Jefferson University Hospitals

A study suggests that spending more money to treat back and neck pain hasn’t equated to better results—but the analysis is fundamentally flawed, say two Jefferson surgeons

In June, the Journal of the American Medical Association published the results of a study suggesting that spending more money on back and neck pain from 1997 to 2005 did not actually produce more or better relief for patients.

According to the article, 26 percent of U.S. adults in 2002 reported lower back pain, and 14 percent reported neck pain during the previous three months. What’s more, low back pain accounted for about 2 percent of all visits to a physician’s office – exceeded only by routine exams, hypertension and diabetes.

The study’s authors note that rates of imaging, injections, use of opiates and surgeries related to spine pain have increased. And they set out to answer the question: Have these expenditures resulted in proportional improvements for patients?

The study’s findings
The investigators used data from the Medical Expenditure Panel Survey, which sampled individuals around the nation ages 17 and older from 1997 to 2005.

In 1997, 23,045 individuals, including 3,139 who reported spine problems, were sampled. At that time, medical costs for those with spine problems averaged $4,695 versus $2,371 for those without spine problems. In 2005, the survey included 22,258 respondents. Of those, 3,187 had self-reported spine problems. That year, medical expenditures for those individuals averaged $6,096 compared to $3,516 for those without spine problems. 

In the JAMA report, the authors called the increase significant, and noted that the cost difference came from outpatient and inpatient services, with a smaller proportion accounted for by prescription medicines. (However, the percentage of expenditures on prescription medications went up more rapidly than for other services.)

In the paper, the study’s authors ultimately asserted that spine-related expenditures have increased without evidence of improvement among patients – suggesting perhaps that physicians are treating individuals who are not likely to benefit.

Responding to the results
When the article was published, it hit a nerve for Alan Hilibrand, MD, a spine surgeon with the Rothman Institute at Jefferson, and John Ratliff, MD, FACS, associate professor of neurological surgery and orthopedic surgery at Jefferson Medical College of Thomas Jefferson University. Together with Alexander Vaccaro, MD, PhD, Dr. Hilibrand and Dr. Ratliff submitted a letter to the editor, which was published in JAMA.

In the letter, they disputed the statistical validity of the expenditure increase from 1997 to 2005.

“Patients reporting spine problems spent 72 percent more than those not reporting spine problems in 1997 and 73 percent more in 2005,” Dr. Hilibrand explains. “Essentially, there is no difference between the two.”

Another issue that Hilibrand, Ratliff and Vaccaro raised: the inclusion of many more patients with spinal cord injuries in the 2005 sampling.

“Those patients are very complex and are likely to be the outliers that the authors mentioned in their JAMA paper,” Dr. Ratliff says. “Treating spinal cord injuries is, indeed, very expensive.”

What’s more, Dr. Hilibrand and Dr. Ratliff say they believe the lack of change in self-reported spinal problems is indicative not of treatment failure, but rather a lack of prevention.

The bottom line for patients
What do patients need to understand about this study and its findings?

“The study in JAMA oversimplified a very complicated issue,” Dr. Hilibrand notes, adding that the study should not deter people from seeking treatment for back and neck pain.

Despite the study’s flaws, Dr. Ratliff says it points to some of the core questions and challenges facing modern health care.

“Physicians today are trying to make patients comfortable,” he notes. “We’re trying to help them remain functional members of societies. We’re no longer a society that says, ‘We have nothing to offer you.’”

But, as Dr. Hilibrand notes, new technologies and therapies do come with often hefty price tags.

“We’ve seen more technology in the world of spine surgery than other fields because this is perceived to be an unsolved problem,” Dr. Hilibrand says. “While it’s true that some of the new technologies may not be worth their salt, we have to ask ourselves if we’re willing to make the investment in new technologies that can benefit patients.

“In other words, as a society, are willing to spend more to improve care?”

That’s a fundamental question that isn’t easy to address – and certainly can’t be answered by this study’s simplistic analysis, Dr. Hilibrand and Dr. Ratliff say.