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Increases in Lumbosacral Injections in the Medicare Population: 1994 to 2001

Friedly, Janna MD*; Chan, Leighton MD, MPH*; Deyo, Richard MD, MPH

doi: 10.1097/BRS.0b013e3180b9f96e
Health Services Research

Study Design. Anecdotal reports and limited data suggest that the use of spinal injections is increasing, despite equivocal evidence about efficacy.

Objective. We sought to evaluate trends in lumbosacral injection use for low back pain, including the specialties providing the injections and the costs of care.

Summary of Background Data. The current literature reports success rates of 18% to 90% for lumbosacral steroid injections, depending on methodology, outcome measures, patient selection, and technique. Preliminary data suggest that spinal injection rates are rising, despite ambiguity in the literature regarding their clinical effectiveness.

Methods. We used Medicare Physician Part B claims for 1994 through 2001 to examine the use of epidural steroid injections (ESI), facet joint injections, sacroiliac joint injections, and related fluoroscopy. Fee-for-service Medicare enrollees 65 years of age and older were included in this study. We used Current Procedural Technology (CPT) codes to identify the number of procedures performed each year, as well as trends in expenditures, physician specialties involved, and diagnoses assigned.

Results. Between 1994 and 2001, there was a 271% increase in lumbar ESIs, from 553 of 100,000 to 2055 of 100,000 patients, and a 231% increase in facet injections from 80 of 100,000 to 264 of 100,000 patients. The total inflation-adjusted reimbursed costs (professional fees only) for lumbosacral injections increased from $24 million to over $175 million. Also, costs per injection doubled, from $115 to $227 per injection. Forty percent of all ESIs were associated with diagnosis codes for sciatica, radiculopathy, or herniated disc, whereas axial low back pain diagnoses accounted for 36%, and spinal stenosis for 23%.

Conclusion. Lumbosacral injections increased dramatically in the Medicare population from 1994 to 2001. Less than half were performed for sciatica or radiculopathy, where the greatest evidence of benefit is available. These findings suggest a lack of consensus regarding the indications for ESIs and are cause for concern given the large expenditures for these procedures.

Trends in epidural steroid injection use using Medicare claims data were evaluated. Lumbosacral injection use and costs increased dramatically from 1994 to 2001. Less than half were performed for radiculopathy, where the greatest evidence of benefit is available. These findings suggest a lack of consensus regarding the indications for ESIs and are cause for concern given the costs. Supplemental Digital Content is Available in the Text.

From the *Department of Rehabilitation Medicine and †General Internal Medicine and Center for Cost and Outcomes Research, University of Washington, Harborview Medical Center, Seattle WA.

Acknowledgment date: August 22, 2006. First revision date: November 27, 2006. Acceptance date: December 21, 2006.

Supported by the Rehabilitation Medicine Scientist Training (RMSTP) K12 Program and Grant No. P60 AR 48093 (National Institute for Arthritis, Musculoskeletal and Skin Disorders).

The manuscript submitted does not contain information about medical device(s)/drug(s).

Federal funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Janna Friedly, MD, Department of Rehabilitation Medicine and University of Washington, Harborview Medical Center, Box 358740, 325 Ninth Ave, Seattle WA 98127; E-mail: friedlyj@u.washington.edu

© 2007 Lippincott Williams & Wilkins, Inc.