Oregon has long been a darling of those who look at health costs. In most measures, the state, including Central Oregon, shows remarkable restraint, turning in some of the lowest costs in the nation.

Against that backdrop, one number sticks out: the rate of back surgeries in Bend.

For more than a decade, this area has had one of the highest rates of back surgery in the country. According to the latest data, from 2005, we have the second highest rate in the nation. Only Casper, Wyo., does more.

In Bend, these numbers show that nearly 10 out of every 1,000 Medicare enrollees receive back surgery. Nationally, that number is four out of every 1,000.

Spine surgeons here, it seems, do more than twice as many back surgeries as the national average.

“What kills me is that no one has called this out,” said Mike Bonetto, board chairman at HealthMatters of Central Oregon, a local nonprofit that works for health care reform. “I think it’s important for the public to understand what these utilization rates are. You should darn well know that you’re twice as likely to get surgery here than anywhere else.”

In 2008, St. Charles Bend did more than 1,400 spinal procedures, according to the hospital.

The high rate of surgery raises two important questions: Why do more surgeries happen here? And are patients better off for it? Unfortunately, the answers remain elusive.

Why more surgeries?

The high number of back surgeries is an open secret in Central Oregon’s medical community. When The Bulletin contacted Bend’s seven spine surgeons, nearly all said they had known about the numbers for some time.

Before Dr. Anthony Haddon, a neurosurgeon, moved to Bend from Southern California, he heard that it was a problem, he said. “I was assuming everyone who comes in through the door, they’re getting fused.”

Several surgeons dismissed the number as a statistical aberration or a result of the unique population of Central Oregon. The doctors all said they tried conservative treatments before resorting to the more expensive and invasive surgical procedures. None said that an excess number of surgeries was a problem in their practices.

Still, the statistic has garnered enough attention that it is now being looked at by a quality committee made up of medical staff from St. Charles Bend and hospital employees. That committee will look at the number of spine surgeries in Central Oregon because the region is an “outlier,” or outside the national average, said Dr. Ray Tien, the chair of the committee. “It may be that we’re doing too much surgery; we have to look at that. That hasn’t been looked at in the past.”

The committee has just started its work and has no solid information currently. Right now, said Tien, there are just no data.

But there are plenty of theories and possible explanations.

It’s possible that Bend has a higher number of people who need back surgeries than other areas. The number could be explained by the high number of people in Central Oregon who work at jobs that involve manual labor, said Dr. Kent Yundt, a Bend neurosurgeon. Indeed, the region’s construction-heavy economy coupled with its farming and ranching roots could mean more people who live here end up with bad backs.

Yet if that explained the difference, you might also expect other parts of the body to break down, such as knees or hips. Our rates for these surgeries, however, are only slightly above national averages, and Bend doesn’t even show up in the top 50 cities for those surgeries.

According to a group at Dartmouth College that analyzes regional differences in health care utilization and that produced the back surgery statistics in 2005, differences in patient characteristics rarely account for variations in surgery rates. “There’s not much evidence to support patient variation in (care) variations around the country,” said Dr. James Weinstein, the chairman of the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center and an author of papers on regional variations in spine surgery.

A second explanation might be that the data don’t represent the full truth. The numbers, which come from the Dartmouth group’s analysis of Medicare data known as the Dartmouth Atlas of Health Care, track only Medicare enrollees, typically people who are disabled and those older than 64. It does not show the rates for people with private insurance, patients with Medicaid or those without insurance.

While data for these groups of people are much harder to come by, private insurers see some of the same trends. The Dartmouth researchers have looked at the trends nationally, Weinstein said, and found variations mirrored in the Medicare data.

In Oregon, at least some health insurance plans see regional variations. The claims data at ODS, a Portland-based insurer, show “Eugene and Bend have higher rates of back surgery than other places,” said Dr. Csaba Mera, medical director at the insurer.

Still, the numbers could be skewed if surgeons here do a lot of surgeries for people from outside the area. The logic is that, because the statistic reflects the number of surgeries per capita, many people coming in from outside the population area could skew that statistic upward.

Dr. Mark Belza, a Bend neurosurgeon, said he does not think the back surgery statistic represents real utilization in this area because the numbers do not take into account the number of referrals from outside the area.

“It’s a deceptive statistic,” agreed Dr. Brad Ward, a Bend neurosurgeon. “The people who get spine surgery in Bend are from all over, so the numbers are skewed.”

Ward mentioned that he recently did surgery on a woman from Sacramento; Yundt said he had a patient come see him from Wasilla, Alaska.

The statistic includes more than just people living in Bend; it includes a large swath of Central and Eastern Oregon with borders at counties along the Columbia River Gorge, Malheur County, the Cascades and within Klamath and Lake counties.

Yet Bend is certainly not the only place that attracts patients from outside the area. Rochester, Minn., where the Mayo Clinic is located, is a relatively small town that attracts patients from across the nation. Its rate of back surgeries, however, is below the national average.

Or consider the rate of spine surgeries in Lebanon, N.H., where Dartmouth is located. That hospital, one of the largest in New England north of Boston, attracts patients from around New England, if not the nation, and boasts a special spine center run by Weinstein, a prominent surgeon. Its rate of back surgeries is about half the national average.

The Dartmouth Atlas numbers, Weinstein said, take into account referrals. When a patient from another area, say Sacramento, comes to Bend, that surgery is tallied as a surgery in Sacramento, not Bend. That means, if specialists had a lot of patients coming in from outside the area, it might actually skew their numbers lower, not higher.

Many people do trust the Dartmouth numbers. On a national level, the Obama administration is analyzing utilization data from the Dartmouth group to try to reshape health policy. Administration officials have focused on differences in the amount of health care Medicare beneficiaries use in different parts of the country (in Central Oregon, it’s a low amount) to make the case that money is wasted by areas that use a lot of health care.

Locally, Tien and others looking at the utilization of health care are relying on the Dartmouth numbers to look at how people use health care in this area. “Though the Dartmouth Atlas isn’t perfect, it is a reasonably standardized format that we can compare our hospital with other similar facilities,” he said. “In the end, the data is pretty accurate.”

Could it be the doctors?

If it’s not the data that are a problem, and not the patients who are different, then the next question is whether the surgeons are doing something different than other surgeons in the country.

By some measures, Central Oregon has more surgeons than the national average. According to the American Association for Neurological Surgeons, there are nationally about 3,500 neurosurgeons, about one for nearly every 86,000 people. In Central Oregon, where the population of Deschutes, Jefferson and Crook counties hovers around 200,000, there are five neurosurgeons, all of whom do back surgery, an excess of the national average.

In addition, the region has two orthopedic surgeons who also specialize in spine surgery, bringing the total number of surgeons to seven. “That’s a high amount of operative spine surgeons,” said Dr. Greg Ha, an orthopedic surgeon who does spine surgery in Bend. “There may be more of a surplus of spine surgeons in Bend.”

The research is conflicting as to whether more back surgeons leads to more back surgery. Though some studies found a correlation, more recent work, again by researchers at Dartmouth, has found no relationship. In a paper published in 2006, the group correlated the number of both neurosurgeons and orthopedic surgeons with the number of spinal procedures done in cities across the country; there was no correlation.

Instead, said Weinstein, an author on that paper, “What you see is the surgeons that are there (are) doing a lot more (surgeries) than other surgeons in the country.”

Weinstein referred to the “surgical signature” of a community, the propensity of surgeons to fix problems with surgery. It may be that in Bend, he said, surgeons simply opt for surgery more often than in other areas. “It’s not that they’re bad doctors or bad surgeons; it’s just that they see a patient and think, ‘We can fix that.’”

Locally, others agreed. “It’s really kind of the culture,” said Bonetto. “It becomes part of the status quo of how a medical community functions, and I think it’s really become part of the norm in terms of utilization.”

There are few studies looking at whether the culture of a particular medical community influences physician decisions. One study last year, led by Brenda Sirovich at Dartmouth Medical School, surveyed primary care physicians from high- and low-cost areas. She found that when guidelines had been established, physicians often made similar decisions no matter where they lived.

However, in cases where there was more gray area, where a screening test could possibly help or where a specialist referral might be beneficial, physicians in high-spending areas were more aggressive than those in low-spending areas, referring more patients for specialty care or ordering more tests.

If the same pattern holds true for surgical care, then that could have implications for back surgery, where there is a lot of gray area about what is best for a specific patient.

Back surgery “is not the kind of home run that hip replacement or knee replacement are,” said Dr. Jeffrey Katz, the director of the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital, an affiliate of Harvard Medical School. It’s not clear, he said, that it’s always a good surgery or that people will see relief.

One in 10 patients, Katz said, will not get better after disc surgery, and for another type, spinal fusion, the risk of a second surgery is increased just by doing the first.

“We spend a ton of money on back surgery,” Katz said. “The question is, what do we get in return?”

Area physicians rejected the notion that they might tend toward more spinal surgeries, at least in their own practices.

“I operate on people who I think it’s appropriate to operate on,” Ward said. “I can only speak for myself.”

The number of back surgeries “doesn’t seem way out of the norm to me,” said Dr. Kathy Moore, an orthopedic surgeon in Bend. “We pride ourselves on being pretty conservative, doing everything we can before surgery.”

“If we discuss this issue with our patients,” Ha said, “we’d be hard-pressed to find someone who thought they were being aggressively treated.”

“If a patient could potentially avoid having a fusion,” Haddon said, “we want to do everything to avoid having a fusion.”

“I’ve been extremely conservative,” Yundt said. “But this afternoon, we have a lady with two compressed fractures in her back. What am I supposed to do? Say, ‘I’m at my quota this month’?”

Insurer’s role

Insurers, in theory, could be a check on an excessive number of back surgeries, refusing approval when surgery is not warranted.

Clear Choice Health Plans, an insurer in Bend that has a large population of Medicare patients, does not track the volumes of spine surgery, said Dr. Joseph Johnson, chief medical officer for the company. “We’re looking at it less from a what’s-the-number perspective and more as if it meets the established guidelines.”

Johnson said he had heard of Bend’s back surgery rates and acknowledged that looking at utilization within the plan’s members would be “healthy” to do in the future.

At ODS, preapproval is a condition for some types of back surgery, Mera said. But even when surgeries are done within the established guidelines, he said, doctors can vary substantially in their patterns of use. “There is enough wiggle room that you can have variation even if you’re following the guidelines. That’s the problem.”

As a check on overutilization of specific procedures, he said, the insurer’s approval process “doesn’t work that well.”

Does Bend do better?

Why Bend does more surgeries is an important question, but at least as important is whether patients in this area benefit from the surgeries done.

If, for example, Bend had better outcomes than most other areas in the country – relieved pain faster, got people back to work sooner and allowed them more function – then our back surgery rate could be heralded as a solution, not a problem.

The problem is no one has the data that would show whether patients here do better than in other areas of the country. Without that, we don’t know whether Bend is doing great care or just simply doing too many surgeries.

“The issue is what are their results,” Weinstein said. “Maybe they are the best in the country, but we don’t know that.”

Tien echoed that problem. “Do we have higher utilization because we have superior outcomes?” That’s something the quality committee wants to look into, he said. “We don’t have the data now.”

Ha said he talks to patients individually to get an idea of how they are doing, but the practice does not do any systematic follow-up on surgical patients. The measures are hard to standardize, he said. “Really, I’m just more focused on getting people better.”

Yet without answers to whether back surgery patients in Bend do better than in the rest of the country, no one can say whether the high rates of surgery in the area are justified. We are left in the same place we have been for years, knowing we do a lot of back surgeries without knowing why.

So, where does that leave patients? For many patients, doctors say, spine surgery can be effective and a necessary operation. There are some times when back surgery is the best option, and for the “right people,” Weinstein said, “spine surgery is very good.”

Still, Tien said, people should keep this information in mind when considering surgery. “If they don’t have complete confidence, they owe it to themselves to get a second opinion.”

Number of back surgeries at St. Charles Bend in 2008

Laminectomy: 505

Most commonly done in the neck or lower back to treat for spinal stenosis, a narrowing of an area in the back that can put pressure on the spinal cord. Surgeons scrape out part of the back bone to allow more room for the spinal cord or nerves.

Removal of implanted device: 96

The majority of these cases are surgeries to remove devices used in fusion operations. It is often done when a patient has had a fusion and comes back, often years later, with pain.

Discectomy: 437

A very common procedure done to alleviate pain from a herniated disc, one of the supple pads that cushion the area between vertebrae. Sometimes the disc slips, or bulges, out from its normal placement, which can require removal in a discectomy.

Cervical fusion: 231

Often done in conjunction with a cervical discectomy, a fusion adds stability to the neck by replacing a lost disc with a graft, and sometimes rods or screws, to fill the space left open by the removed disc and allow the bones to fuse together.

Lumbar fusion: 166

Sometimes done after the failure of conservative treatments to relieve back pain, this surgery fuses the vertebrae of the lower back using bone grafts and, if needed, rods and screws.