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Practice Variation Among Surgeons Treating Lumbar Spinal Stenosis in a Single Institution

STUDY DESIGN: Retrospective study OBJECTIVE.: To examine practice variation in the treatment of lumbar spinal stenosis and identify targets for reducing variation. SUMMARY OF BACKGROUND DATA: Lumbar spinal stenosis is a degenerative condition susceptible to practice variation. Reducing variation aims to improve quality, increase safety, and lower costs. Establishing differences in surgeons’ practices from a single institution can help identify personalized variation. METHODS: We identified adult patients first diagnosed with lumbar spinal stenosis between 2003 and 2015 in three hospitals of the same institution with ICD-9 codes.We extracted number of office visits, imaging procedures, injections, EMG’s, and surgery within the first year after diagnosis; physical therapy within the first 3 months after diagnosis. Multivariable logistic regression was used to identify factors associated with surgery. The coefficient of variation (CV) was calculated to compare the variation in practice. RESULTS: The 10,858 patients we included had an average of 2.5 visits (+/-1.9), 1.5imaging procedures (+/-2.0), 0.03EMG’s (+/-0.22), and 0.16injections (+/-0.53); 36% had at least 1 surgical procedure and 32% had physical therapy as part of their care. The CV was smallest for number of visits (19%) and largest for EMG (140%).Male sex (Odds Ratio [OR]: 1.23, p < 0.001), seeing an additional surgeon (OR: 2.82, p < 0.001), and having an additional spine diagnosis (OR: 3.71, p < 0.001) were independently associated with surgery. Visiting an orthopedic clinic (OR: 0.46, p < 0.001) was independently associated with less surgical interventionthan visiting a neurosurgical clinic. CONCLUSIONS: There is widespread variation in the entire spectrum of diagnosis and therapy for lumbar spinal stenosis among surgeons in the same institution. Male gender, seeing an additional surgeon, having an additional spine diagnosis, and visiting a neurosurgery clinic were independently associated with increased surgical intervention. The main target we identified for decreasing variability was the use of diagnostic EMG. LEVEL OF EVIDENCE: 3

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