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An Influential Index of 20 Overused Medical Procedures Includes Three Spine Interventions

doi: 10.1097/01.BACK.0000585364.40034.19

Over the past decade researchers at Johns Hopkins University have developed a widely employed index of overused medical interventions—a portfolio of 20 “bellwether” procedures that can be used to characterize medical overuse in different healthcare systems, populations, and geographic locations.

The 20-item Johns Hopkins Overuse Index includes four spine interventions: MRI for low back pain, spinal traction, and two commonly overused surgical procedures—laminectomy and/or fusion.

This index has allowed researchers to study broad patterns of overuse across the country and over time. The ultimate goal, of course, is to develop a better understanding of overuse, its drivers, and ways of reducing it.

This influential index defined overuse as “the provision of care where the potential for harm exceeds the potential for benefit.” (See Oakes et al., 2019.)

This index was originally studied in Medicare beneficiaries (the US healthcare system for people 65 years and older and some younger disabled individuals), showing that 14% to 25% of Medicare patients experience one or more overuse events every year. Commercially insured patients have experienced notable but somewhat lower levels of overuse, according to this index.

Besides the spine interventions, the overused procedures included fiberoptic laryngoscopy for sinusitis; hysterectomy for benign disease; nasal endoscopy for sinusitis; more than one emergency department visit in the final 30 days of life; routine monitoring of digoxin in patients with heart failure; EEG monitoring for syncope; serological testing for H. pylori; MRI in patients with traumatic brain injury; PET, CT, and radionuclide bone scans in men with prostate cancer; preoperative chest x-rays without clinical suspicion of thoracic pathology; tumor marker studies in asymptomatic women previously treated for breast cancer; IgG testing or IgE testing for allergies; and sinus CT or routine antibiotics for acute, uncomplicated rhinosinusitis.

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Promising Research Tool

This appears to a promising research tool. Tracey Pérez Koehlmoos of the Uniformed Services University of the Health Sciences in Bethesda, Maryland, recently used it to identify low-value healthcare services in the massive US military healthcare system. Two spine interventions appeared to be prime targets for reducing utilization and costs.

Reining in spending is a key priority for the US government. Healthcare costs in the military have crept up from 4% of the military budget in 1990 to nearly 10% in 2014, threatening the ability of the US military to maintain readiness and strategic capacity.

“Broadly defined as ‘overuse’ or ‘inappropriate care,’ low-value care includes procedures and treatments that are clinically inappropriate (such as the use of antibiotics to treat viral infections), are inappropriate for certain populations (such as cardiac stress imaging in low-risk or asymptomatic patients), are excessively intensive or sophisticated (such as cross-sectional imaging both with and without contrast), or involve the delivery of services with excessive frequency (such as unnecessary follow-up visits),” according to the research team.

They studied 2014 medical claims in TRICARE military insurance programs covering roughly 9.5 million beneficiaries (20% active duty soldiers, the remainder dependents and retirees). They studied the use of low-value care in both “direct care” programs, in which the military system ran the participating healthcare programs, and “purchased care,” in which the military paid for the care at civilian clinics.

The researchers used 19 of the 20 original Johns Hopkins Index procedures to identify overuse. They dropped the emergency room criterion because of difficulties in operationalizing it.

Overall, they found modest utilization of the overused procedures. “While overall usage of these indicator procedures was low (7 percent; data not shown), we found that all nineteen indicator procedures were used in both direct and purchased care settings,” according to Koehlmoos and colleagues. (See Koehlmoos et al., 2019.)

Two spine interventions stood out in their overuse. “The greatest opportunities for improvement appear to involve management of low back pain, as both premature ordering of MRIs for lumbar spine pain and prescribing traction for low back pain were strongly represented in the data set,” the researchers explained.

MRI obviously has a role in spine care. However, as other studies have demonstrated, this form of imaging should be utilized for low back pain at much lower levels.

It is not clear from evidence-based clinical guidelines that traction should play a significant role in the routine medical care of low back pain. So this may be a target for cost-cutting.

Back care is a huge issue in the military—and not just in the United States. Back pain is a prominent complaint of active duty soldiers and those returning from military engagements.

“While the estimated prevalence of low back pain within the TRICARE beneficiary population may be similar to the national prevalence, there is a potential additional cost to military readiness: This condition represents a leading cause of medical discharge from the military and is associated with medical evacuation from deployment settings,” according to the researchers.

However, Koehlmoos et al. pointed out that it is not enough to just identify low-value spine care services. Healthcare systems also need to educate patients and providers in a way that reduces demand for low-value back care services.

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Koehlmoos TP, et al Assessing low-value health care services in the Military Health System, Health Affairs, 2019; 38(8):1351–7.
Oakes AH, et al Systemic overuse of health care in a commercially insured US population, 2010–2015, BMC Health Services Research, 2019; 19:280, published online May 2, 2019. doi: 10.1186/s12913-019-4079-0.
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