The effect of required physiatrist consultation on surgery rates for back pain

Prospective trial with insurance database and surveys. This study was developed to determine whether an insurer rule requiring physiatrist consultation before nonurgent surgical consultation would affect surgery referrals and surgery rates. Spine surgery rates are highly variable by region and increasing without evidence of a concordant decrease in the burden of disease. Efforts to curb misuse of surgery have not shown large changes, especially across different provider groups. As nonsurgical spine experts, physiatrists might provide patients with a different perspective on treatment options. In 2007, the insurer required patients with nonurgent spine surgical consultations in a geographic region to first have a single visit with a physiatrist, who received extra compensation for the assessment. Surgical consultation and surgical rates results were compared between 2006-2007 and 2008-2010. An automated telephone survey of patients evaluated by physiatrists was performed to assess patient satisfaction. Physiatry referrals increased 70%, surgical referrals decreased 48%, and the total number of spine operations dropped 25%, with concomitant decreased overall cost. Although spinal fusion rates dropped, the percentage of fusion operations increased from 55% to 63% of all surgical procedures. Of 740 patients surveyed (48% response rate), 74% were satisfied or very satisfied with the physiatry consultation. Only 40% of patients who underwent previous spine surgery were satisfied. Although surgical rates decreased at all regional hospitals and all surgical groups, there were substantial shifts in market share. Mandatory physiatrist consultation prior to surgical consultation resulted in decreased surgical rates and continued patient satisfaction across a large region.