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

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

doi: 10.1097/BRS.0b013e31827bf40c
Health Services Research

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.

An insurance company mandate for physiatrist consultation prior to surgical consultation for nonemergent spine conditions resulted in a 25% drop in surgical rates accompanied by high patient satisfaction.

*Priority Health, Grand Rapids, MI; and

Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.

Address correspondence and reprint request to John Fox, MD, Priority Health, 1231 East Beltline, NE, Grand Rapids, MI 49525; E-mail:

Acknowledgment date: October 18, 2011. First revision date: May 31, 2012. Second revision date: September 7, 2012. Acceptance date: October 31, 2012.

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

Priority Health, Grand Rapids, Michigan, funds were received to support this work.

Relevant financial activities outside the submitted work: consultancy.

© 2013 Lippincott Williams & Wilkins, Inc.