Introduction: Spinal cord stimulation (SCS) has emerged as an appropriate modality of treatment for intractable chronic pain. The present study examines variations in SCS trial-to-permanent conversion rates based on provider types performing the procedure.
Methods: Thomson Reuters MarketScan database was utilized to obtain a large patient cohort for retrospective analysis. We included all adult patients that underwent a percutaneous or paddle SCS trial with or without IPG implantation from the years 2007 to 2012. Patients were grouped into categories based on provider type performing the implantation including anesthesiologists, pain medicine specialists, neurosurgeons, orthopedic surgeons, and physical medicine and rehabilitation (PM&R) that perform SCS with frequency (>100 implants) . The patient cohort was analyzed using univariate and multivariate models to evaluate for factors associated with successful conversion and healthcare resource utilization.
Results: A total of 7,796 unique instances of SCS implants were identified across five providers. Overall, 4899 (62.8%) of those receiving trials underwent permanent SCS system implantation. Anesthesiology performed the majority of implants (32.9%), followed by pain medicine specialists (31.9%), neurosurgery (20.3%), orthopedic surgery (9.8%), and PM&R (5.1%). Both neurologic (OR 10.07, 95% CI [8.25, 12.29]; p < 0.001) and orthopedic surgeons (OR 4.05, 95% CI [3.30, 4.98]; p < 0.001) had significantly higher conversion rates, while PM&R (OR 0.58, 95% CI [0.47, 0.72]; p < 0.001) had significantly lower. Comparable conversion rates were found between anesthesiologists and pain medicine specialists. Charlson score index did not significantly differ among the providers.
Conclusions: In this study, we identified a key relationship between the provider types and SCS conversion rates. Our results suggest that conversion rates improve when SCS is performed by neurologic or orthopedic surgeons. As the number of SCS implantations continues to increase yearly, our study has important implications for establishing uniform guidelines for training and education of physicians across multiple disciplines.
Patient Care: Chronic pain is a major economic concern in the United States resulting in a $635 billion annual cost, with significant functional disability and lost economic productivity. As more spinal cord stimulation (SCS) procedures are performed annually in the US, our study provides the first concrete evidence of variations in success rates with provider type performing implantation, and underscores the importance of standardizing education and training through uniform guidelines. In exploring prognostic factors associated with optimal SCS outcomes, previous studies demonstrated the importance of appropriate patient selection, pain pattern, and physician expertise. Accumulating evidence in the last 20 years has also shown a significant correlation between procedural volume and surgical outcomes. In the past 15 years, a number of randomized control trials and meta-analyses have demonstrated SCS as a therapeutically beneficial and cost-effective approach to chronic pain management in carefully selected patients.
Over this same period, the number of SCS procedures by pain medicine specialists, PM&R and orthopedic surgeons have grown to service and provide options to major portions of patients undergoing implantation. Yet successful trial-to-permanent conversion rates for SCS remains below 50% nationwide and the predictors of SCS trial outcome remain poorly understood beyond pain etiology. Going forward, a concerted effort is needed to establish and follow uniform guidelines for standardization of training across the different medical and surgical specialties involved in patient selection, implantation, and follow-up, will prove useful in improving the overall quality of care being offered. We hope our study as well as an accompanying oral presentation at CNS is the first step in bringing individuals together to discuss challenges relating to optimal SCS success, as well as opportunities through which marked improvements may be made in delivering better care.
Learning Objectives: By the conclusion of this session, participants should be able to
1) Understand how specialty type affects spinal cord stimulation success rates
2) Discuss specialty-based variations in spinal cord stimulation success rates and healthcare resource utilization
3) Evaluate existing guidelines, recommendations and challenges in training physicians performing spinal cord stimulation