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Comparative Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population

Pre and Post Affordable Care Act

Manchikanti, Laxmaiah MD; Soin, Amol MD; Mann, Dharam P. MD; Bakshi, Sanjay MD§; Pampati, Vidyasagar MSc; Hirsch, Joshua A. MD||

doi: 10.1097/BRS.0000000000002785

Study Design. A retrospective cohort study of utilization patterns of epidural injections.

Objective. The aim of this study was to assess patterns of utilization and variables of in chronic spinal pain in the fee-for-service (FFS) Medicare population, with a comparative analysis of pre- and post-Affordable Care Act (ACA) data from 2000 to 2009 and 2009 to 2016.

Summary of Background Data. Over the years, utilization of interventional pain management techniques, specifically epidural injections have increased creating concern over costs and public health policy.

Methods. The master data from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2016 was utilized to assess utilization patterns. The descriptive analysis of the database analysis was performed using guidance from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Multiple variables were analyzed based on the procedures, specialties, and geography.

Results. Caudal and lumbar interlaminar epidural injections decreased 25% from 2009 to 2016 with an annual decrease of 4% in contrast to lumbosacral transforaminal epidural injection episodes, increasing at an annual rate of 0.3%. In contrast, lumbar interlaminar epidural injections increased 2.4% annually, while transforaminal episodes increased 23% from 2000 to 2009. The ratio of interlaminar epidural injections to transforaminal epidural injection episodes has changed from 7 in 2000 to 1 in 2016, whereas ratio of services changed from 5 to 0.7. From 2009 to 2016, cervical/thoracic interlaminar epidural injections episodes increased at an annual rate of 0.5%, with a decrease of 2.3% for transforaminal epidural injections.

Conclusion. Comparative analysis of the utilization of epidural injections from 2000 to 2009 and 2009 to 2016 showed vast differences with overall significant decreases in utilization, specifically for lumbar interlaminar and caudal epidural injections, with a continued, though greatly slowed increase of lumbosacral transforaminal epidural injections.

Level of Evidence: 3

This study of a comparative analysis of utilization of epidural procedures in managing chronic pain in the Medicare population showed reductions of 4% annual rate for lumbar and caudal interlaminar epidural injections and an increase of 0.3% for lumbosacral transforaminal epidural injections since the initiation of the Affordable Care Act.

Pain Management Center of Paducah Paducah, KY, Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, and Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, New Orleans, LA

Ohio Pain Clinic Centerville, Wright State University, Dayton, OH

Garden State Pain Management, Whiting, NJ

§Lenox Hill Hospital, New York, NY

Pain Management Center of Paducah, Paducah, KY

||Interventional Care, Quality and Safety; NeuroInterventional Spine Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

Address correspondence and reprint requests to Laxmaiah Manchikanti, MD, 2831 Lone Oak Road, Paducah, KY 42003; E-mail:

Received 21 March, 2018

Revised 17 May, 2018

Accepted 20 June, 2018

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

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, grants.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.