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Introduction to Value Based Spine Care

Introduction to Focus Issue

Fehlings, Michael G., MD, PhD, FRCSC, FACS*; Nater, Anick, MD*; Skelly, Andrea, PhD, MPH; McGirt, Matthew, MD; Mroz, Thomas, MD§

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doi: 10.1097/BRS.0000000000000542
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In developed countries, health care costs are rising at an alarming rate. In 2012, in the United States, the National Health Expenditures increased by 3.7%, reaching $2.8 trillion or 17.2% of the gross domestic product. Moreover, hospital expenditures grew faster in 2012 than in 2011 (4.9% vs. 3.5%) totalizing $882.3 billion, which represents 31.5% of the National Health Expenditures.1 With rising health care costs, there is naturally increased focus on the cost-effectiveness of medical and surgical interventions. Because of the prevalence of spinal disorders and the advent of innovative surgical procedures, often using expensive technologies, spine care is in the crosshairs of efforts to control costs. Given this background, it is critical that spine health care professionals understand the issues related to defining value in spine care. It is with this intent that the current Spine Focus Issue was put together.

Not only are spinal surgical procedures individually becoming more expensive, but the overall annual number of surgical spinal interventions also keeps escalating. For instance, hospital charges for spinal fusion averaged $9915 in 1985, whereas Medicare payments for spinal fusion averaged $63,555 in 2003.2 Moreover, there were 238,948 more patients undergoing spinal fusion in 2008 than in 1998, representing a 137% increase in 10 years. In contrast, during the same period of time, the number of laminectomy, hip replacement, and percutaneous coronary angioplasty rose by 11.3%, 49.1%, and 38.8%, respectively. Of course, it is also recognized that shifts in practice do occur as reflected by the increase in knee arthroplasty of 126.8% during this time period. In terms of utilization rates per 100,000 adults, spinal fusion increased by 111%, whereas knee arthroplasty, hip replacement, and percutaneous coronary angioplasty increased by 101.4%, 32.4%, and 23.2%, and laminectomy decreased by 1.2%.3 From 1992 to 2003, the increase in both the average cost per case and the overall number of annual lumbar fusion translate in an inflation-adjusted spending increase of more than 500%, representing an expenditure growth of $407 million.4

In addition to the dramatic increase in the number of surgical spinal interventions and the associated overall cost, spine care attracts considerable attention because there are significant variations in spinal interventions within and across nations. Indeed, despite a relatively stable incidence and prevalence of spinal disorders worldwide, the prevalence of several types of procedures differs geographically; the rate of surgical spinal interventions is markedly higher in the United States.5 Furthermore, medical, clinical, or surgical evidence explaining this variability are lacking. It is reasonable to suspect that the heterogeneity of conclusions of spine care–effectiveness studies, financial incentives and disincentives to surgical procedures, institutions' culture, patient demands, technological advances, and differences in clinical training and professional opinions are potential factors contributing to this variability.

To gain control over health care expenditures and to address one of the key determinants of system viability, “value-based care” is becoming an increasingly important concept. Indeed, quantifying the value proposition of spine surgery is a timely and important challenge because the medical community must answer questions regarding value and quality of care after decades of relatively unbridled expansion. The term “value” generally refers to a quality or standard that is desirable, useful, or worthwhile. In the context of health care delivery, value-based care is a complex concept because it takes into account both the individual and societal perspectives. Patients judge whether a practice is desirable on the basis of the impact it has on their life. Society evaluates the desirability of a practice on the basis of its cost-effectiveness. Assessing the effectiveness of a practice, both in the individual and societal perspectives, involved significant intrinsic variability because it is subjective by nature. However, once the terms have been clearly defined, value-based care becomes a powerful approach.

Given the high incidence and prevalence of spinal disorders and the challenges its surgical management brings to the health care system, as highlighted previously, the evaluation of spine care using value-based principles has been started. This Focus Issue aims to provide a general overview of the topic and examines selected specific issues related to value-based spine care in greater detail.

The key points made in each article in this Focus Issue are summarized in Table 1. The Focus Issue is divided into 3 sections. The first section highlights the fundamental key concepts related to defining value in health care. This section has been designed to allow a better understanding of the different types of economic evaluations and how surgical spine care fits in the context of value-based care. The second section presents 5 systematic economic reviews on surgical spine care topics that are the source of an ongoing polemic: minimal access spine surgery compared with conventional spine surgery, use of biological substitutes or extenders for spinal arthrodesis, management of cervical degenerative disease, metastatic epidural spinal cord compression, and lumbar degenerative spondylolisthesis and spinal stenosis. The last section examines the application of registries and clinical pathways as means to improve value in spine care.

We trust that spinal practitioners, once armed with a working knowledge of concepts related to defining value in spine care, will be better able to navigate this complex field going forward in the future.


1. Centers for Medicare & Medicaid Services. NHE Fact Sheet. 2014. Available at Accessed 14 June, 2014.
2. Chen E, Tong KB, Laouri M. Surgical treatment patterns among Medicare beneficiaries newly diagnosed with lumbar spinal stenosis. Spine J 2010;10:588–94.
3. Rajaee SS, Bae HW, Kanim LE, et al. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine (Phila Pa 1976) 2012;37:67–76.
4. Weinstein JN, Lurie JD, Olson PR, et al. United States' trends and regional variations in lumbar spine surgery: 1992–2003. Spine (Phila Pa 1976) 2006;31:2707–14.
5. Cherkin DC, Deyo RA, Loeser JD, et al. An international comparison of back surgery rates. Spine (Phila Pa 1976) 1994;19:1201–6.
© 2014 by Lippincott Williams & Wilkins