at which "no surgery" was recommended also varied by region.Overall, no surgery was recommended 41.4% of the time, ranging from a low of 29% in the Southwest for both scenarios to 52% in the Midwest for scenario 1, and 50% in the Northeast for scenario 2.
Practice setting played a big role in whether a surgeon recommended no surgery. Researchers found that surgeons in academic practice were nearly 4 times more likely to choose no surgery than surgeons in hybrid and private practice settings. Similarly, surgeons with fellowship training were twice as likely to select no surgery as a first option than surgeons without that training.
Practice setting also seemed to be related to disagreement rates. Surgeons in academic settings had a 56% disagreement rate, compared with 78%-79% disagreement rates among surgeons in hybrid or private practice settings.
Generally, the less-experienced surgeons recommended no surgery more often—and also agreed with each other at higher rates. Surgeons with fewer than 5 years' practice duration recommended no surgery at a 56% rate in scenario 1 and a 60% rate in scenario 2, with rates of disagreement at 65% and 61%, respectively. Surgeons with more than 20 years in practice disagreed at 77% and 80% rates for the 2 scenarios, and chose no surgery 41% of the time for scenario 1 and 36% of the time for scenario 2.
"The lack of definitive evidence supporting one surgical approach versus another, and the lack of definitive evidence identifying the indications for surgery among this patient population, is a major contributor to this variability," authors write. "This heterogeneity … is concerning as it implies patients can present with the same pathology to different surgeons and receive entirely different surgeries, or no surgery."
Authors recommend that surgeons do something about the wide variability, particularly in light of health care's march toward value-based care rooted in identifiable outcomes. "It is imperative that spine surgeons be proactive in defining what works best for their patients, or it is quite possible that such will be dictated to them by other stakeholders (i.e., payers)," they add.
Authors hope that acknowledging this variability "will spur additional studies aimed at identifying the indications as well as the most cost-effective treatments for LBP." In the meantime, they recommend that "patients should be involved in the decision-making process to identify the optimal treatment based on their values."
Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.
Posted by News Now Staff at 1:20 PM
Labels: New in Research