Evidence-based medicine, properly applied, is an important aspect of the current healthcare landscape, and spine surgeons must take a more active approach to research and advocacy for future development and coverage in their field. "The most important thing is for surgeons to become involved in advocating for what we do," says Frank Phillips, MD, a Professor of Orthopaedic Surgery at Rush University Medical Center and a founding surgeon of the Minimally Invasive Spine Institute at Midwest Orthopaedics at Rush. "Although surgeons are busy running their practices and fighting the everyday battle in the trenches, leaving policy decisions and advocacy initiatives to others is allowing those without clinical expertise to define how we practice. We need to get surgeons involved to really make changes in the way healthcare decisions are made."
Here are five steps for spine surgeons to proactively influence spine care policy in the future.
1. Reframe the debate to focus on appropriate real world treatment comparisons. Payors and policy makers have suggested that Level 1 data proving the effectiveness of prescribed treatments is the only evidence that counts. Evidence-based medicine has been misconstrued to mean a reliance on RCTs only, when, in fact, "the practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research," says Dr. Phillips. "Evidence based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions. We need to define which treatments work best for which patients."
In the effort to try and cut costs, there has been an insistence that surgery be compared to "less costly" non-surgical treatment. "This comparison often has no clinical meaning as these should not be viewed as ‘competitive’ treatments," says Dr. Phillips. "For most degenerative conditions, surgery should be reserved for a select group of patients that have failed conservative treatment. To compare surgery to conservative treatments the patients have already failed makes little clinical sense."
This problem explains the high cross-over rates seen in the SPORT study as patients are unwilling to continue to be randomized to conservative treatment that they have already failed.
"Also studies comparing surgery to non-surgical treatment are frequently criticized by 'ivory tower' statisticians because of a lack of blinding," says Dr. Phillips. "It's clearly not possible to blind patients or the surgeons to the treatment received. Spine surgery trials should not be held to a standard they can never meet, or so-called evidence-based medicine will have failed patients by artificially creating barriers to care due to methodological constraints."
2. Emphasize the quality data that does exist. Over the past decade the spine community has published studies supporting not only the effectiveness but also the value of many surgical procedures. The Spine Patient Outcomes Research Trials, which are high-level, multi-center studies examining the effectiveness of spinal treatments have supported the value and effectiveness of surgery for specific diagnoses. The body of evidence must be used to challenge the non-transparent guidelines provided by for-profit companies to the insurance industry.
The recent AHRQ draft report challenges the quality of evidence supporting spinal fusion for a variety of degenerative conditions, but Dr. Phillips argues that quality data does exist. Spine surgeons need to bring quality and cost-effectiveness studies we have done to the forefront and defend procedures that help their patients every day.
"I think we do have good evidence for a lot of surgeries that we do and as a spine community, we have to advocate for ourselves using the evidence we have," says Dr. Phillips. "Spine surgeons in all practice settings can participate in data collection and clinical trials that will impact the field. It's no longer an excuse to say research is up to the universities. All spine surgeons need to proactively collect data. If we don't all get on board with studies proving value in what we do and advocating for effective treatments, we are going to be run over."
3. Advocate priorities to spinal organizations. National spine organizations remain influential advocates for spinal surgery. Spinal organizations play a prominent role in advancing spinal health policy across the country.
"The dues paying members of these organizations must ensure that their views and concerns are adequately represented by these organizations "Instead of just giving money to the organizations, spine surgeons should let the leaders know what they expect of them,” says Dr. Phillips
4. Become involved with decision makers. Often spine surgeons have access to elected government official and they should not be afraid to leverage these relationships.
"Our elected officials are inundated with medical information and sometimes misinformation, and may be dealing with a lot of competing agendas," says Dr. Phillips. "Oftentimes, it's a question of explaining the issues; they are usually receptive to learning more about issues that directly affect patients."
5. Patients are our most powerful advocates. New payor guidelines are being developed across the country based on cherry-picked data that isn't always representative of the evidence base. "We should all be very aggressively fighting these guidelines that aren't evidence-based or transparent," says Dr. Phillips. "These are just an excuse to deny patients care. This requires is a public relations effort — we need all stakeholders to be made aware that the guidelines are arbitrary with little input from clinicians treating patients with spinal disorders."
One of the most powerful advocacy tools surgeons have is their patients. "We have to channel patients," says Dr. Phillips. "Every surgeon has patients with success stories and we need to get this message out. We need to learn from other patient advocacy organizations such as the Arthritis Foundation and the National Osteoporosis Foundation who have been very influential. The International Society for the Advancement of Spine Surgery recently launched an advocacy arm that includes spine professionals as well patients. One of the goals is to make patients spine care advocates. Policy makers and elected government officials tend to listen closely to what patients have to say."
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