Relationship Between Rates and Outcomes of Operative Treatment for Lumbar Disc Herniation and Spinal Stenosis

Keller, Robert B.; Atlas, Steven J.; Soule, David N.; Singer, Daniel E.; Deyo, Richard A.

doi:10.2106/00004623-199906000-00002

Cited by 95 publications

(43 citation statements)

References 10 publications

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“…Conversely, where surgery rates were the lowest, patients had the most severe preoperative disease and the best postoperative outcomes (36). These findings support the notion that some back surgery is unnecessary and may lead to poor patient outcomes.…”

Section: Spinal Mrisupporting

confidence: 62%

Cascade Effects of Medical Technology

Deyo

2002

Annu. Rev. Public Health

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178

134

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Key Words technology, adverse effects, quality-of-care, diagnostic tests s Abstract Cascade effect refers to a process that proceeds in stepwise fashion from an initiating event to a seemingly inevitable conclusion. With regard to medical technology, the term refers to a chain of events initiated by an unnecessary test, an unexpected result, or patient or physician anxiety, which results in ill-advised tests or treatments that may cause avoidable adverse effects and/or morbidity. Examples include discovery of endocrine incidentalomas on head and body scans; irrelevant abnormalities on spinal imaging; tampering with random fluctuations in clinical measures; and unwanted aggressive care at the end of life. Common triggers include failing to understand the likelihood of false-positive results; errors in data interpretation; overestimating benefits or underestimating risks; and low tolerance of ambiguity. Excess capacity and perverse financial incentives may contribute to cascade effects as well. Preventing cascade effects may require better education of physicians and patients; research on the natural history of mild diagnostic abnormalities; achieving optimal capacity in health care systems; and awareness that more is not the same as better. CASCADE EFFECTS OF MEDICAL TECHNOLOGYHealth professionals and laypersons alike tend to equate new medical technology with better-quality health care, assuming that newer is better. Much of the scientific literature on diffusion of innovations focuses on the anticipated beneficial effects of new technology and methods to ensure its rapid adoption (53). However, many new medical technologies are introduced and disseminated with only modest evaluation of efficacy, optimal indications, or impact on practice. Unfortunately, their use in routine care sometimes proves futile or even harmful. The adverse effects and consequences of new technology are often unanticipated (53). One of these is the cascade effect.The term cascade effect, in reference to medical technology, was apparently coined by Mold & Stein in a 1986 article in the New England Journal of Medicine (44). In biology, the term cascade refers to a process that proceeds in stepwise fashion from an initiating event to a seemingly inevitable conclusion. A molecular example is the blood clotting cascade, typically initiated by a cut in the skin. The

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Section: Spinal Mrisupporting

confidence: 62%

Cascade Effects of Medical Technology

Deyo

2002

Annu. Rev. Public Health

Self Cite

178

134

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“…LF presents high practice variation both at the national and international levels (Cherkin et al 1994). One concern is that the outcome in general will be poorer the higher the rate of LF, since this has been shown to be the case for lumbar disc herniation and spinal stenosis surgery (Keller 1999). Another important point of concern is the indication for surgery, because many of these patients suffer significant psychosocial disturbances (Mendelson 1984, Nachemson 1999, Rush et al 2000.…”

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confidence: 99%

No difference in health-related quality of life in hip osteoarthritis compared to degenerative lumbar instability at pre- and 1-year postoperatively: A prospective study of 101 patients

et al. 2006

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(2006) No difference in health-related quality of life in hip osteoarthritis compared to degenerative lumbar instability at pre-and 1-year postoperatively: A prospective study of 101 patients, Acta Orthopaedica, 77:5, 748-754, DOI: 10.1080 Background Total hip replacement (THR) is a very successful and refined surgical procedure when compared to crude bony fusion in degenerative lumbar segmental instability (LF). We compared the pre-and postoperative health-related quality of life status of THR and LF patients.Patients and methods We prospectively studied 51 THR patients and 50 LF patients. The outcome parameters were SF-36 and Oswestry Disability Index (ODI), measured preoperatively and at 1 year postoperatively. The status of the patients was compared to that of an age-matched healthy control group.Results The preoperative SF-36 and ODI scores were similar between the groups, except for the subscale role emotional. One year postoperatively, only the differences in 3 subscales (physical functioning, role physical, and role emotional) and in the standardized physical component reached statistical significance; the THR-patients scored worse than the LF-patients. The improvements in SF-36 and ODI reached statistical significance in both groups.Interpretation The differences in quality of life between the THR and LF patients were similar preand postoperatively. The quality of life of both cohorts improved considerably and significantly after the treatment, but they remained at a level significantly below that of a general age-matched population.

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“…By each of the outcomes measured (Roland Disability Score, satisfaction with surgical outcome, and rates of disability compensation) the best results occurred in areas with the lowest surgery rates and the worse outcomes occurred in areas with the highest surgical rates. The region with intermediate surgical rates had intermediate outcomes on each measure (Table 1) [11]. Although we cannot comment on outcomes for the patients who did not undergo surgery, these results suggest that higher rates of surgery did not necessarily lead to better outcomes.…”

Section: Surgical Outcomesmentioning

confidence: 89%

The case for restraint in spinal surgery: does quality management have a role to play?

Deyo

Mirza

2009

Eur Spine J

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Most quality improvement efforts in surgery have focused on the technical quality of care provided, rather than whether the care was indicated, or could have been provided with a safer procedure. Because risk is inherent in any procedure, reducing the number of unnecessary operations is an important issue in patient safety. In the case of lumbar spine surgery, several lines of evidence suggest that, in at least some locations, there may be excessively high surgery rates. This evidence comes from international comparisons of surgical rates; study of small area variations within countries; increasing surgical rates in the absence of new indications; comparisons of surgical outcomes between geographic areas with high or low surgical rates; expert opinion; the preferences of wellinformed patients; and increasing rates of repeat surgery. From a population perspective, reducing unnecessary surgery may have a greater impact on complication rates than improving the technical quality of surgery that is performed. Evidence suggests this may be true for coronary bypass surgery in the US and hysterectomy rates in Canada. Though similar studies have not been done for spine surgery, wide geographic variations in surgical rates suggest that this could be the case for spine surgery as well. We suggest that monitoring geographic variations in surgery rates may become an important aspect of quality improvement, and that rates of repeat surgery may bear special attention. Patient registries can help in this regard, if they are very complete and rigorously maintained. They can provide data on surgical rates; offer post-marketing surveillance for new surgical devices and techniques; and help to identify patient subgroups that may benefit most from certain procedures.

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Relationship Between Rates and Outcomes of Operative Treatment for Lumbar Disc Herniation and Spinal Stenosis

Cited by 95 publications

References 10 publications

Cascade Effects of Medical Technology

Cascade Effects of Medical Technology

No difference in health-related quality of life in hip osteoarthritis compared to degenerative lumbar instability at pre- and 1-year postoperatively: A prospective study of 101 patients

The case for restraint in spinal surgery: does quality management have a role to play?

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