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Efforts to Standardize Spinal Stenosis Treatment Should Target Certain Patient Groups

Key findings

  • In the treatment of lumbar spinal stenosis within a single institution, there was significant variation among surgeons' practices with regard to number of patient visits and rates of imaging, electromyography, injections, physical therapy and surgery
  • Male patients, patients with an additional spine condition and patients seeking an additional surgeon were at highest odds of undergoing surgery
  • Health systems should consider focusing the use of decision aids on those three patient groups

Within the United States and United Kingdom, the treatment of lumbar spinal stenosis varies greatly across geographic regions. This may be due to the wide number of acceptable interventions, lack of relevant clinical trials and differences in surgeon training and expertise.

Researchers at Massachusetts General Hospital and elsewhere are working to reduce this variation in order to improve quality, increase safety and lower costs. In Spine, they report that by investigating differences in surgeons' practices within a single institution, they identified three groups that need special attention:

  • Male patients
  • Patients with an additional spine condition
  • Those who have visited more than one surgeon

Thomas D. Cha, MD, MBA, assistant chief, Orthopaedic Spine Center, research fellow Paul T. Ogink, MD, and colleagues examined the records of adults at Mass General who were first diagnosed with lumbar spinal stenosis between 2003 and 2015. They selected the practices of all orthopedic surgeons and neurosurgeons who treated at least 100 patients during that period and performed at least 50 surgeries. The sample comprised 18 surgeons and 10,858 patients (50% female, average age 64).

Characteristics of the Patient Sample

Ten percent of the patients had visited at least one additional orthopedic surgeon or neurosurgeon, and 65% had an additional spine diagnosis. About one-third had physical therapy as part of their care. On average, a patient had 2.5 visits, 1.5 imaging procedures, 0.03 electromyograms (EMGs) and 0.16 injections. All of these variables differed significantly among surgeons.

The research team found that 35% of patients had one surgical procedure within one year after diagnosis, 0.87% had two, and 0.04% had three.

Factors Associated with Surgery Rates

On multivariate analysis, four variables independently predicted increased rates of surgical intervention:

  • Male gender (odds of surgery increased by 23%)
  • Seeing an additional surgeon (odds tripled)
  • Having an additional spine diagnosis (odds quadrupled)
  • Treatment by either of two specific surgeons (odds increased by 23%–66%)

Coefficient of Variation

The coefficient of variation was largest by far for Electromyography (EMG) (140%). The researchers say this large variation is unsurprising because experts still disagree about the role of EMG in the diagnostic process.

The other coefficients of variation were 59% for injections, 48% for imaging procedures, 43% for physical therapy, 19% for surgery and 19% for the number of visits.

Decision aids can reduce surgery rates and regional variation in rates, according to previous research. The researchers believe the use of such tools is likely to outperform financial or regulatory changes. They recommend that implementation of decision aids be targeted toward male patients, patients seeking an additional surgeon and patients with an additional spine condition.

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