Elsevier

The Spine Journal

Volume 19, Issue 1, January 2019, Pages 24-33
The Spine Journal

Clinical Study
Patient reported outcomes following surgery for degenerative spondylolisthesis: comparison of a universal and multi-tier health care system

https://doi.org/10.1016/j.spinee.2018.10.005Get rights and content

Abstract

STUDY DESIGN

Retrospective review of results from a prospectively collected Canadian cohort in comparison to published literature.

OBJECTIVES

(1) To investigate whether patients in a universal health care system have different outcomes than those in a multitier health care system in surgical management of degenerative spondylolisthesis (DS).

(2) To identify independent factors predictive of outcome in surgical DS patients.

SUMMARY OF BACKGROUND DATA

Canada has a national health insurance program with unique properties. It is a single-payer system, coverage is universal, and access to specialist care requires referral by the primary care physician. The United States on the other hand is a multitier public/private payer system with more rapid access for insured patients to specialist care.

METHODS

Surgical DS patients treated between 2013 and 2016 in Canada were identified through the Canadian Spine Outcome Research Network (CSORN) database, a national registry that prospectively enrolls consecutive patients with spinal pathology from 16 tertiary care academic hospitals. This population was compared with the surgical DS arm of patients treated in the Spine Patients Outcome Research Trial (SPORT) study. We compared baseline demographics, spine-related, and health-related quality of life (HRQOL) outcomes at 3 months and 1 year. Multivariate analysis was used to identify factors predictive of outcome in surgical DS patients.

RESULTS

The CSORN cohort of 213 patients was compared with the SPORT cohort of 248 patients. Patients in the CSORN cohort were younger (mean age 60.1 vs. 65.2; p<.001), comprised fewer females (60.1% vs. 67.7%; p=.09), and had a higher proportion of smokers (23.3% vs. 8.9%; p<.001). The SPORT cohort had more patients receiving compensation (14.6% vs. 7.7%; p<.001). The CSORN cohort consisted of patients with slightly greater baseline disability (Oswestry disability index scores: 47.7 vs. 44.0; p=.008) and had more patients with symptom duration of greater than 6 months (93.7% vs. 62.1%; p<.001). The CSORN cohort showed greater satisfaction with surgical results at 3 months (91.1% vs. 66.1% somewhat or very satisfied; p<.01) and 1 year (88.2% vs. 71.0%, p<.01). Improvements in back and leg pain were similar comparing the two cohorts. On multivariate analysis, duration of symptoms, treatment group (CSORN vs. SPORT) or insurance type (public/Medicare/Medicaid vs. Private/Employer) predicted higher level of postoperative satisfaction. Baseline depression was also associated with worse Oswestry disability index at 1-year postoperative follow-up in both cohorts.

CONCLUSIONS

Surgical DS patients treated in Canada (CSORN cohort) reported higher levels of satisfaction than those treated in the United States (SPORT cohort) despite similar to slightly worse baseline HRQOL measures. Symptom duration and insurance type appeared to impact satisfaction levels. Improvements in other patient-reported health-related quality of life measures were similar between the cohorts.

Introduction

Canada has a publicly funded, national health insurance (NHI) program that delivers care to the entire population. Health care providers are paid fixed amounts for the services they provide and are not permitted to charge additional fees [1]. The United States has a multitier system where health insurance is purchased in the private marketplace, obtained through one's employer or provided by the government through Medicaid or Medicare [1]. Physician compensation is variable depending on patient coverage. Canada provides universal access to health care for its citizens, while nearly one in five Americans is uninsured [2]. Wait times for both specialist consultation and for surgery are reported as major problems for Canadians, while Americans cite high and rising costs of health care and inequalities in access to health services [2], [3], [4].

The Canadian Spine Outcomes and Research Network (CSORN) is a multicenter group of spine centers collecting prospective clinical registry data. The Spine Patient Outcomes Research Trial (SPORT) was a prospective clinical trial designed to investigate management of degenerative lumbar spinal disorders. It included a trial investigating patients with degenerative spondylolisthesis (DS). This trial either randomized patients to surgery or nonoperative management or, for patients not consenting to randomization, enrolled them in an observational cohort [5], [6]

Comparing patient-reported outcomes of these two contrasting health care systems might provide valuable insight into the impact of the different health service delivery processes of each system in the context of a specific diagnostic group. The primary objective of this study was to compare patient-reported outcome measures (PROMs) between a universal and multitier health care system. The secondary objective was to determine independent factors predictive of outcome in surgical DS patients among both cohorts.

Section snippets

Study design

We conducted a retrospective review of prospectively collected data on consecutive patients from a national registry. This was compared with data from a previously published US cohort, the SPORT [5]. CSORN prospectively enrolls consecutive patients with spinal pathology requiring surgical treatment and recruits from 16 tertiary care academic hospitals across Canada. The registry was queried (years 2013–2016) for consecutive patients who underwent surgical treatment of DS. The SPORT surgical DS

Study population

A total of 461 patients achieved 1-year follow-up, including 213 CSORN and 248 SPORT patients. Baseline demographics are reported in Table 2. Compared with the SPORT cohort, the CSORN cohort comprised younger patients (mean age 5.1 years lower), with 7.6% less females. There were more than twice as many active smokers in the CSORN cohort. The number of actively working patients was similar between the cohorts; however, there were more retirees in the SPORT group and more patients who were not

Discussion

This study is novel as it compares baseline and outcome metrics between two health care systems in two different countries: the Canadian universal system and the American multitier model. Golinvaux et al. compared the SPORT DS surgical arm results to a similar group of patients from the American College of Surgeons National Surgical Quality Improvement Program database [13]. The National Surgical Quality Improvement Program database systematically samples patient records from both private and

Conclusion

Surgical DS patients treated in a universal health care system reported considerably higher satisfaction than those treated in a multitier system despite similar baseline clinical and demographic characteristics and comparable postoperative clinical improvement. The universal health care system was identified as an independent predictor of patient satisfaction. Studies that evaluate patient satisfaction after elective surgical treatment of spinal conditions should consider the health care

Acknowledgments

The Spine Patient Outcomes Research Trial (SPORT) is conducted and supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) in collaboration with Trustees of Dartmouth College (U01-AR45444). This manuscript was not prepared in collaboration with investigators of SPORT and does not necessarily reflect the opinions or conclusions of SPORT Investigators.

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      The symptom duration (fourth strongest predictor in our analysis) has generally been considered to be associated with negative outcomes. In a recent large retrospective review, Ailon et al.28 found a significant correlation between symptom duration and lower satisfaction for patients surgically treated for degenerative spondylolisthesis, with the most notable difference between a symptom duration of 1–2 years versus 0–6 months (odds ratio, 3.6; 95% confidence interval, 1.3–10.1; P = 0.04). Macki et al.,23 Masuda et al.,29 and Ng et al.30 reported a positive correlation between greater patient satisfaction and a shorter wait before surgery.

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    FDA device/drug status: Not applicable.

    Author disclosures: TA: Nothing to disclose. JT: Nothing to disclose. NM: Nothing to disclose. HH: Nothing to disclose. KT: Nothing to disclose. YRR: Medtronic (E), outside the submitted work. AY: Nothing to disclose. ND: Nothing to disclose. AG: Nothing to disclose. CB: Nothing to disclose. SC: Nothing to disclose. MHW: Nothing to disclose. AN: Nothing to disclose. JP: Nothing to disclose. MJ: Nothing to disclose. JN: Nothing to disclose. HA: Nothing to disclose. GM: Nothing to disclose. CGF: Royalties from Medtronic (G), consulting for Medtronic (E, paid directly to institution/employer) and Nuvasive (B), and research support from OREF (E, paid directly to institution/employer), AOSpine (E, paid directly to institution/employer), and Medtronic (F, paid directly to institution/employer).

    Level of Evidence: 3.

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