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An increase in the number of privately funded elective spinal surgeries in Australia has prompted questions about the clinical need for these procedures.
More evidence is needed into how effective back surgery is in helping improve back pain, according to a study published in the Medical Journal of Australia today.
The research investigated rates of elective spinal fusion, decompression, and disc replacement procedures for people with degenerative conditions in New South Wales by the funding types of public, private and workers’ compensation.
“Rates of privately funded spinal fusion and decompression procedures have increased much more rapidly in New South Wales than those of procedures that are publicly funded or covered by workers’ compensation,” the authors wrote.
Increase in privately funded spinal surgeries
The study drew on previous research which showed the rate of privately funded spinal fusions in Australia increased by 167% during 1997–2006 (from 7.7 to 20.5 per 100 000 population), while the publicly funded rate increased by only 2% (from 5.1 to 5.2 per 100 000 population).
It was also informed by a government report which showed that, between 2012 and 2018, 83% of spinal procedures in Australia were performed in the private sector (as were about two-thirds of hip and knee replacement procedures).
“[This suggests] that financial considerations are important and that access to surgical interventions may consequently be inequitable,” the authors write.
“These differences may indicate that some privately funded procedures are unnecessary, or that the number of publicly funded procedures does not reflect clinical need,” they wrote.
Speaking to InSight+, one of the study’s authors, Research Fellow Dr Duong Tran, said the disproportionate increases in privately funded spinal surgeries needed further investigation.
“[The disproportionate increase] may suggest overutilisation of fusion in the private sector, underutilisation of fusion in the public sector, or both,” Dr Tran said.
The availability of private health insurance may also be a factor, Dr Tran said.
“Patients with private health insurance may actively seek surgery if non-surgical management has not provided relief, while surgery may not be readily accessible to patients without private health insurance,” Dr Tran said.
Need for more research
Despite the higher rates of privately funded surgery, there is little high quality evidence for the effectiveness of many spinal procedures (here and here), Dr Tran said.
“Consequently, there are no clear clinical practice guidelines, no consensus on the indications for spinal surgery, and considerable practice variation, as seen in our study and studies internationally,” Dr Tran said.
“In the absence of strong evidence for the effectiveness of elective spinal surgeries, the final decision often comes down to surgeon preference.
“Surgeon preference can be influenced by many factors, such as peer practice and financial incentives.”
Risk of repeat surgery
More investigation is needed of the preferences of patients and surgeons when it comes to spinal surgery, Dr Tran said.
“From previous research in the workers’ compensation sector in NSW, we found that return to work rates are low and approximately one in five patients will undergo repeat surgery within two years (here).
“Given these outcomes, further research on potential factors, for example, financial considerations, access to specialist care and surgery, and the preferences of patients and physicians with respect to surgical and non-surgical care, would be beneficial.”
Health system considerations
The incentives of the health system in encouraging spinal surgery as a treatment should also be considered, Dr Tran said.
“Consideration should be given to how our limited resources are directed when managing people with spinal conditions.
“For example, it is possible that surgery is not the most cost-effective treatment for back pain, yet that is the treatment currently encouraged by some surgeons (here, here and here).”
Limitations
The researchers were not able to identify specific indications for spinal surgery or the spinal regions where surgery was undertaken.
Information about pain management, procedural techniques, and devices was also not available.
Read the Research in the Medical Journal of Australia
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Well done Dr Tran – very good questions that surgeons and the health community including patients need to reflect on. A famous Swedish spinal pain expert was aghast that in Australia patients with somatic spinal pain not associated with any red flag condition were having spinal surgery. It hasn’t changed much over the 15 years since he offered that observation
Based on the information provided, some potential areas for critical comments could include:
The study is a retrospective observational study, which can establish correlations but cannot definitively prove causation [5]. This means that while the study might find a relationship between two variables, it cannot prove that one variable causes the other.
The quality and accuracy of the data used in this retrospective study can vary, affecting the reliability of the study’s findings [6].
The study is based on NSW hospital admissions data for 1 July 2001 – 30 June 2020 [5]. Therefore, the findings may not generalise to other regions or time periods.
The statement that “The benefits of spinal decompression and fusion for people with degenerative conditions are dubious” [1][3] seems to be a general observation about the ongoing debate in the medical community rather than a specific finding from this study. The study appears to focus more on the rates of these procedures and how they vary by funding source [1][2][5]. There is no reference to PROMs, so clinical outcome conclusions are invalid.
The study suggests that some privately funded procedures are unnecessary or that the number of publicly financed approaches does not reflect clinical need [1][2]. However, these conclusions may be premature without further investigation into the factors that influence whether spinal surgery is undertaken, including financial considerations, access to specialist care and surgery, and the preferences of patients and physicians with respect to surgical and non-surgical care. Additionally, the public system’s lack of funding for these procedures requires recognition.
Yeah i think it’s pretty obvious why this is happening. Doctors *are not good * at diagnosing spinal injuries. I know this because I was admitted, and discharged with a severe herniated disc damaging my cauda equina nerves, stopping spinal fluid flow and ended up on crutches for 5 months with a severely paralysed and numb leg – because they couldn’t be bothered to do an MRI until 5 days afterwards, and still took an extra day to perform surgery. They also refused to get a neurosurgeon or orthopaedic surgeon to see me despite my insistence. And do you think this was private or public?
Of course it was public. I’ve now had two spinal surgeries and the public hospital is as pathetic as ever.
I am now seeking a private spinal surgeon for ongoing management because I have been let down by the public system. They do not diagnose correctly, and they avoid treating anyone if they can, including those with severe injury like mine.