While publicly funded fusion rates have also increased, privately funded rates leave them in the dust.
Privately funded spinal fusion rates in New South Wales have increased fourfold over the past two decades, according to new Australian research.
Spinal fusion and decompression surgeries are frequently performed in people with degenerative spinal disorders despite the benefits of these procedures being hotly debated. Financial incentives may be an important driving factor, as over the last decade most spine-related procedures undertaken in Australia have been performed in the private sector.
New Australian research suggests this may be a bigger problem than previously thought.
“The differences in publicly and privately funded procedure rates in NSW suggest that practice is determined by the preferences of the patient and the surgeon rather than by the evidence of effectiveness,” the researchers concluded.
As part of this retrospective cross-sectional study, first reported by TMR in April and now published in the Medical Journal of Australia, researchers analysed two decades of NSW hospital admissions data for adult patients undergoing elective procedures for degenerative spinal conditions and compared rates of spinal fusion and decompression procedures based on funding type (publicly funded patients, privately funded patients and patients covered by workers’ compensation).
The rate of privately funded fusion procedures increased from 26.6 per 100,000 insured patients per year in the 2001/02 financial year to 109.5 per 100,000 insured patients in the 2019/20 financial year.
This outstripped the increases spinal fusion procedures seen in patients covered by worker’s compensation (6.1 to 15.8 per 100,000 insured patients) as well as those covered by public health. The researchers estimated that trends in spinal fusions in the public system jumped from 5.6 to 12.4 per 100,000 patients over the last two decades, to 6.1 to 15.8 per 100,000 patients.
Similar increases in the rates of privately and publicly funded fusion procedures were observed when sex and age were accounted for.
The rate of privately funded decompression procedures increased from 93.4 to 153.6 patients per 100,000 over the last two decades, after peaking at 175.9 per 100,000 in 2014/15.
In contrast, the rate of decompression procedures covered by workers’ compensation decreased (19.7 to 16.7 per 100,000) and there was no significant change in the rate of publicly funded decompression procedures.
Associate Professor Michael Vagg, immediate past dean of the Australian and New Zealand College of Anaesthetists’ Faculty for Pain Medicine, told The Medical Republic that while these types of studies raised “provocative questions”, they required careful interpretation before jumping to conclusions.
“A lot of the media narrative has been about greedy surgeons or entitled patients demanding to be operated on, which are stereotypes, [albeit] not without some colour of truth to them. [But] it’s too simplistic to say ‘surgeons are just greedy, and that’s why there are more operations’. We need to understand why these rates are so different.”
Researchers felt the increases in privately funded spinal fusions were unlikely to be linked to the 25% increase in the uptake of private health insurance during the study period, and that their findings “may indicate that some privately funded procedures are unnecessary, or that the number of publicly funded procedures does not reflect clinical need”.
“The influence of financial considerations, access to specialist care and patient and surgeon preferences should be investigated,” the researchers concluded.
Associate Professor Vagg had similar views.
“It’s very difficult to access proper, comprehensive pain management services. Specialist pain medicine clinics can be a helpful resource, but it’s still a postcode lottery in Australia as to whether you an access these in a timely manner. If all you’ve got is a hammer, then every problem starts to look like a nail,” he told TMR.
“One issue with grand public health statements like ‘we’re doing too many back operations’ is it’s only logical to say that if you actually have an idea of what the right amount is. A more helpful way to think about it is to think beyond the absolute numbers and to think about the indications and the outcomes.
“People with cauda equina syndrome, progressive radiculopathy or instability due to hypermobility or spondylolisthesis gave traditionally been good indications for surgery. It would be nice to know how many of the people having these surgeries have these indicators.”
Medical Journal of Australia 2023, online 21 July
This story has been updated to include comments from Associate Professor Michael Vagg.
