Thursday, September 22, 2011

TX Study on Back Surgery a Positive Step

The Texas Division of Workers’ Compensation (DWC) announced it plans to study lumbar spinal fusions to determine if injured workers benefit from the surgery or suffer long-term problems.

This is a worthwhile study and one that is important to future policy making processes.

There have been numerous studies internationally through the years largely reaching the same conclusion - that back surgery without clinical indication of instability creates more disability and costs than provision of only conservative treatment.

According to DWC medical adviser Dr. Donald Patrick, the annual number of spinal fusions in the United States increased by 77% between 1996 and 2001, while during that same period, hip replacement and knee arthroplasty increased only 14%, according to the U.S. Agency for Healthcare Research and Quality.

Patrick told WorkCompCentral that rates of lumbar spine fusions in the United States increased more than 250% over the prior 10 years, "without scientific or clinical evidence to demonstrate that fusions are effective for most back conditions," citing the medical journal Spine.

Yet, state workers' compensation systems have perverse laws and regulations in place that provide incentive for just the opposite.

For instance, California limits chiropractic intervention at 24 visits per injury unless the medical evidence provides a contrary conclusion. While most of the medical literature indicates that chiropractic has limited value in the medical provision food chain on a regular basis, the same evidence indicates that there is potential value in chiropractic on an occasional basis for pain relief. Yet there is this arbitrary limitation  (of course that was in response to chiropractic outliers who were taking advantage of the liberal provisions of workers' compensation law to profit at the expense of the overall system). 

And our culture celebrates surgery as a "cure all" without recognizing the dangers of surgery or the necessary ambitious rehabilitative effort required on the part of the patient.

It seems that every day there is a report of a sports personality undergoing surgery for some corrective issue and then "returned to work" in an incredibly short period of time. What the reports don't pass along is a) the pain endured by the athlete post surgery and during the rehabilitation process, b) the huge participation by the athlete in the rehabilitative process, and c) whether there is any subsequent health issues related to the surgery that aren't evident "at work." Most people aren't athletes and don't have the athlete's mentality or drive, and willingness to endure pain.

Our culture's penchant for elective cosmetic surgery underscores our social perception that surgery isn't that big of a deal - how many of you know someone, or perhaps yourself, that has undergone some cosmetic surgery and ended up surprised by just how painful and debilitating (at least temporarily) the post surgical process is?

A close friend of our family just underwent a "tummy tuck". It sounds so innocuous! "Tummy tuck" - what could be bad about that? She conveyed to us 2 weeks post surgery, still under a cloud of pain killers, that if she had know how much pain she would endure, and how much disability she would incur over the rehabilitative process, she would not have done it.

So somewhere there is a balance. Understanding, and then communicating, the relative benefits versus the risks (and costs) of invasive procedures in a statistically meaningful manner may help workers' compensation patients make good decisions regarding their health. 

And of course, for those injured workers who can't make good decisions themselves, legislatures and regulators will make the decisions for them - but they too need a macro understanding of the cost/benefit (also known as risk/reward) equation, hopefully with enough foresight to head off unintended consequences.

A major state agency undertaking a project to quantify the results of back surgery is a positive step towards such understanding. I don't think that the results of the study will be all that surprising. Hopefully communication to decision makers, be they injured workers, regulators or legislators, will help change perceptions and eventually culture.

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