Practice Variation Among Surgeons Treating Lumbar Spinal Stenosis in a Single Institution

Spine (Phila Pa 1976). 2019 Apr 1;44(7):510-516. doi: 10.1097/BRS.0000000000002859.


Study design: A retrospective study.

Objective: The aim of this study was to examine practice variation in the treatment of lumbar spinal stenosis and identify targets for reducing variation.

Summary of background data: Lumbar spinal stenosis is a degenerative condition susceptible to practice variation. Reducing variation aims to improve quality, increase safety, and lower costs. Establishing differences in surgeons' practices from a single institution can help identify personalized variation.

Methods: We identified adult patients first diagnosed with lumbar spinal stenosis between 2003 and 2015 in three hospitals of the same institution with ICD-9 codes.We extracted number of office visits, imaging procedures, injections, electromyographies (EMGs), and surgery within the first year after diagnosis; physical therapy within the first 3 months after diagnosis. Multivariable logistic regression was used to identify factors associated with surgery. The coefficient of variation (CV) was calculated to compare the variation in practice.

Results: The 10,858 patients we included had an average of 2.5 visits (±1.9), 1.5 imaging procedures (±2.0), 0.03 EMGs (±0.22), and 0.16 injections (±0.53); 36% had at least one surgical procedure and 32% had physical therapy as part of their care. The CV was smallest for number of visits (19%) and largest for EMG (140%).Male sex [odds ratio (OR): 1.23, P < 0.001], seeing an additional surgeon (OR: 2.82, P < 0.001), and having an additional spine diagnosis (OR: 3.71, P < 0.001) were independently associated with surgery. Visiting an orthopedic clinic (OR: 0.46, P < 0.001) was independently associated with less surgical interventions than visiting a neurosurgical clinic.

Conclusion: There is widespread variation in the entire spectrum of diagnosis and therapy for lumbar spinal stenosis among surgeons in the same institution. Male gender, seeing an additional surgeon, having an additional spine diagnosis, and visiting a neurosurgery clinic were independently associated with increased surgical intervention. The main target we identified for decreasing variability was the use of diagnostic EMG.

Level of evidence: 3.

MeSH terms

  • Adult
  • Aged
  • Costs and Cost Analysis
  • Diagnostic Imaging / statistics & numerical data
  • Electromyography / statistics & numerical data
  • Female
  • Humans
  • Injections, Spinal / statistics & numerical data
  • Lumbar Vertebrae
  • Male
  • Middle Aged
  • Neurosurgery / statistics & numerical data
  • Office Visits / statistics & numerical data
  • Orthopedic Procedures / statistics & numerical data*
  • Orthopedics / statistics & numerical data
  • Physical Therapy Modalities / statistics & numerical data
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Referral and Consultation
  • Retrospective Studies
  • Sex Factors
  • Spinal Stenosis / diagnostic imaging*
  • Spinal Stenosis / therapy*