Factors Affecting Utilization of Steroid Injections in the Treatment of Lumbosacral Degenerative Conditions in the United States

Abstract

Background: Lumbar degenerative conditions are an extremely common set of diagnoses with a large spectrum of treatment options. Epidural steroid injections (ESI) are widely used but have come under increased scrutiny as we move toward a value-based model of health care. We assessed current utilization of epidural steroid injections, changes in utilization over time, and the influence of payer type and geographic region within the United States on their utilization. In addition, we analyzed the relationship between ESIs and surgical rates across states. Methods: The Medicare 5% national sample administrative database (SAF5) and a large national database from a commercial health care company (HORTHO) were used to catalog clinical data for patients with lumbar degenerative conditions. Specific queries into the rate of ESIs and lumbar surgery were also performed within this group. Results: There were 4 108 121 patients found between 2005 and 2015 in the SAF5 and HORTHO databases carrying a diagnosis related to lumbar degenerative conditions. The overall yearly injection rates for patients with lumbar degenerative conditions ranged from 9.84% to 10.18%. In patients older than 65, the rate of ESI was higher for Medicare as compared with private payer insurance (16.27% versus 14.14%, P , .001). There was a higher rate of ESI for patients who eventually underwent surgery in the Medicare group as compared with the commercial group (55.30% versus 40.40%, P , .001). There was a positive correlation between rates of ESI with the rate of surgery between states. Conclusions: There is considerable variation in treatment of lumbar degenerative conditions with ESI based on payer type. There was increased utilization of lumbar ESI between 2007 and 2012, although this change was less than 0.5%. The data also suggest a positive correlation between rates of ESIs and surgical intervention across states. This points to areas in the country with high utilization of both ESI and surgery in the treatment of lumbar degenerative conditions.

Diagnosis and Treatment of Sciatica in the Netherlands: A Survey among Neurologists and Anesthesiologists

“…The management of sciatica in secondary care varies considerably within and between countries. For example, there is significant variation in the use of epidural steroid injections between different US states [8] and referral to physiotherapy between Denmark and the Netherlands [9]. These differences may be due to a paucity of evidence on the value of interventions and a lack of clear clinical guidelines, or they may reflect differences in healthcare and insurance systems [10].…”

Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials

“…Furthermore, non-surgical treatments varied considerably within and between countries. For example, the use of epidural steroid injections varies widely among different US states, as do referrals to physiotherapy between Denmark and the Netherlands 5960. The two included Chinese trials used traditional Chinese medicine in the non-surgical group, which lacks evidence supporting its effectiveness 394761.…”

“…For example, the use of epidural steroid injections varies widely among different US states, as do referrals to physiotherapy between Denmark and the Netherlands. 59 60 The two included Chinese trials used traditional Chinese medicine in the non-surgical group, which lacks evidence supporting its effectiveness. 39 47 61 In our review, we grouped all non-surgical interventions together, however, these interventions were not only poorly detailed but also highly heterogeneous.…”

Estimating individualized treatment effects using a risk-modeling approach: an application to epidural steroid injections for lumbar spinal stenosis

“…Nonsurgical interventional procedures for conditions associated with back pain are commonly used in the United States (US). 12,13,22,30,34 Lumbar spinal stenosis is a specific spine syndrome often associated with back pain. 16 Four of 5 US clinical practice guidelines recommend the use of lumbar epidural steroid injections (LESIs) for symptoms due to lumbar spinal stenosis.…”