The Effect of Required Physiatrist Consultation on Surgery Rates for Back Pain

John Fox, MD; Andrew J. Haig, MD; Brian Todey, BS; Sastish Challa, MS


Spine. 2013;38(3):E178-E184. 

In This Article

Abstract and Introduction


Study Design. Prospective trial with insurance database and surveys.
Objective. This study was developed to determine whether an insurer rule requiring physiatrist consultation before nonurgent surgical consultation would affect surgery referrals and surgery rates.
Summary of Background Data. Spine surgery rates are highly variable by region and increasing without evidence of a concordant decrease in the burden of disease. Efforts to curb misuse of surgery have not shown large changes, especially across different provider groups. As nonsurgical spine experts, physiatrists might provide patients with a different perspective on treatment options.
Methods. In 2007, the insurer required patients with nonurgent spine surgical consultations in a geographic region to first have a single visit with a physiatrist, who received extra compensation for the assessment. Surgical consultation and surgical rates results were compared between 2006–2007 and 2008–2010. An automated telephone survey of patients evaluated by physiatrists was performed to assess patient satisfaction.
Results. Physiatry referrals increased 70%, surgical referrals decreased 48%, and the total number of spine operations dropped 25%, with concomitant decreased overall cost. Although spinal fusion rates dropped, the percentage of fusion operations increased from 55% to 63% of all surgical procedures. Of 740 patients surveyed (48% response rate), 74% were satisfied or very satisfied with the physiatry consultation. Only 40% of patients who underwent previous spine surgery were satisfied. Although surgical rates decreased at all regional hospitals and all surgical groups, there were substantial shifts in market share.
Conclusion. Mandatory physiatrist consultation prior to surgical consultation resulted in decreased surgical rates and continued patient satisfaction across a large region.


Spinal disorders represent an increasing societal burden in terms of pain, disability, lost work productivity, and cost. Surgery is one intervention for back pain. The rates for various types of surgical procedures are increasing in the United States. Americans undergo surgery at a rate higher than persons in other developed countries.[1] In addition, there are geographic discrepancies within the country. For example, discectomy rates vary 8-fold and fusion rates vary 20-fold among regions in the United States.[2] Furthermore, although rates of spinal fusion increased between 1998 and 2008,[3] an increasing number of complex fusions are not justified by the pathology.[4]

Since at least 2000, spine surgery rates in West Michigan have ranked among the highest in the United States. An analysis of spine surgery data from 2000 to 2007 by Priority Health, a major health plan in the region, found that its back surgery rates consistently exceeded the National Committee for Quality Assurance's Quality Compass 90th percentile.[5] Furthermore, 2007 Medicare data from the Dartmouth Atlas showed the 3 of the 5 areas' 3 major hospitals' referral regions were above the 90th percentile for inpatient back surgery.[6]

To begin to address this disparity, in 2007 the health plan instituted a requirement that any patient desiring a surgical evaluation for nonurgent spine-related pain or disability must first be evaluated by a physiatrist. The health plan created a Spine Centers of Excellence program to reduce unwarranted variation, surgical costs, and the total number of spine surgical procedures in its patient population. The genesis of the program was based on 3 types of evidence from medical studies. First, for many types of back and neck pain, outcomes for nonoperative care are comparable with surgery.[7] Second, the implementation of multidisciplinary spine centers has been shown to reduce surgery rates.[8] Third, patients fully informed of all their treatment options tend to choose more conservative treatment than when surgeons act as decision makers. For example, Deyo et al[9] demonstrated a 22% reduction in surgery rates when patients used shared decision-making tools that explored all treatment options available for the condition being treated.

This evidence became the foundation for Priority Health's Spine Centers of Excellence program. In addition, it supported the Triple Aim goals of the Institute for Healthcare Improvement to (1) improve the health of the population, (2) enhance the patient experience of care (including quality, access, and reliability), and (3) reduce, or at least control, the per capita cost of care.[10]