Projections From Surgical Use Models in Germany Suggest a Rising Number of Spinal Fusions in Patients 75 Years and Older Will Challenge Healthcare Systems Worldwide

Abstract

Background Spinal fusion is a well-established procedure in the treatment of degenerative spinal diseases. Previous research shows that the use of this operative treatment has been growing in recent decades in industrialized countries and has become one of the most cost-intensive surgical procedures. It seems that in some countries such as Germany—with its large, industrialized, European population—this increase is mainly driven by demographic changes with low fertility rates, increasing life expectancy, and an aging population. Based on current projections, however, Germany faces a population trend that many other countries are likely to follow within a few decades. An increasingly shrinking and aging working population may eventually put the healthcare system under enormous pressure, with greater demands for spinal fusions and associated higher costs. Thus, we aimed to provide reliable projections regarding the future demand for posterior spinal fusion procedures including age- and gender-related trends up to 2060, which will be necessary for future resource planning and possible improvements in actual treatment strategies. Questions/purposes (1) How is the use of posterior spinal fusions in Germany expected to change from 2019 through 2060, if currents trends continue? (2) How is the use of posterior spinal fusions in Germany expected to change depending on patients’ age and gender during this time period? Methods Comprehensive nationwide data provided by the Federal Statistical Office, the official institution for documenting all data on operations and procedures performed in Germany, were used to quantify posterior spinal fusion rates as a function of calendar year, age, and gender. Because there is a lack of evidence regarding future trends in the use of posterior spinal fusions, an autoregressive integrated moving average model on historical procedure rates from 2005 to 2019 in relation to official population projections from 2020 to 2060 was chosen to forecast future absolute numbers and incidence rates of this procedure in Germany. Long-term forecasting is more prone to unexpected disruptions than forecasting over short-term periods; however, longer spans facilitate estimates of how trends may challenge future healthcare systems if those trends continue, and thus are useful for research and planning. Results The incidence rate of posterior spinal fusion was projected to increase by approximately 83% (95% CI 28% to 139%) to 102% per 100,000 inhabitants (95% CI 71% to 133%) in 2060, with a 1.3-fold higher rate of women undergoing surgery in terms of absolute numbers. The highest increase identified by the model occurred in patients 75 years and older with 38,974 (95% CI 27,294 to 50,653) posterior spinal fusions in 2060, compared with 14,657 in 2019. This trend applied for both women and men, with a 246% (95% CI 138% to 355%) increase in the total number of posterior spinal fusions for women 75 years and older and a 296% (95% CI 222% to 370%) increase for men 75 years and older. At the same time, posterior spinal fusions in all age groups younger than 55 years were projected to follow a constant or even negative trend up to 2060. Conclusion Our findings suggest that increasing use of posterior spinal fusion, particularly in patients 75 years and older, will challenge healthcare systems worldwide if current trends persist. This study may serve as a model for many other industrialized countries facing similar demographic and procedure-specific developments in the future. This emphasizes the need to focus on frailty research as well as appropriate financial and human resource management. Effective perioperative medical management, multidisciplinary treatment, and interinstitutional protocols are warranted, especially in older patients as we attempt to manage these trends in the future. Level of Evidence Level III, economic and decision analysis.

CORR Insights®: Projections From Surgical Use Models in Germany Suggest a Rising Number of Spinal Fusions in Patients 75 Years and Older Will Challenge Healthcare Systems Worldwide

“…As the population in most industrialized countries continues to age, several prior investigations have highlighted the anticipated need for more extensive use of surgical interventions in orthopaedics, including joint replacement and spinal surgery. In the current work, Heck et al [1] summarize this nicely where they state: “A higher demand for spinal fusions, including a higher number of patients experiencing age-related changes, combined with patients’ rising expectations about their quality of life, may lead to increased costs [at the societal level].” The fear, of course, is either that the use of spine surgery and other orthopaedic procedures may exceed the capacity of available providers, leading to long waiting times for treatment and thus “rationing,” or that expenditures will grow to the point of bankrupting the system and culminate in draconian austerity measures that will yield similar postdiluvian realities. To assess the outlook in a more robust manner, Heck et al [1] used data from the German Federal Statistical Office (2005 to 2019) and determined there would be a sustained and steep rise in the demand for posterior spinal fusion, particularly in patients 75 years and older [1].…”

“…The predictions in the current study caused Heck et al [1] to caution healthcare systems, federal agencies, and providers to plan now in order to manage the future need for workforce, clinical space, rehabilitation facilities, and the financial resources to pay for it all. I think the unstated expectation, however, is that these demands will quickly outpace any capacity for the health system in Germany (or elsewhere) to effectively manage them.…”

“…Coming back to the movie Minority Report , the title derives from the fact that for every prognostication, there is always the possibility of a counterfactual. I would like to leverage the data provided by Heck et al [1] in one of their figures ( Fig. 4 in their paper, but Fig.…”

“…It is up to us to make such changes, and we have to decide for ourselves what orthopaedic, spine, and healthcare as a whole will look like globally in the decades to come. If the challenges prognosticated by Heck et al [1], along with others, are indeed dystonic, it behooves us now to engage in near-term action that will result in meaningful change.…”

“…Many prognostic papers have come out of United States data, including Medicare claims, private health insurance collectives like Marketscan or PearlDiver, and the National Inpatient Sample. In this issue of Clinical Orthopaedics and Related Research ® , Heck et al [1] present work from the German healthcare system, evaluating the trajectory of spinal fusions with a special focus on patients 75 years and older.…”