Spine Pain in VA: 

Finding the CompletFinding the Complet

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Patsi Sinnott

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Patsi Sinnott

Andrea Shane, Andrew Siroka

Todd Wagner, Jodie Trafton

Jul

y , 21 2010
O tli u ne

 Bk d ac ground Methods Results Di i scuss on
Bk d ac ground

 M l k l t l S i P i i VA Musculoskeletal Spine Pain in VA, 

Description and Guideline Adherence (I

062)

– Observational study: Administrative – Spine vs. neck vs. back– Acute, mechanical or non Acute, mechanical or non-specific sp

specific sp

pain
Bk d ac ground

 B k P i P ti t O t A 

Back Pain Patient Outcomes Assessmen

(BOAT) (PI – Deyo) 1989 – 1994

– “the back pain PORT, supported by AHCP

analyzes practice variations and examines relative effectiveness of alternative ways orelative effectiveness of alternative ways o

diagnosing and treating back pain”

– 70 publications 70 publications– Evaluate diagnostic tests, surgery and vario

interventions
Bk d ac ground

 Mechanical or non-specific low back or 

pain

– ICD and CPT codes to identify patients in 

data

– Incidence, prevalence - proxy for morbidit

– Inclusion and exclusion algorithms

– Surgical and non-surgical inpatient stays– Variation in surgical rates
Bk d ac ground

 K bli ti Key publications

– Volinn E, Mayer J, Diehr P, Van Koeverin

C ll FA L JD S ll l i Connell FA, Loeser JD. Small area analysi

surgery for low-back pain. Spine (Phila P

May 1992;17(5):575 May 1992;17(5):575-581.

– Cherkin DC, Deyo RA, Volinn E, Loeser J

of the International Classification of Diseaof the International Classification of Disea

(ICD-9-CM) to identify hospitalizations fomechanical low back problems in admini

databases. Spine. 1992;17(7):817-825.
Bk d ac ground

 Ei t dt D K t DL Fih SD D RA V 

Einstadter D, Kent DL, Fihn SD, Deyo RA. V

in the rate of cervical spine surgery in Washi

State. Med Care Med Care. Aug 1993;31(8):711 Aug 1993;31(8):711-718.
Bk d ac ground

 AHRQ H lth C t d Utili ti AHRQ Healthcare Cost and Utilization 

Project (HCUP) – Clinical Classificatio

S ft (CCS) 1988 Software (CCS) 1988

– Homogenous clusters of interest to public p

researchers

– Diagnostic and procedural categories

– Tech i l i li hnical specialists

– Continuing review for accuracy and clinica

si ifi gn cance
Obj ti ec ves

 P i ti r mary assumptions:

– Changes in medical practice– Change in research capacity

– Changes in research focus

 Review algorithms used to identify pati

with spine pain in administrative data

 Revise algorithm if warranted
Obj ti ec ve

 E t bli h t d d th d l t id 

Establish a standard methodology to ide

patients with spine pain in administrativ
M th d e o s

 R i ICD d di th d l Review ICD and coding methodology Identify literature that reports using ICD 

CPT codes to identify patients with spin

and spine surgery in administrative data

 Consolidate definitions – if possible Synthesize and test code lists for compl

Synthesize and test code lists for compl
R lt esu s

 C di h d l Coding methodology

– CPT – Procedures and surgeries – fiv– ICD – Diagnoses and procedures

Three digit Three digitFour digitFi di i ve digit
C di th d l C

oding meth

o

d

o

logy

 721

- S d l i d lli d di d Spondylos

is an

d alli

e

d disor

ders

– 721.4 Thoracic or lumbar spondylosi

m

yelopath

y

 721.41 Thoracic spondylosis with myel 721.42 Lumbar spondylosis with myelo
Lit t R i Litera

ture 

Rev

iew

 Pb d u

bme

d

 BOAT re

port

 Web of knowledge HCUP CCS i HCUP CCS categor

ies
Lit i rev ew - P bM d u e

 I fi ld In any field: B k d ICD d l N 

Back and ICD and prevalence; N

ICD and prevalence; Back and ICD and surg

Neck and ICD and surgery; Neck and ICD and surgery; Back and CPT a

Back and CPT a

prevalence; Neck and CPT and prevalence; BCPT and surgy 

er ; and Neck and CPT and sur

 In the Title: Back pain and prevalence; Neck 

and prevalence; Back pain and surgery; and pain and surgery.
Lit Rev ewi

BOAT – Web of Knowled

 http://www.ahrq.gov/clinic/medtep/backpain. Web of Knowledge (Thomson Reuters Institu

Web of Knowledge (Thomson Reuters Institu

Scientific Information sm)
R lt esu s

 40 papers Excluded those that:

– Did not include a specific list of inclu

exclusion codes exclusion codes

– Did not use administrative data

 Six papers in final synthesis
Fi l R i Final Review

 Si d t HCUP CCS t i Six papers and two HCUP CCS categories

– Volinn E, Mayer J, Diehr P, Van Koevering D, Connell FA, Loeser JD

analysis of surgery for low-back pain. Spine (Phila Pa 1976). May 1992;

– Cherkin DC Deyo RA Volinn E Loeser JD Cherkin DC, Deyo RA, Volinn E, Loeser JD. Use of the International C

Use of the International C

Diseases (ICD-9-CM) to identify hospitalizations for mechanical low bac

administrative databases. Spine. 1992;17(7):817-825.

– Einstadter D, Kent DL, Fihn SD, Deyo RA. Variation in the rate of cerv

surgery i W hi t St t in Washington State. M dC e are. A 1993 31(8) 711 Aug 1993;31(8):711-718.

– Taylor VM, Anderson GM, McNeney B, et al. Hospitalizations for back 

problems: a comparison between the Province of Ontario and Washington 

Serv Res. Oct 1998;33(4 Pt 1):929-945.

– Angevine PD, Arons RR, McCormick PC. National and regional rates a

cervical discectomy with and without anterior fusion, 1990-1999. Spine (P

1976). May 1 2003;28(9):931-939; discussion 940.

– Martin BI, Deyo RA, Mirza SK, et al. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status am

Expenditures and health status am

with back and neck problems. JAMA. Feb 13 2008;299(6):656-664.
C di l ith T bl 

C

oding a

lgorithms....

T

abl
HCUP – CCS

 B k 205 S d l i i t t b l di Back 205 Spondylosis, intervertebral di

disorders; other back problems 

 7201 202 2081 2089 209 210 211 212 213 

201 7202 72081 72089 7209 7210 7211 7212 7213 

72142 7215 7216 7217 7218 72190 72191 7220 722

 7222 72230 72231 72232 72239 7224 72251 72252 7

7222 72230 72231 72232 72239 7224 72251 72252 7

72270 72271 72272 72273 72280 72281 72282 722872291 72292

 72293 7230 7231 7232 7233 7234 7235 7236 7237 7

72400 72401 72402 72409 7241 7242 7243 7244 724

 7246 72470 72471 72479 7248 7249 7246 72470 72471 72479 7248 7249
HCUP-CCS

 S i d St i Sprains and Strains – 232

– 8400 8401 8402 8403 8404 8405 8406 8407 8408 

8410 8411 8412 8413 8418 8419 84200 84201 848410 8411 8412 8413 8418 8419 84200 84201 84

84209

– 84210 84211 84212 84213 84219 8430 8431 843

8440 8441 8442 8443 8448 8449 84500 84501 8484503 84509

– 84510 84511 84512 84513 84519 8460 8461 846

84510 84511 84512 84513 84519 8460 8461 846

8468 8469 8470 8471 8472 8473 8474 8479 8480 8482

– 8483 84840 84841 84842 84849 8485 8488 8489 
D fi iti Definitions

 Mhil ec anical or non-specifi i i ific spine pain Associated with pain including radicular sym E l di xc u ng 

– Neoplasm, infectious, inflammatory cause

– Associated with pregnancy or trauma
White Board White Board
D fi iti Definitions

 Cherkin DC, Deyo RA, Volinn E, Loeser J

Cherkin DC, Deyo RA, Volinn E, Loeser J

the International Classification of Diseases (ICD-9-CM) to identify hofor mechanical low back problems in administrative databases. Spin

1992 17(7) 817 1992;17(7):817-825.

 Elixhauser A, Andrews RM, Fox S. Clinical cla

for health policy research: Discharge statistics by principal diagnosis for health policy research: Discharge statistics by principal diagnosis 

procedure. Rockville, MD: Agency for Health Care Pol

Research; 1993.

 Dionne CE, Dunn KM, Croft PR, et al. A con

approach toward the standardization of back pain definitions for use in 

studies. Spine (Phila Pa 1976) Spine (Phila Pa 1976). Jan 1 2008;33(1)

Jan 1 2008;33(1)
D fi iti Definitions

 HCUP – CCS Cherkin & Deyo Martin “Neck and Back” Dionne
D fi iti Definitions

 C diti th t i i t h i th 

Conditions that originate anywhere in th

– Neck pain – cervical spine

– Back pain – thoracic, lumbar, sacral a

coccyg p eal s ine

– Low back pain – lumbar, sacral, cocc

spine
Definitions
D fi iti Definitions

 C il i ervical spine Thoracic spine Thoraco-lumbar spine Lumbar spine Lumbar spine Lumbo-sacral spine S li acra spine Coccyx
C lid t d li t Consolid

a

t

e

d li

s

t

 Vi E l bl C bi d b k 

View 

Exce

l table :

Combine

d

bac

k a

neck

 Summary of all codes  Indicates inclusion and exclusion p

Indicates inclusion and exclusion p

each paper or HCUP category
P tt a erns

 Ili/ li b d i i Inclusion/exclusion based on criteri

described in paper or software

– Neck pain does not include TLSC spi

vice versa

– HCUP definition back=all spine– Martin = broadest definition of back a

Martin = broadest definition of back a

neck: Angevine = most narrow
T ti Gl b l E l i Testing: Gl

o

b

a

l

Exc

lus

ion

– Vi T bl 9 E l i View 

T

able 

9

Exc

lus

ions
S ti l dditi Sequenti

a

l additions - B 

ac

 Vi T bl 7 View 

T

able 

7
S ti l dditi Sequenti

a

l additions - N 

ec

 Vi T bl 8 View 

T

able 

8
S dP d urgery an

d

Proce

dures

 Vi l k h S d View exce

l wor

k

s

heet 

Surgery an

d

Procedures
Non-specifi d c co es

 Vi T bl 10 View Table 10.
Al ith t if Algorithms 

to specify surg

 Vi T bl 11 View 

T

able 11
D fi i h t D

efi

n

ing your co

hor

t

 Mhil ec

han

ica

l or non-specifi i 

ific sp

ine p

– Excluding 

Neoplasm, infectious, inflammator

causes

Associated with pregnancyAssociated ith tra ma (?) Associated with tra

uma (?)

 Surgical and/or non-surgical patien
D fi i h t D

efi

n

ing your co

hor

t

 Whi h i l ( )? Whi

c

h sp

ina

l segment

(

s)?

– Back– Low back– Neck– Thoracic spine, sacrum and coccyx
D fi i h t D

efi

n

ing your co

hor

t

 BOAT l i h (?) BOAT a

lgor

i

t

hm (?)

 What to do about:

– Ankylosing spondylitis, etc (720.0-72– Curvatures of the spine (737 0 Curvatures of the spine (737.0

– 737 

. 

excludes congenital)

– A i d d l li h i d h Acqu

ire

d spondyl

olist

hes

is an

d ot

her 

acquired deformity of the back or spi

(738 4. -738 5) .
D fi i h t D

efi

n

ing your co

hor

t

 Wh d b at to 

do a

bout:

– Nonallopathic lesions of the spine (73

739.4) 

– Anomalies of the s

p ( ine 

(756.10-756.2

– Open/closed spinal fractures (805.0-8– Other ertebral dislocations (839 0 Other..vertebral dislocations (839.0

-8
D fi i h t D

efi

n

ing your co

hor

t

 C d h i l 

C

o

des w

here sp

ina

l segment not sp

(e.g. could be back or neck)
H di ow we are proceeding

 A hil cute, mec

han

ica

l or non-specifi 

c s

pain

– Including all spine segments and diag– Identify all Veterans treated for spine 

Identify all Veterans treated for spine 

in FY2002-2009

– Identify first event in data Identify first event in data
H di ow we are proceeding

 E l di l b l di i Exc

l

uding g

l

o

b

a

l condi

t

ions (if appea

in a year, etc)

 Excluding post-surgical cases (no sp

procedures within 1 year of entering the spine 

cohort)

 Excludin

g trauma and fractures

– E-codes and vertebral fractures open 

closed (major codes 805 closed (major codes 805

– 806)
H di ow we are proceeding

 D fi i l b ICD d 

D

efine sp

ina

l segment 

by ICD co

de 

possible

 Require additional diagnoses to con

spinal segment for those cases with spinal segment for those cases with specific coding.

 S id ummar

ize an

d report
Q ti ? uestions

?