A small proportion of high resource utilization patients tend to drive the majority of healthcare spending, and prior literature has explored these patients' characteristics. Medical comorbidities, psychological problems, low socioeconomic status, low educational achievement, worker's compensation, disability, litigation, smoking, and opioid use are associated with worse outcomes and higher costs across multiple medical conditions. In order to better understand resource utilization and costs following lumbar fusion, Jason Lerner and colleagues analyzed the IBM MarketScan database of commercial insurance claims for one and two level lumbar fusions from 2007-2016, which included over 18,000 patients eligible for the study. They used a machine-learning program to identify three clusters of patients based on pre-operative healthcare utilization that were associated with post-operative resource utilization. The largest cluster included 14,000 patients who were normal utilizers pre- and post-operatively. The second cluster included over 4,000 high utilizer patients, who used the most opioids pre-operatively and had the highest medical comorbidity burden. The third and smallest cluster (500 patients) were also high utilizers, though this group's utilization was primarily for mental health resources. Very limited demographic data were included, though the high utilizer groups both had a significantly higher proportion of females compared to the normal utilization group (67% cluster 3, 62% cluster 2, and 54% cluster 1). After controlling for potential confounders, the normal utilization groups overall two-year post-operative costs were significantly less than the high utilization groups ($34,000 cluster 1, $52,000 cluster 2, and $48,000 cluster 3). These cost differences were present both for spine-related and other medical costs.
This paper clearly demonstrated that patients with high pre-operative resource utilization continue to have high post-operative utilization. While this comes as no surprise, it does provide some data that could help identify these patients pre-operatively and potentially develop approaches to help address their high utilization. Like most administrative database studies, this study has significant limitations. One major limitation is that other patient characteristics known to affect utilization (i.e. psychosocial problems, socioeconomic status, worker's compensation, etc.) were not included in the database and may have been strong predictors of post-operative utilization. Additionally, those characteristics may be much easier to identify than prior resource utilization. While the authors suggested that prior utilization would be easy to identify, many patients see spine surgeons at referral centers who do not have access to their outside records and may be completely unaware of their resource utilization. Their insurance provider does have these data and could make them available to their surgeon, though this would require more complex communication than is currently the norm. Additionally, the database included no information on patient reported outcomes. While prior literature would suggest that the high utilizers likely had worse outcomes overall, they also likely improved more with surgery than they would have with non-operative treatment. The spine surgery community must be careful with data like these as payors and administrators can use them to identify high resource utilizers and create policy that limits their access to care. These high utilizers tend to be our most vulnerable patients who are in the most need of care, and we must be careful not to create any more barriers for them. Instead, we must work to create ways to mitigate the negative effects of their characteristics on outcomes and resource utilization. That is no small task and likely requires addressing major societal issues.
Please read this article in the January 15 issue. Does this change how you consider surgical decision making or post-operative care in the high resource utilization population? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor