Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30,...
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Transcript of Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30,...
![Page 1: Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30, 2011 Gary M. Franklin, MD, MPH Research Professor.](https://reader035.fdocuments.us/reader035/viewer/2022081700/56649e175503460f94b01e4c/html5/thumbnails/1.jpg)
Lumbar fusion for chronic LBP-WA State Agency/DLI Perspective-
-Robert Bree Collaborative-Sept 30, 2011
Gary M. Franklin, MD, MPHResearch Professor
Departments of Environmental Health, Neurology, and Health Services
University of Washington
Medical DirectorWashington State Department of
Labor and Industries
![Page 2: Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30, 2011 Gary M. Franklin, MD, MPH Research Professor.](https://reader035.fdocuments.us/reader035/viewer/2022081700/56649e175503460f94b01e4c/html5/thumbnails/2.jpg)
WA Public payers compelling issues
• Lumbar fusion has the highest regional variation of any major surgery in the US-20 fold difference between geographic regions– Weinstein et al, Spine 2006, 31: 2707-14.
• Average cost $80-120,000, up to half is instrumentation in absence of DRG’s
• Lumbar fusion number one in-patient cost for Uniform Health Plan (public employees)
• Contribution to long term disability and pension in DLI
![Page 3: Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30, 2011 Gary M. Franklin, MD, MPH Research Professor.](https://reader035.fdocuments.us/reader035/viewer/2022081700/56649e175503460f94b01e4c/html5/thumbnails/3.jpg)
Washington State DLI Outcomes-Population-based restrospective studies-• Franklin et al, 1994; Spine 20: 1897-903 N= 388 fusions from 1986-87
-68% TTD at 2 years; 23% more surgery by 2 yrs -Instrumentation doubled risk of reoperation -Surgical experience didn’t matter• Juratli et al, 2006; Spine 31:2715–23. N=1950 fusions from 1994-2000
-64% disabled at 2 yrs; 22% reoperated by 2 yrs + 12% other complications
-85% received cages and/or instrumentation -Cage/instrumentation use increased complications without improving
disability or reoperation rate• Juratli et al, 2009: Spine 34: 740-47
-Increased mortality associated with opioid use
![Page 4: Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30, 2011 Gary M. Franklin, MD, MPH Research Professor.](https://reader035.fdocuments.us/reader035/viewer/2022081700/56649e175503460f94b01e4c/html5/thumbnails/4.jpg)
Recent developments
• WA HTA:– 2/15/08-Fusion for DDD covered if structured
multidisciplinary program fails, or not available– 8/15/08-Discography for chronic LBP and DDD not covered
• 1/1/2011-North Carolina BC/BS-lumbar fusion not covered for chronic LBP and DDD
• SSB 5801-workers comp health reform-includes authority to define harmful care; eg, are you in the highest decile for failed lumbar fusion or reoperations?
![Page 5: Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30, 2011 Gary M. Franklin, MD, MPH Research Professor.](https://reader035.fdocuments.us/reader035/viewer/2022081700/56649e175503460f94b01e4c/html5/thumbnails/5.jpg)
Complications, death and repeat surgery within 90 days of lumbar fusion (unadjusted %)
CHARS 2004-2007 [n = 5,864]Payer Device
comp.Wound prob.
Life- threatening
Death Repeat Lumbar Surgery
Medicare 0.4 4.4 3.7 0.4 1.9Medicaid 1.6 6.8 2.2 0.0 2.4HMO 1.0 1.4 0.6 0.6 0.7Commercial 1.1 1.8 1.3 0.1 2.0W/C 1.0 1.8 0.6 0.0 1.3Contract 0.5 3.0 1.6 0.1 1.5Other 0.0 2.9 2.2 0.0 1.9
Martin et al, submitted
![Page 6: Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30, 2011 Gary M. Franklin, MD, MPH Research Professor.](https://reader035.fdocuments.us/reader035/viewer/2022081700/56649e175503460f94b01e4c/html5/thumbnails/6.jpg)
What public payers need
• Better information Re outcomes of lumbar fusion across payers (DLI, Uniform, Regence)
• Best new data could only come from a well designed, population-based comparative effectiveness study– With minimum clinically important differences measured
(eg, 30% improved function AND 30% improved pain AND less than daily opioid use)
– Control groups should include other patients with chronic LBP (pain clinics, usual care)
– Clear data on relative safety and costs
![Page 7: Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30, 2011 Gary M. Franklin, MD, MPH Research Professor.](https://reader035.fdocuments.us/reader035/viewer/2022081700/56649e175503460f94b01e4c/html5/thumbnails/7.jpg)
For electronic copies of this presentation, please e-mail Melinda
For questions or feedback, please e-mail Gary Franklin
THANK YOU!