title: Who’s in the driver's seat? The influence of patient and physician enthusiasm on regional variation in degenerative lumbar spinal surgery: a population-based study.
abstract: METHODS
  Cross-sectional population-based study using administrative databases, census data, and surveys of orthopedic/neurosurgeons, family physicians (FPs) and patients in Ontario, Canada.
  
  
  OBJECTIVE
  To determine the influence of the enthusiasm of patients, FPs, and surgeons for surgery on the regional variation in surgical rates for degenerative diseases of the lumbar spine (DDLS), such as spinal stenosis and degenerative spondylolisthesis.
  
  
  BACKGROUND
  Rates of surgery and healthcare costs for treating DDLS have been increasing. Regional variation in spinal surgical rates has been observed and it is thought that the enthusiasm of patients and physicians for surgery contributes to this variation.
  
  
  METHODS
  Using population-based administrative databases, we included all patients aged 50 years and older who underwent DDLS surgery (i.e., decompression/laminectomy, fusion) from 2002 to 2006 and calculated standardized utilization rates across counties. We measured regional "enthusiasm for surgery" for surgeons, FPs, and patients, using responses from a province-wide survey. Small-area variation analysis and multivariate Poisson regression models were performed calculating incidence rate ratios (IRRs) controlling for county demographics, socioeconomic measures, prevalence of disease, and community resources.
  
  
  RESULTS
  We identified 10,318 DDLS surgeries (mean age 65 years, 50.6% female). Significant regional variation was observed (extremal quotient 5.0, coefficient of variation 28.0). Counties with higher rates of surgery had higher surgeon enthusiasm for surgery (IRR: 1.26, P < 0.013), older (IRR: 2.17, P < 0.0001) male patients (IRR: 1.19, P < 0.0001), lower income (IRR: 0.89, P < 0.0015), more knowledge of official languages (IRR: 1.12, P < 0.0003), and the presence of magnetic resonance imaging scanners (IRR: 1.30, P < 0.004). FP and patient enthusiasm for surgery, physician supply, and prevalence of disease were not statistically associated with higher surgical rates.
  
  
  CONCLUSIONS
  Prior studies have not addressed the role of patient enthusiasm for surgery. Although patients and FPs had variable enthusiasm for surgery, surgeon enthusiasm was the dominant potentially modifiable factor influencing surgical rates. Prevalence of disease and community resources were not related to surgical rates. Strategies targeting surgeon practices may reduce regional variation in care and improve access disparities.
authors.affiliation: Department of Orthopaedic Surgery, University of California at Irvine, Orange, CA, USA. sbederma@uci.edu
authors.forename: S Samuel
authors.initials: SS
authors.lastname: Bederman
authors.forename: Peter C
authors.initials: PC
authors.lastname: Coyte
authors.forename: Hans J
authors.initials: HJ
authors.lastname: Kreder
authors.forename: Nizar N
authors.initials: NN
authors.lastname: Mahomed
authors.forename: Warren J
authors.initials: WJ
authors.lastname: McIsaac
authors.forename: James G
authors.initials: JG
authors.lastname: Wright
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D016208:Databases, Factual / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007796:Laminectomy / Q000706:statistics & numerical data; D016015:Logistic Models; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D019637:Orthopedic Procedures / Q000706:statistics & numerical data; D010361:Patients / Q000523:psychology / Q000706:statistics & numerical data*; D010821:Physicians, Family / Q000523:psychology / Q000706:statistics & numerical data*; D015995:Prevalence; D013122:Spinal Diseases / Q000453:epidemiology / Q000601:surgery*; D013123:Spinal Fusion / Q000706:statistics & numerical data; D013130:Spinal Stenosis / Q000601:surgery; D013168:Spondylolisthesis / Q000601:surgery