Claims Data Show More Rapid Intervention in Pain by Anesthesiologists, Pain Specialists

Thomas R. Collins

February 12, 2010

February 12, 2010 (San Antonio, Texas) — Anesthesiologists and pain specialists making pain-related diagnoses are far more likely to quickly perform interventional procedures for pain relief than other physicians providing care, according to a new analysis of commercial insurance claims data presented here at the American Academy of Pain Medicine 26th Annual Meeting.

Among patients with diagnoses that are among the most likely to receive interventional pain procedures — cervical radicular, lumbar radicular, sacroiliac, and postlaminectomy/facet syndrome diagnoses — many had interventional procedures on the same day the diagnosis was made by an anesthesiologist, according to Steve Delaronde, MPH, MSW, director of medical informatics at Triad Healthcare and adjunct professor at the University of Connecticut Health Center in Farmington.

On the other end of the spectrum, very few patients were given injections or other interventional procedures on the same day when the diagnosis was made by a primary-care physician or physiatrist, Mr. Delaronde reported.

"The type of treatment for the same diagnostic group depends upon who makes the initial diagnosis," he said during his presentation. "You could get a lumbar radiculitis diagnosis by an anesthesiologist or you could get one by a primary-care physician and, depending upon who applies it, there's a very different path in terms of what type of treatment you'll receive after that."

The medical claims data cover 1.7 million commercially insured members across the country treated from 2005 to 2007 — a rare look at claims beyond Medicare, Mr. Delaronde noted.

The analysis focused exclusively on the 10,456 new interventional pain patients in 2006, defined as those who had not had any interventional pain visits in the previous 12 months. Although the data were national in scope, the researchers noted that there was an overrepresentation of data from the Midwest and an underrepresentation from the South and Northeast.

The analysis of the data comes at a time when the number of interventional pain procedures is growing.

According to a study published in Spine (2007;32:1754-1760), there was a 271% increase in lumbar epidural steroid injections and a 231% increase in facet injections in the Medicare population between 1994 and 2001.

The success rate for epidural steroid injections has been found to vary widely — ranging from 18% to 90%, depending on the study methodology, according to one meta-analysis (Anesth Analg. 2002;95:403-408).

The number of epidural steroid injections hasn't translated into fewer surgeries; a 2008 study found a positive correlation between the injections and surgery (J Bone Joint Surg Am. 2008;90:1730-7), Mr. Delaronde said.

The data showed a broad range in the way patients in the same diagnostic category are treated, depending on whom they're seeing.

For example, 60% of patients diagnosed with lumbar radicular pain by anesthesiologists had an interventional procedure performed the same day, compared with 40% of those diagnosed by physicians who consider themselves pain-medicine specialists, 12% of those diagnosed by physiatrists, and 2% of those diagnosed by primary-care doctors.

Among patients diagnosed by anesthesiologists, 81% underwent an interventional procedure within a year of the diagnosis, compared with 70% diagnosed by pain-medicine specialists, 39% diagnosed by physiatrists, and 20% diagnosed by primary-care physicians.

The differences were similar in other diagnostic categories, Mr. Delaronde told meeting attendees.

Ajay Wasan, MD, assistant professor at Harvard Medical School in Boston, Massachusetts, and cochair of the AAPM 2010 annual meeting, said the data help clearly define the differences between disciplines.

"There are differences and this has implications for how we consider ourselves as specialists and what we do," Dr. Wasan said during the session. "These are the kinds of data we need for us, as a specialty, to assert our identity."

Experts looking at the data expressed surprise at the percentage of patients undergoing physical and occupational therapy. Only 19% of patients in both the cervical radicular and lumbar radicular diagnostic groups received such therapy, as did 13% in the sacroiliac group and 12% in the laminectomy/facet joint syndrome group.

"It's amazing that [physical and occupational therapy] is actually that low," Dr. Wasan said. "It does seem that there might be some underutilization."

Data on who is actually doing the diagnosis also revealed some surprises. The lion's share were diagnoses by chiropractors, regardless of diagnosis type: 36% of the cervical radicular group, 32% of the lumbar radicular group, 67% of the sacroiliac group, and 64% of the postlaminectomy/facet syndrome group.

"This rate is astonishing. Chiropractors are a huge percentage, the majority, of the providers making the first diagnosis," Dr. Wasan said. "That tells us that there is an incredible number of patients self-seeking chiropractors, because in most states, patients can self-refer to chiropractors."

Among the nonchiropractor diagnoses, most were made by radiologists — a number expected to be large because they're doing the imaging — followed by primary-care providers, anesthesiologists, physiatrists, and pain-medicine specialists.

"What this tells me," Dr. Wasan said, "is that hands-down, the single best referral source and one of the most important relationships you should have is with your primary-care physicians who refer to you."

This analysis received no known commercial financial support. Mr. Delaronde and Dr. Wasan have disclosed no relevant financial relationships.

American Academy of Pain Medicine (AAPM) 26th Annual Meeting. Presented February 5, 2010.

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