0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

Thoracic and Lumbar Vertebroplasties Performed in US Medicare Enrollees, 2001-2005 FREE

Darryl T. Gray, MD, ScD; William Hollingworth, PhD; Nneka Onwudiwe, PharmD; Richard A. Deyo, MD, MPH; Jeffrey G. Jarvik, MD, MPH
[+] Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.


JAMA. 2007;298(15):1760-1762. doi:10.1001/jama.298.15.1760-b.
Text Size: A A A
Published online

To the Editor: Percutaneous vertebroplasty involves the vertebral injection of polymethylmethacrylate cement. Although some indication that this procedure is safe and effective for treating osteoporotic compression fractures exists,1 the US Medicare program promulgated no national coverage policies for this procedure after reviewing the available nonrandomized evidence.2 Nevertheless, local Medicare contractors in multiple jurisdictions have covered vertebroplasty for various indications since as least 2001. We examined vertebroplasty-use patterns in Medicare patients for 2001-2005.

Methods

Using vertebroplasty-related Current Procedural Terminology, 4th Edition (CPT-4), codes 22520 (primary thoracic vertebroplasty) and 22521 (primary lumbar vertebroplasty), we performed cross-sectional analyses of aggregate 2001-2005 fee-for-service data from the Medicare all-age Part B Extract Summary System,3 which excludes denied claims and claims for Medicare managed care enrollees. Annual primary vertebroplasty rates (which exclude additional vertebral levels also treated) were therefore expressed per 100 000 Part B fee-for-service enrollees.

Part B Extract Summary System data are cross-stratified by the billing physician's reported specialty and by the listed place of service. We grouped physician specialties into 5 categories: diagnostic or interventional radiology, orthopedic surgery, neurosurgery, anesthesiology or pain management, and other (including neurologists, physiatrists, internists, emergency department physicians, physicians identified only as members of multispecialty groups, and nonphysicians). We grouped places of service into 4 categories: inpatient hospital settings, outpatient hospital settings, physicians' offices, and ambulatory surgery centers.

Because we analyzed data on 100% of known cases, inferential statistics were not required. This study received institutional review board approval.

Results

Vertebroplasty rates nearly doubled from 2001 to 2005, increasing by 32.3% from 2001 to 2002 alone (Table). However, 2005 rates were only 5.0% higher than those from 2004.

Table Graphic Jump LocationTable. Primary Vertebroplasty Procedures From 2001-2005 Among Medicare Part B Fee-for-Service Enrollees, 2001-2005a

Most procedures were performed by diagnostic or interventional radiologists (Table). The proportion performed by anesthesiologists or pain management specialists increased from 4% to 5% during 2001-2004 to 7.1% in 2005; the proportions performed by other specialties remained stable or declined.

Although outpatient hospital settings were the most common treatment sites, the proportions of procedures performed in physician offices and ambulatory surgery centers increased markedly in 2004-2005 (Table) with varying mixtures of specialist intervention. For example, among office-based procedures from 2005, 37.2% were performed by radiologists, while anesthesiologists or pain management specialists performed 35.9%, and orthopedists performed 19.7%. Among ambulatory surgery center procedures from 2005, anesthesiologists or pain management specialists performed 50.5%, while radiologists performed 37.2% and orthopedists performed 1.8%.

Comment

Most of the observed growth—rates nearly doubled from 2002 to 2005—preceded the US Food and Drug Administration's approval of polymethylmethacrylate cement use for vertebroplasty in December 2004.4 Growth may better reflect factors including shifts in clinical opinion, patient demand, Medicare coverage policies, and the availability of vertebroplasty relative to that of other treatment approaches. The overall increase in outpatient vertebroplasty may mirror earlier trends seen in the growth of outpatient lumbar spine surgery.5

Limitations of our data included a lack of clinical and demographic detail and the potential for coding errors. However, with the exception of transient shortfalls, Medicare claims data may be generally concordant with other population-based clinical procedure data. For example, cataract-procedure volume concordance with record-based data from the Rochester Epidemiology Project was nearly 96% when excluding a circumscribed data shortfall period.6 Our inability to capture denied claims, those for patients with Medicare managed care or Part A coverage alone and for vertebroplasties billed as “unspecified procedures,” makes our vertebroplasty volume data conservative. However, if such cases decreased over time, then we may have overestimated the actual growth of vertebroplasty use. Our data may not apply to Medicare managed care or non-Medicare populations with differing clinical presentations. Finally, available CPT-4 codes did not capture volumes of competing alternative procedures (eg, kyphoplasty).

Nevertheless, the increase in the volume of vertebroplasty procedures seen in our study is noteworthy given the expected contribution of the Medicare population to vertebroplasty volumes. This increase, especially regarding procedures performed in nonhospital settings, has uncertain clinical and resource use implications and argues for close tracking of future vertebroplasty practice patterns and outcomes.

Author Contributions: Dr Gray had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Gray, Javik.

Acquisition of data: Gray, Onwudiwe.

Analysis and interpretation of data: Gray, Hollingworth, Onwudiwe, Deyo, Jarvik.

Drafting of the manuscript: Gray, Hollingworth.

Critical revision of the manuscript for important intellectual content: Gray, Hollingworth, Onwudiwe, Deyo, Jarvik.

Obtained funding: Deyo.

Administrative, technical, or material support: Onwudiwe, Deyo, Jarvik.

Study supervision: Gray.

Financial Disclosures: None reported.

Funding/Support: This work was partially supported by grants P60 AR48093 and 5R01AR049373-04 from the National Institute for Arthritis, Musculoskeletal, and Skin Diseases.

Role of the Sponsors: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Disclaimer: The views expressed herein are not necessarily those of Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare & Medicaid Services, the National Institutes of Health, or the Department of Health and Human Services.

Additional Information: Drs Gray and Onwudiwe worked on this project while employed by the AHRQ. Dr Hollingworth worked on this project while employed by the University of Washington.

Additional Contributions: Leo Porter, AA, formerly of the Centers for Medicare & Medicaid Services (CMS) provided the Part B Extract Summary System data on which this study was based; Pamela Pope, BA, of CMS provided Part B fee-for-service enrollee data; and William Munier, MD, MBA, Artyom Sedrakyan, MD, PhD, and Chunliu Zhan, MD, PhD, of AHRQ provided comments on prior drafts of this paper. None of these persons received compensation for their contributions.

References
Alvarez L, Alcaraz M, Perez-Higueras A.  et al.  Percutaneous vertebroplasty: functional improvement in patients with osteoporotic compression fractures.  Spine. 2006;31(10):1113-1118
PubMed   |  Link to Article
 Treatments for vertebral body compression fractures. Medicare Coverage Advisory Committee Meeting; May 24, 2005; Centers for Medicare & Medicaid Services, Baltimore, MD. http://www.cms.hhs.gov/mcd/viewmcac.asp?where=index&mid=29. Accessed August 7, 2007
 Part B Extract Summary System (BESS) data file [Web page]. Baltimore, MD: Centers for Medicare & Medicaid Services. http://www.cms.hhs.gov/NonIdentifiableDataFiles/03_PartBExtractSummarySystem.asp#TopOfPage. Accessed August 30, 2006
 Center for Devices and Radiological Health [Web Page]. Rockville, MD: US Food and Drug Administration, Product Code Number. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm. Accessed September 9, 2006
Gray DT, Deyo RA, Kreuter W.  et al.  Population-based trends in volumes and rates of ambulatory lumbar spine surgery.  Spine. 2006;31(17):1957-1963
PubMed   |  Link to Article
Gray DT, Hodge DO, Ilstrup DM, Butterfield LC, Baratz KH. Concordance of Medicare data and population-based clinical data on cataract surgery utilization in Olmsted County, Minnesota.  Am J Epidemiol. 1997;145:1123-1126
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable. Primary Vertebroplasty Procedures From 2001-2005 Among Medicare Part B Fee-for-Service Enrollees, 2001-2005a

References

Alvarez L, Alcaraz M, Perez-Higueras A.  et al.  Percutaneous vertebroplasty: functional improvement in patients with osteoporotic compression fractures.  Spine. 2006;31(10):1113-1118
PubMed   |  Link to Article
 Treatments for vertebral body compression fractures. Medicare Coverage Advisory Committee Meeting; May 24, 2005; Centers for Medicare & Medicaid Services, Baltimore, MD. http://www.cms.hhs.gov/mcd/viewmcac.asp?where=index&mid=29. Accessed August 7, 2007
 Part B Extract Summary System (BESS) data file [Web page]. Baltimore, MD: Centers for Medicare & Medicaid Services. http://www.cms.hhs.gov/NonIdentifiableDataFiles/03_PartBExtractSummarySystem.asp#TopOfPage. Accessed August 30, 2006
 Center for Devices and Radiological Health [Web Page]. Rockville, MD: US Food and Drug Administration, Product Code Number. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm. Accessed September 9, 2006
Gray DT, Deyo RA, Kreuter W.  et al.  Population-based trends in volumes and rates of ambulatory lumbar spine surgery.  Spine. 2006;31(17):1957-1963
PubMed   |  Link to Article
Gray DT, Hodge DO, Ilstrup DM, Butterfield LC, Baratz KH. Concordance of Medicare data and population-based clinical data on cataract surgery utilization in Olmsted County, Minnesota.  Am J Epidemiol. 1997;145:1123-1126
PubMed   |  Link to Article
CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles