Commentary: vertebroplasty and kyphoplasty in the United States 2004–2017: national trends, regional variations, associated diagnoses, and outcomes

Abstract

HafeziNejad et al have provided an overview of the United States’ national trends, regional variations, associated diagnoses, and outcomes from hospitalized patients treated with vertebroplasty and/or kyphoplasty between 2004 and 2017. While some results were predictable, such as decreased use following publication of negative augmentation trials, their review has also yielded other surprising and certainly intriguing results. It is important to consider, however, that this review is based on data obtained from the national inpatient sample. As such, the population analyzed would represent a group of patients with the most debilitating symptoms of vertebral compression fractures such as unremitting pain and immobility. The authors describe a period of decreased use from 2008 to 2012 as being attributable to the 2009 publication of two contentious and negative trials comparing vertebroplasty nonoperative treatment, with which we concur. We also agree with the authors that the subsequent publication of numerous positive trials after 2009 that have supported intervention in these patients also contributed to the rebound in use. What is not referenced by the authors are the numerous publications over the same period and more recently that have demonstrated a significant and consistent mortality benefit from vertebral augmentation across multiple distinct populations. These data reflects a critically important driver in the return growth of vertebral augmentation in patients with osteoporotic and malignant compression fractures in the period since 2013. Figure 4, in the referenced manuscript graphically summarizes regional variations in numbers of procedures, mortality, complications, length of stay, routine disposition percentages, and total hospital charges. Many surprising regional variations are evidenced, especially so as related to charges and length of stay. These findings are perhaps even more interesting than the distinct phases of use described by the authors. Some relationships illustrated are as might be expected. In the southeast region, higher numbers of procedures were performed and complications were low. Conversely, in the mountain region, low numbers of procedures were performed with a higher rate of complications. These relationships are typical for surgical procedures. Mortality was significantly higher in the west and mountain regions. Complications were higher in the mountain region, which might at least partially explain the higher mortality. The high mortality observed in the west region remains unexplained and surprising. What might be so different about the patient population or vertebral augmentation technique in the west region? In addition, in the west region, length of stay was low yet the total charges were high. This relationship is the inverse of what would be expected. The wide regional variations in total charges and length of stay are also quite intriguing. What factors might underlie these variations? It is bewildering to find that medical practice varies to such a degree throughout the country. The authors’ findings have impact far beyond their relevance to vertebral augmentation. The unexpected and large regional variations in cost and outcomes implore further analysis and explanation. Standardization of treatment is widely recognized as a fundamental of providing costeffective healthcare. In contrast to many surgical procedures, standard vertebral augmentation techniques are reasonably similar and not overly complex, even allowing for the selective use of kyphoplasty or vertebroplasty. A similar analysis of more complex surgical procedures would likely be highly enlightening. Furthermore, it would be interesting to conduct an updated review in the same patient target group in years to come as INR practices evolve and instrumented or deviceassisted vertebral augmentation potentially finds an expanded role in patient care. These procedures will increase both cost and procedural intricacy. We congratulate the authors for alerting us to the opportunity and necessity for the performance of additional research into healthcare variations.