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Al-Ghetaa RK, Alabousi M, You JJ, Emary PC, Riva JJ, Dufton J, Kagoma YK, Rampersaud R, Goytan MJ, Feasby TE, Reed M, Busse JW. Temporal Trends in Spinal Imaging in Ontario (2002-2019) and Manitoba (2001-2011), Canada. Cureus 2024; 16:e63267. [PMID: 39070358 PMCID: PMC11282485 DOI: 10.7759/cureus.63267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
Background Several studies have reported the overuse of spinal imaging, which, in Canada, led to several provincial pathways aimed at optimizing the use of imaging. We assessed temporal trends in spine imaging in two Canadian provinces. Methods We explored the use of X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) examinations of the cervical, thoracic, and lumbar spine regions among adults in Ontario (April 1, 2002, to March 31, 2019) and in Manitoba, Canada (April 1, 2001, to March 31, 2011) using linked Ontario Health Insurance Plan administrative databases and data from Manitoba Health. We calculated the age- and sex-adjusted rates of spinal X-ray, CT, and MRI examinations by dividing the number of imaging studies by the population of each province for each year and estimated the use of each imaging modality per 100,000 persons. Results The total cost of spine imaging in Ontario increased from $45.8 million in 2002/03 to $70.3 million in 2018/19 (a 54% increase), and in Manitoba from $2.2 million in 2001/02 to $5 million in 2010/11 (a 127% increase). In Ontario, rates of spine X-rays decreased by 12% and spine CT scans decreased by 28% over this time period, while in Manitoba, rates of spine X-rays and CT scans remained constant. Age- and sex-adjusted utilization of spinal MRI scans per 100,000 persons markedly increased over time in both Ontario (277%) and Manitoba (350%). Conclusion Despite efforts to reduce the use of inappropriate spinal imaging, both Ontario and Manitoba have greatly increased utilization of spine MRI in the past two decades.
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Affiliation(s)
- Rayeh K Al-Ghetaa
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, CAN
| | | | - John J You
- Medicine, Trillium Health Partners, Mississauga, CAN
| | | | - John J Riva
- Family Medicine, McMaster University, Hamilton, CAN
| | - John Dufton
- Imaging, University Hospital of Northern British Columbia, Prince George, CAN
| | | | | | | | | | - Martin Reed
- Radiology, University of Manitoba, Winnipeg, CAN
| | - Jason W Busse
- Health Research Methodology, McMaster University, Hamilton, CAN
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Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study. Spine J 2020; 20:874-881. [PMID: 32007652 DOI: 10.1016/j.spinee.2020.01.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT An important step in improving spinal care is understanding how current health-care resources and associated cost are being utilized and distributed across a health-care system. PURPOSE Our objective was to examine the magnitude and distribution of direct health care costs for spinal conditions across physician type and hospital setting. DESIGN/SETTING Cross-sectional analysis of administrative health data for the fiscal year 2013-2014 from the province of Ontario, Canada. PATIENT SAMPLE Adult population aged 18+ years (N=10,841,302). OUTCOME MEASURES Person visit rates and total number of people and visits by specific care settings were calculated for all spinal conditions as well as stratified by nontrauma and trauma-related conditions. Variation in rates by age and sex was examined. The proportion of patients seeing physicians of different specialties was calculated for each condition grouping. Direct medical costs were estimated and their percentage distribution by care setting calculated for nontrauma and trauma-related conditions. Additionally, costs for spinal imaging overall and stratified by type of scan were determined. METHODS Administrative health databases were analyzed, including data on physician services, emergency department visits, and hospitalizations. ICD-9 and -10 diagnostic codes were used to identify nontraumatic (degenerative or inflammatory) and traumatic spinal disorders. A validated algorithm was used to estimate direct medical costs. RESULTS Overall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions; the majority (1.1 million) of these visits were for nontrauma conditions. Approximately, 86% of outpatient visits were in primary care. Emergency Department (ED) visits for nontrauma spinal conditions (130,000 out of 156,000 ED visits) accounted for 2.8% of all ED visits in the province. Total costs for spine-related care were $264 million (CDN) with 64% of costs due to nontrauma conditions. For these nontrauma conditions, ED visits cost $28 million for 130,000 visits ($215 per visit). For $32 million spent in primary care, 890,000 visits were made ($36 per visit). Spine imaging costs were $66.5 million, yielding a combined total of $330 million in health care spending for spinal conditions. CONCLUSIONS Spinal conditions place a large and costly burden on the health-care system. The disproportionate annual cost associated with ED visits represents a potential opportunity to redirect costs to fund more clinically and cost-effective models of care for nontraumatic spinal conditions.
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Zarrabian M, Bidos A, Fanti C, Young B, Drew B, Puskas D, Rampersaud R. Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings. Can J Surg 2018. [PMID: 30246685 DOI: 10.1503/cjs.016116] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The Inter-professional Spine Assessment and Education Clinics (ISAEC) were developed to improve primary care assessment, education and management of patients with persistent or recurrent low back pain-related symptoms. This study aims to determine the effect of ISAEC on access for surgical assessment, referral appropriateness and efficiency for patients meeting a priori referral criteria in rural, urban and metropolitan settings. METHODS We conducted a retrospective review of prospective data from networked ISAEC clinics in Thunder Bay, Hamilton and Toronto, Ontario. For patients meeting surgical referral criteria, wait times for surgical assessment, surgical referral-related magnetic resonance imaging (MRI) scans and appropriateness of referral were recorded. RESULTS Overall 422 patients, representing 10% of all ISAEC patients in the study period, were referred for surgical assessment. The average wait times for surgical assessment were 5.4, 4.3 and 2.2 weeks at the metropolitan, urban and rural centres, respectively. Referral MRI usage for the group decreased by 31%. Of the patients referred for formal surgical assessment, 80% had leg-dominant pain and 96% were deemed appropriate surgical referrals. CONCLUSION Contrary to geographic concentration of health care resources in metropolitan settings, the greatest decrease in wait times was achieved in the rural setting. A networked, shared-cared model of care for patients with low back pain-related symptoms significantly improved access for surgical assessment despite varying geographic practice settings and barriers. The greatest reductions were noted in the rural setting. In addition, significant improvements in referral appropriateness and efficiency were achieved compared with historical reports across all sites.
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Affiliation(s)
- Mohammad Zarrabian
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Andrew Bidos
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Caroline Fanti
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Barry Young
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Brian Drew
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - David Puskas
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
| | - Raja Rampersaud
- From the Division of Orthopedic Surgery, University of Manitoba, Winnipeg, Man. (Zarrabian); the Toronto Western Hospital University Health Network, Toronto, Ont. (Bidos); the Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ont. (Fanti, Puskas); Absolute Chiropractic, Hamilton, Ont. (Young); the Division of Orthopedic Surgery, McMaster University, Hamilton, Ont. (Drew); the Arthritis Program, Toronto Western Hospital, University of Toronto, Toronto, Ont. (Rampersaud); and the Division of Orthopaedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont. (Rampersaud)
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Liew I, Dean F, Anderson G, Murray O. Requesting spinal MRIs effectively from primary care referrals. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2436-2441. [PMID: 29637264 DOI: 10.1007/s00586-018-5578-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/03/2018] [Accepted: 03/30/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To define if MRI scans can accurately be requested based on information provided in the primary care referral and, therefore, streamline the patient journey. The demand for outpatient spinal appointments significantly exceeds our services' ability to provide efficient, high-quality patient care. Currently, magnetic resonance imaging (MRI) of the spine is requested following first consultation. METHODS During routine vetting of primary care referral letters, three consultant spinal surgeons recorded how likely they thought each patient would be to have an MRI scan. Following the first consultation with the spinal service, the notes of each patient were reviewed to see if an MRI was requested. We measured the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of ordering MRI scans based on primary care referral letters. RESULTS 149 patients were included [101 females, 48 males, mean age 49 (16-87)]. There were 125 routine, 21 urgent, and 3 'urgent-suspected cancer' referrals. The PPV of ordering MRIs before first consultation was 84%, NPV was 56% with the sensitivity and specificity being 82 and 59%, respectively. Ordering MRIs during initial vetting could shorten the patient journey with potential socioeconomic benefits. CONCLUSIONS MRI scans can be effectively ordered based on the information provided by the primary care referral letter. Requesting MRI scans early in the patient journey can save considerable time, improve care, and deliver cost savings. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Ignatius Liew
- Department of Spine, Trauma and Orthopaedics, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK
| | - Fraser Dean
- Department of Spine, Trauma and Orthopaedics, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK
| | - Gillian Anderson
- Department of Management Science, University of Strathclyde Business School, Glasgow, UK
| | - Odhrán Murray
- Department of Spine, Trauma and Orthopaedics, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK.
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Robarts S, Stratford P, Kennedy D, Malcolm B, Finkelstein J. Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction. Can J Surg 2017; 60:266-272. [PMID: 28730987 DOI: 10.1503/cjs.013416] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Surgery for lumbar spine pain is indicated for specific etiologies. Given the majority of individuals referred to spine surgeons are not surgical candidates, care delivery is inefficient, with consultations being of limited value for most. Using specially trained physiotherapists in triage is a human resource strategy that may optimize surgeons' time and the patient experience. METHODS An advanced-practice physiotherapist (APP) and a surgeon assessed consecutive patients with lumbar spine pain presenting at an academic health centre's spine surgery clinic. The second assessor was blinded to the outcome of the first. We used the κ statistic to evaluate surgeon-APP level of chance-corrected agreement concerning patients' need for a surgical consultation. To assess satisfaction with the APP, patients completed a modified version of the validated Visit-specific Questionnaire. RESULTS The sample included 102 participants (54 women) with a mean age of 54.3 ± 14.3 years and a mean Oswestry Disability Index score of 35.4 ± 16.6. The assessors' overall agreement was 86%. The κ coefficient for the need for a surgical consultation was 0.69 (95% confidence interval 0.54-0.84). The APP identified that 77% of patients did not require a surgical consultation. Twenty-one patients underwent surgery. Satisfaction scores for the APP were very high (mean score 92 out of 100). CONCLUSION In triaging patients with lumbar spine pain, the APP and surgeon had a high level of agreement. An APP performing triage at a surgical centre can effectively reduce wait lists by 70%, reserving surgical consultations for those patients in whom they are indicated.
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Affiliation(s)
- Susan Robarts
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
| | - Paul Stratford
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
| | - Deborah Kennedy
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
| | - Barry Malcolm
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
| | - Joel Finkelstein
- From the Department of Rehabilitation, Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, Ont. (Robarts, Kennedy); the School of Rehabilitation Science, McMaster University, Hamilton, Ont. (Stratford, Kennedy); the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Malcom, Finkelstein); and the Department of Surgery, Faculty of Medicine, University of Toronto, Ont. (Finkelstein)
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Widdifield J, Tu K, Carter Thorne J, Bombardier C, Michael Paterson J, Liisa Jaakkimainen R, Wing L, Butt DA, Ivers N, Hofstetter C, Lyddiatt A, Ahluwalia V, Bernatsky S. Patterns of Care Among Patients Referred to Rheumatologists in Ontario, Canada. Arthritis Care Res (Hoboken) 2016; 69:104-114. [PMID: 27110847 DOI: 10.1002/acr.22910] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/17/2016] [Accepted: 04/05/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Our aim was to characterize referrals to rheumatologists, the early care management of patients with rheumatic diseases, and timeliness of care and treatment. METHODS We conducted a retrospective observational study involving patients with first-time rheumatology referrals between 2000 and 2013 in the primary care Electronic Medical Record Administrative data Linked Database (EMRALD) in Ontario, Canada. Referrals were characterized in terms of diagnoses, patient demographics, diagnostic tests, treatment initiated by family physicians and rheumatologists, and other specialists seen prior to rheumatology consultation. Timeliness of referrals, rheumatologist consultations, and treatment were determined overall and for each diagnostic category. RESULTS Among 2,430 patients referred to a rheumatologist, 69% were female, with an average age of 53 years. The principal diagnosis associated with the referral included osteoarthritis (32%), systemic inflammatory rheumatic diseases (31%), regional musculoskeletal conditions (16%), chronic pain conditions (14%), osteoporosis (2%), and other/miscellaneous (5%). Family physicians most frequently prescribed nonsteroidal antiinflammatory drugs/cyclooxygenase 2 inhibitors (38%), and their pre-referral diagnostic testing practice varied considerably. The duration of time from symptom onset to rheumatology consultation varied by diagnoses, with the shortest being for patients with systemic rheumatic diseases; for rheumatoid arthritis (RA), the median time to consultation was 327 days. Most of the delay occurred prior to referral; 36% of RA patients initiated a disease-modifying antirheumatic drug within 6 months of symptom onset. CONCLUSION Approximately 1 in 3 referrals to rheumatologists were for a systemic inflammatory rheumatic disease. We observed substantial delays to rheumatology consultations and variations in patterns of care that could be amenable to quality improvement interventions.
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Affiliation(s)
- Jessica Widdifield
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada, and McGill University, Montreal, Quebec, Canada
| | - Karen Tu
- Institute for Clinical Evaluative Sciences, University of Toronto, and University Health Network, Toronto Western Hospital Family Health Team, Toronto, Ontario, Canada
| | | | | | - J Michael Paterson
- Institute for Clinical Evaluative Sciences and University of Toronto, Toronto, Ontario, Canada, and McMaster University, Hamilton, Ontario, Canada
| | - R Liisa Jaakkimainen
- Institute for Clinical Evaluative Sciences and University of Toronto, Toronto, Ontario, Canada
| | - Laura Wing
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Debra A Butt
- University of Toronto and Scarborough Hospital, Toronto, Ontario, Canada
| | - Noah Ivers
- Institute for Clinical Evaluative Sciences and Women's College Hospital, Toronto, Ontario, Canada
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de Schepper EIT, Koes BW, Veldhuizen EFH, Oei EHG, Bierma-Zeinstra SMA, Luijsterburg PAJ. Prevalence of spinal pathology in patients presenting for lumbar MRI as referred from general practice. Fam Pract 2016; 33:51-6. [PMID: 26659653 DOI: 10.1093/fampra/cmv097] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of magnetic resonance imaging (MRI) as initial imaging for back pain has increased in general practice. However, few data are available on the characteristics of these referred patients. The objective of this study was to describe the baseline characteristics and MRI findings of patients presenting for a lumbar MRI examination as referred by their GP. METHODS Patients presenting for a lumbar MRI examination as referred by their GP were recruited at the MRI Center. The MRI radiology reports were scored for the presence of disc bulging, disc herniation, nerve root compression, spinal stenosis, spondylolisthesis and serious pathologies. Information on patients' characteristics, characteristics of the complaints and red flags were derived from questionnaires. Cross-sectional differences between patients with and without specific MRI findings were analyzed. RESULTS A total of 683 low back pain (LBP) patients were included; mean age was 49.9 (range 19-80) years and 53% was male. Mean back pain severity score was 6.6 (SD 2.0) and 67% of the patients reported having chronic LBP. In total, 374 patients (55%) reported sciatica complaints for at least 6 weeks. Of all MRI reports, 69% mentioned signs of nerve root compression. Serious pathologies were reported in 3% of the patients. In total, 94% of patients had abnormal MRI findings. CONCLUSIONS Almost all patients presenting for a lumbar MRI examination as referred by their GP had abnormal MRI findings. In total, 55% of the patients reported persistent sciatica in which imaging is recommended according to international guidelines.
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Affiliation(s)
| | - Bart W Koes
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam
| | | | | | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, Department of Orthopaedics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Pim A J Luijsterburg
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam
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Machado GC, Ferreira PH, Harris IA, Pinheiro MB, Koes BW, van Tulder M, Rzewuska M, Maher CG, Ferreira ML. Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis. PLoS One 2015; 10:e0122800. [PMID: 25822730 PMCID: PMC4378944 DOI: 10.1371/journal.pone.0122800] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 02/13/2015] [Indexed: 12/31/2022] Open
Abstract
Background The management of spinal stenosis by surgery has increased rapidly in the past two decades, however, there is still controversy regarding the efficacy of surgery for this condition. Our aim was to investigate the efficacy and comparative effectiveness of surgery in the management of patients with lumbar spinal stenosis. Methods Electronic searches were performed on MEDLINE, EMBASE, AMED, CINAHL, Web of Science, LILACS and Cochrane Library from inception to November 2014. Hand searches were conducted on included articles and relevant reviews. We included randomised controlled trials evaluating surgery compared to no treatment, placebo/sham, or to another surgical technique in patients with lumbar spinal stenosis. Primary outcome measures were pain, disability, recovery and quality of life. The PEDro scale was used for risk of bias assessment. Data were pooled with a random-effects model, and the GRADE approach was used to summarise conclusions. Results Nineteen published reports (17 trials) were included. No trials were identified comparing surgery to no treatment or placebo/sham. Pooling revealed that decompression plus fusion is not superior to decompression alone for pain (mean difference –3.7, 95% confidence interval –15.6 to 8.1), disability (mean difference 9.8, 95% confidence interval –9.4 to 28.9), or walking ability (risk ratio 0.9, 95% confidence interval 0.4 to 1.9). Interspinous process spacer devices are slightly more effective than decompression plus fusion for disability (mean difference 5.7, 95% confidence interval 1.3 to 10.0), but they resulted in significantly higher reoperation rates when compared to decompression alone (28% v 7%, P < 0.001). There are no differences in the effectiveness between other surgical techniques for our main outcomes. Conclusions The relative efficacy of various surgical options for treatment of spinal stenosis remains uncertain. Decompression plus fusion is not more effective than decompression alone. Interspinous process spacer devices result in higher reoperation rates than bony decompression.
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Affiliation(s)
- Gustavo C. Machado
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- * E-mail:
| | - Paulo H. Ferreira
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Ian A. Harris
- South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, University of New South Wales, Sydney, NSW, Australia
| | - Marina B. Pinheiro
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Bart W. Koes
- Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Maurits van Tulder
- Department of Health Sciences, VU University, Amsterdam, The Netherlands
| | - Magdalena Rzewuska
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Chris G. Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Manuela L. Ferreira
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Institute of Bone and Joint Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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The cascade of medical services and associated longitudinal costs due to nonadherent magnetic resonance imaging for low back pain. Spine (Phila Pa 1976) 2014; 39:1433-40. [PMID: 24831502 PMCID: PMC4105318 DOI: 10.1097/brs.0000000000000408] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To compare type, timing, and longitudinal medical costs incurred after adherent versus nonadherent magnetic resonance imaging (MRI) for work-related low back pain. SUMMARY OF BACKGROUND DATA Guidelines advise against MRI for acute uncomplicated low back pain, but is an option for persistent radicular pain after a trial of conservative care. Yet, MRI has become frequent and often nonadherent. Few studies have documented the nature and impact of medical services (including type and timing) initiated by nonadherent MRI. METHODS A longitudinal, workers' compensation administrative data source was accessed to select low back pain claims filed between January 1, 2006 and December 31, 2006. Cases were grouped by MRI timing (early, timely, no MRI) and subgrouped by severity ("less severe," "more severe") (final cohort = 3022). Health care utilization for each subgroup was evaluated at 3, 6, 9, and 12 months post-MRI. Multivariate logistic regression models examined risk of receiving subsequent diagnostic studies and/or treatments, adjusting for pain indicators and demographic covariates. RESULTS The adjusted relative risks for MRI group cases to receive electromyography, nerve conduction testing, advanced imaging, injections, and surgery within 6 months post-MRI risks in the range from 6.5 (95% CI: 2.20-19.09) to 54.9 (95% CI: 22.12-136.21) times the rate for the referent group (no MRI less severe). The timely and early MRI less severe subgroups had similar adjusted relative risks to receive most services. The early MRI more severe subgroup cases had generally higher adjusted relative risks than timely MRI more severe subgroup cases. Medical costs for both early MRI subgroups were highest and increased the most over time. CONCLUSION The impact of nonadherent MRI includes a wide variety of expensive and potentially unnecessary services, and occurs relatively soon post-MRI. Study results provide evidence to promote provider and patient conversations to help patients choose care that is based on evidence, free from harm, less costly, and truly necessary. LEVEL OF EVIDENCE N/A.
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Busse JW, Riva JJ, Rampersaud R, Goytan MJ, Feasby TE, Reed M, You JJ. Spine surgeons' requirements for imaging at the time of referral: a survey of Canadian spine surgeons. Can J Surg 2014; 57:E25-30. [PMID: 24666456 PMCID: PMC3968210 DOI: 10.1503/cjs.003713] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2013] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Routine imaging of patients with spine-related complaints referred for surgical assessment may represent an inefficient use of technological resources. Our objective was to explore Canadian spine surgeons' requirements with respect to imaging studies accompanying spine-related referrals. METHODS We administered an 8-item survey to all 100 actively practising surgeon members of the Canadian Spine Society that inquired about demographic variables and imaging requirements for patients referred with spine-related complaints. RESULTS Fifty-five spine surgeons completed our survey, for a response rate of 55%. Most respondents (43; 78%) required imaging studies to accompany all spine-related referrals. The type of imaging required was highly variable, with respondents endorsing 7 different combinations. Half (47%) required magnetic resonance imaging and 38% required plain radiographs either alone or in combination with other forms of imaging. Half of the respondents refused to see 20% or more of all patients referred for spine-related complaints. CONCLUSION Most Canadian spine surgeons require imaging studies to accompany spine-related referrals; however, the type and combination of studies is highly variable, and many patients who are referred are never seen (for a consultation). Standardization and optimization of imaging practices for patients with spine-related complaints referred for surgical assessment may be an important area for cost savings.
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Affiliation(s)
- Jason W. Busse
- Department of Anesthesia, McMaster University, Hamilton, Ont
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont
| | - John J. Riva
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont
- Department of Family Medicine, McMaster University, Hamilton, Ont
| | - Raja Rampersaud
- Divisions of Orthopedic Surgery and Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ont
| | | | - Thomas E. Feasby
- Departments of Clinical Neurosciences and Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alta
| | - Martin Reed
- Department of Radiology, Children’s Hospital, Winnipeg, Man
| | - John J. You
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont
- Department of Medicine, McMaster University, Hamilton, Ont
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Re: You JJ, Bederman SS, Symons S et al. Patterns of care after magnetic resonance imaging of the spine in primary care. Spine (Phila Pa 1976). 2013;38:51-9. Spine (Phila Pa 1976) 2013; 38:1708. [PMID: 24509553 DOI: 10.1097/brs.0b013e31829ce39f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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