WA State AgencyDLI Perspective Robert Bree Collaborative Sept 30 2011 Gary M Franklin MD MPH Research Professor Departments of Environmental Health Neurology and Health Services ID: 629363
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Lumbar fusion for chronic LBP-WA State Agency/DLI Perspective--Robert Bree Collaborative-Sept 30, 2011
Gary
M. Franklin, MD, MPH
Research Professor
Departments of Environmental Health,
Neurology, and Health Services
University of Washington
Medical Director
Washington State Department of
Labor and IndustriesSlide2
WA Public payers compelling issuesLumbar fusion has the highest regional variation of any major surgery in the US-20 fold difference between geographic regionsWeinstein et al, Spine 2006, 31: 2707-14.Average cost $80-120,000, up to half is instrumentation in absence of DRG’s Lumbar fusion number one in-patient cost for Uniform Health Plan (public employees)Contribution to long term disability and pension in DLI Slide3
Washington State DLI Outcomes-Population-based restrospective studies-Franklin et al, 1994; Spine 20: 1897-903 N= 388 fusions from
1986-87
-
68
% TTD at 2 years; 23% more surgery by 2
yrs
-Instrumentation
doubled risk of reoperation
-Surgical
experience
didn
’
t
matter
Juratli
et al, 2006; Spine
31:2715–23
.
N
=
1950 fusions
from 1994-2000
-64
% disabled at 2
yrs
; 22%
reoperated
by 2
yrs
+ 12% other
complications
-85
% received cages and/or instrumentation
-Cage
/instrumentation use increased complications without improving disability or reoperation
rate
Juratli
et al, 2009: Spine 34: 740-47
-
Increased mortality associated with opioid useSlide4
Recent developmentsWA HTA:2/15/08-Fusion for DDD covered if structured multidisciplinary program fails, or not available8/15/08-Discography for chronic LBP and DDD not covered1/1/2011-North Carolina BC/BS-lumbar fusion not covered for chronic LBP and DDDSSB 5801-workers comp health reform-includes authority to define harmful care; eg, are you in the highest decile for failed lumbar fusion or reoperations?Slide5
Complications, death and repeat surgery within 90 days of lumbar fusion (unadjusted %) CHARS 2004-2007 [n = 5,864]Payer Device comp.Wound prob.Life- threateningDeath
Repeat
Lumbar Surgery
Medicare
0.4
4.4
3.7
0.4
1.9
Medicaid1.66.82.20.02.4HMO1.01.40.60.60.7Commercial1.11.81.30.12.0W/C1.01.80.60.01.3Contract0.53.01.60.11.5Other0.02.92.20.01.9
Martin et al, submittedSlide6
What public payers needBetter information Re outcomes of lumbar fusion across payers (DLI, Uniform, Regence)Best new data could only come from a well designed, population-based comparative effectiveness studyWith minimum clinically important differences measured (eg, 30% improved function AND 30% improved pain AND less than daily opioid use)Control groups should include other patients with chronic LBP (pain clinics, usual care)Clear data on relative safety and costsSlide7
For electronic copies of this presentation, please e-mail Melinda Fujiwaravasudha@u.washington.eduFor questions or feedback, please e-mail Gary Franklinmeddir@uw.edu
THANK YOU!