Practice Variation Between Salaried and Fee-for-Service Surgeons for Lumbar Surgery

Objective: To examine differences in surgical practices between salaried and fee-for-service surgeons for two common degenerative spine conditions. Surgeons may offer different treatments for similar conditions on the basis of their compensation mechanism. Methods: The study assessed the practices of 63 spine surgeons across eight Canadian provinces (39 fee for service surgeons and 24 salaried) who performed surgery for two lumbar conditions: stable spinal stenosis and degenerative spondylolisthesis. The study included a multicentre, ambispective review of consecutive spine surgery patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) registry between Oct 2012 and July 2018. The primary outcome was the difference in type of procedures performed between the two groups. Secondary study variables included surgical characteristics, baseline patient factors, patient91 reported outcome. Results: For stable spinal stenosis (n=2234), salaried surgeons performed statistically fewer uninstrumented fusion (p<0.05) than fee-for-service surgeons. For degenerative spondylolisthesis (n=1292), salaried surgeons performed significantly more instrumentation plus interbody fusions (p<0.05). There were no statistical differences in patient-reported outcomes between the two groups. Conclusions: Surgeon compensation was associated with different approaches to stable lumbar spinal stenosis and degenerative lumbar spondylolisthesis. Salaried surgeons chose a more conservative approach to spinal stenosis, and a more aggressive approach to degenerative spondylolisthesis, which highlights that remuneration is likely a minor determinant in the differences in practice of spinal surgery in Canada. Further research is needed to further elucidate which variables, other than patient demographics and financial incentives, influence surgical decision-making.