August 17, 2017
John P. Ney, MD, MPH
Assistant Professor of Neurology
Daniel P. Kessler, PhD, JD
Professor, Graduate School of Business and Law School
Senior Fellow, Hoover Institution
“We have an enormous problem that is often not beginning on street corners; it is starting in doctor’s offices and hospitals in every state in our nation.” This quote comes from the recent interim report by the Commission on Combating Drug Addiction and the Opioid Crisis. The report goes on to say that, since 1999, the number of opioid overdoses in the U.S. has quadrupled. Over that same period, the amount of prescription opioids sold has quadrupled as well. With a substantial portion of the population experiencing chronic pain and more than 650,000 prescriptions dispensed every day, the medical profession must employ every available strategy to address the tragic human and economic costs of opioid misuse, abuse, and dependence. One such tactic is to avoid the need for prescription opioids in the first place, or to limit a patient’s pain management need to a very short duration.
This idea is of great interest to us and prompted a study into the possible role of intraoperative neuromonitoring (IONM) in reducing post-operative readmissions, neurologic complications, and pain in cervical spine patients. Our study, Intraoperative Neurophysiological Monitoring in Cervical Spine Surgeries: Longitudinal Costs and Outcomes, which was originally presented at the Cervical Spine Research Society Annual Meeting in December 2016, found that patients who received IONM during cervical spine surgery had less opiate usage in the year following surgery compared to those who did not receive IONM. The data show that using IONM during cervical spine surgeries:
- Reduced opioid use
- Reduced readmissions
- Reduced neurologic complications
These findings have profound implications for long-term addiction and morbidity, and demonstrate that it is possible to avoid or reduce the need for prescription pain medication after cervical spine surgery, which can create a gateway for opioid addiction.
Prior research using administrative claims data has been limited to a 30-day period after discharge and does not account for differences in patients’ medical histories or ancillary services received. Our study of 8,400 cases took a longer view and controlled for detailed patient characteristics. We found that patients receiving IONM had a significant reduction in nervous system complications one year after surgery and a significant reduction in readmission at 30 days, 90 days, and one year post discharge.
Longitudinal data provide a new and important perspective because complications from surgery may take time to manifest. Additionally, to the extent that patients who receive IONM have a history of higher utilization, controlling for detailed characteristics of patients and their index surgeries is essential to obtaining valid estimates of IONM’s effectiveness. Our follow-up is based on all outpatient and prescription claims as well as hospital claims to detect differences that may not be captured otherwise. We constructed comprehensive measures of patients’ prior medical treatments based on their claims history in the 180 days before surgery, and of ancillary services received during the index hospitalization that may be correlated with, but not caused by, IONM. For these reasons, our approach provides a more accurate assessment of the consequences of IONM.
America’s opioid crisis has reached epidemic proportions. Beyond the adverse health effects and emotional distress for individuals and families, opioid misuse and addiction adds tremendous financial pressure on our healthcare system. With the Centers for Disease Control identifying opioid misuse as one of our top public health challenges, it is clear that changes to medical practice that reduce demand for prescription opiates can have important social, economic, and lifetime health benefits for patients.
About the Authors
John P. Ney, MD, MPH
John P. Ney, MD, MPH, is a researcher in health outcomes and comparative effectiveness for Neurology and Clinical Neurophysiology interventions. John is a board-certified Neurologist and Clinical Neurophysiologist with ten years of attending-level clinical neurophysiology experience. He has over forty peer-reviewed publications and has presented at numerous national meetings. His research forms much of the evidence base for outcomes and cost-effectiveness in intraoperative monitoring and continuous EEG. He is an active member of the American Academy of Neurology (AAN), a member of the Medical Economics and Management Committee and Health Services Research subcommittees of the AAN, and an editorial Board Member of Neurology: Clinical Practice. He is the former medical director of Surgical Neuromonitoring Associates and a current full-time neurologist at the VA Medical Center in Bedford, MA. He holds academic titles of Assistant Professor of Neurology at Boston University, Affiliated Assistant Professor at the University of Washington, and faculty at the Indiana University School of Public Health. Dr. Ney is an investigator with the VA Center for Healthcare Organization and Implementation Research. He completed a BA at the University of Virginia, and earned his medical degree from Tulane University and his MPH from University of Washington. He received postgraduate training at Walter Reed Army Medical Center. Dr. Ney is a former U.S. Army officer and veteran of combat operations in Afghanistan where he was awarded a Bronze Star.
Daniel P. Kessler, PhD, JD
Daniel P. Kessler, PhD, JD, is a professor at Stanford Graduate School of Business, a senior fellow at Stanford’s Hoover Institution, a professor at Stanford Law School, and a Research Associate at the National Bureau of Economic Research. His research interests include empirical studies in antitrust law, law and economics, and the economics of healthcare. Dr. Kessler has won awards for his advising and research from Stanford, the National Institute of Health Care Management Foundation, and the International Health Economics Association. He has received grants from the National Institute of Health, the National Science Foundation, and the California Health Care Foundation. He has served as a consultant to corporations, foundations, and the governments of the United States and Canada. He has taught courses in health economics, public policy, and antitrust law at Stanford and the Wharton School at the University of Pennsylvania. He has published numerous papers in economics journals and law reviews, and has written extensively on healthcare reform for the Wall Street Journal and Health Affairs. He is co-author of the book, “Healthy, Wealthy, and Wise: Five Steps to a Better Health Care System,” which outlines how market-based healthcare reform in the U.S. can help fix our system’s problems. Dr. Kessler earned a BA in economics from Harvard University, a PhD in economics from the Massachusetts Institute of Technology, and a law degree from Stanford.