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Thread: Cost/Benefit of Non-Operative Treatment in Adults

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    Cost/Benefit of Non-Operative Treatment in Adults

    Spine (Phila Pa 1976). 2010 Jan 28. [Epub ahead of print]
    The Costs and Benefits of Nonoperative Management for Adult Scoliosis.

    Glassman SD, Carreon LY, Shaffrey CI, Polly DW, Ondra SL, Berven SH, Bridwell KH.

    From the *Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, KY; daggerLeatherman Spine Center, Louisville, KY; double daggerDepartment of Neurological Surgery, University of Virginia, Charlottesville, VA; section signDepartment of Orthopaedics, University of Minnesota, Minneapolis, MN; paragraph signDepartment of Neurosurgery, Northwestern University, Chicago, IL; parallelDepartment of Orthopaedic Surgery, University of California, San Francisco, CA; and **Department of Orthopedic Surgery, WA University School of Medicine, St. Louis, MO.

    STUDY DESIGN.: A prospective cohort of adult scoliosis patients treated nonoperatively had a minimum of 2-year follow-up during which time data were collected on the type and quantity of nonoperative treatment used. OBJECTIVE.: To quantify the use, cost, and effectiveness of nonoperative treatment for adult scoliosis. SUMMARY OF BACKGROUND DATA.: A 2007 systematic review of nonsurgical treatment in adult scoliosis revealed minimal data, and concluded that evidence for nonoperative care was lacking. METHODS.: Duration of use and frequency of visits were collected for 8 specific treatment methods: medication, physical therapy, exercise, injections/blocks, chiropractic care, pain management, bracing, and bed rest. Costs for each intervention were determined using the Medicare Fee schedule. Outcome measures were the SRS-22, SF-12, and ODI. Analysis was performed for the entire group, and for subsets of high (ODI, >40), mid (ODI = 21-40) and low (ODI, </=20) symptom patients. RESULTS.: A total of 123 patients (111 females, 12 males) with a mean age of 53.3 (18-79) years were evaluated. In 55 scoliosis patients who received no treatment, the only significant change in HRQOL measures over the 2-year period was in SRS satisfaction subscore (0.3 points, P = 0.014). Among the 68 adult scoliosis patients who used nonoperative resources, there was no significant change in any of the HRQOL outcome parameters. Mean treatment cost over the 2-year period was $10,815. Mean cost over the 2-year period averaged $9704 in the low symptom patients, $11,116 in the mid symptom, and $14,022 in the high symptom patients. CONCLUSION.: This study questions the value of nonoperative treatment commonly used for adult scoliosis patients. Documented costs are substantial and noimprovement inhealth status was observed. An important caveat is that treatment was not randomized and therefore the treatment group might have deteriorated if not for the treatment they received.

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    I wish they included chanting and prayer...
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

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    "We are all African."

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    I'm not sure how to evaluate this data without a control group of similarly-aged patients who have had surgical treatment. Also, are these people who have *never* had any scoliosis surgery? Or does it include people who are being recommended revision surgery?

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    This study was designed to weigh the benefits of non operative methods against the costs of non operative methods.

    A study design in 2007 that does not define what type of physical therapy, what type of exercise, what type of bracing, or what type of chiropractic care .. leaves me with a lot of questions.

    Can we presume that the treatment referrals were from surgical practices? In which case I would expect the referral treatments to be ultra conservative methods which we already know are not highly successful. With a mean age of 54 - all mature spines and no adolescents, the results are not telling us anything we don't already know about ultra conservative non operative methods. About the most this small piece of the larger study tells me - is that the cost of everything is going up. I wonder how much money was spent on a study to document that?

    The only value of this study, that I see - is that this should be telling the medical community to spend some research dollars to investigate new (previously unexplored through research study) non operative methods.

    I would be most interested a future similar study which would include Physical Therapy specific to scoliosis, Exercise specific to scoliosis, Schroth, Spincor (and other European bracing methods) SEAS, and Clear ... I'm guesstimating that will be about 50 years down the road unless someone with the money of Bill Gates gets a wild hair.


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    Yes, exactly. There is no way to evaluate any of these treatments unless you're talking about a specific protocol. What, exactly, does "medicine" mean, for example? What exercises are included with physical therapy? The only protocol that's clear is "bed rest"

    Also, the numbers are tiny. They're splitting 68 patients across 8 different kinds of treatment. That's about 8 people in each overall method. And, given the lack of any clear protocol, it likely means one person for each specific protocol.

    I said this about the other study comparing "non surgical treatments," but this simply is not how good science is done. It's the kind of science one does when one has some kind of ax to grind - the same thing I'd call out Weiss for in his review of surgical treatments.

    If you want to know if alternate treatments work, pick the most promising one and compare it to surgery. But these kinds of studies really get us nowhere.

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    It's not up to a bunch of surgeons to evaluate the cost effectiveness of any single alternative method. The science of this study is not flawed. It's very simple. The people who tried the alternative method of their own choice are evaluating it as having no impact on the quality of life.

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    Quote Originally Posted by LindaRacine View Post
    It's not up to a bunch of surgeons to evaluate the cost effectiveness of any single alternative method. The science of this study is not flawed. It's very simple. The people who tried the alternative method of their own choice are evaluating it as having no impact on the quality of life.
    This is a penetrating glimpse into the obvious. If there was an effective non-operative alternative treatment we would know about it by now. These authors are putting a number on the obvious.

    The world is still waiting.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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    Amen!!

    The world is still waiting....

    And I for one, HOPE,people don't quit trying!!

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    Quote Originally Posted by LindaRacine View Post
    It's not up to a bunch of surgeons to evaluate the cost effectiveness of any single alternative method. The science of this study is not flawed. It's very simple. The people who tried the alternative method of their own choice are evaluating it as having no impact on the quality of life.
    They don't have to design a valid study if they're interested in keeping informal notes. But, if they're actually interested in doing science and finding out something, then they do have to design a valid study.

    Maybe it would be more obvious if it was the CLEAR people doing the study. So, they keep notes on everyone who didn't take their treatment and, at the end of 2 years, they publish the results. They have a category they call "Physician treated" which includes eight medically-treated patients (who may have had bracing, or been given prescriptions, or had surgery), then another category for all the different physical therapy treatments, then one for bed rest, then (hearing Pooka's request) one for chanting and praying. In all, they have 68 patients, of which maybe two got surgery. I'm guessing they'd have overall results much like the one these doctors posted (except, with a few surgeries thrown in, the costs would be much, much higher). At the end of two years, all of the different valid and invalid methods would average out into "no change."

    That gives you a nice study to point to when someone comes in and tells you they're going to try something different - "Oh, no need to do that. We did a study and the rest of the methods don't do anything and cost a bunch." Sale made.

    OTOH, if you're honestly looking to see what non-surgical treatment might make a difference in scoliosis patients lives because, even though you're a surgeon, you understand that not everyone wants or needs to take that risk - then you design a study where you include things that you've heard are effective. If it's just pain management you're after, there are functional restoration programs that help a good deal with pain. Schroth has also shown some promise. Maybe some bracing. And you clearly describe the protocols for all of the other treatments. *That's* a scientific study - i.e., one in which you go in with a genuine sense of inquiry to learn something. You *don't* include obvious non-treatments like "bed rest" and try to pretend that that's a valid form of treatment which differs significantly from no treatment at all. I'll eat my hat (which I am currently wearing) if *any* of these doctors honestly thought that the bed rest patients were going to improve. To throw that in to their "everything but the kitchen sink" protocol just reaks of a kind a cynicism and hackery.
    Last edited by hdugger; 02-07-2010 at 07:45 PM.

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    I have to agree with this. And the fact that it appears that a blind eye (in terms of serious research funding) is being turned towards methods showing much promise - does a huge dis-service to us all.

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    Quote Originally Posted by hdugger View Post
    They don't have to design a valid study if they're interested in keeping informal notes. But, if they're actually interested in doing science and finding out something, then they do have to design a valid study.

    Maybe it would be more obvious if it was the CLEAR people doing the study. So, they keep notes on everyone who didn't take their treatment and, at the end of 2 years, they publish the results. They have a category they call "Physician treated" which includes eight medically-treated patients (who may have had bracing, or been given prescriptions, or had surgery), then another category for all the different physical therapy treatments, then one for bed rest, then (hearing Pooka's request) one for chanting and praying. In all, they have 68 patients, of which maybe two got surgery. I'm guessing they'd have overall results much like the one these doctors posted (except, with a few surgeries thrown in, the costs would be much, much higher). At the end of two years, all of the different valid and invalid methods would average out into "no change."

    That gives you a nice study to point to when someone comes in and tells you they're going to try something different - "Oh, no need to do that. We did a study and the rest of the methods don't do anything and cost a bunch." Sale made.

    OTOH, if you're honestly looking to see what non-surgical treatment might make a difference in scoliosis patients lives because, even though you're a surgeon, you understand that not everyone wants or needs to take that risk - then you design a study where you include things that you've heard are effective. If it's just pain management you're after, there are functional restoration programs that help a good deal with pain. Schroth has also shown some promise. Maybe some bracing. And you clearly describe the protocols for all of the other treatments. *That's* a scientific study - i.e., one in which you go in with a genuine sense of inquiry to learn something. You *don't* include obvious non-treatments like "bed rest" and try to pretend that that's a valid form of treatment which differs significantly from no treatment at all. I'll eat my hat (which I am currently wearing) if *any* of these doctors honestly thought that the bed rest patients were going to improve. To throw that in to their "everything but the kitchen sink" protocol just reaks of a kind a cynicism and hackery.
    Surgeons have published hundreds of studies on what works in terms of surgery. And, they've published dozens of long-term follow up studies on surgical methods. There's a real benefit to knowing which methods provide the best results. On the other hand, there is zero benefit to them from finding what specific, if any, alternative treatments work. If CLEAR or Schroth wants to prove that their specific treatment works, the onus is on them.

    If you want to blame someone for coming up with the result of the referenced study, blame the patients whose answers showed no improvement in quality of life.

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    Quote Originally Posted by LindaRacine View Post
    On the other hand, there is zero benefit to them from finding what specific, if any, alternative treatments work.
    That's a very troubling statement. Is that just your own sense? Or do you feel that represents the outlook of the surgeons you work with. Children and adults with scoliosis are routinely told that they need to have their cases managed by orthopedic surgeons. If your contention is that orthopedic surgeons are deliberately turning a blind eye to any alternate treatments because there's no cost benefit to them . . . that's just a very, very shocking statement.

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    Quote Originally Posted by hdugger View Post
    That's a very troubling statement. Is that just your own sense? Or do you feel that represents the outlook of the surgeons you work with. Children and adults with scoliosis are routinely told that they need to have their cases managed by orthopedic surgeons. If your contention is that orthopedic surgeons are deliberately turning a blind eye to any alternate treatments because there's no cost benefit to them . . . that's just a very, very shocking statement.
    Interesting jump from no benefit in a surgeon studying CLEAR or Schroth methods to keeping alternative treatments to themselves because there's no benefit. If an alternative treatment is ever proved to be beneficial, I'm sure that most surgeons will tell their patients about it.

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    Quote Originally Posted by LindaRacine View Post
    Surgeons have published hundreds of studies on what works in terms of surgery. And, they've published dozens of long-term follow up studies on surgical methods. There's a real benefit to knowing which methods provide the best results. On the other hand, there is zero benefit to them from finding what specific, if any, alternative treatments work. If CLEAR or Schroth wants to prove that their specific treatment works, the onus is on them.

    If you want to blame someone for coming up with the result of the referenced study, blame the patients whose answers showed no improvement in quality of life.
    Regarding the study in question - I blame a flawed design from the start - using ultra conservative methods, on an adult population, that we already know are of little value. What the heck was the point on spending money on such a study - which tells us nothing whatsoever, that wasn't already known? Complete and utter waste of research dollars.

    I'm not so concerned with what benefits our surgeons. I am very concerned with what benefits patients and future generataions. Both surgical and non surgical.

    The research should be fair and equitable - and the scales not financially tipped in favor of one over the other. And certainly not blinded by the past to the ignorance of present and future realities.

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    Quote Originally Posted by hdugger View Post
    [...] hackery.
    Excellent.

    Quote Originally Posted by hdugger View Post
    If your contention is that orthopedic surgeons are deliberately turning a blind eye to any alternate treatments because there's no cost benefit to them . . . that's just a very, very shocking statement.
    They are turning a blind eye to treatments that don't have a lick of evidence that they are efficacious. After decades and decades in some cases.

    There is no benefit to them and especially to their patients if they recommend ineffective treatments. They are prfessionals with reputations but beyond that, they want to help people. That's largely why they go into medicine.

    Surgeons are the good guys. If an effective alternative treatment appeared, it would go in the science column and then surgeons would recommend it. If there was even a faint glimmer of hope like with bracing, they would eventually consider it.
    Sharon, mother of identical twin girls with scoliosis

    No island of sanity.

    Question: What do you call alternative medicine that works?
    Answer: Medicine


    "We are all African."

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