Tuesday, July 26, 2011

TX Surgical Audit Not Properly Focused

While I think it's a good idea to perform an "audit" to determine the success or failure rate of lumbar fusion surgery in workers' compensation patients, it is a mistake to place blame entirely on the physicians who perform such procedures.

The Texas Division of Workers' Compensation (DWC) plans to audit doctors who perform lumbar fusion surgeries in order to:
  • Promote delivery of quality health care “in a cost-effective manner, including protection of injured employee safety.”
  • Assure that health care providers “adhere to medically accepted standards of care for conducting lumbar fusions.”
  • Assess return-to-work outcomes for workers who undergo lumbar fusions.
There are many studies internationally over the past 30 years that have documented poorer health outcomes in workers' compensation spinal surgery patients versus the general population.

Indeed, there are several studies which conclude that spinal surgery results in poorer return to work outcomes when controlled against groups that don't get surgery.

So part of DWC's audit objectives have already been well documented in the medical literature.

What we really don't know is why there are such disparate results in workers' compensation spinal surgery cases versus the general population.

Is spinal surgery more likely to be prescribed in a workers' compensation setting? Are physicians more receptive to performing spinal surgery if it is a workers' compensation case, and if so, why? Are spinal candidates more carefully screened for successful outcomes in the general population than in work comp, and if so, why? Are work comp patients in poorer general health than the general population? There are many other such questions that have never been answered, or for which we may never know the answer.

There are likely a number of complex, interrelated reasons why spinal surgery in a workers' compensation setting might result in overall poorer health outcomes.

One big factor that requires study is the injured worker him/her self - our society is a quick fix society, and surgery is part of that mentality. We see in the news and on television every day athletes who have major injuries get surgery to return to their sport in almost no time at all.

The problem is that most people are not athletes, either in body OR mind! Surgery is a very small part in the injury recovery process for athletes (or any surgical patient for that matter). The biggest factor is the post surgical rehabilitation, which requires a lot of work, and a lot of PAIN - the very element for which most patients seek surgery in the first place.

The Texas DWC states that the audit plan is intended to set out the basis for the DWC to take action against providers who perform large numbers of particular procedures, or when a large number of procedures are unsuccessful.

I can understand singling out a few physicians who are out of control with spinal surgeries - but really the goal of the audit should be to educate the injured worker population about the RISKS of spinal surgery.

Perhaps taking action against those few physicians who are determined by DWC to violate standards of care may make physicians more careful who they choose as surgical candidates, but DWC also needs to ensure that injured workers know, themselves, whether they are a surgical candidate and that they take responsibility for their own outcomes.

Its easy to place blame on the provider. Don't forget, though, that a physician can't perform surgery unless there is a willing patient.

The real question is how do you make a patient responsible for his/her own health outcome? This is much more vexing, much more difficult, and much more controversial than placing blame on doctors.

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