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DOI: 10.1016/j.bjpt.2018.09.004
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Second opinion programs in spine surgeries: an attempt to reduce unnecessary care for low back pain patients
Isadora Orlando de Oliveiraa,b,c, Mario Lenzaa, Rodrigo Antunes de Vasconcelosb, Eliane Antoniolia, Miguel Cendoroglo Netoa, Mário Ferrettia,
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Corresponding author at: Hospital Israelita Albert Einstein, Avenida Albert Einstein 627/701, Bloco A1 – Programa Locomotor, Jardim Leonor, CEP: 05652-900, São Paulo, SP, Brazil.
a Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
b Instituto Wilson Mello, Campinas, SP, Brazil
c Universidade Cidade de São Paulo, São Paulo, SP, Brazil
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Low back pain is the leading cause of years lived with disability worldwide.1 Studies show that over the past two decades, costs related to spinal surgery have increased substantially.2 Although expenses with physical therapy treatments and less invasive surgical procedures remained relatively stable, the amount spent with more complex spinal surgeries increased exponentially.3 Complex spinal surgeries are the procedures with the highest costs in healthcare, and its clinical outcomes still needs to be further investigated.3

Currently, the criteria to determine which patients should undergo to surgical procedures are interpreted non-uniformly by surgeons. Surgical interventions are often planned based upon clinical and imaging studies, which may result in unnecessary procedures4 as the diagnostic accuracy of both clinical examination and imaging are low. As a result of these uncertainties, there is no consensus on what would be the best criteria for recommending surgery for patients with low back pain.

Advances in healthcare technology (e.g. imaging exams, implants and surgical techniques), and the aging population may also be partially responsible for the increasing number of spinal surgeries and also the costs associated to these procedures. However, different methods and techniques of treatments were developed in an attempt to establish the best intervention for patients. Therefore, second opinion programs have a crucial role in low back pain cases in order to reduce unnecessary care.5

Second opinion programs have been used as a tool to improve the quality of patients’ care in all private care systems, improving medical practice. Second opinion programs are defined as an alternative to validate or not the decision of having surgery for back pain in first place.6 Although second opinion is not mandatory in most healthcare systems, these programs may be very useful for patients, health insurances and for physicians contributing to either improve outcomes or to reduce possible harms due to unnecessary surgical procedures.7

In the field of spinal surgery, second opinion programs have the potential to reduce not only costs, but also risks of surgical over-reporting, promoting a more ethical clinical practice. One way of conducting a second opinion is the first contact being held by a senior nurse who explains to the patient how the second opinion process works after the spinal surgeon's diagnosis. After consenting, the patient attends a medical appointment with a clinician, who performs a clinical assessment in order to establish a second opinion, which can be either a surgical procedure or a suggestion for other types of conservative treatment. After that, patients can agree or disagree with the second opinion referral and proceed with the procedure of their choice.6

Several factors contributed to the increase in demand for a second opinion: patients’ awareness and knowledge of their symptoms; the increase in high complexity procedures that were not validated by the best scientific evidence; legal and economic problems associated with medical practice and also, specifically concerning spinal surgeries, non-pharmacological treatment such as exercise therapy and education that supports self-management presenting good clinical outcomes in patients with low back pain.8,9 In Brazil, according to a national health agency recommendation, insurance companies have also adopted the practice of second opinion as a tool to improve the quality of healthcare, making it more rational and efficient.

Previous literature has shown that after a second opinion approximately 61% of referrals for surgery may be considered inadequate resulting in a reduction of up to 50% in surgical procedures.6 Clinical practice guidelines strictly reinforce obtaining a second opinion when spinal surgery is indicated, but currently there is not enough published evidence confirming its effectiveness.7 Therefore, it is important that research is expanded in this area and second opinion programs are tested in various settings using rigorous research methods.

In summary, second opinion programs can significantly reduce the proportion of patients who undergo unnecessary procedures. Although further efforts are needed to ensure that clinical practice is in line with evidence. It is highly recommended that patients, healthcare services and general practitioners should consider seeking a second opinion for spinal surgery. This will hopefully contribute for a more ethic and multidisciplinary practice, reducing the socioeconomic burden associated to low back pain and also helping to improve quality of life of patients with low back pain.

GBD 2016 Disease and Injury Incidence and Prevalence Collaborators
Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
S. Dagenais, J. Caro, S. Haldeman
A systematic review of low back pain cost of illness studies in the United States and internationally
B.I. Martin, R.A. Deyo, S.K. Mirza
Expenditures and health status among adults with back and neck problems
N.E. Foster, J.R. Anema, D. Cherkin
Prevention and treatment of low back pain: evidence, challenges, and promising directions
pii: S0140-6736(18)30489-6 [Epub ahead of print]
S. Nishtar
Corruption in health systems
M. Lenza, R. Buchbinder, M.P. Staples
Second opinion for degenerative spinal conditions: an option or a necessity? A prospective observational study
BMC Musculoskelet Disord, 18 (2017), pp. 354
N.E. Epstein
Are recommended spine operations either unnecessary or too complex? Evidence from second opinions
Surg Neurol Int, 4 (2013), pp. S353-S358
D.C. Viola, M. Lenza, S.L. Almeida
Spine surgery cost reduction at a specialized treatment center
Einstein (Sao Paulo), 11 (2013), pp. 102-107
G. Sowden, J.C. Hill, L. Morso, Q. Louw, N.E. Foster
Advancing practice for back pain through stratified care (STarT Back)
Braz J Phys Ther, 22 (2018), pp. 255-264
Brazilian Journal of Physical Therapy

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