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Outcomes/Effectiveness Research

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Spinal surgery probability and outcomes vary depending on where the patient lives

Spinal surgery for lumbar disc herniation and spinal stenosis, which is performed to ease a person's symptoms and improve function, is nearly always elective. The probability of undergoing spinal surgery and surgical outcome are highly dependent on the practice style of the surgeons in the area in which the patient lives, according to a study by the Back Pain Outcome Assessment Team, which is supported by the Agency for Health Care Policy and Research (HS06344 and HS08194) and led by Robert B. Keller, M.D., of the Maine Medical Assessment Foundation. The researchers are conducting an ongoing prospective study of 655 patients with herniated lumbar disc or spinal stenosis.

For this study, the researchers analyzed spinal surgery practices in three distinct areas in Maine (small-area variation analysis). They compared outcomes through 4 years of followup for 279 spine surgery patients and found that surgery rates varied more than four-fold across the three spine service areas, from 40 percent below to 72 percent above the State's average rate of such surgery. Seventy-nine percent of the patients in the low-rate area—who initially (baseline) had less severe symptoms—had marked or complete relief of leg pain compared with 60 percent of patients in the high-rate area. Patients in the low-rate area also had significantly greater improvement in disability score, quality of life, and satisfaction.

Superior outcomes in the low-rate area may be related to more stringent patient selection criteria for lumbar spine surgery, since the researchers' previous studies showed that surgery had the least benefit among patients with the mildest baseline severity of disease. Surgeons in the two high-rate areas may have had a lower severity threshold for recommending surgery to their patients. The stability of the area-based surgical rates over time indicates that these local practice styles are entrenched, and that physicians remain consistent in how they make recommendations and treat patients.

For more information, see "Relationship between rates and outcomes of operative treatment for lumbar disc herniation and spinal stenosis," by Robert B. Keller, M.D., Steven J. Atlas, M.D., M.P.H., David N. Soule, B.A., and others in the June 1999 Journal of Bone and Joint Surgery 81(6), pp. 752-762.

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