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Geographic Variation in Epidural Steroid Injection Use in Medicare Patients
Janna Friedly, MD1; Leighton Chan, MD, MPH2; Richard Deyo, MD, MPH3
1 Department of Rehabilitation Medicine and Center for Comparative Effectiveness, Cost and Outcomes Research, University of Washington, Harborview Medical Center, Box 358740, 325 Ninth Avenue, Seattle, WA 98127. E-mail address: friedlyj@u.washington.edu
2 National Institutes of Health, Building 10, CRC, Room 1-1469, 10 Center Drive, MSC 1604, Bethesda, MD 20892-1604
3 Family Medicine Department, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Intramural Research Program of the National Institutes of Health, Clinical Research Center, Rehabilitation Medicine Scientist Training (RMSTP) K12 Program (National Institutes of Health grant 2K12HD001097-11) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (National Institutes of Health grant P60 AR 48093), National Institutes of Health. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Synthes) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
Investigation performed at the University of Washington, Seattle, Washington

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Aug 01;90(8):1730-1737. doi: 10.2106/JBJS.G.00858
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Background: The rates of epidural steroid injections have increased dramatically over time, with conflicting evidence regarding the efficacy of epidural steroid injections for the treatment of various low-back pain disorders. Given the uncertainty about their role, we sought to evaluate the geographic variation in the use of epidural steroid injections for low back pain within the United States. We also sought to determine whether greater rates of epidural steroid injections are associated with lower rates of lumbar surgery.

Methods: We used the 2001 Medicare Physician Part-B claims to examine the geographic variation in the use of epidural steroid injections. Current Procedural Technology codes were used to identify the number of procedures performed as well as the percentage of injections that were fluoroscopically guided. Procedure rates were analyzed with use of several geographic indicators, including state, United States Census Bureau regions (Northeast, South, Midwest, and West), and health referral regions as defined by the Dartmouth Atlas of Health Care.

Results: In 2001, there was a 7.7-fold difference between the state with the lowest rate (Hawaii at 5.2 per 1000) and the state with the highest rate (Alabama at 39.9 per 1000). The variation among health referral regions, which are smaller in size, was even greater, with an 18.4-fold difference from 5.6 per 1000 in Honolulu, Hawaii, to 103.6 per 1000 in Palm Springs, California. Higher statewide rates of epidural steroid injections were associated with significantly higher rates of lumbar surgery (p = 0.001). In areas with high injection rates, a significantly higher percentage of patients who sought care for low back pain received injections (p < 0.001). In addition, in areas with high injection rates, a significantly higher percentage of patients who presented with low back pain received both injections and lumbar surgery within the same year (p < 0.001).

Conclusions: There is substantial geographic variation in the rates of epidural steroid injections within the United States. Southern states tend to have the highest procedure rates, whereas northeastern states have the lowest. Injection rates are positively correlated with lumbar surgery rates; therefore, epidural steroid injections do not appear to be substituting for lumbar surgeries or reducing overall rates of lumbar surgery.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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