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Utilization and Outcomes for Spine Surgery in the United States and Canada

Cram, Peter MD, MBA∗,†,‡,§; Landon, Bruce E. MD, MBA¶,||; Matelski, John MSc; Ling, Vicki MSc; Perruccio, Anthony V. PhD‡,∗∗,††; Paterson, J. Michael MSc; Rampersaud, Y. Raja MD∗∗,‡‡,§§

doi: 10.1097/BRS.0000000000003083

Study Design. A retrospective cohort study.

Objective. The aim of this study was to examine variation in spine surgery utilization between the province of Ontario and state of New York among all patients and pre-specified patient subgroups.

Summary of Background Data. Spine surgery is common and costly. Within-country variation in utilization is well studied, but there has been little exploration of variation in spine surgery utilization between countries.

Methods. We used population-level administrative data from Ontario (years 2011–2015) and New York (2011–2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery using relevant procedure codes. Patients were stratified according to age and surgical urgency (elective vs. emergent). We calculated standardized utilization rates (procedures per-10,000 population per year) for each jurisdiction. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared utilization rates of spinal decompression and fusion surgery in Ontario and New York among all patients and after stratifying by surgical urgency and patient age.

Results. Patients in Ontario were older than patients in New York for both decompression (mean age 58.8 vs. 51.3 years; P < 0.001) and fusion (58.1 vs. 54.9; P < 0.001). A smaller percentage of hospitals in Ontario than New York performed decompression (26.1% vs. 54.9%; P < 0.001) or fusion (15.2% vs. 56.7%; P < 0.001). Overall, utilization of spine surgery (decompression plus fusion) in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 16.5 per-10,000 per-year (P < 0.001). Ontario-New York differences in utilization were smaller for emergent cases (2.0 per 10,000 in Ontario vs. 2.5 in New York; P < 0.001), but larger for elective cases (4.6 vs. 13.9; P < 0.001). The lower utilization in Ontario was particularly large among younger patients (age <60 years).

Conclusion. We found significantly lower utilization of spine surgery in Ontario than in New York. These differences should inform policy reforms in both jurisdictions.

Level of Evidence: 3

Spine surgery is common and costly, but there has been little exploration of variation between countries. We used administrative data from Ontario and New York to compare spine surgery utilization rates between jurisdictions. Utilization was approximately 60% lower in Ontario with differences in utilization driven largely by lower rates of elective spine procedures among younger (age <60) patients.

Department of Medicine, University of Toronto, Toronto, ON

Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, ON

Institute for Clinical Evaluative Sciences, Toronto, ON

§North American Observatory on Health Systems and Policies, University of Toronto, Toronto, ON

Department of Health Care Policy, Harvard Medical School, Boston, MA

||Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA

∗∗Healthcare & Outcomes Research, Arthritis Program, Krembil Research Institute, University Health Network, Toronto, ON

††Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON

‡‡Department of Surgery, Division of Orthopaedic Surgery, University of Toronto, Toronto, ON

§§Division of Orthopaedic Surgery, Arthritis Program, Krembil Research Institute, University Health Network, Toronto, ON.

Address correspondence and reprint requests to Peter Cram, MD, MBA, Division of General Internal Medicine, Toronto General Hospital, Eaton 14th Floor, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada; E-mail:

Received 29 October, 2018

Revised 24 February, 2019

Accepted 28 March, 2019

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

This work was supported by K24AR062133 from NIAMS at the US NIH and was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Relevant financial activities outside the submitted work: grants.

Approximately 900,000 American and 30,000 Canadian adults undergo spine surgery annually1,2 with inpatient direct hospital cost per-procedure ranging from $4500 to $30,000 depending upon procedure and country.3,4 Researchers and policy makers believe that utilization of spine surgery in the US is significantly higher than in other industrialized countries, but international comparisons of spine surgery are largely lacking.5,6 Meanwhile, in Ontario, surgeons and patients are concerned about inadequate access to spine surgery resulting in treatment delays and unwarranted suffering.7 Neither country has a clear understanding of their spine surgery utilization rates or how they directly compare. In an era when both countries are looking externally for solutions to vexing problems,8,9 international comparisons can provide new insights.

An estimated 10% to 15% of the population has chronic back pain,10,11 and while pain often improves with conservative management, surgery is extremely effective in some cases.12,13 Given continued uncertainty over precisely which patients will benefit from surgery, patients and surgeons have considerable discretion whether to choose surgery and which procedure is best (spinal decompression alone vs. fusion).14,15 As a result, most countries are struggling to balance an epidemic of chronic back pain with concerns about growth in spine surgery and cost implications.16,17 While an array of international studies have done an excellent job in characterizing the structural differences between nations’ health care systems at a macro-level,18,19 more granular data comparing health care utilization and outcomes for individual procedures and conditions remain extremely limited.20

We used contemporary administrative health data from Ontario (Canada) and New York State (US) to examine differences in utilization of in-patient decompression alone and spinal fusion procedures. We hypothesized that spine surgery utilization would be lower in Ontario than New York and that lower utilization in Ontario would primarily be manifested by a smaller percentage of hospitals performing spine surgery and lower utilization of elective spine procedures.

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Building on prior international comparative work,21,22 we used administrative data from the most populous Canadian province (Ontario: population 14.3 million, median age 39.8 years, 68% white, 5% black) and a large US state (New York: population 19.8 million, median age 38.4 years, 66% white, 16% black).23,24 Ontario and New York share a common border, are diverse, have an extremely large city (Toronto and New York City), and significant rural areas. Our primary data source for Ontario was the 2011 to 2015 Discharge Abstract Database (DAD) held and analyzed at ICES ( These administrative records provide information on all hospitalizations (excluding psychiatric admissions) paid for by the Ontario Health Insurance Plan (OHIP); OHIP provides health insurance to all legal residents of Ontario (∼99% of the population) and pays for virtually 100% of inpatient hospitalizations. Ontario's DAD provides information regarding demographic characteristics (age, sex), primary and secondary diagnoses coded using International Classification of Diseases Version 10 (ICD-10) codes, procedures captured using Canadian Classification of Health Interventions (CCI) codes, discharge disposition (e.g., died-in-hospital, home, transfer to another acute-care hospital), a unique patient identifier (used to track patients over time), and unique hospital identifiers. Comorbid conditions present at the time of the index hospital stay were identified using the Quan ICD-10 adaptation of the Elixhauser comorbidity coding scheme, which maps ICD-10 coded comorbidities to ICD-9.25

Our primary data for New York were the 2011 to 2014 State Inpatient Database (SID).22,26 The SID contains administrative data for all patients admitted to all acute care hospitals, excluding a small number of Veterans Administration and psychiatric hospitals. Data elements for each admission include patient demographics, primary and secondary diagnosis and procedures (coded using ICD9-CM codes), discharge disposition, patient identifier, and hospital identifier. Comorbid conditions present for the index hospital stay were captured using algorithms developed by Elixhauser et al.27

Estimates of the New York population were obtained from US Census Data; estimates of the Ontario population were obtained from analogous Canadian Census Data. We linked the New York data to the American Hospital Association annual survey to ascertain information regarding hospital teaching status and bed size. We linked the Ontario DAD to information from the Ontario Ministry of Health and Long-Term Care for hospital-level data.

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Cohort Generation

Our cohorts were constructed at two levels: patient level, where everyone who underwent spine surgery was counted once; and procedure level, where patients were counted once for each procedure they underwent.

We identified adults aged 18 to 105 years who underwent decompression alone or fusion between January 1, 2011, and September 30, 2015, in Ontario and September 30, 2014, in New York using CCI codes in Ontario and ICD9-CM codes for New York that have been used in prior spine surgery research (Appendix 1).28–30 We excluded patients with missing age or sex. We used a 90-day lookback (October 1, 2010–December 31, 2010) to exclude procedures performed during the 90 days before study initiation to avoid counting readmissions or staged procedures as a new procedure. Patients who had both a fusion code and a decompression code during the same surgery were categorized as having had fusion surgery (Appendix 1); patients who underwent laminectomy/laminotomy (with or without a discectomy) were categorized as having decompression surgery. We decided a priori that repeat spine procedures performed ≤90 days after a prior procedure would be counted as either a staged procedure and/or readmission; any procedures that occurred >90 days after the index procedure were counted as new procedures.

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Statistical Analyses

First, at the patient level, we compared demographics and comorbidity of patients who underwent spine surgery in Ontario and New York using bivariate measures. Analyses were conducted separately for the decompression and fusion cohorts. We then stratified patients into elective and emergent procedures (Appendix 2): elective procedures were categorized as scheduled admissions without evidence of trauma, metastatic cancer, or active infection: emergent procedures were those categorized as emergency cases or cases with evidence of trauma, metastatic cancer, or infection. Subjects who met neither our elective nor emergent criteria (0 in Ontario, 430 in New York) were judged indeterminate urgency and excluded from subgroup analysis. Second, we compared the percentage of all acute care hospitals in Ontario and New York that performed decompression and fusion and the mean annual hospital decompression and fusion volumes after excluding hospitals with implausibly low volumes (< one procedure per year). We also identified the number of physicians in Ontario and New York who performed an average of one or more spine procedures per year in our dataset. We then calculated the mean, median, and interquartile ranges for spine surgery volume for Ontario and New York surgeons.

Third, we compared the overall per-capita spine surgery rates (procedures per 10,000 per year) for adults in Ontario and New York. The numerator for Ontario was the total number of spine surgery procedures (decompressions and fusions) performed and the denominator was the number of adults age ≥18 years residing in Ontario in 2013. For New York utilization, we identified all spine procedures performed in New York (N = 103,790), but subsequently used zip code of residence to exclude procedures performed on patients who resided outside of New York State (N = 9283) resulting in a final cohort of 94,507 procedures performed in New York on residents of New York State; our denominator for New York was the number of adults age ≥18 years residing in New York in 2013. We then conducted subgroup analyses focusing on elective procedures, emergency procedures, decompression alone, and fusion alone. We calculated age and sex standardized utilization rates (Ontario as the reference) using direct standardization. Fourth, we compared the percentage of patients in Ontario and New York who underwent multiple procedures.

Fifth, we compared unadjusted outcomes in Ontario and New York, including hospital acute length of stay (LOS), in-hospital mortality, and hospital readmission within 30 and 90 days of discharge among those who survived to discharge. Analyses were conducted for all patients as well as the subgroups described previously. We used generalized estimating equations to compare adjusted outcomes in Ontario and New York using three sequential models: Model 1 adjusted for only patient age and sex; Model 2 adjusted for Model 1 factors along with hospital decompression or fusion volume, surgical urgency (elective, emergent), and hospital LOS; Model 3 included all Model 2 factors plus comorbid conditions. This analysis was approved by the Research Ethics Board at University along with Network, Toronto. Our analyses were pre-specified before the initiation of any statistical analysis and are publicly available through Open Science ( All analyses were performed using either SAS (SAS Institute Inc., Cary, NC) or R statistical software packages.

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Our analyses included 15,103 patients in Ontario and 15,294 in New York who received decompression and 16,968 in Ontario and 79,716 in New York who received fusion (Table 1 ). Patients receiving spine surgery in Ontario were older and had fewer comorbidities (Table 1 ). A smaller percentage of Ontario than New York hospitals performed decompression (26.1% vs. 54.9%; P < 0.001) and fusion (15.2% vs. 56.7%; P < 0.001) (Table 2). Mean hospital decompression volume was higher for Ontario than New York (79.7 vs. 34.4 procedures per year; P = 0.025) (Table 2) but similar for fusion (166.8 vs. 184.6; P = .658); in both Ontario and New York, 25% of hospitals had annual decompression volumes of less than 10 and fusion volumes of less than 35. In New York, there were 548 surgeons who performed four or more procedures during our 4-year study window (36.4 surgeons per-million population), while Ontario had 228 surgeons who performed five or more procedures during the 5-year study window (21.0 surgeons per-million).



TABLE 1 (Continued)

TABLE 1 (Continued)



Annual spine surgery utilization was significantly higher in New York (16.5 procedures per 10,000 per year) than Ontario (6.6 per 10,000 per year; P < 0.001) (Table 3). In analyses stratified by surgical urgency (Table 3), utilization of elective procedures in New York was approximately 300% higher than in Ontario (13.9 vs. 4.6 procedures per 10,000 per year; P < 0.001), while utilization of emergent spine procedures was only 25% higher in New York (2.5 vs. 2.0; P < 0.001). In analyses stratified by surgical subtype, utilization of decompression was lower in New York than Ontario (2.1 vs. 3.1; P < 0.001) (Table 3), while utilization of fusion was approximately 400% higher in New York than Ontario (14.3 vs. 3.5; P < 0.001). Further analysis demonstrated that the New York-Ontario difference in utilization was substantially larger among younger patients and smaller for older patients (Figure 1 and Supplementary Table S1, For example, utilization of spine procedures in New York was 315% greater than Ontario for patients less than 50 years of age (10.7 vs. 3.4), but only 14% greater in patients age 80 years and above (11.4 vs. 10.0). The percentage of patients who had multiple hospitalizations for spine surgery was higher in New York (8.3%) than Ontario (5.2%) (P < 0.001) (Supplementary Table S2,



Figure 1

Figure 1

In unadjusted analyses, hospital acute LOS was approximately 2 days longer for decompression and 3.5 days longer for fusion in Ontario than New York (P < 0.001) (Table 4); however, stratified analyses demonstrate that Ontario-New York differences in LOS were quite small in the elective surgery population and much larger in the emergent group (Table 4). Unadjusted in-hospital mortality was significantly higher in Ontario for both emergent decompression and fusion cohorts (Table 4). After adjusting for patient demographics, hospital LOS, and surgical urgency (Model 2), differences in mortality in Ontario and New York were no longer significant for elective or emergent decompression or fusion (Supplementary Tables S3-S7, In adjusted analyses, differences in hospital LOS were reduced and readmission rates in Ontario were significantly lower than in New York (Supplementary Tables S3–S7,



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In an analysis of data from the US and Canada, we found significantly higher per-capita utilization of spine surgery in New York than in Ontario. The higher utilization in New York was attributable to higher rates of elective fusion procedures particularly in younger patients. In aggregate, these results provide important insight into differences in health care delivery in the US and Canada.

Several aspects of our study require discussion. It is important to consider our results in the context of nearly two decades of concern about excessive utilization of spine surgery in the US.16,31 We found that utilization of emergent spine surgery in New York and Ontario was similar, while utilization of elective surgery was markedly higher in New York. From an epidemiologic standpoint, we had no reason to expect that the need for emergent spine surgery would be different between New York and Ontario populations. Alternatively, our finding that elective spine surgery utilization was 300% higher in New York than Ontario updates and expands on an extremely small body of international population-based spine surgery literature from more than two decades ago.5,32,33

Higher utilization of spine surgery in New York was driven almost entirely by higher rates of elective fusion. Elective spine surgery, particularly fusion, has long been characterized as a prototype for preference-sensitive care.34 Identified drivers of utilization have included patient and surgeon preference, overuse of imaging, surgeon-industry financial relationships, and supply of spine surgeons.35–37 Utilization of spine surgery has also been driven by an epidemic of chronic back pain and evidence of improvements in symptoms with spinal fusion in a subset of patients who have failed conservative management.38,39 However, there remains significant uncertainty over how to identify patients who are most likely to benefit from surgery and which patients benefit from fusion above and beyond decompression alone.39,40

While it is tempting to assume that our findings represent excess utilization in New York, it is also important to consider potential underuse in Ontario. Data from the Canadian Institute for Health Information suggest that utilization of spine surgery in Ontario is 20% to 30% below the Canadian average.41 Meanwhile, data from the Dartmouth Atlas suggest that spine surgery utilization (for spinal stenosis) in New York is well below the US average.42

It is important to consider the role of health system financing and incentives. Although the recent introduction of bundled payments and accountable care organizations may change the economic incentives that have driven exceedingly high utilization of many expensive procedures in the US,18,43 fee-for-service reimbursement remains the dominant model in the US. In New York (and most of the US), fee-for-service reimbursement incentivizes both spine surgeons and hospitals to perform surgery.44 In Ontario (and most of Canada), surgeons are reimbursed on a fee-for-service basis and hospitals operate under global budgets determined largely by historical services and volumes. Any increases in spine surgery volume increase hospital “costs.” As a result, Canadian hospitals have an incentive to minimize spine surgery volumes, typically done through restriction of operating room time for elective cases. Our finding that approximately 55% of New York hospitals but only 25% of Ontario hospitals provide spine surgery reflect fundamental differences in hospital financing and regulation in the US and Canada. Our finding that New York had approximately 75% more spine surgeons per capita than Ontario is also interesting. Due to constraints in the number of spine surgeons and hospital surgical capacity, Ontario patients often wait 6 months or more to see a surgeon and an additional 6 months or more (particularly for fusion) to receive surgery when recommended.45 Given these pressures, Canadian spine surgeons commonly screen incoming referrals carefully, seeing only those patients with pathology on imaging that is most likely to be amenable to intervention.46 We suspect that differences in ability to supply spine surgery is a major factor underlying cross-border differences in utilization rates per capita.

Cognizant of intra- and cross-state variation in utilization and cost of spinal fusion across the US,4 it is important to consider the economic and clinical implications of the different utilization rates that we found. We do not know what the correct or appropriate fusion rate is. However, if we were to assume a desired fusion rate of 8.0 procedures per 10,000 per year (i.e., halfway between that of Ontario (2.4/10,000) and New York (13.7/10,000) (Table 3), patients in New York may be undergoing an excess of six fusion procedures per 10,000 per year. This would amount to 9031 additional spine fusions annually, which at a mean national cost of $27,600 (US) per procedure1 translates to $249,255,600 annually. Alternatively, if we were to assume that utilization of fusion in Ontario should be increased by six procedures per 10,000 per year, this would translate into an additional 6513 fusions annually, which at a mean average cost of $13,000 CDN per procedure, translates to $42,419,169 (CDN).3

A number of other findings warrant brief mention. First, our finding that the higher utilization in New York relative to Ontario was more pronounced in younger patients and less pronounced in older patients is interesting. This likely reflects several issues including patient and provider preference as well as differences in reimbursement between private insurance (more generous) common in younger patients (more generous) relative to Medicare (less generous) in the US; Ontario provincial insurance provides identical reimbursement for patients of any age. From a clinical perspective, older patients and/or surgeons, regardless of geography, may be less likely to choose spinal surgery than younger patients due to perceived or actual increased risk of adverse events.47,48 Second, our finding of significantly lower rates of most comorbid conditions in Ontario likely reflects the intense pressure on US hospitals to completely code all comorbidities---a pressure that does not exist to the same extent in Canada; risk-adjustment including comorbidities in international comparative research using administrative data should consider this carefully. Third, our finding that outcomes in Ontario and New York were similar for elective procedures, but worse in Ontario for emergent procedures warrant further study. Much of the difference in outcomes (e.g., higher mortality in Ontario) appears to have been driven by the lower elective-to-emergent ratio in Ontario than in New York. Another component of the higher mortality in Ontario can be attributed to the longer hospital LOS in Ontario, which, in turn, provided a longer observation period during which in-hospital mortality could occur. The longer hospital LOS in Ontario than New York is consistent with previous Canada-US comparative studies.22 Longer hospital LOS in Canada is related to an array of factors, most importantly a chronic shortage of postacute care and rehabilitation beds that delay discharge.49 Fourth, it is important to comment on differences in hospital volume and percentage of hospitals offering spine surgery: Ontario has a small percentage of hospitals offering spine surgery with higher volumes for decompression; New York has a large percentage of hospitals offering spine surgery and lower volume for decompression. At the same time, both Ontario and New York had a larger number of low-volume hospitals than might be optimal. To the extent that lower volumes have been associated with inferior surgical outcomes,50 our results highlight a potential problem in both jurisdictions. Finally, it is important to consider our work in the context of growing interest in international comparative population-based health services research.22,51 There is growing appreciation that these studies can provide important insights into the tradeoffs inherent to different health care delivery systems.20

Our study has several limitations. First, our analysis is limited to administrative data from one Canadian province and one US state and our results should be interpreted with this perspective. Our analyses should be replicated by comparing different Canadian provinces and US states. Second, our analysis was limited to inpatient spine procedures and did not include outpatient procedures; available data suggest that ambulatory spine procedures are much more common in the US (13–20% of all procedures vs. <5% in Canada) and the result of inclusion of these procedures would likely have been to magnify the already markedly higher US spine surgery utilization rates even further.52–54 Third, our study did not capture New York residents who may have received surgery outside of New York. Fourth, we did not address differences in utilization by diagnosis or surgical indication. Finally, we lacked detailed data on surgical indications including symptoms and imaging in our administrative data.

In conclusion, we found significantly lower utilization of spine surgery in Ontario when compared with New York. The difference in utilization was attributable to less elective fusion surgery, primarily in younger (i.e., non-Medicare) patients. These differences should inform broader spine surgery policy reforms in both jurisdictions.

Supplemental digital content is available for this article. Direct URL citations appearing in the printed text are provided in the HTML and PDF version of this article on the journal's Web site (

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back pain; Canada; decompression; fusion; health services research; spine surgery; United States; variation

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