Rural-urban disparities in health outcomes, clinical care, health behaviors, and social determinants of health and an action-oriented, dynamic tool for visualizing them

While rural-urban disparities in health and health outcomes have been demonstrated, because of their impact on (and intervenability to improve) health and health outcomes, we sought to examine cross-sectional and longitudinal inequities in health, clinical care, health behaviors, and social determinants of health (SDOH) between rural and non-rural counties in the pre-pandemic era (2015 to 2019), and to present a Health Equity Dashboard that can be used by policymakers and researchers to facilitate examining such disparities. Therefore, using data obtained from 2015-2022 County Health Rankings datasets, we used analysis of variance to examine differences in 33 county level attributes between rural and non-rural counties, calculated the change in values for each measure between 2015 and 2019, determined whether rural-urban disparities had widened, and used those data to create a Health Equity Dashboard that displays county-level individual measures or compilations of them. We followed STROBE guidelines in writing the manuscript. We found that rural counties overwhelmingly had worse measures of SDOH at the county level. With few exceptions, the measures we examined were getting worse between 2015 and 2019 in all counties, relatively more so in rural counties, resulting in the widening of rural-urban disparities in these measures. When rural-urban gaps narrowed, it tended to be in measures wherein rural counties were outperforming urban ones in the earlier period. In conclusion, our findings highlight the need for policymakers to prioritize rural settings for interventions designed to improve health outcomes, likely through improving health behaviors, clinical care, social and environmental factors, and physical environment attributes. Visualization tools can help guide policymakers and researchers with grounded information, communicate necessary data to engage relevant stakeholders, and track SDOH changes and health outcomes over time.

An observational, sequential analysis of the relationship between local economic distress and inequities in health outcomes, clinical care, health behaviors, and social determinants of health

BACKGROUND

Socioeconomic status has long been associated with population health and health outcomes. While ameliorating social determinants of health may improve health, identifying and targeting areas where feasible interventions are most needed would help improve health equity. We sought to identify inequities in health and social determinants of health (SDOH) associated with local economic distress at the county-level.

METHODS

For 3,131 counties in the 50 US states and Washington, DC (wherein approximately 325,711,203 people lived in 2019), we conducted a retrospective analysis of county-level data collected from County Health Rankings in two periods (centering around 2015 and 2019). We used ANOVA to compare thirty-three measures across five health and SDOH domains (Health Outcomes, Clinical Care, Health Behaviors, Physical Environment, and Social and Economic Factors) that were available in both periods, changes in measures between periods, and ratios of measures for the least to most prosperous counties across county-level prosperity quintiles, based on the Economic Innovation Group's 2015-2019 Distressed Community Index Scores.

RESULTS

With seven exceptions, in both periods, we found a worsening of values with each progression from more to less prosperous counties, with least prosperous counties having the worst values (ANOVA p < 0.001 for all measures). Between 2015 and 2019, all except six measures progressively worsened when comparing higher to lower prosperity quintiles, and gaps between the least and most prosperous counties generally widened.

CONCLUSIONS

In the late 2010s, the least prosperous US counties overwhelmingly had worse values in measures of Health Outcomes, Clinical Care, Health Behaviors, the Physical Environment, and Social and Economic Factors than more prosperous counties. Between 2015 and 2019, for most measures, inequities between the least and most prosperous counties widened. Our findings suggest that local economic prosperity may serve as a proxy for health and SDOH status of the community. Policymakers and leaders in public and private sectors might use long-term, targeted economic stimuli in low prosperity counties to generate local, community health benefits for vulnerable populations. Doing so could sustainably improve health; not doing so will continue to generate poor health outcomes and ever-widening economic disparities.

Trends in Characteristics of Adults Enrolled in Traditional Fee-for-Service Medicare and Medicare Advantage, 2011-2019

BACKGROUND

While overall Medicare Part C (Medicare Advantage) enrollment has grown more rapidly than fee-for-service Medicare enrollment, changes in the growth and characteristics of different enrollee populations have not been examined.

OBJECTIVES

For 2011-2019, to compare changes in the growth and characteristics of younger (age younger than 65) and older (age 65 and older) Medicare beneficiaries enrolled in Medicare Part A only, Medicare Parts A & B, and Medicare Part C.

RESEARCH DESIGN

This was a retrospective, observational study.

SUBJECTS

Medicare beneficiaries who were alive and enrolled in Medicare Part A only, Medicare Parts A & B, or Medicare Part C on June 30 of each year and in no other plan that year.

MEASURES

For each plan type and age group the numbers and mean ages of enrollees and the proportion of enrollees who were: black, female, concurrently enrolled in Medicaid, and (for older enrollees), whose initial reason for eligibility was old age and survivors' benefits.

RESULTS

Between 2011 and 2019, Medicare Part C experienced rapid expansions of 85.0% among older and 109.5% among younger enrollees. Part C enrollees were increasingly likely to be dually enrolled in Medicaid, Black and, among younger enrollees, female.

CONCLUSIONS

Trends in demographic characteristics and changes in policy and growth in employer group plan offerings will likely continue to impact health care service utilization and costs in the Medicare population. Particularly as Medicare expansion to younger age groups is considered, future research should explore disparities in risk scores and care equity, quality, and costs across different Medicare enrollment options.

Assessment of Year-to-Year Patient-Specific Comorbid Conditions Reported in the Medicare Chronic Conditions Data Warehouse

This cross-sectional study evaluates the persistence of chronic condition flags for 51 conditions over single-year and multiyear periods.

The Essential Role of Technology in the Public Health Battle Against COVID-19

Technology has played an important role in responding to the novel coronavirus (SARS-CoV-2) and subsequent COVID-19 pandemic. The virus's blend of lethality and transmissibility have challenged officials and exposed critical limitations of the traditional public health apparatus. However, throughout this pandemic, technology has answered the call for a new form of public health that illustrates opportunities for enhanced agility, scale, and responsiveness. The authors share the Microsoft perspective and illustrate how technology has helped transform the public health landscape with new and refined capabilities - the efficacy and impact of which will be determined by history. Technologies like chatbot and virtualized patient care offer a mechanism to triage and distribute care at scale. Artificial intelligence and high-performance computing have accelerated research into understanding the virus and developing targeted therapeutics to treat infection and prevent transmission. New mobile contact tracing protocols that preserve patient privacy and civil liberties were developed in response to public concerns, creating new opportunities for privacy-sensitive technologies that aid efforts to prevent and control outbreaks. While much progress is still needed, the COVID-19 pandemic has highlighted technology's importance to public health security and pandemic preparedness. Future multi-stakeholder collaborations, including those with technology organizations, are needed to facilitate progress in overcoming the current pandemic, setting the stage for improved pandemic preparedness in the future. As lessons are assessed from the current pandemic, public officials should consider technology's role and continue to seek opportunities to supplement and improve on traditional approaches.

Association of Declines in End-of-Life Health Care Costs With Fee-for-Service Enrollee Per Capita Expenditures

This cross-sectional study assesses the association between end-of-life health care costs and fee-for-service Medicare spending and examines whether expenditures attributed to decedents have changed over time.

Development and Implementation of a Person-Centered, Technology-Enhanced Care Model For Managing Chronic Conditions: Cohort Study

Background

Caring for individuals with chronic conditions is labor intensive, requiring ongoing appointments, treatments, and support. The growing number of individuals with chronic conditions makes this support model unsustainably burdensome on health care systems globally. Mobile health technologies are increasingly being used throughout health care to facilitate communication, track disease, and provide educational support to patients. Such technologies show promise, yet they are not being used to their full extent within US health care systems.

Objective

The purpose of this study was to examine the use of staff and costs of a remote monitoring care model in persons with and without a chronic condition.

Methods

At Dartmouth-Hitchcock Health, 2894 employees volunteered to monitor their health, transmit data for analysis, and communicate digitally with a care team. Volunteers received Bluetooth-connected consumer-grade devices that were paired to a mobile phone app that facilitated digital communication with nursing and health behavior change staff. Health data were collected and automatically analyzed, and behavioral support communications were generated based on those analyses. Care support staff were automatically alerted according to purpose-developed algorithms. In a subgroup of participants and matched controls, we used difference-in-difference techniques to examine changes in per capita expenditures.

Results

Participants averaged 41 years of age; 72.70% (2104/2894) were female and 12.99% (376/2894) had at least one chronic condition. On average each month, participants submitted 23 vital sign measurements, engaged in 1.96 conversations, and received 0.25 automated messages. Persons with chronic conditions accounted for 39.74% (8587/21,607) of all staff conversations, with higher per capita conversation rates for all shifts compared to those without chronic conditions (P<.001). Additionally, persons with chronic conditions engaged nursing staff more than those without chronic conditions (1.40 and 0.19 per capita conversations, respectively, P<.001). When compared to the same period in the prior year, per capita health care expenditures for persons with chronic conditions dropped by 15% (P=.06) more than did those for matched controls.

Conclusions

The technology-based chronic condition management care model was frequently used and demonstrated potential for cost savings among participants with chronic conditions. While further studies are necessary, this model appears to be a promising solution to efficiently provide patients with personalized care, when and where they need it.

Considering Spine Surgery: A Web-Based Calculator for Communicating Estimates of Personalized Treatment Outcomes

STUDY DESIGN

Prospective evaluation of an informational web-based calculator for communicating estimates of personalized treatment outcomes.

OBJECTIVE

To evaluate the usability, effectiveness in communicating benefits and risks, and impact on decision quality of a calculator tool for patients with intervertebral disc herniations, spinal stenosis, and degenerative spondylolisthesis who are deciding between surgical and nonsurgical treatments.

SUMMARY OF BACKGROUND DATA

The decision to have back surgery is preference-sensitive and warrants shared decision making. However, more patient-specific, individualized tools for presenting clinical evidence on treatment outcomes are needed.

METHODS

Using Spine Patient Outcomes Research Trial data, prediction models were designed and integrated into a web-based calculator tool: http://spinesurgerycalc.dartmouth.edu/calc/. Consumer Reports subscribers with back-related pain were invited to use the calculator via email, and patient participants were recruited to use the calculator in a prospective manner following an initial appointment at participating spine centers. Participants completed questionnaires before and after using the calculator. We randomly assigned previously validated questions that tested knowledge about the treatment options to be asked either before or after viewing the calculator.

RESULTS

A total of 1256 consumer reports subscribers and 68 patient participants completed the calculator and questionnaires. Knowledge scores were higher in the postcalculator group compared to the precalculator group, indicating that calculator usage successfully informed users. Decisional conflict was lower when measured following calculator use, suggesting the calculator was beneficial in the decision-making process. Participants generally found the tool helpful and easy to use.

CONCLUSION

Although the calculator is not a comprehensive decision aid, it does focus on communicating individualized risks and benefits for treatment options. Moreover, it appears to be helpful in achieving the goals of more traditional shared decision-making tools. It not only improved knowledge scores but also improved other aspects of decision quality.

LEVEL OF EVIDENCE

2.

Proportion of Decedents' Expenditures Among Recent Reductions in Medicare Expenditures

This cohort study uses Medicare data from the Dartmouth Atlas Project to determine the source of recent changes in end-of-life Medicare expenditures.

Using Publicly Available Data to Construct a Transparent Measure of Health Care Value: A Method and Initial Results

POLICY POINTS

Using publicly available Hospital Compare and Medicare data, we found a substantial range of hospital-level performance on quality, expenditure, and value measures for 4 common reasons for admission. Hospitals' ability to consistently deliver high-quality, low-cost care varied across the different reasons for admission. With the exception of coronary artery bypass grafting, hospitals that provided the highest-value care had more beds and a larger average daily census than those providing the lowest-value care. Transparent data like those we present can empower patients to compare hospital performance, make better-informed treatment decisions, and decide where to obtain care for particular health care problems.

CONTEXT

In the United States, the transition from volume to value dominates discussions of health care reform. While shared decision making might help patients determine whether to get care, transparency in procedure- and hospital-specific value measures would help them determine where to get care.

METHODS

Using Hospital Compare and Medicare expenditure data, we constructed a hospital-level measure of value from a numerator composed of quality-of-care measures (satisfaction, use of timely and effective care, and avoidance of harms) and a denominator composed of risk-adjusted 30-day episode-of-care expenditures for acute myocardial infarction (1,900 hospitals), coronary artery bypass grafting (884 hospitals), colectomy (1,252 hospitals), and hip replacement surgery (1,243 hospitals).

FINDINGS

We found substantial variation in aggregate measures of quality, cost, and value at the hospital level. Value calculation provided additional richness when compared to assessment based on quality or cost alone: about 50% of hospitals in an extreme quality- (and about 65% more in an extreme cost-) quintile were in the same extreme value quintile. With the exception of coronary artery bypass grafting, higher-value hospitals were larger and had a higher average daily census than lower-value hospitals, but were no more likely to be accredited by the Joint Commission or to have a residency program accredited by the American Council of Graduate Medical Education.

CONCLUSIONS

While future efforts to compose value measures will certainly be modified and expanded to examine other reasons for admission, the construct that we present could allow patients to transparently compare procedure- and hospital-specific quality, spending, and value and empower them to decide where to obtain care.

The High Value Healthcare Collaborative: Observational Analyses of Care Episodes for Hip and Knee Arthroplasty Surgery

BACKGROUND

Broader use of value-based reimbursement models will require providers to transparently demonstrate health care value. We sought to determine and report cost and quality data for episodes of hip and knee arthroplasty surgery among 13 members of the High Value Healthcare Collaborative (HVHC), a consortium of health care systems interested in improving health care value.

METHODS

We conducted a retrospective, cross-sectional observational cohort study of 30-day episodes of care for hip and knee arthroplasty in fee-for-service Medicare beneficiaries aged 65 or older who had hip or knee osteoarthritis and used 1 of 13 HVHC member systems for uncomplicated primary hip arthroplasty (N = 8853) or knee arthroplasty (N = 16,434), respectively, in 2012 or 2013. At the system level, we calculated: per-capita utilization rates; postoperative complication rates; standardized total, acute, and postacute care Medicare expenditures for 30-day episodes of care; and the modeled impact of reducing episode expenditures or per-capita utilization rates.

RESULTS

Adjusted per-capita utilization rates varied across HVHC systems and postacute care reimbursements varied more than 3-fold for both types of arthroplasty in both years. Regression analysis confirmed that total episode and postacute care reimbursements significantly differed across HVHC members after considering patient demographic differences. Potential Medicare cost savings were greatest for knee arthroplasty surgery and when lower total reimbursement targets were achieved.

CONCLUSION

The substantial variation that we found offers opportunities for learning and collaboration to collectively improve outcomes, reduce costs, and enhance value. Ceteris paribus, reducing per-episode reimbursements would achieve greater Medicare cost savings than reducing per-capita rates.

Per-Capita Medicare Expenditures, Primary Care Access, Mortality Rates, and the Least Healthy Cities in America

PURPOSE

To determine whether several measures of health care expenditures, access, and outcomes for the 25 recently identified "least healthy cities in America" differed from those in the rest of America.

METHODS

For 2004 and 2013, we obtained publicly available price-, age-, sex-, and race-adjusted hospital service area per-capita Medicare expenditures; age-, sex-, and race-adjusted Medicare mortality rates; and 2 indicators of primary care access: the proportion of enrollees having at least one ambulatory visit to a primary care clinician and the per-capita discharge rate for ambulatory care sensitive conditions. Using population weighting, we used Student t test for expenditure data and the chi-squared test for access and outcomes data to compare results of the 25 least healthy cities in aggregate to the rest of America.

RESULTS

In both years examined, the 25 least healthy cities had substantially (about $500 per capita per year) and statistically significantly higher total per-capita Medicare Part A and Part B expenditures than the rest of America: about 4/5 of this difference was due to higher hospital and skilled nursing facility expenditures; physician expenditures were modestly lower in the 25 least healthy cities. While a greater proportion of Medicare beneficiaries in the least healthy cities had a primary care clinician both years, mortality and ambulatory care sensitive condition admission rates were substantially higher in the least healthy cities.

CONCLUSIONS

Policymakers and health system executives should work together to determine the best asset allocation across determinants of health that maximizes value creation from a community health perspective.

Recurrence of Pain After Usual Nonoperative Care for Symptomatic Lumbar Disk Herniation: Analysis of Data From the Spine Patient Outcomes Research Trial

OBJECTIVE

To determine risks and predictors of recurrent leg and low back pain (LBP) after unstructured, usual nonoperative care for subacute/chronic symptomatic lumbar disk herniation (LDH).

DESIGN

Secondary analysis of data from a concurrent randomized trial and observational cohort study.

SETTING

Thirteen outpatient spine practices.

PARTICIPANTS

A total of 199 participants with resolution of leg pain and 142 participants with resolution of LBP from among 478 participants receiving usual nonoperative care for symptomatic LDH.

ASSESSMENT OF RISK FACTORS

Potential predictors of recurrence included time to initial symptom resolution, sociodemographics, clinical characteristics, work-related factors, imaging-detected herniation characteristics, and baseline pain bothersomeness.

MAIN OUTCOME MEASUREMENTS

Leg pain and LBP bothersomeness were assessed by the use of a 0-6 numerical scale at up to 4 years of follow-up. For individuals with initial resolution of leg pain, we defined recurrent leg pain as having leg pain, receiving lumbar epidural steroid injections, or undergoing lumbar surgery subsequent to initial leg pain resolution. We calculated cumulative risks of recurrence by using Kaplan-Meier survival plots and examined predictors of recurrence using Cox proportional hazards models. We used similar definitions for LBP recurrence.

RESULTS

One- and 3-year cumulative recurrence risks were 23% and 51% for leg pain, and 28% and 70% for LBP, respectively. Early leg pain resolution did not predict future leg pain recurrence. Complete leg pain resolution (adjusted hazard ratio [aHR] 0.47, 95% confidence interval [CI] 0.31-0.72) and posterolateral herniation location (aHR 0.61; 95% CI 0.39-0.97) predicted a lower risk of leg pain recurrence, and joint problems (aHR 1.89; 95% CI 1.16-3.05) and smoking (aHR 1.81; 95% CI 1.07-3.05) predicted a greater risk of leg pain recurrence. For participants with complete initial resolution of pain, recurrence risks at 1 and 3 years were 16% and 41% for leg pain and 24% and 59% for LBP, respectively.

CONCLUSIONS

Recurrence of pain is common after unstructured, usual nonsurgical care for LDH. These risk estimates depend on the specific definitions applied, and the predictors identified require replication in future studies.

SPORT: Does incidental durotomy affect longterm outcomes in cases of spinal stenosis?

BACKGROUND

Incidental durotomy is a familiar encounter during surgery for lumbar spinal stenosis. The impact of durotomy on long-term outcomes remains a matter of debate.

OBJECTIVE

To determine the impact of durotomy on the long-term outcomes of patients in the Spine Patient Outcomes Research Trial (SPORT).

METHODS

The SPORT cohort participants with a confirmed diagnosis of spinal stenosis, without associated spondylolisthesis, undergoing standard, first-time, open decompressive laminectomy, with or without fusion, were followed up from baseline at 6 weeks, and 3, 6, and 12 months and yearly thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean follow-up among all analyzed patients was 43.8 months.

RESULTS

Four hundred nine patients underwent first-time open laminectomy with or without fusion. Thirty-seven of these patients (9%) had an incidental durotomy. No significant differences were observed with or without durotomy in age; sex; race; body mass index; the prevalence of smoking, diabetes mellitus, and hypertension; decompression level; number of levels decompressed; or whether an additional fusion was performed. The durotomy group had significantly increased operative duration, operative blood loss, and inpatient stay. There were, however, no differences in incidence of nerve root injury, mortality, additional surgeries, or primary outcomes (Short Form-36 Bodily Pain or Physical Function scores or Oswestry Disability Index) at yearly follow-ups to 4 years.

CONCLUSIONS

Incidental durotomy during first-time lumbar laminectomy for spinal stenosis did not impact long-term outcomes in affected patients.

Associations between physical therapy and long-term outcomes for individuals with lumbar spinal stenosis in the SPORT study

BACKGROUND CONTEXT

A period of nonsurgical management is advocated before surgical treatment for most patients with lumbar spinal stenosis. Currently, little evidence is available to define optimal nonsurgical management. Physical therapy is often used, however its use and effectiveness relative to other nonsurgical strategies has not been adequately explored.

PURPOSE

Describe the use of physical therapy and other nonsurgical interventions by patients with lumbar spinal stenosis and examine the relationship between physical therapy and long-term prognosis.

STUDY DESIGN

Secondary analysis of the Spine Patient Outcomes Research Trial (SPORT) combining data from randomized and observational studies.

SETTING

Thirteen spine clinics in 11 states in the United States.

PATIENT SAMPLE

Patients with lumbar spinal stenosis receiving nonsurgical management including those who did or did not receive physical therapy within 6 weeks of enrollment.

OUTCOME MEASURES

Primary outcome measures included crossover to surgery, the bodily pain and physical function scales changes from the Survey Short Form 36 (SF-36), and the modified Oswestry Disability Index. Secondary outcome measures were patient satisfaction and the Sciatica Bothersomeness Index.

METHODS

Baseline characteristics and rates of crossover to surgery were compared between patients who did or did not receive physical therapy. Baseline factors predictive of receiving physical therapy were examined with logistic regression. Mixed effects models were used to compare outcomes between groups at 3 and 6 months and 1 year after enrollment adjusted for baseline severity and patient characteristics.

RESULTS

Physical therapy was used in the first 6 weeks by 90 of 244 patients (37%) and was predicted by the absence of radiating pain and being single instead of married. Physical therapy was associated with a reduced likelihood of crossover to surgery after 1 year (21% vs. 33%, p=.045), and greater reductions on the Short Form 36 physical functioning scale after 6 months (mean difference=6.0, 95% confidence interval: 0.2-11.7) and 1 year (mean difference=6.5, 95% confidence interval: 0.6-12.4). There were no differences in bodily pain or Oswestry scores across time.

CONCLUSIONS

Many patients with lumbar spinal stenosis pursuing conservative management receive physical therapy. Using physical therapy was associated with reduced likelihood of patients receiving surgery within 1 year. Results for other outcomes were mixed with no differences in several measures. Further research is needed to examine the effectiveness of physical therapy relative to other nonsurgical management strategies for patients with lumbar spinal stenosis.

SPORT: does incidental durotomy affect long-term outcomes in cases of spinal stenosis?

BACKGROUND

Incidental durotomy is a familiar encounter during surgery for lumbar spinal stenosis. The impact of durotomy on long-term outcomes remains a matter of debate.

OBJECTIVE

To determine the impact of durotomy on the long-term outcomes of patients in the Spine Patient Outcomes Research Trial (SPORT).

METHODS

The SPORT cohort participants with a confirmed diagnosis of spinal stenosis, without associated spondylolisthesis, undergoing standard, first-time, open decompressive laminectomy, with or without fusion, were followed up from baseline at 6 weeks, and 3, 6, and 12 months and yearly thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean follow-up among all analyzed patients was 43.8 months.

RESULTS

Four hundred nine patients underwent first-time open laminectomy with or without fusion. Thirty-seven of these patients (9%) had an incidental durotomy. No significant differences were observed with or without durotomy in age; sex; race; body mass index; the prevalence of smoking, diabetes mellitus, and hypertension; decompression level; number of levels decompressed; or whether an additional fusion was performed. The durotomy group had significantly increased operative duration, operative blood loss, and inpatient stay. There were, however, no differences in incidence of nerve root injury, mortality, additional surgeries, or primary outcomes (Short Form-36 Bodily Pain or Physical Function scores or Oswestry Disability Index) at yearly follow-ups to 4 years.

CONCLUSIONS

Incidental durotomy during first-time lumbar laminectomy for spinal stenosis did not impact long-term outcomes in affected patients.

Variation in outcomes across centers after surgery for lumbar stenosis and degenerative spondylolisthesis in the spine patient outcomes research trial

STUDY DESIGN

Retrospective review of a prospectively collected database.

OBJECTIVE

To examine whether short- and long-term outcomes after surgery for lumbar stenosis (SPS) and degenerative spondylolisthesis (DS) vary across centers.

SUMMARY OF BACKGROUND DATA

Surgery has been shown to be of benefit for both SPS and DS. For both conditions, surgery often consists of laminectomy with or without fusion. Potential differences in outcomes of these overlapping procedures across various surgical centers have not yet been investigated.

METHODS

Spine Patient Outcomes Research Trial cohort participants with a confirmed diagnosis of SPS or DS undergoing surgery were followed from baseline at 6 weeks, 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Baseline characteristics and short- and long-term outcomes were analyzed.

RESULTS

A total of 793 patients underwent surgery. Significant differences were found between centers with regard to patient race, body mass index, treatment preference, neurological deficit, stenosis location, severity, and number of stenotic levels. Significant differences were also found in operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and wound infection. When baseline differences were adjusted for, significant differences were still seen between centers in changes in patient functional outcome (Short Form-36 bodily pain and physical function, and Oswestry Disability Index) at 1 year after surgery. In addition, the cumulative adjusted change in the Oswestry Disability Index Score at 4 years significantly differed among centers, with Short Form-36 scores trending toward significance.

CONCLUSION

There is a broad and statistically significant variation in short- and long-term outcomes after surgery for SPS and DS across various academic centers, when statistically significant baseline differences are adjusted for. The findings suggest that the choice of center affects outcome after these procedures, although further studies are required to investigate which center characteristics are most important.

Spine patient outcomes research trial: do outcomes vary across centers for surgery for lumbar disc herniation?

BACKGROUND

Lumbar discectomy is the most commonly performed spine procedure. Academic spine centers with potentially differing caseloads and experience may have different outcomes.

OBJECTIVE

To determine whether the choice of center in which surgery is performed affects lumbar discectomy outcomes.

METHODS

Spine Patient Outcomes Research Trial participants with a confirmed diagnosis of intervertebral disc herniation undergoing standard first-time open discectomy were followed from baseline at 6 weeks, and 3, 6, and 12 months, and yearly thereafter, at 13 spine clinics in 11 US states. Patient data from this prospective study were reviewed. Enrollment began in March 2000 and ended in November 2004.

RESULTS

Seven hundred ninety-two patients underwent first-time lumbar discectomy. Significant differences were found among centers in patient age and race, baseline levels of disability, and treatment preferences. There were no significant differences among the centers in other patient characteristics (eg, sex, body mass index, the prevalence of smoking, diabetes, or hypertension), or disease characteristics (herniation level or type). Some short-term outcomes varied significantly among centers, including operative duration and blood loss, the incidence of durotomy, the length of hospital stay, and reoperation rate. However, there were no differences among the centers in incidence of nerve root injury, postoperative mortality, Short Form 36 scores of body pain or physical function, or Oswestry Disability Index at 4 years.

CONCLUSION

Although mean blood loss, risk of durotomy, length of stay, and rate of reoperation vary among academic spine centers performing lumbar discectomy, there appears to be no difference in long-term functional outcomes.

The unintended consequences of bundled payments

Consensus is building that episode-based bundled payments can produce substantial Medicare savings, and the Center for Medicare & Medicaid Innovation's Bundled Payment Initiative endorses this concept. The program generates potential cost savings by reducing the historic cost of time-defined episodes of care, provided through a discount. Although bundled payments can reduce waste primarily in the postacute care setting, concerns arise that, in an effort to maintain income levels that are necessary to cover fixed costs, providers may change their behaviors to increase the volume of episodes. Such actions would mitigate the savings that Medicare might have accrued and may perpetuate the fee-for-service payment mechanism, with episodes of care becoming the new service. Although bundled payments have some advantages over the current reimbursement system, true cost-savings to Medicare will be realized only when the federal government addresses the use issue that underlies much of the waste inherent in the system and provides ample incentives to eliminate capacity and move toward capitation.

The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial

BACKGROUND

The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment.

METHODS

One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first three months of the study or prior to the study (the No-ESI group).

RESULTS

There was a significant difference in the preference for surgery between groups (19% in the ESI group compared with 56% in the No-ESI group, p < 0.001). There was no difference in primary or secondary outcome measures at four years between the groups. A higher percentage of patients changed from surgical to nonsurgical treatment in the ESI group (41% versus 12% in the No-ESI, p < 0.001).

CONCLUSIONS

Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection. There was a higher prevalence of crossover to nonsurgical treatment among surgically assigned ESI-group patients, although this was confounded by the increased baseline desire to avoid surgery among patients in the ESI group. Given these data, we concluded that more studies are necessary to establish the value of epidural steroid injection for symptomatic lumbar intervertebral disc herniation.

A collaborative of leading health systems finds wide variations in total knee replacement delivery and takes steps to improve value

Members of a consortium of leading US health care systems, known as the High Value Healthcare Collaborative, used administrative data to examine differences in their delivery of primary total knee replacement. The goal was to identify opportunities to improve health care value by increasing the quality and reducing the cost of that procedure. The study showed substantial variations across the participating health care organizations in surgery times, hospital lengths-of-stay, discharge dispositions, and in-hospital complication rates. The study also revealed that higher surgeon caseloads were associated with shorter lengths-of-stay and operating time, as well as fewer in-hospital complications. These findings led the consortium to test more coordinated management for medically complex patients, more use of dedicated teams, and a process to improve the management of patients' expectations. These innovations are now being tried by the consortium's members to evaluate whether they increase health care value.

Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes: analysis of the Spine Patient Outcomes Research Trial (SPORT)

BACKGROUND

The purpose of the present study was to determine if the duration of symptoms affects outcomes following the treatment of intervertebral lumbar disc herniation.

METHODS

An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial (SPORT) for the treatment of intervertebral lumbar disc herniation. Randomized and observational cohorts were combined. A comparison was made between patients who had had symptoms for six months or less (n = 927) and those who had had symptoms for more than six months (n = 265). Primary and secondary outcomes were measured at baseline and at regular follow-up intervals up to four years. The treatment effect for each outcome measure was determined at each follow-up period for the duration of symptoms for both groups.

RESULTS

At all follow-up intervals, the primary outcome measures were significantly worse in patients who had had symptoms for more than six months prior to treatment, regardless of whether the treatment was operative or nonoperative. When the values at the time of the four-year follow-up were compared with the baseline values, patients in the operative treatment group who had had symptoms for six months or less had a greater increase in the bodily pain domain of the Short Form-36 (SF-36) (mean change, 48.3 compared with 41.9; p < 0.001), a greater increase in the physical function domain of the SF-36 (mean change, 47.7 compared with 41.2; p < 0.001), and a greater decrease in the Oswestry Disability Index score (mean change, -41.1 compared with -34.6; p < 0.001) as compared with those who had had symptoms for more than six months (with higher scores indicating less severe symptoms on the SF-36 and indicating more severe symptoms on the Oswestry Disability Index). When the values at the time of the four-year follow-up were compared with the baseline values, patients in the nonoperative treatment group who had had symptoms for six months or less had a greater increase in the bodily pain domain of the SF-36 (mean change, 31.8 compared with 21.4; p < 0.001), a greater increase in the physical function domain of the SF-36 (mean change, 29.5 compared with 22.6; p = 0.015), and a greater decrease in the Oswestry Disability Index score (mean change, -24.9 compared with -18.5; p = 0.006) as compared with those who had had symptoms for more than six months. Differences in treatment effect between the two groups related to the duration of symptoms were not significant.

CONCLUSIONS

Increased symptom duration due to lumbar disc herniation is related to worse outcomes following both operative and nonoperative treatment. The relative increased benefit of surgery compared with nonoperative treatment was not dependent on the duration of the symptoms.

Outcomes after incidental durotomy during first-time lumbar discectomy

OBJECT

Incidental durotomy is an infrequent but well-recognized complication during lumbar disc surgery. The effect of a durotomy on long-term outcomes is, however, controversial. The authors sought to examine whether the occurrence of durotomy during surgery impacts long-term clinical outcome.

METHODS

Spine Patient Outcomes Research Trial (SPORT) participants who had a confirmed diagnosis of intervertebral disc herniation and were undergoing standard first-time open discectomy were followed up at 6 weeks and at 3, 6, and 12 months after surgery and annually thereafter at 13 spine clinics in 11 US states. Patient data from this prospectively gathered database were reviewed. As of May 2009, the mean (± SD) duration of follow-up among all of the intervertebral disc herniation patients whose data were analyzed was 41.5 ± 14.5 months (41.4 months in those with no durotomy vs 40.2 months in those with durotomy, p < 0.68). The median duration of follow-up among all of these patients was 47 months (range 1-95 months).

RESULTS

A total of 799 patients underwent first-time lumbar discectomy. There was an incidental durotomy in 25 (3.1%) of these cases. There were no significant differences between the durotomy and no-durotomy groups with respect to age, sex, race, body mass index, herniation level or type, or the prevalence of smoking, diabetes, or hypertension. When outcome differences between the groups were analyzed, the durotomy group was found to have significantly increased operative duration, operative blood loss, and length of inpatient stay. However, there were no significant differences in incidence rates for nerve root injury, postoperative mortality, additional surgeries, or SF-36 scores for Bodily Pain or Physical Function, or Oswestry Disability Index scores at 1, 2, 3, or 4 years.

CONCLUSIONS

Incidental durotomy during first-time lumbar discectomy does not appear to impact long-term outcome in affected patients.

A longitudinal comparison of 5 preference-weighted health state classification systems in persons with intervertebral disk herniation

OBJECTIVE

To assess the longitudinal validity of widely used preference-weighted measurement systems for economic studies of intervertebral disk herniation (IDH).

METHODS

Using data at baseline and 1 year from 1000 Spine Patient Outcomes Research Trial (SPORT) participants with IDH and complete data, the authors considered the EQ-5D with UK and US values (EQ-5D-UK and EQ-5D-US), 2 versions of the Health Utilities Index (HUI3 and HUI2), the SF-6D, and a regression-estimated quality of well-being score (eQWB). Differences in mean change scores (MCS) were assessed using signed rank tests, and Spearman correlations were calculated for change scores by system pairs. Using the Oswestry Disability Index, symptom satisfaction, progress rating, and self-perceived health ratings as criterion measures, the authors tested for trend in MCS across levels of change in criteria. They calculated floor and ceiling effects, effect size (ES), standardized response mean, and minimal important difference estimates.

RESULTS

All systems demonstrated linear trends with external criteria and moderate to strong correlations between systems. However, differences in performance were evident. SF-6D and eQWB were most responsive (ES: 1.9 and 2.3, respectively), whereas EQ-5D-US and EQ-5D-UK were least responsive (ES: 1.23/1.20). Ceiling and floor effects were noted for all systems within key dimensions and for EQ-5D-UK and EQ-5D-US for overall score. MCS ranged from 0.40 (0.38) for EQ-5D-UK to 0.13 (0.09) for eQWB and differed significantly, except between EQ-5D-US and HUI2.

CONCLUSIONS

This research supports the validity of all systems for measuring change in persons with IDH, without finding a clearly superior system. The unique characteristics of each system revealed in this study should guide system choice.

Predictors of long-term opioid use among patients with painful lumbar spine conditions

Our objective was to assess predictors of self-reported opioid use among patients with back pain due to lumbar disc herniation or spinal stenosis. Data were from the Spine Patient Outcomes Research Trial (SPORT), a multi-site observational study and randomized trial. We examined characteristics shown or hypothesized to be associated with opioid use. Using generalized estimating equations, we modeled associations of each potential predictor with opioid use at 12 and 24 months. At baseline, 42% of participants reported opioid use. Of these participants, 25% reported continued use at 12 months and 21% reported use at 24 months. In adjusted models, smoking (RR = 1.9, P < .001 at 12 months; RR = 1.5, P = .043 at 24 months) and nonsurgical treatment (RR = 1.7, P < .001 at 12 months; RR = 1.8, P = .003 at 24 months) predicted long-term opioid continuation. Among participants not using opioids at baseline, incident use was reported by 8% at 12 months and 7% at 24 months. We found no significant predictors of incident use at 12 or 24 months in the main models. In conclusion, nonsurgical treatment and smoking independently predicted long-term continued opioid use. To our knowledge, this is the first longitudinal study to assess predictors of long-term and incident opioid use among patients with lumbar spine conditions.

PERSPECTIVE

This longitudinal study of patients with disc herniation or spinal stenosis found that nonsurgical treatment and smoking predicted long-term self-reported opioid use. The greater risk of opioid continuation with nonsurgical therapy may be helpful in decision-making about treatment. The relationship between opioid use, smoking, and other substance use deserves further study.