President's Column: Be Specific

By Daniel Resnick posted 01-09-2018 10:39 AM

Many challenges face those of us involved in spine care. We are constantly having to justify our activities and prove our worth to patients, payers and policy makers.
At the national level, NASS is intimately involved in the development, interpretation and dissemination of the highest quality evidence available to support or, in some
cases, refute any one of hundreds of practices and procedures performed in the name of spine care. Having had the privilege to serve on numerous NASS committees charged with these tasks over the last 20 years, I have experienced many frustrations when interacting with important stakeholders who simply don’t understand what exactly we do or why we do it.

To some extent, this is unavoidable and a critical justification for the existence of NASS. It is probably not reasonable to expect a career government appointee or an insurance executive to have an in-depth appreciation for the differences in treatment algorithms between degenerative and isthmic spondylolisthesis, to understand the differences between directed and non-directed physical therapy, or to differentiate between interlaminar and transforaminal injections for diagnosis or treatment of radiculopathy. In these situations, it is incumbent upon us to educate through clinical practice guidelines, appropriate use criteria and payer policy recommendations. These documents are produced by NASS' Research Council and used by the Health Policy and Advocacy Councils to disseminate reasonable, balanced and easily understood recommendations.

More worrisome are situations where a stakeholder has done apparent due diligence and invested heavily in independent assessment of the literature regarding a particular procedure without including appropriate clinical expertise.

In the early 2000s, a group of academic centers contracted with the Agency for Healthcare Research and Quality (AHRQ), state insurance boards, or directly with insurance companies to produce evidence reviews of specific topics. These centers, in general, employed recognized experts— in library science, epidemiology and statistics—who would perform a literature search, grade the references with regard to methodological quality, and produce initial evidentiary tables. Question selection was directed by policy makers and specialty clinician input was provided by clinicians selected by the center who may or may not have had any specific training in evidence-based medicine or experience in policy-making.

These centers produced recommendations that were methodologically rigorous, logically impenetrable and, on occasion, completely antithetical to clinical experience. An example would be the cervical fusion guidelines developed for the Washington State Health Care Authority by a group called Institute for Clinical and Economic Review (ICER). This group, funded by the AHRQ and multiple insurance and pharmaceutical companies, was charged with developing policies regarding the use of cervical fusion for degenerative disc disease. The writing panel consisted of five individuals, one of whom was a nonpracticing primary care physician. Three masters level epidemiologists and a PharmD rounded out the group. What they found was that for the treatment of cervicalgia, spinal fusion was not cost-effective compared to physical therapy, injection or discectomy without fusion but was better than lamino-foraminotomy.

Based on the results of this analysis, Washington State recommended against paying for cervical fusions. What ICER failed to consider is that cervicalgia in the absence of deformity is not an indication for which cervical fusion is recommended by NASS or any other medical society. The authors completely disregarded data showing that the vast majority of these procedures are performed for radiculopathy, myelopathy or deformity correction. They did not include results regarding resolution of radiculopathy or improvement of function in myelopathy in their analysis. Their report, despite being methodologically sound and logically rigorous, was irrelevant. It took a substantial amount of sweat equity by NASS volunteers in conjunction with our neurosurgical allies to reverse the authority’s decision, but the decision was reversed.

*This is an excerpt from the November/December 2017 issue of SpineLine. To read the full column and more, click here.