CHICAGO - Hint: It's not radiologists. Except for deep bone biopsies and a few disk aspirations, a large and growing majority of interventional spine procedures are performed by other medical specialists.
In Wednesday's health services policy sessions at the RSNA meeting, Dr. William Morrison from Thomas Jefferson University Hospital in Philadelphia looked at trends in his institution and concluded that greater radiologist involvement would benefit patients as well as radiologists.
"Spine intervention procedures are becoming very popular," Morrison said. "It's a burgeoning field consisting of biopsies, discography, disk aspiration, selective and non-selective nerve blocks, epidural steroid injection, facet injections, as well as vertebroplasty. These procedures require precise needle placement, so radiologic guidance is key to these procedures, not only for efficacy of the procedure, but also for the safety of the patient.”
The researchers sought to determine which physician specialties are performing the procedures, and whether any trends were evident for the years studied: 1993, 1996 and 1998. They looked at Medicare Part B reimbursements for data categorized by procedure code, excluding multispecialty groups because it was impossible to tell who was performing the procedures within such groups. Morrison acknowledged some other study limitations as well.
"Prior to 2000 the codes are somewhat vague and, and they're interpreted in different ways by the people who do the procedures. You can't link the image guidance code to the procedure code to see if people are actually using image guidance to do the procedures. Also, the Medicare population is an older, and may not be representative of the whole population."
For example, bone biopsy codes, divided into deep and superficial categories, represent all bone biopsies, not just spinal biopsies, he said. Bucking the trend, radiologists performed 56.5% of deep bone biopsies in 1993 and 73.6% in 1998. They performed 10.4% of superficial bone biopsies in 1993, a figure that grew to 26.3% in 1998. However, total Medicare reimbursement for these procedure codes declined 55% during the five-year period.
"Discography has rapidly become a more popular procedure especially because of the minimally invasive disk procedures that are becoming very popular including disk electrothermal therapy ... which require that you do a discogram beforehand."
Between 1993 and 1998, lumbar discographies performed by radiologists declined from 44.8% to 37.9%. In that same time, the percentage performed by anesthesiologists more than doubled, from 11.2% to 26.6%, while total Medicare dollars paid for the procedure have increased by 132% during the same time.
Cervical discography told a similar story. Radiologists' piece of the pie shrank from 36.6% to 27.5% between 1993 and 1998, while anesthesiologists' market share grew from 34.2% to 43.5%.
"Disk aspiration is also a well-defined procedure. Radiology does perform the majority of them (44.6% vs. 14.8% in 1993), however, a lot of other specialties like to perform this procedure (orthopedic surgeons, 29.2% in 1998)," Morrison said. "It's mostly used for things like ruling out infection of the disk, and radiology's dominance of this probably has to do with the fact that it's often done with CT guidance."
Total Medicare dollars have decreased 31% over the study period, however.
"Selective and non-selective (lumbar) epidural injection also requires precise needle placement," Morrison said. However, radiologists performed only 6.1% of them in 1998, up from just 2.9% in 1993, while anesthesiologists performed the vast majority of the procedures. Medicare dollars for these procedures rose 50% during the 5-year period.
In 1998 radiologists performed just 1% of anesthetic, lumbar or caudial epidural injections, while anesthesiologists performed 73.9% of them. For injection of other substances, radiologists performed 0.8% in 1998, compared with 91.2% for anesthesiologists. Meanwhile, Medicare reimbursement for these procedures has risen by 104% over five years, Morrison said.
Radiology's share of paravertebral facet joint nerve injections declined from 8.2% to 3.9% between 1993 and 1998, while Medicare reimbursement rose 147% over the same five years. Any way you look at it, non-radiologists are doing most spine interventions, Morrison said.
"It's unclear if these [other] specialties are using image guidance for these procedures, which really benefit from image guidance, not only for efficacy but safety as well. And for non-radiologists, self-referral is a potential problem. Considering that image guidance is essential to these types of procedures, radiologists should probably be doing more of [them] since we have more experience in precisely placing needles."
By Eric Barnes
AuntMinnie.com staff writer
November 30, 2000
Copyright © 2000 AuntMinnie.com
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