1. Lumbar fusion for chronic LBP -WA State Agency/DLI Perspective- -Robert Bree Collaborative- Sept 30, 2011 Gary M. Franklin, MD, MPH Research Professor Departments of Environmental Health, Neurology, and Health Services University of Washington Medical Director Washington State Department of Labor and Industries

2. WA Public payers compelling issues Lumbar fusion has the highest regional variation of any major surgery in the US-20 fold difference between geographic regions – Weinstein et al, Spine 2006, 31: 2707-14. Average cost $80-120,000, up to half is instrumentation in absence of DRG’s Lumbar fusion number one in-patient cost for Uniform Health Plan (public employees) Contribution to long term disability and pension in DLI

3. Washington State DLI Outcomes - Population-based restrospective studies - Franklin et al, 1994; Spine 20: 1897-903 N= 388 fusions from 1986-87 - 68% TTD at 2 years; 23% more surgery by 2 yrs -Instrumentation doubled risk of reoperation -Surgical experience didn’t matter Juratli et al, 2006; Spine 31:2715–23. N=1950 fusions from 1994-2000 -64% disabled at 2 yrs; 22% reoperated by 2 yrs + 12% other complications -85% received cages and/or instrumentation -Cage/instrumentation use increased complications without improving disability or reoperation rate Juratli et al, 2009: Spine 34: 740-47 -Increased mortality associated with opioid use

4. Recent developments WA HTA: – 2/15/08-Fusion for DDD covered if structured multidisciplinary program fails, or not available – 8/15/08-Discography for chronic LBP and DDD not covered 1/1/2011-North Carolina BC/BS-lumbar fusion not covered for chronic LBP and DDD SSB 5801-workers comp health reform-includes authority to define harmful care; eg, are you in the highest decile for failed lumbar fusion or reoperations?

5. Complications, death and repeat surgery within 90 days of lumbar fusion (unadjusted %) CHARS 2004-2007 [n = 5,864] Payer Device comp. Wound prob. Life- threatening DeathRepeat Lumbar Surgery Medicare0.44.43.70.41.9 Medicaid1.66.82.20.02.4 HMO1.01.40.6 0.7 Commercial1.11.81.30.12.0 W/C1.01.80.60.01.3 Contract0.53.01.60.11.5 Other0.02.92.20.01.9 Martin et al, submitted

6. What public payers need Better information Re outcomes of lumbar fusion across payers (DLI, Uniform, Regence) Best new data could only come from a well designed, population-based comparative effectiveness study – With minimum clinically important differences measured (eg, 30% improved function AND 30% improved pain AND less than daily opioid use) – Control groups should include other patients with chronic LBP (pain clinics, usual care) – Clear data on relative safety and costs

7. For electronic copies of this presentation, please e-mail Melinda Fujiwara vasudha@u.washington.edu For questions or feedback, please e-mail Gary Franklin meddir@uw.edu THANK YOU!