I am a hospital administrator who has recently switched from a VA hospital to a nonprofit acute care hospital. When I was at the VA there was an investigation into the overuse of spinal injection procedures. As a result, there were big cuts in reimbursement and stricter guidelines for that treatment. Now that I’m in the private sector, I thought it would be a good idea to see if similar problems are occurring here. Have there been any reports about this that you know of?

You are exactly right that studies have shown Medicare and VA (Veterans Administration) patients receive a large number of spinal injection procedures. Spinal injections are used for people with back pain that has not improved with conservative care.

Such injections include epidural steroid injections, nerve blocks, radiofrequency neurotomy (heat nerves to stop pain transmission), sacroiliac injections, and discography (injecting dye into the disc to look for disc protrusion or herniation).

There is a concern about this pattern of overuse because research does NOT support this treatment as an effective way to manage back pain. And in the case of spinal injection treatment, more is not better. In other words, if the first three injections didn’t help, further injection therapy isn’t likely to benefit the patient either.

In studies of Medicare and VA patients, the majority of spinal injection procedures were being done by a small number of medical specialists. Anesthesiologists, neurologists, and physicians at specialty pain clinics were the ones most likely to be giving these injections. And the top 10 per cent of providers were responsible for one-third of all spinal injections.

You are not alone in wondering about the use of spinal injections in the private sector. As a result of reports of overutilization of spinal injections, a new study was set into motion. Researchers at the University of Colorado School of Medicine looked for similar patterns of overutilization among privately insured adults.

They found similar patterns of overuse by using data entered into a central database for privately insured adults between the ages of 18 and 99. Billing codes were used to calculate how many of each type of spinal injection were given to each patient over a 12-month period of time.

Ten per cent of all injections were given by the same providers (neurologist and pain management specialists). This group of physicians did nine times as many procedures per patient than providers in the lowest 10 per cent group. And more than half of all spinal injection procedures were done by 20 per cent of the providers who did these kinds of injections.

This was not a small study. There were 200,000 patients, 20,000 physicians, and over 875,000 injections given. Besides the groups already mentioned (anesthesiologists, pain management specialists, neurologists), other types of providers giving spinal injections included orthopedic surgeons, radiologists, internal medicine physicians, neurosurgeons, physiatrists, and family practice physicians.

When considering your own hospital situation, you may want to read the study for yourself.The authors concluded that policy makers must be very careful with the information provided in their study. It would not be in the best interest of patients to rush in and cut and slash services — especially if those services (i.e., spinal injections) are helping someone in pain.

They suggest, it may be too soon for aggressive regulations. But certainly when a small number of physicians are providing a large number of treatments that have not been shown effective, it’s time to target those cases and take a closer look.