Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study

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Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study Y. Raja Rampersaud MD , J. Denise Power PhD , Anthony V. Perruccio PhD , J. Michael Paterson MSc , Christian Veillette MD, MSc , Peter C. Coyte PhD , Elizabeth M. Badley PhD , Nizar N. Mahomed MD, ScD PII: DOI: Reference:

S1529-9430(20)30041-3 https://doi.org/10.1016/j.spinee.2020.01.013 SPINEE 58103

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The Spine Journal

Received date: Revised date: Accepted date:

11 September 2019 27 January 2020 27 January 2020

Please cite this article as: Y. Raja Rampersaud MD , J. Denise Power PhD , Anthony V. Perruccio PhD , J. Michael Paterson MSc , Christian Veillette MD, MSc , Peter C. Coyte PhD , Elizabeth M. Badley PhD , Nizar N. Mahomed MD, ScD , Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study, The Spine Journal (2020), doi: https://doi.org/10.1016/j.spinee.2020.01.013

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Healthcare utilization and costs for spinal conditions in Ontario, Canada - opportunities for funding high-value care: a retrospective cohort study Authors: Y. Raja Rampersaud1,2, MD; J. Denise Power1, PhD; Anthony V. Perruccio1,3, PhD; J. Michael Paterson3,4, MSc; Christian Veillette1,2, MD, MSc; Peter C. Coyte3, PhD; Elizabeth M. Badley1,5, PhD; Nizar N. Mahomed1,2, MD, ScD Affiliations: 1. Arthritis Program, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada 2. Orthopaedics, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; 3. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 4. ICES, Toronto, Ontario, Canada 5. Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. Corresponding Author: Y. Raja Rampersaud Toronto Western Hospital, University Network 399 Bathurst Street, East Wing, 1st Floor, Room 1-441 M5T 2S8 Toronto, Ontario, Canada (416) 603-5800 ext. 5252 Email: [email protected]

Funding: This study was financially supported by the Toronto General & Western Hospital Foundation through the University Health Network Arthritis Program. The funding source had no involvement in study design or manuscript preparation. Acknowledgements: This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. Parts of this material are based on data and information compiled and provided by CIHI. The analyses, conclusions, opinions and statements expressed herein are those of the authors and not those of the funding or data sources; no endorsement is intended or should be inferred.

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Abstract

Background Context: An important step in improving spinal care is understanding how current healthcare resources and associated cost are being utilized and distributed across a healthcare system. Purpose: Our objective was to examine the magnitude and distribution of direct healthcare costs for spinal conditions across physician type and hospital setting. Design/Setting: Cross-sectional analysis of administrative health data for the fiscal year 20132014 from the province of Ontario, Canada. Patient Sample: Adult population aged 18+ years (N=10,841,302) Outcome Measures: Person visit rates and total number of people and visits by specific care settings were calculated for all spinal conditions as well as stratified by non-trauma and traumarelated conditions. Variation in rates by age and sex was examined. The proportion of patients seeing physicians of different specialties was calculated for each condition grouping. Direct medical costs were estimated and their percentage distribution by care setting calculated for nontrauma and trauma-related conditions. Additionally, costs for spinal imaging overall and stratified by type of scan were determined. Methods: Administrative health databases were analyzed, including data on physician services, emergency department visits and hospitalizations. ICD-9 and -10 diagnostic codes were used to identify non-traumatic (degenerative or inflammatory) and traumatic spinal disorders. A validated algorithm was used to estimate direct medical costs. Results: Overall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions; the majority (1.1 million) of these visits were for non-trauma conditions. Approximately, 86% of outpatient visits were in primary care. Emergency Department (ED) visits for non-trauma spinal conditions (130,000 out of 156,000 ED visits) accounted for 2.8% of 2

all ED visits in the province. Total costs for spine-related care were $264 million (CDN) with 64% of costs due to non-trauma conditions. For these non-trauma conditions, ED visits cost $28 million for 130,000 visits ($215 per visit). For $32 million spent in primary care, 890,000 visits were made ($36 per visit). Spine imaging costs were $66.5 million, yielding a combined total of $330 million in health care spending for spinal conditions. Conclusions: Spinal conditions place a large and costly burden on the healthcare system. The disproportionate annual cost associated with ED visits represents a potential opportunity to redirect costs to fund more clinically and cost-effective models of care for non-traumatic spinal conditions.

Keywords: spine, trauma, non-trauma, back pain, emergency medicine, primary care, health care utilization, costs

Introduction Spinal conditions are among the most prevalent, disabling and costly disorders globally. Estimates suggest that the global prevalence of low back pain (LBP) specifically is approximately 9% at any given point in time. LBP is the number one cause of years lived with disability, as well as a leading cause of visits to family physicians. (1-4) The economic burden of spinal conditions is significant and includes indirect costs due to lost work productivity and direct medical costs associated with the use of health care services. Dieleman et al (5) reported that LBP and neck pain accounted for the third largest fraction of health care spending in the United States, after diabetes and ischaemic heart disease, at $87.6 billion in 2013. Despite large increases in spine related healthcare spending over time, no incremental benefits in mental health, physical functioning and work and social limitations have been demonstrated.(6) 3

There is a globally recognized critical need for high quality, (7) value-based spine care that will be amplified in the coming years by the increasing prevalence of spinal-based pain in the aging population. (6, 8-13) Recent reviews (13-15) continue to highlight several areas of spinal care described as “low-value” health services, or services that provide little to no benefit or cause harm (16), including the inappropriate use of diagnostic imaging and surgical interventions. The 2018 Lancet series on LBP has provided a compelling “call for action” that requires system wide transformation of how patients, providers, payers and society in general approach the management of LBP.(7, 13, 17) However, the need for active implementation of best practices and regionally appropriate integrated models-of-care requires sustainable funding. From a system perspective, an important first-step in transforming spinal care is a clear understanding of how services are currently being used. At present there are only very limited Canadian data on healthcare utilization (HCU) and the direct care costs for spinal conditions. Accordingly, we set out to develop an understanding of how spinal care services and associated costs are distributed across the healthcare system in Canada’s most populous province, Ontario. Secondarily, we sought to identify opportunities where cost could be redirected from potentially low-value care to high-value care for LBP.

Material and Methods Study Design, Setting and Patients A population-based cohort study of administrative health data from April 1 2013 to March 31 2014 in Ontario, Canada, for adults aged 18 years and older (N= 10,841,302) was undertaken. The Ontario Ministry of Health and Long-term Care provides publicly-funded, universal

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coverage for medically necessary hospital, diagnostic and physician services without the use of co-payments. Over 90% of Ontario physicians are paid on a fee-for-service basis or submit shadow bills.(18, 19)

Data Sources Tables 1 and 2 list the databases and diagnosis codes used to identify the health service encounters under study, respectively. Ambulatory physician visits were identified in the Ontario Health Insurance Plan (OHIP) Claims History Database by the fee code provided on the physician claim. Physician claims to OHIP require a single diagnosis code reflecting the main reason for the physician consultation. An ambulatory visit was defined as one claim per patient per diagnosis per service date. Hospital-based care for spinal conditions was identified as the most responsible diagnosis (the diagnosis most responsible for the patient’s hospital stay or visit) in the Discharge Abstract Database (in-patient hospitalizations) or National Ambulatory Care Reporting System (day surgery, emergency department (ED)). Diagnosis codes were selected and grouped into non-trauma and trauma-related spinal conditions (Table 2) based on previous research (20, 21) and to provide the opportunity to differentiate care acuity.

Health care utilization Person-visit rates were defined as the number of persons with at least one visit coded for the spinal condition grouping of interest. These rates were calculated per 1,000 population for ambulatory care and per 100,000 population for hospital care. We computed total, age- and sexspecific ambulatory care visit rates and total number of visits and persons receiving care for each spinal condition category for Ontario as a whole. For each group, we computed the percentage

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of individuals with at least one ambulatory visit according to physician specialty. For hospital care, total number of ED visits and person-visit rates stratified by hospital setting were determined.

Spinal imaging claims were identified using specific fee codes for spine-specific x-ray, computerized tomography (CT) and magnetic resonance imaging (MRI) scans for individuals who had a musculoskeletal-related ambulatory care visit in 2013/14. The total number of spinal imaging exams and associated costs were calculated overall and by type of scan. The percentage distribution of costs by scan type was determined.

Health care costs Total direct costs for ambulatory and hospital care were computed for all spinal conditions combined, as well as for the groupings of non-trauma and trauma-related conditions. The percentage distribution of costs by care setting was calculated for these two groups. Costs were estimated using the methods described by Wodchis et al.(22) Briefly, fees for services rendered by physicians paid on a fee-for-service (FFS) basis were as recorded in the OHIP Claims History Database. Services rendered by physicians who were paid via capitation or other blended methods but who ‘shadow’ bill were assigned the mean fee paid to FFS physicians for the same service. Payments to salaried physicians and those under alternative payment plans that do not shadow bill, which vary widely in number according to specialty but represent roughly 5-10% of physicians overall,(19) were not included.

Non-physician ED costs were estimated by assigning patients to Comprehensive Ambulatory Classification System (CACS) groups, each of which is assigned an individual resource intensity 6

weight reflecting the average resource utilization for each CACS group relative to the average patient. A similar approach was used for both same-day surgery and acute inpatient care. However, in the latter case, patients are assigned to specific Case Mix Groups based upon the patient’s age, major diagnoses (comorbidities), procedures and interventions. Costs for hospital stays that began before or extended beyond the study period were prorated according to the portion of the hospital stay within the study period. As with emergency service costs, costs related to surgeon services rendered during same-day surgery or hospital-based physician services are not included in the estimated costs per weighted case, as these are paid directly to physicians and surgeons through OHIP claims, as described above.

Costs for imaging include both technical and professional (physician) fees in outpatient clinic settings. Imaging costs conducted in hospitals do not include technical costs, as these are included in hospital global budgets that are not billed to OHIP. Results Overall, 822,000 adult Ontarians (7.6%) made 1.6 million outpatient physician visits for spinal conditions in 2013-2014 (Table 3). Approximately 1.1 million of these visits (69%) were for non-trauma related conditions, with 5.3% of the adult population making at least one physician visit for conditions such as spinal stenosis and lumbar strain. Visits for spinal strains and sprains were made by 2.8% of the population. Person visit rates for all spinal conditions combined were 14% higher in women than men.

Overall, 86% of outpatient visits for all spinal conditions were in primary care (Table 4), accounting for 3.4% of all primary care visits for any reason in the province. For non-trauma conditions, approximately 12% of people with at least one physician visit for this group of 7

conditions saw a medical specialist such as a rheumatologist (3.7%) at least once, and 6.3% saw a surgeon at least once.

Non-ambulatory care setting person visit rates for all spinal conditions combined were higher in EDs than day surgeries and inpatient hospitalizations (Table 5). In total, there were 156,000 ED visits for spinal conditions, with 130,000 (83%) of these visits being for non-trauma related conditions specifically. Spinal conditions were responsible for 3.4% of all ED visits for any cause in Ontario. Non-trauma spinal conditions specifically accounted for 2.8% of all ED visits, with approximately 1% of the adult Ontario population going to an ED in 2013-2104 for care for one of these conditions. Hospital care for strains/sprains was primarily in the ED, whereas spinal fractures and dislocations resulted in both ED visits and inpatient hospitalizations.

Estimated direct costs for health care for all spinal conditions, considering ambulatory and hospital care were $263,700,000 (CDN), with 64% of costs ($168,100,000) due to non-trauma conditions. Figures 1 and 2 illustrate how these costs were distributed across care setting for nontrauma and trauma-related spinal conditions, respectively. For both groups, the majority of costs were due to inpatient hospitalizations. It is notable that for non-trauma conditions, total costs due to ED and primary care were quite similar, with these settings responsible for 17% ($28,100,000) and 19% ($31,600,000) of costs, respectively. These similar cost totals are associated with very dissimilar patient visit volumes. For instance, the ED costs were associated with 130,000 patient visits while the primary care costs were associated with 890,000 visits (Tables 3 and 4). This translates to per visit cost estimates for non-trauma spinal conditions of $215 in the ED versus

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$36 in primary care. Furthermore, as ED cost estimates include direct hospital costs only (i.e. fees paid to physicians are not included), total ED costs are in fact higher than reported here.

Among individuals who made musculoskeletal-related ambulatory physician visits, there were a total of 927,000 spinal imaging exams: 467,000 x-ray, 128,000 CT and 332,000 MRI scans. Total costs for these scans were $66,500,000, with just over half the total costs (Figure 3) attributed to MRI scans. Adding the costs associated with spinal imaging to that for spine-related physician and hospital care yields an aggregate estimate of $330,200,000 in health care spending on spinal conditions. Discussion Our study presents a unique comprehensive look at HCU and associated costs for spinal conditions in a single payer health care system. We found that nearly 8% of the adult Ontario population made 1.6 million spine related outpatient physician visits, the vast majority of which were in primary care. Total costs for spine-related visits were $264 million, with 64% of costs due to non-trauma conditions. Including spinal imaging, the total estimated direct costs were $330 million.

The majority (71%) of the cost for trauma related spine care results from inpatient care for a small proportion of patients who typically require urgent care that has not been under scrutiny for appropriateness. Approximately, half of costs for non-trauma spinal conditions were due to hospitalizations, the majority of which is related to surgical intervention. Complimentary work from our centre demonstrated that utilization of spine surgery for non-emergent conditions in

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Ontario was 3.5 times lower than New York state. (23) Although the overutilization of surgery for LBP is a concern in healthcare systems such as the US (13, 14) the current challenges with spine surgical access in Canada are more consistent with underutilization.(23, 24) The other half of costs for non-trauma spinal care was near equally dominated by primary and ED care. LBP is a common presenting complaint in the ED in Canada, ranking 4th of all complaints among adults aged 19-64 years and 9th for adults aged 65+ years.(25) However, low-value care such as the misuse and overuse of pharmacology and non-indicated imaging are associated with ED visits for LBP.(15, 26) A report by Bellan et al. (27) noted that LBP accounted for 57% of ED visits for non-traumatic musculoskeletal disorders. A chart review revealed that the vast majority (88%) of these back pain patients were considered non-urgent and could have been dealt with in primary care. In our study, 83% of the ED visits were for non-traumatic conditions. While a chart review was not possible, the available literature suggests that the prevalence of serious underlying pathology in non-traumatic LBP is well below 10%. (13, 14, 28) Consequently, we feel it is reasonable to infer that a significant majority of non-traumatic ED spine visits in Ontario could be managed in primary care. Without evidence to suggest better outcomes relative to primary care, (15, 26) our finding of a 6 times greater per visit cost in the ED relative to primary care, coupled with a relatively high utilization of the ED, points to a possible area for policy change. For example, in Ontario non-emergent ED visits could be averted or redirected by funding service expansion of the recently implemented inter-professional, integrated care, rapid access clinics for LBP (www.isaec.org).(29-33) These clinics utilize a shared-care model of care in which patients receive a standardized low back assessment, including determination of psychosocial risk factors, by an Advanced Practice Provider (specially trained physiotherapists or chiropractors) within 4 weeks of referral from their primary care provider. Providers deliver

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best practice education and management recommendations for both the patient and their primary care provider as well as create patient specific evidence-based self-management plans. Structured follow-up is provided and, when indicated, providers can recommend appropriate diagnostic imaging and refer patients on for a consultation with a spine specialist.

Imaging for spinal conditions, particularly LBP without red flags, has been deemed a key area of low-value care across the spectrum of primary to specialty care in Canada (34, 35) and elsewhere. (13, 14) In 2013, Busse et al.(34) reported that the total cost of spinal imaging in Ontario (x-ray, CT, MRI) had risen 55% over 10 years from $40.4 million in 2001/2002 to $62.6 million in 2010/2011. Our findings for 2013/2014 of $66.5 million is consistent and in keeping with the continued rise in MRI utilization. Furthermore, there is an overlap between low-value spinal ED visits and imaging, wherein there exists significant over-use of inappropriate spinal imaging in the ED.(15, 26) We found that MRIs accounted for just over half of spinal imaging costs, yet it is estimated that half of the spinal MRIs in Ontario are inappropriate and of lowvalue. (36, 37) Inter-professional models of care as noted above have also demonstrated the ability to improve quality of care and significantly reduce utilization of inappropriate diagnostic imaging for LBP. (29, 38-40)

Although the use of administrative data facilitated our work, it is also associated with some limitations. Diagnosis codes collected for administrative purposes may not accurately reflect clinical diagnoses. For estimates associated with hospital care, we only considered diagnoses coded as “the most responsible diagnosis”. Our estimates of spinal care are therefore underestimates. Similarly, as only a single diagnosis code can be entered on OHIP physician

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claims, some spinal diagnoses may have been missed. Although shadow bills were considered in our analyses, care delivered by salaried physicians and under alternative payment plans were not included. The number of these physicians varies widely by specialty and care setting, but represents roughly 5-10% of physicians overall. (19) Imaging costs underestimate the total costs associated with spinal imaging, as they do not include technical fees associated with imaging in hospitals. The considered data sources do not include uninsured or non-physician health services including allied health services such as chiropractic services. Our study is limited to direct costs only and does not include expenditures to operate the health care system or capital costs. (22) Further, our findings are based on the perspective of the ministry of health in a single Canadian province. Previous work suggests that ambulatory health care utilization for spinal conditions may be higher in other provinces.(20) Although the reasons behind this are unclear, it is likely influenced by variations in coding practices. The generalizability of our findings to jurisdictions with different models of health care delivery may also be limited.

The findings of our study underscore the significant burden on the Ontario healthcare system attributed to spinal conditions, and point to a potential avenue for both improved spinal care and cost savings. Specifically, the disproportionate cost associated with ED visits represents a potential opportunity to redirect costs to more clinically and cost-effective models of care for non-traumatic spinal conditions. Future work to better characterize the patient population using the ED, as well as their patterns of use, are needed to further inform the development of these models.

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37. Kennedy SA, Fung W, Malik A, Farrokhyar F, Midia M. Effect of governmental intervention on appropriateness of lumbar MRI referrals: a Canadian experience. J Am Coll Radiol. 2014;11(8):802-7. 38. Rampersaud R, Bidos A, Schultz S, Fanti C, Young B, Drew B, et al. Ontario’s Inter-professional Spine Assessment and Education Clinics (ISAEC): Patient, provider and system impact of an integrated model of care for the managementof LBP. Can J Surg. 2016;59(3):S39. 39. Kim JS, Dong JZ, Brener S, Coyte PC, Rampersaud YR. Cost-effectiveness analysis of a reduction in diagnostic imaging in degenerative spinal disorders. Healthc Policy. 2011;7(2):e105-21. 40. Ministry of Health and Long-term Care. Quality-Based Pathway Clinical Handbook for NonEmergent Integrated Spine Care. 2017.

3.4%

Ambulatory -Primary Care

18.8%

Ambulatory - Specialist 8.2%

ED

52.9%

Hospital Inpatient

16.7%

Day Surgery

Figure 1 - Percentage distribution of direct costs for non-trauma spinal conditions, by care setting* *

Total costs for non-trauma spinal conditions were $168,100,000. This total does not include imaging-related costs which are presented separately in Figure 3.

16.3%

70.9%

9.3%

3.5%

Ambulatory -Primary Care Ambulatory - Specialist ED Hospital Inpatient

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Figure 2 - Percentage distribution of costs for trauma-related spinal conditions, by care setting* * Total costs for trauma-related spinal conditions were $95,600,000. This total does not include imaging-related costs which are presented separately in Figure 3. Percentage distribution of costs for day surgery are not included as estimate is <1%.

35.6%

X-ray CT scan

52.9%

MRI 11.3%

Figure 3- Percentage distribution of costs for spinal imaging, by type of imaging* *

Total costs for spinal imaging were $66,500,000.

Table 1 – Data sources Database Ontario Health Insurance Plan (OHIP) Claims History Database OHIP Registered Person Database (ORPD) ICES Physician Database (IPDB) Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD) CIHI National Ambulatory Care Reporting System (NACRS)

Information provided Diagnoses and service fee codes for in- and outpatient physician services Patient age, sex, place of residence, insurance coverage status, vital status Physician specialty Diagnoses and procedures for inpatient hospitalizations Diagnoses for emergency department encounters; diagnoses and procedures for day surgery

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Table 2: Diagnosis codes for spinal conditions* Ambulatory Care – OHIP diagnosis codes (ICD-9 based)† All spinal conditions

Condition groupings Sero-negative spondyloarthropathies; Non-trauma invertebral disc disorders; lumbar strain, lumbago, coccydynia, sciatica Trauma-related

Diagnosis codes

721; 722; 724; 737

Strains/sprains

847

Fractures/dislocations

805; 806

Hospital Care – ICD-10 diagnosis codes‡ All spinal conditions Non-trauma

Deforming dorsopathies, spondylosis, other dorsopathies; Spinal stenosis, ankylosing hyperostosis, other spondylopathies

M40-M43, M47, M49-M54; M48.0-M48.3, M48.8-M48.9

Trauma-related

Strains/sprains

S13.4-S13.5, S23.3, S33.5S33.7

Fracture/dislocation

S13.0-S13.3, S23.0-S23.2, S33.0-S33.3, S12, S22.1, S32, T02.1, T02.7, T08

Dislocations/sprains/strains

T03.1

*

Spinal tumors and infections were not included. The classification scheme used in the OHIP database is based on a subset of 3-digit codes adapted from the International Classification of Diseases, 9th Revision (ICD-9). OHIP claims include only a single diagnosis code per physician visit. ‡ Databases for hospital care (The Discharge Abstract Database, National Ambulatory Care Reporting System database) use the full range of diagnosis codes from the ICD-10. The “most responsible diagnosis” was used to identify care for spinal conditions. †

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Table 3: Ambulatory care utilization for spinal conditions overall, by age group and by sex, Ontario, Canada, 2013-2014 # persons (thousands )

# visits (thousands )

822

1 557

Non-trauma

572

1 073

Strains/sprains

308

471

7

14

Condition group All spinal conditions

Fracture/dislocation

Person visit rate per 1000 population* 18- 45Wome Me All 44 64 65+ n n 60. 90. 86. 75.8 80.7 70.7 2 3 6 38. 64. 65. 52.8 55.2 50.2 6 4 3 26. 32. 25. 28.4 31.0 25.5 0 8 8 0.7 0.3 0.6 1.7 0.7 0.7

*

Person visit rate is defined as the number of persons with at least one visit coded for the condition grouping of interest per 1,000 population.

Table 4: Primary and specialist care utilization for spinal conditions, Ontario, Canada, 2013-2014 Percentage of people with at least one visit to a physician of % of all # of indicated specialty* ambula primar Medical Specialists Surgical Specialists tory y care Neur visits in visits Orthop o (thousa primar Condition Primary Al Rheumatol Physiat Al edic surge nds) y care group Care l ogist rist l surgeon on All spinal 10 5. 1 333 85.6 91.2 2.7 2.9 3.1 2.4 conditions .0 6 11 6. Non-trauma 890 83.0 88.3 3.7 2.8 3.5 2.7 .9 3 5. 2. Strains/sprains 437 92.7 94.0 0.1 2.5 1.3 1.1 0 5 Fracture/dislo 12 45 6 42.6 48.4 0.3 6.7 28.5 17.1 cation .3 .5 *

The sum of percentages for a given condition is greater than 100% as an individual can consult more than one type of physician during the study year.

Table 5: Hospital care for spinal conditions*, Ontario, Canada, 2013-2014 # of ED Person visit rate per 100,000 population** visits (thousands Emergency Hospital Day Condition group ) department Inpatient Surgery All spinal conditions 156 1237.8 121.0 26.6 Non-trauma 130 1031.6 80.4 26.5 Strains/sprains 17 151.0 0.5 0.0 Fracture/dislocation 8 71.0 40.5 0.0 Dislocations/sprains/strain 0.6 5.8 0.0 0.0 s *

The “most responsible diagnosis” code was used to classify patients into the condition groups of interest Person visit rate is defined as the number of persons with at least one visit coded for the condition grouping of interest per 100,000 population. **

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