Discrepancies in spine surgeon conflict of interest disclosures between a national meeting and physician payment listings on device manufacturer web sites

Background contextPrevious studies have identified inconsistencies in physician conflict-of-interest disclosures at academic meetings. The Physician Payment Sunshine Act (PPSA) will require industry to disclose anything of value given to physicians by 2014. In preparation, some spine device companies have begun reporting payments online.PurposeTo evaluate potential inconsistencies between physician disclosures and payments reported by industry before the PPSA implementation.Study designComparison of publically available disclosure/payment data.Patient samplePhysicians participating in the 2011 North American Spine Society (NASS) annual meeting and physicians listed on the 2010 physician payment web sites of Medtronic and Depuy Spine.MethodsDisclosures of participants at NASS were compared with the published Medtronic and Depuy Spine physician payments. The periods reflected by the disclosures compared should have coincided (except the Depuy site, which was only listed for one quarter of the NASS disclosure period). Discrepancies were noted whenever participant disclosures and company listings did not match as well as whenever payment ranges did not overlap. Fisher's exact test was used to compare disclosure discrepancy rates based on Medtronic payment size. No funding was received for this work. The authors report no conflicts of interest directly related to this study; however, one of the authors does do consulting unrelated to this study.ResultsMedtronic and Depuy Spine were disclosed by 12.1% and 8.75% of NASS participants, respectively. Based on NASS disclosures, 52.4% of NASS participants affiliated with Medtronic had their disclosures inaccurately reflected on the Medtronic web site. Based on Medtronic payment postings, 45.7% of NASS participants listed on Medtronic's webpage had discrepancies in their NASS disclosures. Those who received payments <$100,000 from Medtronic were more likely to have discrepancies in their disclosures than those who received payments >$100,000 (p=.009). Based on Depuy Spine payment postings, 30% of NASS participants listed on Depuy Spine's site had discrepancies in their NASS disclosures.ConclusionsDiscrepancy rates between what spine surgeons disclosed at NASS 2011 and what companies reported for their consultants were high. This is concerning given the passage of the PPSA as well as the increased public visibility of potential discrepancies. More uniform practices will certainly be necessary.     

Orthopaedic Surgeons Receive the Most Industry Payments to Physicians but Large Disparities are Seen in Sunshine Act Data

Background

Industry payments made to physicians by drug and device manufacturers or group purchasing organizations are now reported to the Centers for Medicare and Medicaid Services (CMS) as a part of the Physician Payments Sunshine Act. Initial reports from the program show that orthopaedic surgeons lead all physician specialties in total and average industry payments. However, before further discussion of these payments and their implications can take place, it remains to be seen whether these figures are a true reflection of the field of orthopaedic surgery in general, rather than the result of a few outlier physicians in the field. In addition, the nature and sources of these funds should be determined to better inform the national dialogue surrounding these payments.

Questions/Purposes

We asked: (1) How do industry payments to orthopaedic surgeons compare with payments to physicians and surgeons in other fields, in terms of median payments and the Gini index of disparity? (2) How much do payments to the highest-receiving orthopaedic surgeons contribute to total payments? (3) What kind of industry payments are orthopaedic surgeons receiving? (4) How much do the highest-paying manufacturers contribute to total payments to orthopaedic surgeons?

Materials and Methods

We reviewed the most recent version of the CMS Sunshine Act Open Payments database released on December 19, 2014, containing data on payments made between August 1, 2013 and December 31, 2013. Data on total payments to individual physicians, physician specialty, the types of payments made, and the manufacturers making payments were reviewed. The Gini index of statistical dispersion was calculated for payments made to orthopaedic surgeons and compared with payments made to physicians and surgeons in all other medical specialties. A Gini index of 0 indicates complete equality of payments to everyone in the population, whereas an index of 1 indicates complete inequality, or all income going to one individual.

Results

A total of 15,376 orthopaedic surgeons receiving payments during the 5-month period were identified, accounting for USD 109,846,482. The median payment to orthopaedic surgeons receiving payments was USD 121 (interquartile range, USD 34–619). The top 10% of orthopaedic surgeons receiving payments (1538 surgeons) received at least USD 4160 and accounted for 95% of total payments. Royalties and patent licenses accounted for 69% of all industry payments to orthopaedic surgeons.

Conclusions

Even as a relatively small specialty, orthopaedic surgeons received substantial payments from industry (more than USD 110 million) during the 5-month study period. Whether there is a true return of value from these payments remains to be seen; however, future ethical and policy discussions regarding industry payments to orthopaedic surgeons should take into account the large disparities in payments that are present and also the nature of the payments being made. It is possible that patients and policymakers may view industry payments to orthopaedic surgeons more positively in light of these new findings.

Level of Evidence

Level III, Economic and Decision Analysis.     

Variations in Medicare payments for episodes of spine surgery

Background contextAlthough the high cost of spine surgery is generally recognized, there is little information on the extent to which payments vary across hospitals.PurposeTo examine the variation in episode payments for spine surgery in the national Medicare population. We also sought to determine the root causes for observed variations in payment at high cost hospitals.Study designAll patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were included.Patient sampleIncluded 185,954 episodes of spine surgery performed between 2005 and 2007.Outcome measuresPayments per episode of spine surgery.MethodsAll patients in the national fee for service Medicare population undergoing surgery for three conditions (spinal stenosis, spondylolisthesis, and lumbar disc herniation) between 2005 and 2007 were identified (n=185,954 episodes of spine surgery). Hospitals were ranked on least to most expensive and grouped into quintiles. Results were risk- and price-adjusted using the empirical Bayes method. We then assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variations in payment.ResultsEpisode payments for hospitals in the highest quintile were more than twice as high as those made to hospitals in the lowest quintile ($34,171 vs. $15,997). After risk- and price-adjustment, total episode payments to hospitals in the highest quintile remained $9,210 (47%) higher. Procedure choice, including the use of fusion, was a major determinant of the total episode payment. After adjusting for procedure choice, however, hospitals in the highest quintile continued to be 28% more expensive than those in the lowest. Differences in the use of postacute care accounted for most of this residual variation in payments across hospitals. Hospital episode payments varied to a similar degree after subgroup analyses for disc herniation, spinal stenosis, and spondylolisthesis. Hospitals expensive for one condition were also found to be expensive for services provided for other spinal diagnoses.ConclusionsMedicare payments for episodes of spine surgery vary widely across hospitals. As they respond to the new financial incentives inherent in health care reform, high cost hospitals should focus on the use of spinal fusion and postacute care.     

Industry Payments to Adult Reconstruction-Trained Orthopedic Surgeons: An Analysis of the Open Payments Database From 2014 to 2019

BackgroundIn recent time, there has been an increased push toward transparency in industry funding toward physicians. The Physician Payments Sunshine Act called for the creation of the Open Payments Database managed by the Centers for Medicare & Medicaid Services. To our knowledge, there have been no studies evaluating the trends in payments among adult reconstruction fellowship-trained orthopedic surgeons. The purpose of this study is to investigate trends in all payments to adult reconstruction-trained orthopedic surgeons from 2014 to 2019. Secondary outcomes included evaluating trends in yearly subpayment categories, regional variations, as well as characterizing the top 5 industry companies.MethodsA review of the Centers for Medicare & Medicaid Services Open Payments Database was performed to identify all payments to adult reconstruction-trained orthopedic surgeons. A total of 94,265 payments were made to 4911 surgeons accounting for a total of $258,865,231.20 during the study period. Our primary outcome was to assess the trend in median payment per year to individual surgeons. Secondary outcomes included evaluating payment trends with respect to subtype, location as defined by United States Census regions, as well as specifics concerning the top 5 companies.ResultsOver the study period, there was a nonsignificant increasing trend in median payment per surgeon (r = 0.49, P = .096). However, there was also a significantly increasing trend in the number of payments per year (r = 0.83, P = .014), as well as the number of surgeons receiving payments (r = 0.88, P = .019). With respect to subcategory payments, there were significantly increasing trends in the median payment per surgeon for education (1054%, r = 0.942, P < .001) and entertainment/food and beverage expenses (20.2%, r = 0.49, P = .020), as well as a significantly decreasing trend for median honoraria payments per surgeon (20.2%, r = −0.04, P = .005). No significant regional trends were identified. Of the top 5 companies, one demonstrated a significantly decreasing trend in median payment per surgeon (21.6%, r = −0.109, P < .001), whereas the others remained unchanged.ConclusionIn this study, we found a nonsignificant increasing trend in payments to adult reconstruction-trained surgeons as well as an increasing number of surgeons receiving payments. There were increasing trends in median payment per surgeon for education and entertainment expenses, but a decreasing trend for honoraria payments. No significant regional trends were identified. The majority of the top 5 companies had nonsignificant trends in their payments. Further studies are needed to characterize the disclosure of payments and the impact of industry payments on clinical outcomes.Level of EvidenceIV.     

Where the Sun Shines: Industry's Payments to Transplant Surgeons

The Open Payments Program (OPP) was recently implemented to publicly disclose industry payments to physicians, with the goal of enabling patient awareness of potential conflicts of interests. Awareness of OPP, its data, and its implications for transplantation are critical. We used the first wave of OPP data to describe industry payments made to transplant surgeons. Transplant surgeons (N = 297) received a total of $759 654. The median (interquartile range [IQR]) payment to a transplant surgeon was $125 ($39–1018), and the highest payment to an individual surgeon was $83 520; 122 surgeons received <$100, and 17 received >$10 000. A higher h‐index was associated with 30% higher chance of receiving >$1000 (relative risk/10 unit h‐index increase = _1.181.30_1.44, p < 0.001). The highest payment category was consulting fees, with a total of $314 448 paid in this reported category. Recipients of consulting fees had higher h‐indices, median (IQR) of 20 (10–35) versus nine (3–17) (p < 0.001). Ten of 122 companies accounted for 62% of all payments. Kidney transplant and liver transplant (LT) centers that received >$1000 had higher center volumes (p < 0.001). LT centers that received payments of >$1000 had a higher percentage of private‐insurance/self‐pay patients (p < 0.01). Continued surveillance of industry payments may further elucidate the relationship between industry payments and physician practices.     

Industry Payments and Their Association With Academic Influence in Total Joint Arthroplasty

BackgroundThe relationship between industry payments and academic influence, as measured by the Hirsch index (h-index) and number of publications, among adult reconstruction surgeons is not well characterized. The aims of the present study are to determine the relationship between an adult reconstruction surgeons’ academic influence and their relevant industry payments and National Institutes of Health (NIH) funding.MethodsAdult reconstruction surgeons were identified through the websites for the orthopedic surgery residency programs in the United States during the 2019-2020 academic year.Academic influence was approximated by each physician’s h-index and total number of publications. Industry payment data were obtained through the Open Payments Database, and NIH funding was determined through the NIH website. Mann-Whitney U testing and Spearman correlations were performed to examine relevant associations.ResultsSurgeons who received industry research payments had a higher mean h-index (16.1 vs 10.2, P < .001) and mean number of publications (79.1 vs 35.9, P < .001) than physicians who received no industry research payments. Surgeons receiving NIH funding had a higher mean h-index (48.1 vs 10.4, P < .001) and mean number of publications (294.5 vs 36.8, P < .001) than surgeons who did not receive NIH funding. There was no association between the average h-index (P = .668) and number of publications (P = .387) among adult reconstruction surgeons receiving industry nonresearch funding.Conclusionh-index and total publications do not seem to be associated with industry nonresearch payments in the field of total joint arthroplasty. Altogether, these data suggest that industry bias may not play a strong role in total joint arthroplasty.     

Conflict of interest disclosure in orthopaedic and general surgical trauma literature

SignificanceFinancial relationships between industry and physicians are a key aspect for the advancement of surgical practice and training, but these relationships also result in a conflict of interest with respect to research. Financial payments to physicians are public within the United States in the Open Payments Database, but the rate of accurate financial disclosure of payments has not previously been studied in trauma surgery publications.ObjectiveTo determine the rate of accurate financial disclosure in major surgical trauma journals compared with the Open Payments Database.Materials and MethodsThe names of all authors publishing in The Journal of Orthopaedic Trauma, Injury, and The Journal of Trauma and Acute Care Surgery between 2015 and 2018 were obtained from MEDLINE. Non-physicians, physicians outside of the United States, physicians without payments in the Open Payments Database, and physicians with payments types of only “Food and Drink” were excluded. Financial disclosure statements were obtained from the journal websites and manually compared against Open Payments Database entries the year prior to submission and during the year of submission up until 3 months prior to publication for each individual physician. Main outcomes were accuracy of disclosure published with each article, total amount of payments received (disclosure or undisclosed), surgical subspecialty of the reporting physician. Statistical comparisons were made using Chi-square testing with significance defined as p<0.05.ResultsBetween 2015 and 2018, 5070 articles were published involving 28,948 authors. 2945 authors met inclusion criteria. 490 authors accurately disclosed their financial relationships with industry (16.6%). The median value of undisclosed payments was $22,140 [IQR $6465, $77,221] which was significantly less than the medial value of disclosed payment of $66,433 [IQR $24,624, $161,886], p<0.001 Orthopaedic surgeons disclosed at a higher rate (26.3%, 479/1818) than general surgeons (4.8%, 47/971), p<0.001.ConclusionsPhysician-industry relationships are key for advancing surgical practice and providing training to physicians. These relationships are not inherently unethical, but there is consistently high inaccuracy of financial disclosure across multiple trauma surgery journals which may indicate the need for further education on financial disclosures during surgical training or active obtainment of publicly available financial disclosures by journals.     

Bundled payments in spine surgery

Interest in the application of bundled payments to the field of spine surgery continues to grow. There may be great potential for cost-savings for spinal procedures under bundled payments. However, challenges such as heterogeneity of DRGs, complex procedures requiring lengthy recoveries, and appropriate outcomes measurement pose barriers to successful bundled payment design. In this paper, we review the challenges and opportunities posed by bundled payments in spine surgery. We also present several key considerations for policymakers interested in payment reform within spine surgery. Surgeon involvement will be critical in providing guidance for generating effective alternative payment models.     

Perception of gender discrimination among spine surgeons across Latin America: a web-based survey

BACKGROUND CONTEXTFemale physicians rarely choose spine surgery as their specialty. Although the specialty's nature and its associated lifestyle are potential barriers, gender-related issues may play an important part.PURPOSETo evaluate the gender discrimination among spine surgeons across Latin America.STUDY DESIGNCross-sectional survey.PATIENT SAMPLEThe participants in this study were 223 AO Spine Latin America (AOSLA) registered members who answered the web-based survey.OUTCOME MEASURESPersonal and professional demographics; gender-related objective and subjective experiences regarding career and personal life.METHODSA survey link containing a 24-item questionnaire was sent to the members’ e-mails in September 2019. The survey was designed to evaluate the perception of gender discrimination by spine surgeons during their academic and professional lives.RESULTSOut of 223 members who answered the survey, 196 (87.96%) were male and 27 (12.11%) female. Most were orthopedic surgeons (64.13%), ≥40 years of age (55.16%), and had <20 years of experience (69.95%). Gender discrimination was more frequent among women than among men (66.67% vs. 1.02%), as did discouragement from becoming a spine surgeon, orthopedic surgeon, or neurosurgeon (81.48% vs. 0.51%). Females reported higher rates of sexual harassment (44.44% vs. 7.65%) and more often felt disadvantaged because of gender (55.56% vs. 2.55%). Working harder than men to achieve the same prestige and lack of female mentorship were the most common obstacles reported by women (55.56%). Residency/fellowship influenced the decision to postpone/avoid having children for 66.67% of women but only 37.75% of men. Creation of a Women's Committee in AO Spine was supported by 74.07% of women and 38.78% of men.CONCLUSIONSGender-based discrimination affects women more frequently than men in spine surgery. These experiences likely contribute to the low prevalence of female spine surgeons. Efforts to mitigate bias and support the professional development of women in neurosurgery, orthopedics and spine communities are encouraged.     

Increased Patient-Level Payment After Removal of Total Knee Arthroplasty From the Inpatient-Only List

BackgroundIn January 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the Inpatient Only (IPO) list. This study aimed to compare patient-level payments in TKA cases with a length of stay (LOS) <2 midnights before and after removal of TKA from IPO list.MethodsIn this retrospective cohort study, all Medicare patients who received a primary elective TKA from 2016-2019 with a LOS <2 midnights at an academic tertiary center were identified. Total and itemized charges and patient-level payments were compared between eligible TKA cases performed in 2016-2017 and those in 2018-2019. There were 351 eligible TKA cases identified: 151 in 2016-2017 and 200 in 2018-2019.ResultsThe percentage of patients making any out-of-pocket payment increased in 2018-2019 from 2016-2017 (51.0% versus 10.6%), as did median patient-level payment ($7.30 [range, $0.00-$3,389] versus $0.00 [range, $0.00-$1,248], P < .001 for both). A greater proportion of patients in 2018-2019 paid $1-$50 than in 2016-2017 (37.5% versus 1.3%, P < .001) with no change in the proportion of patients who made payments >$50. Total charges were less in 2018-2019 than in 2016-2017 (P = .001). Charges for drugs, laboratory tests, admissions/floor, and therapies decreased in 2018-2019, whereas charges for the operating room and radiology increased (P < .001 for all).ConclusionPatients receiving outpatient TKA in 2018-2019 were more likely to have out-of-pocket payments than patients with comparable hospital stay who were designated as inpatients, although most of these payments were less than $50.     

Are current DRG-based bundled payment models for lumbar fusions risk-adjusting adequately? An analysis of Medicare beneficiaries

BACKGROUND CONTEXTCurrent bundled payment programs in spine surgery, such as the bundled payment for care improvement rely on the use of diagnosis-related groups (DRG) to define payments. However, these DRGs may not be adequate enough to appropriately capture the large amount of variation seen in spine procedures. For example, DRG 459 (spinal fusion except cervical with major comorbidity or complication) and DRG 460 (spinal fusion except cervical without major comorbidity or complication) do not differentiate between the type of fusion (anterior or posterior), the levels/extent of fusion, the use of interbody/graft/BMP, indication of surgery (primary vs. revision) or even if the surgery was being performed for a vertebral fracture.PURPOSEWe carried out a comprehensive analysis to report the factors responsible for cost-variation in a bundled payment model for spinal fusions.STUDY DESIGNRetrospective review of a 5% national sample of Medicare claims from 2008 to 2014 (SAF5).OUTCOME MEASURESTo understand the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day costs for patients undergoing spinal fusions under DRG 459 and 460.METHODSThe 2008 to 2014 Medicare 5% standard analytical files (SAF) were used to retrieve patients undergoing spinal fusions under DRG 459 and DRG 460 only. Patients with missing gender, age, and/or state-level data were excluded. Only those patients who had complete data, with regard to payments/costs/reimbursements, starting from day 0 of surgery up to 90 days postoperatively were included to prevent erroneous collection. Multivariate linear regression models were built to assess the independent marginal cost impact (decrease/increase) of each patient-level, state-level, and procedure-level characteristics on the average 90-day cost while controlling for other covariates.RESULTSA total of 21,367 patients (DRG-460=20,154; DRG-459=1,213) were included in the study. The average 90-day cost for all lumbar fusions was $31,716±$18,124, with the individual 90-day payments being $54,607±$30,643 (DRG-459) and $30,338±$16,074 (DRG-460). Increasing age was associated with significant marginal increases in 90-day payments (70–74 years: +$2,387, 75–79 years: +$3,389, 80–84 years: +$2,872, ≥85: +$1,627). With regards to procedure-level factors—undergoing an anterior fusion (+$3,118), >3 level fusion (+$5,648) vs. 1 to 3 level fusion, use of interbody device (+$581), intraoperative neuromonitoring (+$1,413), concurrent decompression (+$768) and undergoing surgery for thoracolumbar fracture (+$6,169) were associated with higher 90-day costs. Most individual comorbidities were associated with higher 90-day costs, with malnutrition (+$12,264), CVA/stroke (+$5,886), Alzheimer's (+$4,968), Parkinson's disease (+$4,415), and coagulopathy (+$3,810) having the highest marginal 90-day cost-increases. The top five states with the highest marginal cost-increase, in comparison to Michigan (reference), were Maryland (+$12,657), Alaska (+$11,292), California (+$10,040), Massachusetts (+$8,800), and the District of Columbia (+$8,315).CONCLUSIONSUnder the proposed DRG-based bundled payment model, providers would be reimbursed the same amount for lumbar fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion (1–3 level vs. >3 level), use of adjunct procedures (decompressions) and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated costs. When defining and developing future bundled payments for spinal fusions, health-policy makers should strive to account for the individual patient-level, state-level, and procedure-level variation seen within DRGs to prevent the creation of a financial dis-incentive in taking care of sicker patients and/or performing more extensive complex spinal fusions.     

Prevalence and risk factors of neck pain in spine surgeons - Are we our own patients?

AimThis survey of spine surgeons aimed to determine the prevalence of neck pain and identify the associated risk factors. The prevalence of neck pain has been reported in various medical sub-specialities including laparoscopy surgeons, dentists, plastic surgeons, ophthalmologist, urologist and orthopaedic surgeons. However, the literature is lacking on prevalence and risk factors for neck pain in spine surgeons.MethodsA survey questionnaire containing demographic, Neck pain and work practice details was administered to 300 spine surgeons (members of an online group) via text message and e-mail.ResultsOne hundred and eighty surgeons responded to the survey (response rate, 60%). Three spine surgeons had previous cervical spine surgeries. The 1-month prevalence rate of neck pain was 74.4% (134/180 surgeons). One hundred and eighteen surgeons (88%) reported only neck pain, 16 surgeons (11.9%) had neck pain with radicular arm pain. Only 20.5% of surgeons used a loupe, 18% of surgeons used a microscope, and 24% of surgeons used operating table height at umbilicus during surgery. There was no significant difference between the mean age (p = 0.65), work experience (p = 0.8), time spent in surgery (p = 0.7), and operating table height preference (p = 0.4) when symptomatic and asymptomatic groups were compared. However, a significantly greater percentage of surgeons had a sedentary lifestyle (p = 0.002) & used loupes as compared to microscopes (p = 0.04) in the symptomatic group. There was significant correlation between the surgeon's lifestyle & use of loupe and the incidence of neck pain.ConclusionSpine surgeons have a higher prevalence of neck pain than general populations and surgeons from other specialties. Considering the high prevalence of neck pain, general health, work, and ergonomic guidelines and recommendations must be formulated to help prevent and decrease the burden of neck pain among spine surgeons.     

Utilization and costs of lumbar and full spine radiography by Ontario chiropractors from 1994 to 2001

Background contextIn Ontario, chiropractors see one-third of patients who seek care for low back pain. Previous studies suggest that chiropractors have high utilization rates of lumbar and full spine radiography. There has been a proliferation of evidence-based guidelines recommending that plain film radiography be used only to assess high-risk patients with low back pain. Evidence for the use of full spine radiography, except for the evaluation of scoliosis is lacking. It is uncertain what impact the growing evidence against their use has had on radiography utilization by Ontario chiropractors.PurposeTo describe the annual costs and use of lumbar and full spine plain film radiography among Ontario chiropractors between 1994 and 2001.Study design/settingTime-trend analysis of radiography utilization by Ontario chiropractors.Patient sampleChiropractic claims data submitted to the Ontario Health Insurance Plan or the Workplace Safety & Insurance Board from 1994/1995 to 2000/2001.Outcome measuresChange in the annual cost and proportion of claimants receiving lumbar and full spine radiography.MethodsTime-trend analysis of chiropractic claims submitted to the Ontario Health Insurance Plan (OHIP) or Workplace Safety & Insurance Board (WSIB) from 1994/1995 to 2000/2001 fiscal years.ResultsDuring the 7-year period, the proportion of OHIP claimants receiving lumbar spine radiography decreased from 4.54% to 3.25% and for full spine radiography from 3.87% to 3.04%. For WSIB claimants, lumbar spine radiography deceased from 6.49% to 3.30% of claimants and full spine radiography from 1.51% to 0.94%. OHIP payments for lumbar spine radiography decreased 12.7% to $562,944, whereas full spine radiography payments decreased 5.3% to $1,071,408. WSIB lumbar and full spine radiography payments decreased 44.2% and 34.3% to $31,202 and $11,713 respectively.ConclusionsClaims data from the two largest third-party payers of chiropractic services in Ontario, suggest that lumbar and full spine radiography, and their associated costs decreased steadily between 1994 and 2001.     

Patient-level payment patterns prior to single level lumbar decompression are associated with resource utilization,postoperative payments,and adverse events

BACKGROUNDUnderstanding patient-specific trends in costs and healthcare resource utilization (HCRU) surrounding lumbar spine surgery is critically needed to better inform surgical decision making and the development of targeted interventions.PURPOSE1) Identify subgroups of patients following distinct patterns in direct healthcare payments pre- and postoperatively, 2) determine whether these patterns are associated with patient and surgical factors, and 3) examine whether preoperative payment patterns are related to postoperative payments, healthcare resource utilization (HCRU), and adverse events.STUDY DESIGN/SETTINGRetrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007—2015).PATIENT SAMPLEAdults undergoing primary single-level decompression surgery for lumbar stenosis (n=12,394).OUTCOME MEASURESDirect healthcare payments, HCRU payments (15 categories), 90-day complications and all-cause readmission, 2-year reoperationMETHODSGroup-based trajectory modeling is an application of finite mixture modeling that is able to identify meaningful subgroups within a population that follow distinct developmental trajectories over time. We used this technique to identify subgroups of patients following distinct profiles in preoperative direct healthcare payments. A separate analysis was performed to identify distinct profiles in payments postoperatively. Patient and surgical factors associated with these payment profiles were assessed with multinomial logistic regression, and associations with adverse events were assessed with risk-adjusted multivariable logistic regression.RESULTSWe identified 4 preoperative patient payment subgroups following distinct profiles in payments: Pre-Low (5.8% of patients), Pre-Early-Rising (4.8%), Pre-Medium (26.1%), and Pre-High (63.3%). Postoperatively, 3 patient subgroups were identified: Post-Low (8.9%), Post-Medium (29.6%), and Post-High (61.4%). Patients following the higher-cost pre- and postoperative payment profiles were older, more likely female, and had a greater physical and mental comorbidity burden. With each successively higher preoperative payment profile, patients were increasingly likely to have high postoperative payments, use more HCRU (particularly high-cost services such as inpatient admissions, ER, and SNF/IRF care), and experience postoperative adverse events. Following risk adjustment for patient and surgical factors, patients following the Pre-High payment profile had 209.5 (95% CI: 144.2, 309.7; p<.001) fold greater odds for following the Post-High payment profile, 1.8 (1.3, 2.5; p=.003) fold greater odds for 90-day complications, and 1.7 (1.2, 2.6; p=.035) fold greater odds for 2-year reoperation relative to patients following the Pre-Low payment profile.CONCLUSIONSThere are identifiable subgroups of patients who follow distinct profiles in direct healthcare payments surrounding lumbar decompression surgery. These payment profiles are related to patient age, sex, and physical and mental comorbidities. Notably, preoperative payment profiles may provide prognostic value, as they are associated with postoperative costs, HCRU, and adverse events.LEVEL OF EVIDENCEIII     

Thromboprophylaxis in spinal trauma surgery: consensus among spine trauma surgeons

Background contextAlthough there are several studies evaluating the necessity and efficacy of thromboprophylaxis after spinal trauma with or without spinal cord injury (SCI), to date there is no established standard of practice pertaining to this specific patient population with regards to venous thromboembolism (VTE) prophylaxis.PurposeTo reach a consensus opinion in the administration of thromboprophylaxis in both preoperative and postoperative care in the settings of spinal trauma and SCI.Study designA live survey on thromboprophylaxis after spinal surgery in the setting of trauma was conducted at a meeting among spine trauma surgeons.MethodsTwenty-five spine surgeons (Neurosurgeons and Orthopedic surgeons), all members of the Spine Trauma Study Group, participated in a live survey in which they attempted to reach consensus pertaining to the management of deep vein thrombosis prophylaxis in patients with spine fractures (with and without a concomitant SCI). The consensus survey consisted of a 10-item questionnaire. Chi-square test was used for group comparisons in questionnaire responses.ResultsComplete agreement was reached for the need of postoperative pharmacologic thromboprophylaxis in cervical spine injuries with SCI and anterior thoracolumbar procedures with or without SCI. Postoperative pharmacologic thromboprophylaxis after cervical spine injuries without SCI was agreed not to be needed. In cases of delayed surgery for patients with SCI, pharmacologic thromboprophylaxis was recommended to be started as soon as possible in the presurgical period. The optimal duration of pharmacologic VTE prophylaxis was determined to be 3 months. Only 53% agreement was noted for the withholding of preoperative chemical prophylaxis in cervical or thoracolumbar spinal injuries with SCI (and 68% without SCI). Only 80% of the surgeons agreed that postoperative pharmacologic thromboprophylaxis is needed after posterior thoracolumbar procedures in patients with or without SCI. The use of vena cava filter after SCI was not universally recommended.ConclusionsPostoperative pharmacologic thromboprophylaxis was opined to be unnecessary in patients with cervical spine injuries without SCI, however, it is recommended for cervical spine trauma with SCI or anterior thoracolumbar procedures irrespective of SCI. Pharmacologic thromboprophylaxis was recommended to start preoperatively as soon as possible in SCI cases or in cases with surgical delay. Pharmacologic prophylaxis was recommended to be administered for at least 3 months postinjury. Although these recommendations met complete consensus by this group, individual patient factors should also be considered in determining optimal thromboprophylaxis in this patient population. Future research recommendations on thromboprophylaxis in spinal trauma are proposed.     

Patient views on financial relationships between surgeons and surgical device manufacturers

Background

Over the past decade, revelations of inappropriate financial relationships between surgeons and surgical device manufacturers have challenged the presumption that surgeons can collaborate with surgical device manufacturers without damaging public trust in the surgical profession. We explored postoperative Canadian patients’ knowledge and opinions about financial relationships between surgeons and surgical device manufacturers.

Methods

This complex issue was explored using qualitative methods. We conducted semistructured face-to-face interviews with postoperative patients in follow-up arthroplasty clinics at an academic hospital in Toronto, Canada. Interviews were audiotaped, transcribed and analyzed. Patient-derived concepts and themes were uncovered.

Results

We interviewed 33 patients. Five major themes emerged: 1) many patients are unaware of the existence of financial relationships between surgeons and surgical device manufacturers; 2) patients approve of financial relationships that support innovation and research but are opposed to relationships that involve financial incentives that benefit only the surgeon and the manufacturer; 3) patients do not support disclosure of financial relationships during the consent process as it may shift focus away from the more important risks; 4) patients support oversight at the professional level but reject the idea of government involvement in oversight; and 5) patients entrust their surgeons to make appropriate patient-centred choices.

Conclusion

This qualitative study deepens our understanding of financial relationships between surgeons and industry. Patients support relationships with industry that provide potential benefit to current or future patients. They trust our ability to self-regulate. Disclosure combined with appropriate oversight will strengthen public trust in professional collaboration with industry.