title: How do coverage policies influence practice patterns, safety, and cost of initial lumbar fusion surgery? A population-based comparison of workers' compensation systems.
abstract: BACKGROUND
  In response to increasing use of lumbar fusion for improving back pain, despite unclear efficacy, particularly among injured workers, some insurers have developed limited coverage policies. Washington State's workers' compensation (WC) program requires imaging confirmation of instability and limits initial fusions to a single level. In contrast, California requires coverage if a second opinion supports surgery, allows initial multilevel fusion, and provides additional reimbursement for surgical implants. There are no studies that compare population-level effects of these policy differences on utilization, costs, and safety of lumbar fusion.
  
  
  OBJECTIVE
  The purpose of this study was to compare population-level data on the use of complex fusion techniques, adverse outcomes within 3 months, and costs for two states with contrasting coverage policies.
  
  
  METHODS
  The study design was an analysis of WC patients in California and Washington using the Agency for Healthcare Research and Quality's State Inpatient Databases, 2008-2009.
  
  
  METHODS
  All patients undergoing an inpatient lumbar fusion for degenerative disease (n=4,628) were included the patient sample.
  
  
  METHODS
  Outcome measures included repeat lumbar spine surgery, all-cause readmission, life-threatening complications, wound problems, device complications, and costs.
  
  
  METHODS
  Log-binomial regressions compared 3-month complications and costs between states, adjusting for patient characteristics.
  
  
  RESULTS
  Overall rate of lumbar fusion operations through WC programs was 47% higher in California than in Washington. California WC patients were more likely than those in Washington to undergo fusion for controversial indications, such as nonspecific back pain (28% versus 21%) and disc herniation (37% versus 21%), as opposed to spinal stenosis (6% versus 15%), and spondylolisthesis (25% versus 41%). A higher percentage of patients in California received circumferential procedures (26% versus 5%), fusion of three or more levels (10% versus 5%), and bone morphogenetic protein (50% versus 31%). California had higher adjusted risk for reoperation (relative risk [RR] 2.28; 95% confidence interval [CI], 2.27-2.29), wound problems (RR 2.64; 95% CI, 2.62-2.65), device complications (RR 2.49; 95% CI, 2.38-2.61), and life-threatening complications (RR 1.31; 95% CI, 1.31-1.31). Hospital costs for the index procedure were greater in California ($49,430) than in Washington ($40,114).
  
  
  CONCLUSIONS
  Broader lumbar fusion coverage policy was associated with greater use of lumbar fusion, use of more invasive operations, more reoperations, higher rates of complications, and greater inpatient costs.
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, and the Department of Orthopaedic Surgery, Geisel School of Medicine at Dartmouth College, One Medical Center Dr., HB 7541, Lebanon, NH 03756, USA. Electronic address: Brook.I.Martin@Dartmouth.edu.
authors.forename: Brook I
authors.initials: BI
authors.lastname: Martin
authors.affiliation: Washington State Department of Labor & Industries, P.O. Box 44000, Olympia, WA 98504, USA.
authors.forename: Gary M
authors.initials: GM
authors.lastname: Franklin
authors.affiliation: Department of Family Medicine, Department of Medicine, Department of Public Health & Preventive Medicine, Oregon Health & Science University, Mail Code FM, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Deyo
authors.affiliation: Division of Health Services Management and Policy, College of Public Health, Ohio State University, 1841 Neil Ave., Columbus, OH 43210, USA.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Wickizer
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, and the Department of Orthopaedic Surgery, Geisel School of Medicine at Dartmouth College, One Medical Center Dr., HB 7541, Lebanon, NH 03756, USA.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Lurie
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, and the Department of Orthopaedic Surgery, Geisel School of Medicine at Dartmouth College, One Medical Center Dr., HB 7541, Lebanon, NH 03756, USA.
authors.forename: Sohail K
authors.initials: SK
authors.lastname: Mirza
mesh_terms: D000328:Adult; D000368:Aged; D002140:California; D005260:Female; D017721:Hospital Costs; D006801:Humans; D019458:Insurance Coverage / Q000191:economics*; D055959:Intervertebral Disc Degeneration / Q000601:surgery; D007405:Intervertebral Disc Displacement / Q000601:surgery; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000191:economics; D010359:Patient Readmission / Q000191:economics; D010818:Practice Patterns, Physicians'; D012086:Reoperation / Q000191:economics; D013123:Spinal Fusion / Q000009:adverse effects / Q000191:economics* / Q000379:methods*; D013130:Spinal Stenosis / Q000601:surgery; D013168:Spondylolisthesis / Q000601:surgery; D014861:Washington; D014942:Workers' Compensation / Q000191:economics*; D055815:Young Adult
keywords: Coverage and reimbursement; Degenerative disease; Lumbar spine fusion; Readmission; Safety and quality; Workers' compensation