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# Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014

BMJ Open

BMJ Publishing Group

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### Abstract

##### Objective

To assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA.

##### Design

A retrospective cohort.

##### Methods

The descriptive analysis of the administrative database from Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) master data from 2000 to 2014 was performed. The guidance from Strengthening the Reporting of Observational studies in Epidemiology (STROBE) was applied. Analysis included multiple variables based on the procedures, specialties and geography.

##### Results

Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population.

##### Conclusions

Usage of epidural injections increased from 2000 to 2014, with a decline thereafter. However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections.

### Most cited references39

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### The rising prevalence of chronic low back pain.

(2009)
National or state-level estimates on trends in the prevalence of chronic low back pain (LBP) are lacking. The objective of this study was to determine whether the prevalence of chronic LBP and the demographic, health-related, and health care-seeking characteristics of individuals with the condition have changed over the last 14 years. A cross-sectional, telephone survey of a representative sample of North Carolina households was conducted in 1992 and repeated in 2006. A total of 4437 households were contacted in 1992 and 5357 households in 2006 to identify noninstitutionalized adults 21 years or older with chronic (>3 months), impairing LBP or neck pain that limits daily activities. These individuals were interviewed in more detail about their health and health care seeking. The prevalence of chronic, impairing LBP rose significantly over the 14-year interval, from 3.9% (95% confidence interval [CI], 3.4%-4.4%) in 1992 to 10.2% (95% CI, 9.3%-11.0%) in 2006. Increases were seen for all adult age strata, in men and women, and in white and black races. Symptom severity and general health were similar for both years. The proportion of individuals who sought care from a health care provider in the past year increased from 73.1% (95% CI, 65.2%-79.8%) to 84.0% (95% CI, 80.8%-86.8%), while the mean number of visits to all health care providers were similar (19.5 [1992] vs 19.4 [2006]). The prevalence of chronic, impairing LBP has risen significantly in North Carolina, with continuing high levels of disability and health care use. A substantial portion of the rise in LBP care costs over the past 2 decades may be related to this rising prevalence.
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### An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations.

(2013)
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### Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997-2006.

(2009)
Analysis of nationally representative survey data for spine-related health care expenditures, utilization and self-reported health status. To study trends from 1997 to 2006 in per-user expenditures for spine-related inpatient, outpatient, pharmacy, and emergency services; and to compare these trends to changes in health status. Although prior work has shown overall spine-related expenditures accounted for $86 billion in 2005, increasing 65% since 1997, the study did not report per-user expenditures. Understanding population-level per-user expenditure for specific services relative to changes in the health status may help assess the value of these services. We analyzed data from the Medical Expenditure Panel Survey, a multistage survey sample designed to produce unbiased national estimates of health care utilization and expenditure. Spine-related hospitalizations, outpatient visits, prescription medications and emergency department visits were identified using ICD-9-CM diagnosis codes. Regression analyses controlling for age, sex, comorbidity, and time (years) were used to examine trends from 1997 to 2006 in inflation-adjusted per-user expenditures, and utilization, and self-reported health status. An average of 1774 respondents with spine problems was surveyed per year; the proportion suggested an increase in the number of people who sought treatment for spine problems in the United States from 14.8 million in 1997 to 21.9 million in 2006. From 1997 to 2006, the mean adjusted per-user expenditures were the largest component of increasing total costs for inpatient hospitalizations, prescription medications, andemergency department visits, increasing 37% (from$13,040 in 1997 to $17,909 in 2006), 139% (from$166 to $397), and 84% (from$81 to \$149), respectively. A 49% increase in the number of patients seeking spine-related care (from 12.2 million in 1997 to 18.2 million in 2006) was the largest contributing factor to increased outpatient expenditures. Population measures of mental health and work, social, and physical limitations worsened over time among people with spine problems. Expenditure increases for spine-related inpatient, prescription, and emergency services were primarily the result of increasing per-user expenditures, while those related to outpatient visits were primarily due to an increase in the number of users of ambulatory services.
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### Author and article information

###### Journal
BMJ Open
BMJ Open
bmjopen
bmjopen
BMJ Open
BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
2044-6055
2016
12 December 2016
: 6
: 12
###### Affiliations
[2 ]Department of Anesthesiology and Perioperative Medicine, University of Louisville , Louisville, Kentucky, USA
[3 ]Massachusetts General Hospital , Boston, Massachusetts, USA
[4 ]Harvard Medical School , Boston, Massachusetts, USA
###### Author notes
[Correspondence to ] Dr Laxmaiah Manchikanti; drlm@ 123456thepainmd.com
###### Article
bmjopen-2016-013042
10.1136/bmjopen-2016-013042
5168679
27965254

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

###### Categories
Health Services Research
Research
1506
1704
1710

Medicine