06 MAY 2021

How many of you look up the reviews of a restaurant, mechanic, or any business in fact, before deciding to book?  The internet has allowed us to be more selective about where we spend our money.  We want good value, high quality products and services and we make our opinions known when our expectations aren’t met.   

We don’t quite have this immediate feedback available when it comes to healthcare, but some reports, such as the Atlas of Healthcare Variation, do shine a light on whether some treatment options are providing low value to the Australian healthcare consumer.

Australians pay for about 17 per cent of total health expenditure directly through out-of-pocket expenses which adds up to $29.8 billion, or about $1,235 per person.  Compared to other countries, Australia has the third highest reliance on individual healthcare contributions, behind only Switzerland and Belgium.  It would make sense for us to be discerning about where that money goes.

One area that needs greater transparency is low back pain. Forty percent of early retirements are due to back pain.  The most effective way to manage chronic back pain is with multidisciplinary pain management combined with self-management. Proactive approaches to management are recommended while surgery for back pain is not recommended and may lead to worsening of the condition.  

Last week, the Fourth Atlas Healthcare Variation was released by the Australian Commission on Safety and Quality in Health Care and the Australian Institute of Health and Welfare. This reporting series explores how healthcare use in Australia varies depending on where people live. It investigates reasons why certain treatments and health outcomes are higher or lower than what is expected and outlines what can be done to reduce unwarranted variations.  In summary, think of the Atlas as a way for us to understand whether Australians are getting good value healthcare and what we can do if not.

First published in in 2015 and roughly every 2 years since, the latest Atlas examines early planned birth, chronic disease and infection – potentially preventable hospitalisations, lumbar spinal surgery (to address low back pain), ear nose and throat surgery in children and young people, gastrointestinal investigations and medicines use in older people.  Most relevant for us is the focus on chronic low back pain.

The Fourth Atlas recommends that priority should be given to examining and improving access to services that provide multidisciplinary review and non-surgical treatments for chronic low back pain. The report also highlights the need for more pain specialists and the importance of multidisciplinary care; raises questions about the long wait times to see a pain specialist; and potential cost savings that could be made from using a best practice approach to pain management for low back pain, rather than low value surgical options.

Two key recommendations in the report call for a central coordination point in mapping the services that relate to the treatment of low back pain, and the need for established patient reported outcome measures.

One chapter of the Atlas relates to lumbar spinal surgery. Lumbar spinal fusion joins (fuses) two or more vertebrae to stop them from moving against each other. Spinal fusion can be done on its own or with another type of surgery called spinal decompression. This is sometimes used to treat chronic low back pain and other symptoms of degenerative spinal disorders. However, evidence for the effectiveness of lumbar spinal fusion to treat chronic low back pain is low quality and uncertain. The surgery can also lead to serious complications.  While lumbar spinal fusion surgery has a role in treating a small number of people who have degenerative spinal disorders with nerve-related problems, the role of spinal fusion in people without these problems is limited and controversial.  In general, first-line treatment for most people with chronic low back pain involves non-surgical measures such as exercise and weight loss.

The Atlas suggests reducing the number of people opting for this type of surgery and provides some reasons as to why there’s an increase in its use, such as:

• There is low-quality evidence and lack of established guidelines which lead to variations in practice that influence clinical decision making.

• Some patients may not be aware of the uncertainties about the benefit of surgery for treating chronic low back pain and have expectations that surgery will solve the problem.
• Alternatives to surgery may not be affordable or accessible to some consumers and that private health insurance provides access to spinal fusion but may not cover non-surgical treatments, and
• There may not be enough clinicians who provide alternatives to surgery in some areas and so consumers are left with only surgery as a treatment option.

In a recent blog, I outlined how paracetamol was for decades marketed as having abilities to provide targeted pain relief, while a recent study published in the Medical Journal of Australia found that the evidence is not clear that paracetamol medications are more effective than a placebo for the most common illnesses or injuries.   

As recently as 2016, pharmaceutical companies were advertising the ability of paracetamol to provide pain relief for specific conditions such as back and neck pain.  A Federal Court ruling found that this was misleading as claims by certain pharmaceutical companies that their products could target specific pain could not in fact be substantiated.  I raise this point on paracetamol again as it highlights how, left unchecked, one low value treatment option can become so ubiquitous in treatment.

One key recommendation in the Atlas is to map the services in the pain space. This may go some way to ensuring that Australians have and are aware of alternative options to surgery and that surgery will only be used when it has a high probability of being effective.   

Another recommendation is to establish patient reported outcome measures when it comes to chronic low back pain treatments which will hopefully lead to good value, high quality products and services and to empowering consumers to make their opinions known when their expectations aren’t met.   

What is interesting, although not surprising to see is how the same needs for people living with chronic pain are echoed regardless of the chronic pain condition.  The need for greater awareness of best practice multidisciplinary approach, better health practitioner education and knowledge, better and more timely access and the need to listen to consumers about how treatments might benefit them, are all touched on in Australia’s National Strategic Action Plan for Pain Management.   I guess you could almost call the Action Plan a consolidated assessment by people living with chronic pain of their expectations –  hopefully governments at all levels will ensure it is realised and implemented and not just a review of what is needed.