Spine Surgeons Wrath

Spine Surgeons Wrath

 By

 JCS

 There may be one ray of hope to ending this onslaught of spine surgeries, which in the near future will rank alongside tonsillectomy, appendectomy, hysterectomy, and mastectomy as another common but unnecessary surgery. The fact that an independent insurance payer has called for restraint in spine surgery is huge rather than a governmental agency as we saw in 1994 with the AHCPR guideline on acute low back pain. For those who do not recall the warfare that followed this federal guideline, let me recap the NASS and its Center for Patient Advocacy that stormed Capitol Hill calling for the elimination of AHCPR.

The history of this event began when the U.S. Public Health Service was designed to be an ongoing partnership with the health professions in an effort to improve medical care in America.  During the first Bush administration in 1989, they were charged by Congress to be a federal arbiter of evidence-based, clinical practice guidelines for many common treatments and tests; the Agency for Health Care Policy & Research (AHCPR) was to study and make recommendations.

The AHCPR’s responsibility was to choose conditions, focusing on high-cost, high-use procedures like back surgery for low back pain.  The AHCPR convened multi-disciplinary panels consisting of 18 to 25 highly-regarded researchers to create guidelines that were to be updated as new evidence was discovered.  The goal was to improve the quality and cost-effectiveness of care.

Unlike the first 13 previous guidelines produced by AHCPR that met little objection, the 14^th on acute low back pain in adults and its analysis of back surgery met the full fury of the medical profession since it posed a much more serious threat. The surgeons found sympathetic ears among House Republicans and House Leader Newt Gingrich who were prepared to believe the worst about the agency.^[1] Recall, this 1994 AHCPR guideline came shortly after Clinton’s healthcare reform in 1993.

A bogus patient advocacy group known as the Center for Patient Advocacy was formed by Neil Kahanovitz, a back surgeon from Arlington, Virginia, to lobby on the issue. It organized a letter-writing campaign to gain congressional support for its attack on AHCPR, similar to the Operation Coffee Cup effort organized by the AMA and led by actor Ronald Reagan to attack JFK’s proposed Medicare/Medicaid bill. We recently saw the same ploy with the FOX News and Tea Party attack on Obama’s healthcare reform bill. The medical profession has consistently used phony public groups to do its bidding.

The North American Spine Society (NASS) also created an ad hoc committee, which attacked the literature review and the subsequent AHCPR practice guideline on acute care of low back pain. In a letter published in 1994 in the journal Spine, the committee not only criticized the methods used in the literature review but it also charged that AHCPR had wasted taxpayer dollars on the study. Foremost, however, the spine surgical society expressed concern that the conclusions might be used by payers or regulators to limit the number and types of spinal fusion procedures.^[2] 

The NASS waged a political battle never seen before on Capitol Hill to cut the funding of AHCPR, illustrating once again how political medicine trumps over science and a congressional mandate. Indeed, the AMA has a long history of pushing around legislators with fear-mongering, money, and its illusion as the 4^th branch of government.

On January 9, 1995, Eric J. Muehlbauer, executive director for NASS sent out a memorandum regarding the release of the clinical practice guideline from the Agency for Health Care Policy and Research (AHCPR), Acute Low Back Problems in Adults. The front page of the 1995 summer edition of the NASS News proclaimed, “AHCPR Guidelines Disputed,” suggesting that “this has become a political, and not a scientific document.”^[3] Is this the pot calling the kettle black or what?

NASS concluded:

“We, the North American Spine Society, feel that this document should not be published in its present form. Instead, a new consensus should be sought, with appointed input from all relevant medical specialties dealing with LBP (low back pain) issues, and with AHCPR staff that is responsive to the criticisms of the methodology raised in this letter.” ^[4]

Inexplicably, the consensus the NASS sought is exactly what happened with the panel members selected from nominees of all medical, osteopath, physical therapy, and chiropractic societies. Instead of these baseless excuses, the only real objection by NASS was the panel’s conclusion that recommended spinal manipulation.

Ironically, ^TheBACKLETTER editors^[5] made a comparison of the consensus statements to the AHCPR guidelines and, with the exception of the statement on the use of epidural steroid injections, which many experts find ineffective, the NASS consensus statements generally agreed with the conclusions of the AHCPR low back panel.

 “Perhaps the NASS experience typifies the evolution most groups undergo as they wrestle with practice guidelines,” as the editorial staff of Dynamic Chiropractic journal opined. “Could it be that rage, denial, review and grudging acceptance are all part of the guidelines experience for most health care providers?”^[6] Perhaps it was the potential loss of a billion dollar gravy train that bothered the NASS the most.

The AHCPR guideline did not come as a complete surprise to the spine societies. In the presidential speech by Dr. Casey Lee to NASS in 1994, “Challenges for Spine Specialists,” he discussed the impending guideline with frank honesty:

There are reasons why spine care is under the microscope. The prevalence of spinal symptoms for which patients seek physicians’ expertise is the fourth highest, behind throat symptoms, cough, and earache or infection. The direct annual cost of personal medical care for back pain was six times higher than for AIDS in 19889 ($17.9 billion for back pan vs. $3.3 billion for AIDS). The total estimated cost for back pain related compensation as far back as in 1986 was 11.1 billion dollars. The number of operations for spinal disorders, especially disc excisions and spinal fusions, have been steadily rising over the years; 75% and 200% in percentage change from 1079 to 1987, respectively, for discectomy and spinal fusion.

As the result of this continued increase, many proposals to change practice patterns have emerged, and some have been already imposed on us. I believe we are in a time of volatility and confusion. Do we have to change? What brought these changes? What will happen if we do not change? What can we do?

Do we have to change? The answer is yes. We have to change either voluntarily or involuntarily. The more important question is “should it be reactive or proactive?” Clearly “proactive” is the better answer.

What brought these changes? Certainly the perception of costly and ineffective medical care is a factor. Experts assume that the culprit for costly and ineffective medical care is the extreme variability of clinical practice—a wide range of practice patterns and in outcome.

Reasons for the variations are lack of uniquely successful diagnostics and therapeutic approaches and lack of consensus in diagnosis and management. This implies that there is very little scientific basis for clinical practice, and the conventional method for care is wasteful and pernicious.

Practice variability comes in many different forms—differences in the rate of treatment outcomes among nations, regions, institutions, group, and individual practitioners. You may know that he rate of laminectomy for disc herniation in the United States is three times higher than in Canada and nine times higher than in Europe.

The role of hospital admission for medical and surgical procedures is eight times different between two hospitals, one in Boston and the other in New Haven. The rate of spinal fusion in the western region of the United States is nine times higher than in the Northeast.[7]

Ironically, rather than heeding Dr. Casey’s call to be proactive about the onslaught of “the perception of costly and ineffective medical care,” the spine surgeons showed no self-restraint by ignoring his advice and actually increasing the number of surgeries.

Spine researchers like Scott Boden, Richard Deyo, James Weinstein, among others, continue to state there is “very little scientific basis for clinical practice, and the conventional method for care is wasteful and pernicious.” Instead of becoming proactive and cooperating with the AHCPR guidelines, the NASS formed a political witch hunt to kill funding to this congressionally mandated regulatory body in order to keep its sacred cow alive.

Indeed, the history of the NASS has been proven to be reactive in order to maintain the status quo. Hopefully the NC BC/BS decision to limit spine fusion for disc abnormalities will be outside the reach of this political witch hunt. If this policy algorithm actually utilizes the best of chiropractic conservative care before drugs, shots or surgery, this will be the change we chiropractors have long expected.

[1] Gray, Bradford H., Michael K. Gusmano, and Sara R. Collins, AHCPR And The Changing Politics Of Health Services Research, Lessons from the falling and rising political fortunes of the nation’s leading health services research agency.