The Effect of Required Physiatrist Consultation on Surgery Rates for Back Pain

John Fox, MD; Andrew J. Haig, MD; Brian Todey, BS; Sastish Challa, MS


Priority Health's new policy, which required a physiatrist consultation before surgery, significantly reduced surgery rates and costs.
Limited evidence suggests that patient satisfaction remained good. To our knowledge, no intervention to date has shown a decrease in surgical rates of this magnitude across an entire region. Changes across multiple hospital service areas in a wide region of a state suggest that the results are not due to some individual clinician or group but instead can be generalized across communities, hospitals, and practices.
Back pain is a huge burden on society. The direct costs might be as high as $90 billion per year in the United States,[11] with personal suffering and indirect impact on the patient, family, and society much greater than that. Yet, back pain is generally a benign process in comparison with other high-impact health problems such as cancer or heart disease. Although there are well-established guidelines, most primary care physicians do not follow them.[12,13]
With few exceptions, spine surgery is an elective procedure and, for most conditions, a treatment option rather than a required treatment.[7]
Epidemiological evidence shows that surgery is not appropriately or evenly applied to the American population as a whole.[1,2] Many patient and clinician factors other than the pathology play into this decision. The path to costly and devastating chronic low back pain is well known to relate to psychosocial factors more than surgical pathology.[14] These factors, such as marital status, litigation, depression, fear and avoidance beliefs, and work conditions, are routinely addressed in physiatric management.
There could be many reasons for the influence of physiatric consultation demonstrated in this study. The passage of time imposed by this consultation process favors improvement or recovery from most spinal disorders. Physiatric consultation might give patients a more balanced understanding of their diagnosis, prognosis, and treatment options; the physiatrist might spend more time in counseling about these issues. In some cases, the physiatrist might change the diagnosis, find treatable secondary musculoskeletal pain generators, or detect psychosocial factors that would make surgery inappropriate. Finally, treatments resulting from the visit might be more successful than those provided initially by the primary care physician.
The scientific reproducibility of "physiatrist consultation" is worthy of comment. Empirically, the results were similar across physiatrist groups. Four years of training and a stringent board certification process result in some level of homogeneity within the physiatrists and difference from other potential consultants. The current methodology also does not permit examination of whether physiatrists in the study actually followed evidence-based recommendations. More stringent evidence-based control debatably might have improved quality and thus improved outcomes. However, one can debate whether a more stringent protocol would dumb down or improve outcomes compared with this standard. Overall, the process favored a broader patient understanding of the problem and their options, opening the door to more shared decision making.[15]
This study demonstrated substantial benefits of physiatric consultation compared with primary care and spine surgeon management of potential surgical intervention. Other models might be compared with this standard. They include the use of patient pamphlets, nurse practitioners, physical therapists, and other professionals. At face value, each of these seems to lack some aspect of the competency provided by board-certified specialist physicians in the field of physical medicine and rehabilitation; however, a comparative study would be interesting.
The consequences of this policy on clinical practice are worth noting. Although the decrease in surgery rates occurred in 5 of 6 hospital systems, the program resulted in a substantial shift in volume between the different hospital systems, perhaps related to their ability to adapt to this new process. Another adaptation might not have been so beneficial. The substantial drop in surgical procedures was accompanied by an increase in the ratio of more extensive and costly fusion operations.
Physiatrists employed in surgical practices did not have increased referrals to surgery when compared with others. There was no significant increase in the number of electrodiagnostic studies or spinal injections despite the fact that such procedures positively influence physiatrists' income.
Patients who underwent previous surgery were more likely to seek a surgical consultation and be less satisfied with the physiatrist. Patients who underwent surgery in the past might simply have wished to see the physician they knew or perceived a physiatrist as less knowledgeable than a surgeon. People who underwent previous surgery may, on the average, have had more severe or complex problems as a result of their initial pathology or as a consequence of their previous operation. The level of trust that patients place in surgeons is high. In one study, for instance, patients chose surgery largely because their surgeon recommended it.[16]
This study looks only at actions and costs that can be measured from an insurance database. The total cost and potentially the cost savings related to time off work, litigation, and other factors are undoubtedly higher. The halo effect on primary care physician behavior and consumer education may have decreased cost accrued by patients covered by other insurances, including workers compensation, federal insurance schemes, and other private insurers, but is also not measured in this study.
The reproducibility of these findings in other circumstances should be discussed. The study used a region with higher than average rates of surgery. It is possible that the intervention would only decrease aggressive surgical practices that are less frequently encountered in other communities. However, the decreases were across the board in 5 of 6 health care systems. Also, this study involved only 1 insurer. Although this insurer is typical of many other private insurers, the effect of this policy on older people insured by Medicare or on patients in the workers' compensation system might be different. However, the complexity of diagnosis and treatment in the older population is such that a physiatric approach is even more likely to benefit them.[17] Individuals on workers' compensation were not evaluated in this study. In general, they have poorer surgical outcomes, yet the reimbursement for surgery is typically much higher for workers' compensation cases. Thus, it seems likely that a similar policy would have a similar or greater positive effect on the workers' compensation and Medicare populations.
Execution of this kind of program on a wider scale is feasible but challenging. Although there are more than 8000 physiatrists in the United States,[18] they are fully engaged and employed. The financial incentive to provide access to presurgical patients was an important factor in the willingness of local physiatrists to shift their priorities. In the short term, efforts to increase primary care expertise in diagnosing spinal disorders, counseling patients, and appropriately referring surgical patients is a daunting task. In the long term, an increase in the number of physiatrists might be warranted. One might consider the use of other experts, such as physical therapists, chiropractors, or anesthesia-trained pain specialists. However, these practitioners have limitations in training or licensure that make them less than optimal when it comes to psychological assessment, advanced diagnostics and treatment, or functional rehabilitation. Development of efficient and effective systems of care around the primary care/physiatrist/surgeon axis might be the most important strategy.
This study showed that a required physiatrist consultation for elective spine surgery radically decreased the operative rate while maintaining patient satisfaction across a large region. Although experiences might be different in other communities, policies such as this one have the potential to improve spine care and decrease cost elsewhere.

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