Wide variation across hospitals leaves patients vulnerable to bad medicine
Every eight minutes an unnecessary back surgery is performed on an older adult, putting thousands of patients at risk of a negative outcome and increasing Medicare spending, according to a new analysis from the Lown Institute, an independent think tank.
Researchers examined hospital data for common back surgeries, including spinal fusion, laminectomy, and vertebroplasty, for which clinical trials have repeatedly shown lack of benefit for certain patients. Patients with low-back pain caused by aging (excluding cases with neurologic symptoms, trauma, or structural abnormalities) receive little to no benefit from spinal fusion or laminectomy. Patients with spinal fractures caused by osteoporosis (excluding cases with bone cancer, myeloma, or hemangioma) receive little to no benefit from vertebroplasty.
More than 200,000 procedures met criteria for overuse and are estimated to have cost Medicare around $2 billion over a three-year period.
“We trust that our doctors make decisions based on the best available evidence, but that’s not always the case,” said Vikas Saini, MD, president of the Lown Institute. “In spinal surgery, as with other fields of medicine, physicians routinely overlook evidence to make exceptions, sometimes at shockingly high rates. This type of waste in Medicare is costly, both in terms of spending, and in risk to patients.”
Hospitals with highest rates of spinal fusion/laminectomy overuse, 2019-2021
Of hospitals performing at least 500 total procedures, the rank order by highest proportion of procedures meeting overuse criteria.
| Hospital | # Overuse procedures | Total procedures | Overuse rate |
|---|---|---|---|
| Mount Nittany Medical Center (Pa.) | 336 | 535 | 62.8% |
| The Medical Center of Aurora (Colo.) | 275 | 653 | 42.1% |
| Jefferson Abington Hospital (Pa.) | 295 | 726 | 40.6% |
| Concord Hospital (N.H.) | 212 | 522 | 40.6% |
| Heritage Valley Sewickley (Pa.) | 203 | 506 | 40.1% |
| HSHS St. John’s Hospital (Ill.) | 204 | 521 | 39.2% |
| Lutheran Hospital (Ind.) | 459 | 1174 | 39.1% |
| Baystate Medical Center (Mass.) | 326 | 838 | 38.9% |
| Mobile Infirmary (Ala.) | 221 | 589 | 37.5% |
| Cape Coral Hospital (Fla.) | 210 | 560 | 37.5% |
Mount Nittany Medical Center in Pennsylvania has the highest rate of unnecessary spinal fusion/laminectomy in the nation at 62.8%. The hospital performed 535 procedures with 336 of them meeting criteria for overuse. Lown’s research also found that a single physician is responsible for 92% (308) of those overuse procedures.
Hospitals with lowest rates of spinal fusion/laminectomy overuse, 2019-2021
Of hospitals performing at least 500 total procedures, the rank order by lowest proportion of procedures meeting overuse criteria.
| Hospital | # Overuse procedures | Total procedures | Overuse rate |
|---|---|---|---|
| Avala Hospital (La.) | Data omitted to avoid sharing information that could be personally identifiable. | 0.1% | |
| Northwest Specialty Hospital (Idaho) | 1.2% | ||
| Fresno Surgical Hospital (Calif.) | 1.2% | ||
| Baylor Surgical Hospital at Las Colinas (Texas) | 1.3% | ||
| CHRISTUS Mother Frances Hospital – Tyler (Texas) | 18 | 1083 | 1.7% |
| McBride Orthopedic Hospital (Okla.) | 15 | 840 | 1.8% |
| UC San Diego Medical Center (Calif.) | 15 | 783 | 1.9% |
| Hendrick Medical Center (Texas) | 18 | 852 | 2.1% |
| Methodist Hospital for Surgery (Texas) | 18 | 758 | 2.4% |
| Erlanger Baroness Hospital (Tenn.) | 22 | 876 | 2.5% |
Notable variation in spinal fusion/laminectomy overuse rates are present even among the nation’s most prestigious hospitals, including those on the U.S. News & World Report Honor Roll for America’s Best Hospitals. At UC San Diego (1.2% overuse rate), the hospital performed 783 procedures with only 15 meeting criteria for overuse. While at the Hospital of the University of Pennsylvania (32.6% overuse rate), 641 procedures were performed with 209 meeting overuse criteria.
As many as 30 million people receive medical care for a spine problem each year. While surgery is an appropriate treatment option for some, many procedures are performed despite little to no evidence of benefit, and they come with risks. Possible complications include infection, blood clots, stroke, heart and lung problems, paralysis, and even death.
Methodology
Hospital overuse was measured using Medicare fee-for-service and Medicare Advantage claims data for three years of the most recently available data (2020-2022 for fee-for-service and 2019-2021 for Medicare Advantage).
Spinal fusion and/or laminectomy was defined as overuse for patients with low-back pain if they did not have radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain or scoliosis. Spinal fusion-only cases were not considered overuse for patients with stenosis with neural claudication and spondylolisthesis. Laminectomy-only cases were not considered overuse for patients with stenosis who had neural claudication. Vertebroplasty was defined as overuse for patients with spinal fractures caused by osteoporosis, excluding patients with bone cancer, myeloma, or hemangioma.
The cost of low-value back surgeries was calculated using Medicare’ procedure price lookup tool for outpatient procedures, and the average Diagnosis Related Group (DRG) cost from Medicare claims for inpatient procedures. Learn more about the methodology.
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SEE ALSO
- Hospitals with the highest rate of vertebroplasty overuse
- Hospitals with the lowest rate of vertebroplasty overuse
- State-by-state back surgery overuse rates
- US News Honor Roll hospital back surgery overuse rates
About the Lown Institute
The Lown Institute is an independent think tank advocating bold ideas for a just and caring system for health. We envision a healthcare system focused on what’s best for people, like hospitals caring for those most in need, patients living without fear of financial distress, and health professionals finding joy in their roles. The Lown Hospitals Index, a signature project of the Institute, is the first ranking to assess the social responsibility of U.S. hospitals by applying measures never used before like racial inclusivity, avoidance of overuse, and pay equity.
Contact
Aaron Toleos, Lown Institute, (978) 821-4620, atoleos@lowninstitute.org