With the United States presidential campaign ramping up, there has been much debate about healthcare system design and policy. The United States continues to have a system that is predominantly fee for service, funded through private and government insurance, while most other nations with advanced economies fund healthcare primarily through the government with various forms of capitation or rationing. Canada has a government insurance program that pays hospitals a capitated rate to care for a population based on historical data and pays surgeons with a fee for service model. In order to better understand the effects of these systems on large-scale care patterns, Dr. Cram and a team of researchers from Toronto and Boston analyzed the Ontario and New York state administrative databases in order to compare spine surgery rates, characteristics, and outcomes. Ontario and New York have similar populations with similar demographic characteristics. The number of spine surgeons per capita is 73% higher in New York than in Ontario, and New York has 36% more hospitals. Only 15% of Ontario hospitals perform spinal fusion compared to 57% of New York hospitals. The overall rate of spine surgery was 2.5-fold higher in New York (16.5/10,000 vs. 6.6/10,000). Interestingly, the rate of elective decompression without fusion was higher in Ontario (3.1/10,000 vs. 2.1/10,000), while the rate of elective fusion surgery was over 5-fold higher in New York (12.5/10,000 vs. 2.4/10,000). In fact, 88% of elective spinal surgeries in New York included a fusion compared to 53% in Ontario. Rates of emergent surgeries were similar for the two jurisdictions. The average age of a surgery patient in New York was 8 years younger for decompression alone (51 vs. 59) and 3 years younger for fusion (55 vs. 58). Unadjusted length of stay and in-hospital mortality were higher in Ontario, though the mortality difference was no longer significant after controlling for patient characteristics.
This paper paints a picture of two markedly different healthcare systems with very different approaches to spinal surgery. While some of the differences may be attributable to coding variations in the two databases (i.e. the much higher rate of comorbidities in the New York cohort), basic statistics like rates of surgery are most likely fair to compare between the two. The much higher rate of elective fusion surgery, especially in patients under age 60, is what drove most of the difference. While the incidence of spinal pathology is likely similar between Ontario and New York, almost 90% of spinal surgery involved fusion in New York (compared to about 50% in Ontario), indicating that New York surgeons are much more enthusiastic about fusion than their neighbors to the North. The proportion of cases involving fusion may be artificially elevated in New York due to many patients undergoing discectomy and one level laminectomy as outpatients, though this likely does not account for the entire difference. The article begs the question about the "right" rate of spinal surgery and spinal fusion. No one knows the answer to that question or even what methodology could be used to determine the answer. In a society with limitless resources, the answer might be the rate that leads to maximization of utility (i.e. the best patient outcomes). In the real world with economic constraints, it might be the rate that maximizes value (i.e. utility/cost). Others have defined the optimal rate as that which would exist if patients were truly informed about their options and likely outcomes and came to their treatment decision through excellent shared decision making. It is unlikely that either Ontario or New York have the "right" rate, as their rates seems to be largely determined by characteristics of their healthcare systems rather than disease characteristics or patient preferences. As nations debate how to best structure their health systems, they should consider the differences between systems illustrated by papers like this.
Please read Dr. Cram's article on this topic in the October 1 issue. Does this change how you view the Canadian and American healthcare systems? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor