SCS in Workman's Comp

[101N]

In appears that in the workers comp realm, SCS is, at best, a palliative endeavor, but not rehabilitative. (1,2).

1. Pain. 2010 Jan;148(1):14-25. Epub 2009 Oct 28.
Spinal cord stimulation for failed back surgery syndrome: outcomes in a workers' compensation setting.Turner JA, Hollingworth W, Comstock BA, Deyo RA.

Abstract
Questions remain concerning effectiveness and risks of spinal cord stimulation (SCS) for chronic back and leg pain after spine surgery ("failed back surgery syndrome" [FBSS]). This prospective, population-based controlled cohort study evaluated outcomes of workers' compensation recipients with FBSS who received at least a trial of SCS (SCS group, n=51) versus those who (1) were evaluated at a multidisciplinary pain clinic and did not receive SCS (Pain Clinic, n=39) or (2) received neither SCS nor pain clinic evaluation (Usual Care, n=68). Patients completed measures of pain, function, medication use, and work status at baseline and 6, 12, and 24 months later. We also examined work time loss compensation over 24 months. Few (<10%) patients in any group achieved success at any follow-up on the composite primary outcome encompassing less than daily opioid use and improvement in leg pain and function. At 6 months, the SCS group showed modestly greater improvement in leg pain and function, but with higher rates of daily opioid use. These differences disappeared by 12 months. Patients who received a permanent spinal cord stimulator did not differ from patients who received some pain clinic treatment on the primary outcome at any follow-up (<10% successful in each group at each follow-up) and 19% had them removed within 18 months. Both trial and permanent SCS were associated with adverse events. In sum, we found no evidence for greater effectiveness of SCS versus alternative treatments in this patient population after 6 months.


2. Spine (Phila Pa 1976). 2011 Nov 15;36(24):2076-83.
Costs and Cost-Effectiveness of Spinal Cord Stimulation (SCS) for Failed Back Surgery Syndrome: An Observational Study in a Workers' Compensation Population. Hollingworth W, Turner JA, Welton NJ, Comstock BA, Deyo RA.

Abstract
STUDY DESIGN.: Prospective cohort study. OBJECTIVE.: We estimated the cost-effectiveness of spinal cord stimulation (SCS) among workers' compensation recipients with failed back surgery syndrome (FBSS). SUMMARY OF BACKGROUND DATA.: Randomized controlled trial (RCT) evidence suggests that SCS is more effective at 6 months than medical management for patients with FBSS. However, procedure costs are high and workers' compensation claimants often have worse outcomes than other patients. METHODS.: We enrolled 158 FBSS patients receiving workers' compensation into three treatment groups: trial SCS with or without permanent device implant (n = 51), pain clinic (PC) evaluation with or without treatment (n = 39), and usual care (UC; n = 68). The primary outcome was a composite measure of pain, disability and opioid medication use. As reported previously, 5% of SCS patients, 3% of PC patients and 10% of UC patients achieved the primary outcome at 24 months. Using cost data from administrative databases, we calculated the cost-effectiveness of SCS, adjusting for baseline covariates. RESULTS.: Mean medical cost per SCS patient over 24 months was $52,091. This was $17,291 (95% confidence intervals [CI], $4100-30,490) higher than in the PC group and $28,128 ($17,620-38,630) higher than in the UC group. Adjusting for baseline covariates, the mean total medical and productivity loss costs per patient of the SCS group were $20,074 ($3840-35,990) higher than those of the PC group and $29,358 ($16,070-43,790) higher than those of the UC group. SCS was very unlikely (<5% probability) to be the most cost-effective intervention. CONCLUSION.: In this sample of workers' compensation recipients, the high procedure cost of SCS was not counterbalanced by lower costs of subsequent care, and SCS was not cost-effective. The benefits and potential cost savings reported in RCTs may not be replicated in workers' compensation patients treated in community settings.

---

Members don't see this ad.

 

[bedrock]

In appears that in the workers comp realm, SCS is, at best, a palliative endeavor, but not rehabilitative. (1,2).

1. Pain. 2010 Jan;148(1):14-25. Epub 2009 Oct 28.
Spinal cord stimulation for failed back surgery syndrome: outcomes in a workers' compensation setting.Turner JA, Hollingworth W, Comstock BA, Deyo RA.

Abstract
Questions remain concerning effectiveness and risks of spinal cord stimulation (SCS) for chronic back and leg pain after spine surgery ("failed back surgery syndrome" [FBSS]). This prospective, population-based controlled cohort study evaluated outcomes of workers' compensation recipients with FBSS who received at least a trial of SCS (SCS group, n=51) versus those who (1) were evaluated at a multidisciplinary pain clinic and did not receive SCS (Pain Clinic, n=39) or (2) received neither SCS nor pain clinic evaluation (Usual Care, n=68). Patients completed measures of pain, function, medication use, and work status at baseline and 6, 12, and 24 months later. We also examined work time loss compensation over 24 months. Few (<10%) patients in any group achieved success at any follow-up on the composite primary outcome encompassing less than daily opioid use and improvement in leg pain and function. At 6 months, the SCS group showed modestly greater improvement in leg pain and function, but with higher rates of daily opioid use. These differences disappeared by 12 months. Patients who received a permanent spinal cord stimulator did not differ from patients who received some pain clinic treatment on the primary outcome at any follow-up (<10% successful in each group at each follow-up) and 19% had them removed within 18 months. Both trial and permanent SCS were associated with adverse events. In sum, we found no evidence for greater effectiveness of SCS versus alternative treatments in this patient population after 6 months.


2. Spine (Phila Pa 1976). 2011 Nov 15;36(24):2076-83.
Costs and Cost-Effectiveness of Spinal Cord Stimulation (SCS) for Failed Back Surgery Syndrome: An Observational Study in a Workers' Compensation Population. Hollingworth W, Turner JA, Welton NJ, Comstock BA, Deyo RA.

Abstract
STUDY DESIGN.: Prospective cohort study. OBJECTIVE.: We estimated the cost-effectiveness of spinal cord stimulation (SCS) among workers' compensation recipients with failed back surgery syndrome (FBSS). SUMMARY OF BACKGROUND DATA.: Randomized controlled trial (RCT) evidence suggests that SCS is more effective at 6 months than medical management for patients with FBSS. However, procedure costs are high and workers' compensation claimants often have worse outcomes than other patients. METHODS.: We enrolled 158 FBSS patients receiving workers' compensation into three treatment groups: trial SCS with or without permanent device implant (n = 51), pain clinic (PC) evaluation with or without treatment (n = 39), and usual care (UC; n = 68). The primary outcome was a composite measure of pain, disability and opioid medication use. As reported previously, 5% of SCS patients, 3% of PC patients and 10% of UC patients achieved the primary outcome at 24 months. Using cost data from administrative databases, we calculated the cost-effectiveness of SCS, adjusting for baseline covariates. RESULTS.: Mean medical cost per SCS patient over 24 months was $52,091. This was $17,291 (95% confidence intervals [CI], $4100-30,490) higher than in the PC group and $28,128 ($17,620-38,630) higher than in the UC group. Adjusting for baseline covariates, the mean total medical and productivity loss costs per patient of the SCS group were $20,074 ($3840-35,990) higher than those of the PC group and $29,358 ($16,070-43,790) higher than those of the UC group. SCS was very unlikely (<5% probability) to be the most cost-effective intervention. CONCLUSION.: In this sample of workers' compensation recipients, the high procedure cost of SCS was not counterbalanced by lower costs of subsequent care, and SCS was not cost-effective. The benefits and potential cost savings reported in RCTs may not be replicated in workers' compensation patients treated in community settings.

I would wager that it's more cost effective than spinal fusions on manual laborers which WC seems to think is cost effective.

 

[ampaphb]

Is anyone actually surprised that, when Dr. Deyo is the lead author, an expensive technology is found to not be cost effective.

I have not read the full text, but it seems, based on the abstract, that they lumped all FBSS together, not distinguishing primary nociceptive back pain from primary neuropathic leg pain

 

[101N]

Is anyone actually surprised that, when Dr. Deyo is the lead author, an expensive technology is found to not be cost effective.

I have not read the full text, but it seems, based on the abstract, that they lumped all FBSS together, not distinguishing primary nociceptive back pain from primary neuropathic leg pain

Nope.

N = 158
Inclusion Criteria

1. WA state workers comp claim
2. Currently off work due to claim
3. Pain radiating into one or both legs > 6mo
4. Leg pain > back pain
5. Average leg pain > 6
6. No previous SCS
7. No DM or CA
8. Ability to speak English or Spanish

 

[bedrock]

Nope.

N = 158
Inclusion Criteria

1. WA state workers comp claim
2. Currently off work due to claim
3. Pain radiating into one or both legs > 6mo
4. Leg pain > back pain
5. Average leg pain > 6
6. No previous SCS
7. No DM or CA
8. Ability to speak English or Spanish

The study was done in WA?

That must be part of the reason they're so down on SCS in WA. The state never pays for it for state employees and SCS is used less often at WA academic medical centers compared to elsewhere.

 

[Ligament]

This is correct. I am in Seattle. The state will not cover SCS for anything, any reason. I have seen fulminant, end-stage CRPS in injured workers whose limbs would have likely been saved with SCS, but the state would prefer to have them on high dose opioids and on disability payments rather than put a stim in the "worker."

I have had patients with a new diagnosis of CRPS, whom I diagnosed early on, who have temporarily responded great to sympathetic blocks, whom the state has denied SCS for.

Just a real shame.

 

[101N]

I have seen fulminant, end-stage CRPS in injured workers whose limbs would have likely been saved with SCS, but the state would prefer to have them on high dose opioids and on disability payments rather than put a stim in the "worker."

And now you know why. Until/if we can provide data to show that SCS makes a meanful difference in an injured worker's rehab - decreased opioid use, RTW, diminished utilization of
other resources - it won't be funded.

Given the data that we have, I don't consider this to be a draconian practice.

 

[PMR 4 MSK]

And now you know why. Until/if we can provide data to show that SCS makes a meanful difference in an injured worker's rehab - decreased opioid use, RTW, diminished utilization of
other resources - it won't be funded.

Given the data that we have, I don't consider this to be a draconian practice.

From what I've read here about Washington, I don't think it would make a difference. They won't even let the experts chime in. Why would they take the time to review medical literature?