Modesto residents seeking pain relief from fractured vertebrae underwent two controversial back procedures at double the statewide rate between 2005 and 2010, according to an analysis of state hospital data released last week.
Just a half hour's drive away, during the same period, Stockton residents underwent the same treatment at a frequency about half the state average, or only one fourth as often as Modestans. And while the number of these procedures around the state has dropped off in recent years, in Modesto use of them has increased.
The data place Modesto in the middle of a national debate about the issue of overtreatment.
Depending on whom you ask, these numbers show that Modesto patients have better access to the procedures than their counterparts elsewhere in the state or that they are undergoing them too frequently, assuming unnecessary risks and costs.
This tale of two cities' differing medical treatment approaches is a stark example of a well-documented phenomenon the type of care patients receive is often a function of where they live. This concept, known as geographic variation, holds significant consequences for health care spending and patient well-being.
Local doctors who perform the procedures say they do so with only the best interests of their patients in mind. They use words like "extremely beneficial" and "instantaneous pain relief." The treatments' critics acknowledge that patients often feel better after they've had acrylic cement injected to stabilize a fractured vertebra.
But they say that many of those patients would probably feel better regardless, and that, for the most part, these are wounds that time can heal. They suggest that the interventional radiologists and orthopedic surgeons who perform the procedures sometimes recommend them when they aren't essential, and that patients don't know enough to disagree.
"The only right decision is the decision we help patients come to with very fair information," said Dr. David Goodman, co-principal investigator of the Dartmouth Atlas of Health Care, which uses data to show geographic differences in care. "That decision-making process is generally widely defective in the United States."
Goodman said different back surgery rates frequently reflect the preferences of local surgeons, which can vary tremendously due to training, philosophy, and economic incentives.
Analysis accounts for differences
The new analysis, by health research and policy professor Laurence Baker of Stanford University, demonstrates just how much such variation occurs in communities around California. Baker, who received funding from the California HealthCare Foundation, adjusted the rates to account for differences in age, sex, race, income, education and health insurance status.
While the resulting analysis shows a significant contrast between Modesto and Stockton, the cities weren't the most extreme on either end. According to Baker's report, residents in the city of Watsonville in Santa Cruz County had the back procedures done at the state's highest rate, about 28 times as frequently as residents of Lodi, which had the state's lowest rate.
Baker chose to examine the two back procedures, vertebroplasty and kyphoplasty, in part because they are controversial and also, he said, because doctors and hospitals can be relatively well-paid for performing them: Medicare pays about $2,300 for vertebroplasties done on an outpatient basis, and close to $6,000 for kyphoplasties.
In California, the treatments increased in popularity until 2009. Then, a pair of studies came out in the prestigious New England Journal of Medicine showing that vertebroplasty produced results no better than a sham procedure, in which patients believed they were undergoing surgery, but instead had only a local anesthetic injected into their spines.
Those studies remain controversial some experts believe they offer the best information available; others believe they were executed poorly.
In the studies' aftermath, the number of the procedures done in California dropped 17 percent, according to state hospital data.
But in Modesto hospitals, the total number of procedures continued to climb even after the studies were published. According to state hospital data, local physicians performed 53 vertebroplasties and kyphoplasties in 2006. That number rose to 179 in 2009 the year the studies came out and then to 201 the following year. The numbers dipped slightly in 2011, the last year for which such data was available.
Dr. Richard Haak, one of three interventional radiologists who perform the treatments at Doctors Medical Center in Modesto, said more referring physicians are sending patients his way.
Haak said the procedures are incredibly effective for pain relief, especially in older patients who could suffer adverse effects from extended periods of bed rest or pain medication.
"There's not very many procedures in this world where you can turn someone around as quickly," he said.
The criticism of the treatments published in the New England Journal of Medicine, he said, "just doesn't jibe with the results we've had or seen."
Dr. Stephen Liu, an interventional radiologist who performs the procedures in his office and at Memorial Medical Center in Modesto, said he has done more than 1,600 of them since 2001. He called them "the most clinically rewarding" of any procedure he does because patients respond so well to it.
Liu said he was not surprised to learn that Modesto has a relatively high rate of the treatments.
"We do more of everything here," he said, citing the area's high rates of diabetes, dialysis and other medical problems.
Some resistance from insurers
He said he has encountered some resistance from certain insurance companies to paying for them, and suspects that doctors around the state may perform fewer of them if it becomes more difficult to claim reimbursement.
Based on his own experience, he called the procedure "extremely beneficial," especially to older patients such as Martha Baucom, a 75-year-old Turlock resident, who said she came to him more than a year ago with two fractured vertebrae.
Baucom, an avid bowler, had felt a snap in her back as she went to roll the ball. For three months afterward, she'd been in such severe pain that her daughter, Reneé Desaire, had to lift her out of bed. The pain sometimes brought Baucom to tears.
"I could walk," she said, "but it hurt like heck."
She was referred to Liu, who, Desaire said, highly recommended vertebroplasty.
Desaire was apprehensive "I'm kind of funny about the back, because so many things can go wrong" but she wanted her mom to have a chance to walk again.
The procedure lasted 45 minutes. Baucom woke up pain-free. A week later, she was back to bowling.
"If I had to do it over, I would not hesitate," Baucom said.
Dr. Anh Le, an orthopedic surgeon in Stockton, said he has done the procedures for 14 years. He believes the difference in the two communities' rates might boil down, in part, to different doctors' beliefs about how long patients should wait prior to having the surgery.
One line of thought, Le said, is that patients should have the surgery nine or 10 days after the fracture for maximum effectiveness. A second line of thought, to which he subscribes, is that doctors should wait a month before doing it. During that time, he said, most compression fractures begin to heal on their own.
But making patients wait too long can also be problematic, other doctors say, since the procedures are likely more effective before the bones begin to knit together.
Dr. Alex Davis, a Modesto-based back surgeon, performed the procedures in the past, but stopped doing them five years ago because he believed his expertise was better suited to more complicated surgeries.
Davis agrees that the procedures can work very well on the right people but he said that, too often, they are performed on the wrong people. He believes the best candidates are elderly people who have a single fracture, are relegated to bed rest and require morphine to be comfortable. Whenever possible, he thinks patients should manage their pain with medicine and back braces, and give the bones a chance to heal on their own.
Davis said he frequently has patients come into his office who are still in pain after receiving the procedures. He believes some of these patients never should have undergone the treatments in the first place. Recently, Davis said, a woman who'd had a kyphoplasty came into his office unable to walk.
"It's a very difficult problem to try to fix," Davis said. "You can't get the cement out. Once it's in there, it's there forever."
Flawed health care system cited
As it is, he believes the overuse of the spinal procedures is symptomatic of a flawed health care system.
"The entire system is based on being paid to do a procedure rather than being paid to think about, evaluate and treat people," he said. "As long as people are being paid to do procedures, people are going to do procedures."
Locally, state data shows that physicians at Memorial Medical Center have performed the majority of vertebroplasties and kyphoplasties.
Dr. Ash Gokli, chief medical officer of the Central Valley Region of Sutter Health, which includes Memorial, said he feels certain that financial gain is not driving the region's high numbers. Instead, he thinks doctors here have developed an expertise and that many local primary care physicians refer their patients for the procedures because they're impressed by the results they've seen. Patients who have had positive experiences with the treatment are then likely recommending them to friends, he said.
Le, the Stockton orthopedist, said that word of mouth certainly is powerful. Some patients come to him with newspaper clippings, requesting the procedure. He sits them down and outlines all the risks.
"There are those of us who say it, potentially, could have a catastrophic side effect, so you need to be mindful," he said.
The CHCF Center for Health Reporting is an independent news organization based at the University of Southern California's Annenberg School for Communication and Journalism and funded by the nonprofit California HealthCare Foundation. For more, go to www.centerforhealthreporting.org.