Schoenfeld Andrew J, Makanji Heeren, Jiang Wei, Koehlmoos Tracey, Bono Christopher M, Haider Adil H
Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Clin Orthop Relat Res. 2017 Dec;475(12):2838-2844. doi: 10.1007/s11999-017-5229-5.
Whether compensation for professional services drives the use of those services is an important question that has not been answered in a robust manner. Specifically, there is a growing concern that spine care practitioners may preferentially choose more costly or invasive procedures in a fee-for-service system, irrespective of the underlying lumbar disorder being treated.
QUESTIONS/PURPOSES: (1) Were proportions of interbody fusions higher in the fee-for-service setting as opposed to the salaried Department of Defense setting? (2) Were the odds of interbody fusion increased in a fee-for-service setting after controlling for indications for surgery?
Patients surgically treated for lumbar disc herniation, spinal stenosis, and spondylolisthesis (2006-2014) were identified. Patients were divided into two groups based on whether the surgery was performed in the fee-for-service setting (beneficiaries receive care at a civilian facility with expenses covered by TRICARE insurance) or at a Department of Defense facility (direct care). There were 28,344 patients in the entire study, 21,290 treated in fee-for-service and 7054 treated in Department of Defense facilities. Differences in the rates of fusion-based procedures, discectomy, and decompression between both healthcare settings were assessed using multinomial logistic regression to adjust for differences in case-mix and surgical indication.
TRICARE beneficiaries treated for lumbar spinal disorders in the fee-for-service setting had higher odds of receiving interbody fusions (fee-for-service: 7267 of 21,290 [34%], direct care: 1539 of 7054 [22%], odds ratio [OR]: 1.25 [95% confidence interval 1.20-1.30], p < 0.001). Purchased care patients were more likely to receive interbody fusions for a diagnosis of disc herniation (adjusted OR 2.61 [2.36-2.89], p < 0.001) and for spinal stenosis (adjusted OR 1.39 [1.15-1.69], p < 0.001); however, there was no difference for patients with spondylolisthesis (adjusted OR 0.99 [0.84-1.16], p = 0.86).
The preferential use of interbody fusion procedures was higher in the fee-for-service setting irrespective of the underlying diagnosis. These results speak to the existence of provider inducement within the field of spine surgery. This reality portends poor performance for surgical practices and hospitals in Accountable Care Organizations and bundled payment programs in which provider inducement is allowed to persist.
Level III, economic and decision analysis.
专业服务的报酬是否会推动这些服务的使用，这是一个重要问题，但尚未得到有力解答。具体而言，人们越来越担心，在按服务收费的体系中，脊柱护理从业者可能会优先选择成本更高或侵入性更强的手术，而不管所治疗的潜在腰椎疾病是什么。
问题/目的：（1）与国防部薪资制环境相比，按服务收费环境下椎间融合术的比例是否更高？（2）在控制手术指征后，按服务收费环境下椎间融合术的几率是否增加？
确定2006年至2014年接受腰椎间盘突出症、椎管狭窄症和椎体滑脱手术治疗的患者。根据手术是在按服务收费环境下（受益人在民用机构接受治疗，费用由TRICARE保险支付）还是在国防部设施（直接护理）进行，将患者分为两组。整个研究共有28344名患者，21290名在按服务收费环境下接受治疗，7054名在国防部设施接受治疗。使用多项逻辑回归评估两种医疗环境下基于融合的手术、椎间盘切除术和减压术的发生率差异，以调整病例组合和手术指征的差异。
在按服务收费环境下接受腰椎疾病治疗的TRICARE受益人接受椎间融合术的几率更高（按服务收费：21290例中的7267例[34%]，直接护理：7054例中的1539例[22%]，优势比[OR]：1.25[95%置信区间1.2020 - 1.30]，p < 0.001）。购买护理的患者因椎间盘突出症诊断接受椎间融合术的可能性更大（调整后的OR为2.61[2.36 - 2.89]，p < 0.001），因椎管狭窄症接受椎间融合术的可能性也更大（调整后的OR为1.39[1.15 - 1.69]，p < 0.001）；然而，椎体滑脱患者之间没有差异（调整后的OR为0.99[0.84 - 1.16]，p = 0.86）。
无论潜在诊断如何，按服务收费环境下椎间融合手术的优先使用率更高。这些结果表明脊柱外科领域存在医疗服务提供者诱导行为。这一现实预示着在允许医疗服务提供者诱导行为持续存在的 accountable care organizations和捆绑支付计划中，外科手术机构和医院的表现不佳。
三级，经济和决策分析。
