Trends in Health Care Expenditures, Utilization, and Health Status Among US Adults With Spine Problems, 1997-2006

Brook I. Martin, MPH; Judith A. Turner, PhD; Sohail K. Mirza, MD, MPH; Michael J. Lee, MD; Bryan A. Comstock, MS; Richard A. Deyo, MD, MPH


Spine. 2009;34(19):2077-2084. 

In This Article

Abstract and Introduction


Study Design: Analysis of nationally representative survey data for spine-related health care expenditures, utilization and self-reported health status.
Objective: To study trends from 1997 to 2006 in per-user expenditures for spine-related inpatient, outpatient, pharmacy, and emergency services; and to compare these trends to changes in health status.
Summary of Background Data: Although prior work has shown overall spine-related expenditures accounted for $86 billion in 2005, increasing 65% since 1997, the study did not report per-user expenditures. Understanding population-level per-user expenditure for specific services relative to changes in the health status may help assess the value of these services.
Methods: We analyzed data from the Medical Expenditure Panel Survey, a multistage survey sample designed to produce unbiased national estimates of health care utilization and expenditure. Spine-related hospitalizations, outpatient visits, prescription medications and emergency department visits were identified using ICD-9-CM diagnosis codes. Regression analyses controlling for age, sex, comorbidity, and time (years) were used to examine trends from 1997 to 2006 in inflation-adjusted per-user expenditures, and utilization, and self-reported health status.
Results: An average of 1774 respondents with spine problems was surveyed per year; the proportion suggested an increase in the number of people who sought treatment for spine problems in the United States from 14.8 million in 1997 to 21.9 million in 2006. From 1997 to 2006, the mean adjusted per-user expenditures were the largest component of increasing total costs for inpatient hospitalizations, prescription medications, andemergency department visits, increasing 37% (from $13,040 in 1997 to $17,909 in 2006), 139% (from $166 to $397), and 84% (from $81 to $149), respectively. A 49% increase in the number of patients seeking spine-related care (from 12.2 million in 1997 to 18.2 million in 2006) was the largest contributing factor to increased outpatient expenditures. Population measures of mental health and work, social, and physical limitations worsened over time among people with spine problems.
Conclusion: Expenditure increases for spine-related inpatient, prescription, and emergency services were primarily the result of increasing per-user expenditures, while those related to outpatient visits were primarily due to an increase in the number of users of ambulatory services.


Treatment for back and neck problems accounted for approximately $86 billion in healthcare expenditure in the United States in 2005.[1] Sustained growth in expenditures for surgical and nonsurgical treatments for spinal disorders has raised questions about the value of common and often expensive interventions. Value in healthcare can be viewed as improvement in patient outcomes per unit of cost. At the population level, value can be assessed by comparing the relative improvement in the health of the affected population to the investment of resources. To get an estimate of value for spine expenditures at the population level, it is important to understand changes in spine expenditures relative to changes in the health status of individuals with spine problems.

We previously demonstrated that although total health care expenditures in US adults with spine problems increased 65% between 1997 and 2005, measures of mental health, physical functioning, and work and social limitations in this population worsened during this interval.[1] We calculated those expenditure estimates as the mean expenditure for the sample multiplied by the population size. Such per-capita estimates distribute the costs for a particular service over the population of interest whether or not the service was used. Per-capita estimates of expenditures are useful for policy makers, but are less informative to patients than are per-user estimates of expenditures. Per-user estimates distribute expenditures for a service over the population of service users, and therefore reflect the average individual financial burden for using a specific service.

In this report, we extend our previous analysis by estimating per-user expenditures (i.e., expenditures among those who sought health care services for spine problems) in 4 major components of health care: (1) inpatient care, (2) outpatient care, (3) pharmaceutical care, and (4) emergency department care. We also extend our estimates an additional year by including 2006 data. Specifically, we: (1) document changes from 1997 to 2006 in expenditures in these 4 components of health care among those who sought services for spine problems; (2) identify the contributions of treatment prevalence, per-user cost, and mean number of visits to expenditures within each component; and (3) describe the changes in from 1997 to 2006 on indicators of health status among patients with spine problems.


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