Journal article focusing on surgical complications

[Back-out]

Outcome-based research, "misused" to deny spinal surgery. A prediction.

http://www.researchchannel.org/prog/...=31081&fID=345
This might be of some interest.
Enjoy
Ed

Looks very interesting. As it is close to an hour, I haven't had time to watch it though I read all descriptive notes. I am struck by the fact that it appears to deal with spinal surgery, as a type.

One help in getting what I want will naturally be the government itself.

This reminds me to mention this important issue. I said elsewhere I was "tilting at windmills". Not really. Since spinal surgery - the more complex, the truer - is the most expensive single health problem facing the health-care industry, the govt. has a STRONG interest in addressing its efficacy for cost control. (Alzheimer's and long-term care cost more, but they don't involve a single treatment choice).

Why should they want to pay for surgery which is not only massively expensive, but which may lead to disability and further surgery down the line? Even if it leads to aggravated need only a significant percentage of the time, it will still be cause for govt. concern and probable intervention.

Except for people enabled by surgery to remain in the taxpaying workforce (the higher the bracket, the more worthwhile) - outcome research showing net increased cost, could, probably WILL - mean approving far fewer operations under Medicare, maybe even for younger adults covered by govt. programs. I wonder what the "Minimal H-care standards" list will eventually include re covered spinal treatments and what the criteria for qualification will be!

Outcome-based treatment research is a two-edged sword.

Even with Medi-gap coverage ("Advantage" plans appear on the point of being phased out), those who depend on Medicare and other plans, are likely to be faced with having coverage for a growing list of procedures DENIED! Depending on what such quantitative rsx reveals, patients risk having treatment/surgery denied if and when the total cost to the System proves to be "not worth it" - and not according to the pt's preference!

With spinal surgery this will necessarily mean examining the total cost, including over time. The cost of more surgery or pt disability, must be factored into the equation - not merely the initial high outlay. This research is bound to happen because of cost factors, not to please patients like me. Besides, it is largely a matter of data collection and organization (i.e., cheap) rather than actual clinical research.

If patients DO turn out to fare worse globally, bad things will happen to our choices! This is truest, of course, of older patients like me who may not be deemed to be worth "fixing" temporarily, especially, if it looks like we will need more surgery when we are even older and less able to withstand the rigors.

I argue the need for "meta-studies", to facilitate OUR most informed choices - not those of the actual payers, govt or not. Nevertheless, this research and the figures emerging from it, are certain to be used as rationales to remove choice from our hands, especially for seniors.

UGH. But after all, the value of complex spinal surgery is really THE classic issue of possibly "wasted" late-life care, in the utilitarian sense that appears to be the guiding principle of Obama's savings plan. To reiterate, I don't refer, of course, to children/adolescents nor to younger adults, but to older adults; moreover, as Pooka points out elsewhere, their medical outcomes are qualitatively better than those of older adults who have complex problems in correction and recovery.

[Back-out]

"Quality of Life", drugs and outcome based research on complex spinal surgery

Quality of life measures are well and good, but if the life at stake is not still paying into the system, it is bound to be discounted especially if the enhancement is temporary - worse, if it leads to more costs later on.

I care about experienced pain and disability. The govt cares about what that pain and disability costs. As I remarked elsewhere, it's a good thing that narcotic pain relief is still fairly taboo in Medicine (ye old Puritan Ethic), but I predict sorrowfully that this will become a hotly debated topic as time goes on. Just as lower class mental health patients are increasingly medicated - even forcibly - with powerful drugs to control symptoms (instead of costly talking therapy and residential programs), so I predict, there will be an "enlightenment" at the top about the wonders and worthwhileness of permanent narcotic pain relief for spinal problems.

Perhaps this will coincide with legalization of numerous presently controlled substances, thus leading to almost unimaginable savings in the federal /state budgets by eliminating the problem of prosecuting and housing drug offenders. At the same time, the government may be able to take over drug sales including a sales tax! "Follow the money" would predict this as a certainty, following the Scandinavian model , and necessitated by the Deficit. Popularization of this approach is also predicted by the coming of Age of Gen X-ers as they're confronted by the cost of Elder Care and a to-them outdated Ethos against illicit drugs, especially when the cost factor for them is fully grasped.

This also fits in with the so-called increased choice model about end of life treatments which are already in force de facto, whereby morphine is used to provide an accelerated "death with dignity". I've seen this first hand twice already and read abt its use much more, in connection with an elderly friend.

Here too, the issue for individuals is choice; for the System, the issue is cost. If "the price of liberty is eternal vigilance", perhaps I need to look ahead to the unintended consequences of what I advocate!

The need for more outcome based research is not just of interest to patients, but society/the govt., because of the cost factor. If indeed, this MOST expensive operation proves to have, on balance (economically) a negative value, it will be out the window, at least for older adults. When I asked whether given surgeons accept Medicare, all those participating underlined their affirmative reply, with a resounding: "FOR NOW!"

[Back-out]

the law of unintended consequences - increased information and choice. Whose?

The alliance between interested patients and govt seems unconflicted when it comes to data collection, but I fear it will split when the question of application/implementation arises. Rational? Sure. Good? I say no, at least, not morally - but then, I have a more than vested interest.

I may end up "sorry for what I wished for", as the saying goes, because I may well get it - with unintended consequences. Then, I won't be able to do individual cost:benefit analyses, and decide accordingly, as it will already have been done for me based on my demographic. My ability to impact my treatment outcomes favorably by my personal skills and ingenuity (such as they are) won't count for anything!

There's no way to avoid this risk except to try to insure you have good supplementary coverage as you age - nearly impossible, as even top employers switch increasingly to HDSPs (High Deductible Savings Plans) instead of employee health plans. I am afraid approval of scoliosis/complex spinal surgery on older and/or disabled patients, will increasingly be declined even when they are healthy enough for surgery and stand to gain years of increased quality of life. That's because the "QUALIs" (familiar with this term? BRRR) calculus will not favor the expense, taken as a treatment whole.

This study, at a guess, much favors spinal surgery. That's because I see that Washington U plays host, and a keynote speaker is Swedish. What's more, spinal surgery per se, is far cheaper than the subset of complex spinal surgery, especially with instrumentation as in scoliosis surgery. Recovery and complications I expect are qualitatively different too (better), for the larger set.

Let's see what happens later, with further studies. All our debates here will be moot when the cost factor - THE major social driver - replaces our personal calculi! However, we WILL get answers.

[LindaRacine]

Right. I've studied that research backward and forward, beginning from where you linked it in the Revisions sub-forum.

I referred to it several times in rxes to these two threads. It's an example of what I'd like to see much more of, along with meta studies linking many institutions.

from article intro:


This is conspicuous in its onliness (except AFAIK the CA study) highlighting the absence of similar ones.
And not only similar, but as I said, we need meta-studies giving a national overview BY DEMOGRAPHIC AND OTHER SCRIPTORS.

Would you feel comfortable with the cancer research you refer to if it contained treatments going back to the 60's?

If you want a cross section, do a PubMed search on "Spinal Deformity Study Group." There are 31 centers around the world contributing data.

[LindaRacine]

This study, at a guess, much favors spinal surgery. That's because I see that Washington U plays host,

Just an observation... there's a world of difference between the University of Washington (from Ed's link) to Washington University (think Larry Lenke and Keith Bridwell).

[Back-out]

Just an observation... there's a world of difference between the University of Washington (from Ed's link) to Washington University (think Larry Lenke and Keith Bridwell).

ARGH!

I briefly wondered abt that but after a session of re-pounding CTRL, forgot to check!

[Back-out]

Would you feel comfortable with the cancer research you refer to if it contained treatments going back to the 60's?

You know the answer. But somehow they come up with good prediction charts including reasonable probability of error figures.

Maybe because the numbers are greater.

However, they DO look at older mortality figures when (as all too often) it hasn't substantially changed as in certain cancers - eg., adv. lung cancers (depends cell type) and pancreatic cancer.

If you want a cross section, do a PubMed search on "Spinal Deformity Study Group." There are 31 centers around the world contributing data.

Thank you! Will do!!

[Pooka1]

http://www.researchchannel.org/prog/...=31081&fID=345
This might be of some interest.
Enjoy
Ed

Excellent post, Ti Ed. Very apt.

[Pooka1]

If patients DO turn out to fare worse globally, bad things will happen to our choices! This is truest, of course, of older patients like me who may not be deemed to be worth "fixing" temporarily, if it looks like we will need more surgery when we are even older and less able to withstand the rigors of revision surgery.

Non-scoliosis-related fusion may well go that way. Fusions for scoliosis in adults and children will never not be covered because they are the only game in town that has shown any efficacy whatsoever.

If they start limiting fusions for scoliosis patients in certain categories (progressive, painful, etc.) you are going to break the bank with torts for malpractice, wrongful death, etc.. Fusion is the only game in town and it is unconscionable to deny people the only hope out there.

[Back-out]

Non-scoliosis-related fusion may well go that way. Fusions for scoliosis in adults and children will never not be covered because they are the only game in town that has shown any efficacy whatsoever.

If they start limiting fusions for scoliosis patients in certain categories (progressive, painful, etc.) you are going to break the bank with torts for malpractice, wrongful death, etc.. Fusion is the only game in town and it is unconscionable to deny people the only hope out there.

The age bit, the age bit, Sharon...It's only for seniors (except for Congresspersons and families, etc.) See? "No one" gets hurt

[hdugger]

Old people are a reliable (and vocal) voting block. They're in no risk of having their access to medical procedures reduced.

Poor and young are the people who have reduced access. For scoliosis, the young have Shriners as a safety net. That leaves the poor and uninsured.

[leahdragonfly]

[QUOTE=Back-out;101302]. Since spinal surgery - the more complex, the truer - is the most expensive single health problem facing the health-care industry, the govt. has a STRONG interest in addressing its efficacy for cost control.

Hi Back-out,

Do you have a reference for this statement? I work in interventional cardiology, and with heart disease the number one killer of Americans, I would argue that cardiac care adds up to a much greater expense each year than spine surgery. And don't forget diabetes...and smoking-related illnesses, etc.

I bet spine surgery for scoliosis is a drop in the bucket compared to some of these.

Just something to keep in mind.

[hdugger]

I *think* she means the most expensive single event. So, not the biggest slice of medical expenditures (it couldn't be - too few people), but the most expensive single procedure.

I don't know if that's true, btw, but I think that's what she meant.

[LindaRacine]

This thread has gone off track, but the healthcare cost issue is definitely interesting. At UCSF, we routinely do deformity surgeries that probably cost in the neighborhood of $300,000-$500,000, on 70 and 80 year olds. Without these surgeries, these people would probably have no quality of life. But, the cost per quality adjusted life-year is huge. With the aging of the population, the government is looking very hard at expensive treatments.

[Back-out]

This thread has gone off track, but the healthcare cost issue is definitely interesting. At UCSF, we routinely do deformity surgeries that probably cost in the neighborhood of $300,000-$500,000, on 70 and 80 year olds. Without these surgeries, these people would probably have no quality of life. But, the cost per quality adjusted life-year is huge. With the aging of the population, the government is looking very hard at expensive treatments.

egzackly.

And I misspelled the key term.

A "Qaly" IS a "quality adjusted life-year " as Linda wrote it out. Even though Daschle didn't win approval, the term he introduced to the conversation is IN. Scoli surgery for seniors is unlikely to fly for much longer - not through govt-sponsored plans, anyhow.

It will be terrible also for younger pts like me too, if outcomes research shows that revisions are a built in expectation, especially for elders. If the govt Healthcare Commission (to be established) approves an initial surgery for "young seniors" (~ early to mid sixties), they may be seen as obligating themselves for a later revision; thus endangering approval for ALL. It's also worrying what may happen to ANYONE subject to a government plan, when seeking primary OR revision surgery.

Maybe others too, depending on what is included in the yet-to-be-drafted minimum procedure/treatment coverage list, to be required of all insurance plans. Again, it may be a multiple procedures cost calculation with a probability coefficient attached to the second one. Let's suppose ( I suspect it's so) that scoli ops for anyone surviving long enough, are basically temporizing, especially for elders with multiple complicating conditions. That would mean approving an op known to cost at present 1/3 to 1/2 million per Linda's report which corresponds to figures I've been given. Doubling that would make a person's life cost close to a cool million, and if that person is already older...

These are the "unintended consequences" of which I speak. But this was really built into Obama's plan. Rationing is a given, long in force (think organ transplants),

Per same model, Avastin for macular degeneration (thanks to which my mom is still able to illustrate books and putter around alone), is proven efficacious. However until a four year hue and cry reversed the Brit ruling - modeled after the same QALY concept - Avastin was only approved after one eye had already gone blind!

This medicine "only" costs a few hundred a month. Luckily (for those unlucky enough to already have it), macular degeneration is relatively common. Just how common are major spinal deformities and what is the per/patient cost for surgery - including recovery? What is the mortality rate of pt. and/or correction? We don't have much of a lobby, based on sheer numbers and "other people's pain" is always easier to bear. Get ready to picket - walkers and all!