VIDEO: Our November 14, 2024 launch event featuring Claire Brockbank, director of policy and strategy for 32BJ Health Fund; Dr. Sohail Mirza, orthopedic surgeon and professor at Dartmouth College; and Dr. Vikas Saini, president of the Lown Institute.
The Lown Institute Hospitals Index is the first to evaluate how well individual hospitals avoid overuse of common low-value tests and procedures. The Institute measured overuse of spinal fusion/laminectomy and vertebroplasty at hospitals with the capacity to perform the procedure using Medicare fee-for-service (2020-2022) and Medicare Advantage (2019-2021) claims data. (press release | methodology)
These are the hospitals with the lowest rates of spinal fusion/laminectomy overuse, including all hospitals that performed at least 500 total spinal fusion/laminectomies over three years. The rate of overuse is measured as the proportion of total procedures performed that meet overuse criteria. The average overuse rate for all U.S. hospitals was 14%.
NAME | STATE | Overuse rate | Overuse procedures | Total procedures |
Avala Hospital | LA | 0.1% | Data omitted to avoid sharing information that could be personally identifiable.* | |
Northwest Specialty Hospital | ID | 1.2% | ||
Fresno Surgical Hospital | CA | 1.2% | ||
Baylor Surgical Hospital at Las Colinas | TX | 1.3% | ||
CHRISTUS Mother Frances Hospital – Tyler | TX | 1.7% | 18 | 1083 |
McBride Orthopedic Hospital | OK | 1.8% | 15 | 840 |
UC San Diego Medical Center | CA | 1.9% | 15 | 783 |
Hendrick Medical Center | TX | 2.1% | 18 | 852 |
Methodist Hospital for Surgery | TX | 2.4% | 18 | 758 |
Erlanger Baroness Hospital | TN | 2.5% | 22 | 876 |
iLegent Orthopedic and Spine | TX | 2.6% | 32 | 1234 |
Southeast Kansas Specialty Hospital | KS | 2.9% | 22 | 771 |
Asante Rogue Regional Medical Center | OR | 2.9% | 17 | 586 |
Piedmont Augusta | GA | 2.9% | 31 | 1061 |
Morristown Medical Center | NJ | 3.0% | 28 | 923 |
Arkansas Surgical Hospital | AR | 3.2% | 34 | 1076 |
CHRISTUS Santa Rosa Hospital – Medical Center | TX | 3.2% | 20 | 629 |
HonorHealth Scottsdale Thompson Peak Medical Center | AZ | 3.2% | 19 | 591 |
MultiCare Deaconess Hospital | WA | 3.3% | 23 | 704 |
Tallahassee Memorial Hospital | FL | 3.3% | 21 | 635 |
*Exact procedure counts under 11 may not be released under CMS’ rules for using Medicare claims
These are the hospitals with the highest rates of spinal fusion/laminectomy overuse, including all hospitals that performed at least 500 total spinal fusion/laminectomies over three years. The rate of overuse is measured as the proportion of total procedures performed that meet overuse criteria. The average overuse rate for all U.S. hospitals was 14%.
NAME | STATE | Overuse rate | Overuse procedures | Total procedures |
Mount Nittany Medical Center |
PA |
62.8% |
336 |
535 |
The Medical Center of Aurora |
CO |
42.1% |
275 |
653 |
Jefferson Abington Hospital |
PA |
40.6% |
295 |
726 |
Concord Hospital |
NH |
40.6% |
212 |
522 |
Heritage Valley Sewickley |
PA |
40.1% |
203 |
506 |
HSHS St. John’s Hospital |
IL |
39.2% |
204 |
521 |
Lutheran Hospital |
IN |
39.1% |
459 |
1174 |
Baystate Medical Center |
MA |
38.9% |
326 |
838 |
Mobile Infirmary |
AL |
37.5% |
221 |
589 |
Cape Coral Hospital |
FL |
37.5% |
210 |
560 |
Unity Hospital |
NY |
35.9% |
284 |
792 |
The Orthopedic Specialty Clinic at TOSH |
UT |
35.8% |
227 |
635 |
The Orthopedic Hospital of Lutheran Health Network |
IN |
35.3% |
351 |
995 |
Rochester General Hospital |
NY |
35.3% |
207 |
587 |
Advocate Condell Medical Center |
IL |
35.0% |
181 |
517 |
Mount Carmel East |
OH |
34.5% |
217 |
629 |
UnityPoint Health – Iowa Methodist Medical Center |
IA |
34.1% |
287 |
842 |
Black Hills Surgical Hospital |
SD |
33.5% |
282 |
842 |
Springfield Memorial Hospital |
IL |
32.8% |
265 |
807 |
Hospital of the University of Pennsylvania |
PA |
32.6% |
209 |
641 |
These are the hospitals with the lowest rates of vertebroplasty overuse, including all hospitals with at least 500 eligible patient visits over three years. The rate of overuse is measured as the proportion of patient visits with osteoporotic fracture that resulted in an unnecessary vertebroplasty. The average overuse rate for all U.S. hospitals was 11%.
Many hospitals on this list performed no vertebroplasties over three years despite having opportunities to do so.
NAME | STATE | OVERUSE RATE | OVERUSE PROCEDURES | PATIENT VISITS |
MetroHealth Medical Center | OH | 0.00% | 0 | 1562 |
Essentia Health – St. Joseph’s Medical Center (Brainerd) | MN | 0.00% | 0 | 1005 |
Marshall Hospital | CA | 0.00% | 0 | 885 |
Denver Health Main Campus | CO | 0.00% | 0 | 795 |
Benefis Hospitals Inc. | MT | 0.00% | 0 | 660 |
St. Joseph Hospital | ME | 0.00% | 0 | 647 |
Froedtert Holy Family Memorial Hospital | WI | 0.00% | 0 | 614 |
Cayuga Medical Center | NY | 0.00% | 0 | 575 |
AdventHealth Sebring | FL | 0.00% | 0 | 506 |
St. Luke’s Magic Valley Medical Center | ID | 0.13% | Data omitted to avoid sharing information that could be personally identifiable.* | |
St. Luke’s Hospital – Anderson Campus | PA | 0.17% | ||
Harborview Medical Center | WA | 0.17% | ||
Johns Hopkins Bayview Medical Center | MD | 0.17% | ||
Trinity Hospital | ND | 0.19% | ||
Essentia Health – Duluth (Miller-Dwan Building) | MN | 0.19% | ||
NYC Health + Hospitals/Lincoln | NY | 0.20% | ||
Logan Health Medical Center | MT | 0.26% | ||
Mayo Clinic Health System – Franciscan Healthcare – La Crosse | WI | 0.32% | ||
Boston Medical Center | MA | 0.36% | ||
Bozeman Health Deaconess Regional Medical Center | MT | 0.38% |
*Exact procedure counts under 11 may not be released under CMS’ rules for using Medicare claims
These are the hospitals with the highest rates of vertebroplasty overuse, including all hospitals with at least 500 eligible patient visits over three years. The rate of overuse is measured as the proportion of patient visits with osteoporotic fracture that resulted in an unnecessary vertebroplasty. The average overuse rate for all U.S. hospitals was 11%.
At some hospitals, half of all patient visits with osteoporotic fractures resulted in an unnecessary vertebroplasty.
NAME | STATE | Overuse rate | Overuse procedures | Patient visits |
Shannon Medical Center |
TX |
55.5% |
336 |
605 |
CHI St. Vincent Infirmary |
AR |
50.5% |
320 |
634 |
St. Elizabeth Florence Hospital |
KY |
48.7% |
348 |
714 |
Lutheran Hospital |
IN |
44.6% |
300 |
672 |
Ascension Providence Hospital – Southfield Campus |
MI |
42.3% |
222 |
525 |
Washington Regional Medical Center |
AR |
38.9% |
289 |
743 |
Swedish Cherry Hill Campus |
WA |
38.3% |
198 |
517 |
Ascension Borgess Hospital |
MI |
38.0% |
381 |
1004 |
Ascension St. Mary’s Hospital |
MI |
37.4% |
187 |
500 |
Liberty Hospital |
MO |
37.2% |
335 |
901 |
Mather Hospital |
NY |
36.3% |
219 |
603 |
Texoma Medical Center |
TX |
36.1% |
190 |
526 |
Blanchard Valley Hospital |
OH |
34.9% |
196 |
561 |
Parkview Regional Medical Center |
IN |
34.7% |
351 |
1012 |
Baptist Health Medical Center – Little Rock |
AR |
34.6% |
174 |
503 |
Northside Hospital Forsyth |
GA |
34.4% |
207 |
601 |
Lakeland Regional Health Medical Center |
FL |
34.0% |
172 |
506 |
St. Bernards Medical Center |
AR |
32.3% |
178 |
552 |
CHRISTUS Spohn Hospital Corpus Christi – Shoreline |
TX |
32.1% |
251 |
781 |
Hays Medical Center |
KS |
31.5% |
158 |
501 |
Below are rates of overuse among the 2024-25 US News Honor Roll hospitals. Although all of these hospitals are large academic medical centers, their rates of overuse varied. For example, Cedars-Sinai Medical Center performed 355 low-value spinal fusion procedures while UC San Diego Medical Center only did 15. At the Cleveland Clinic, fewer than 1% of patient visits with osteoporotic fracture resulted in an unnecessary vertebroplasty, compared to nearly 20% at the Mayo Clinic Phoenix.
Spinal fusion/laminectomy |
Vertebroplasty | ||||
NAME | STATE | Overuse procedures | Overuse rate | Overuse procedures | Overuse rate |
Brigham and Women’s Hospital |
MA |
250 |
16.4% |
71 |
2.0% |
Cedars-Sinai Medical Center |
CA |
355 |
17.7% |
52 |
2.4% |
Cleveland Clinic Main Campus |
OH |
269 |
13.8% |
45 |
0.5% |
Duke University Hospital |
NC |
132 |
12.7% |
89 |
4.2% |
Hospital of the University of Pennsylvania |
PA |
209 |
32.6% |
26 |
1.5% |
Houston Methodist Hospital |
TX |
239 |
10.2% |
240 |
17.9% |
Massachusetts General Hospital |
MA |
286 |
20.9% |
408 |
8.0% |
Mayo Clinic Hospital, Phoenix |
AZ |
55 |
6.6% |
132 |
19.5% |
Mayo Clinic Hospital, Rochester |
MN |
240 |
11.7% |
229 |
8.4% |
Mount Sinai Hospital |
NY |
104 |
12.4% |
154 |
13.9% |
New York-Presbyterian Hospital |
NY |
287 |
19.5% |
177 |
7.5% |
North Shore University Hospital |
NY |
105 |
13.1% |
33 |
5.0% |
Northwestern Memorial Hospital |
IL |
78 |
10.0% |
20 |
1.2% |
Ronald Reagan UCLA Medical Center |
CA |
n/a |
n/a |
26 |
1.1% |
RUSH University Medical Center |
IL |
163 |
12.1% |
52 |
2.3% |
Stanford Hospital |
CA |
314 |
21.3% |
127 |
4.0% |
The Johns Hopkins Hospital |
MD |
151 |
13.8% |
40 |
5.8% |
Tisch Hospital |
NY |
158 |
7.9% |
263 |
8.0% |
UC San Diego Medical Center |
CA |
15 |
1.9% |
51 |
2.2% |
UCSF Medical Center |
CA |
295 |
17.8% |
47 |
1.7% |
Total counts and rates of low-value spinal fusion/laminectomy and vertebroplasty by state. The average overuse rates nationwide were 14% for spinal fusions/laminectomy and 11% for vertebroplasty.
|
Spinal fusion/laminectomy |
Vertebroplasty |
||
State |
Overuse procedures |
Overuse rate |
Overuse procedures |
Overuse rate |
Alabama |
3344 |
17.9% |
1360 |
14.2% |
Alaska |
189 |
17.5% |
16 |
1.5% |
Arizona |
1946 |
10.7% |
555 |
4.5% |
Arkansas |
792 |
9.4% |
2094 |
20.0% |
California |
6679 |
13.4% |
5361 |
7.3% |
Colorado |
1766 |
10.9% |
1337 |
7.4% |
Connecticut |
1065 |
13.8% |
913 |
8.6% |
DC |
408 |
14.9% |
78 |
9.6% |
Delaware |
404 |
15.6% |
269 |
9.2% |
Florida |
6771 |
14.0% |
7585 |
14.6% |
Georgia |
2680 |
12.8% |
2353 |
13.3% |
Hawaii |
287 |
17.9% |
218 |
5.1% |
Idaho |
562 |
9.7% |
882 |
6.4% |
Illinois |
3262 |
15.4% |
4994 |
10.2% |
Indiana |
3063 |
16.1% |
3420 |
15.8% |
Iowa |
1254 |
19.7% |
927 |
8.6% |
Kansas |
894 |
10.7% |
2507 |
19.8% |
Kentucky |
1622 |
16.4% |
2642 |
13.1% |
Louisiana |
1482 |
11.5% |
1794 |
10.2% |
Maine |
477 |
15.6% |
476 |
4.8% |
Maryland |
1393 |
13.9% |
955 |
11.6% |
Massachusetts |
2703 |
18.2% |
3177 |
7.8% |
Michigan |
3679 |
14.8% |
4178 |
9.5% |
Minnesota |
1805 |
13.5% |
898 |
3.6% |
Mississippi |
679 |
13.4% |
1377 |
12.6% |
Missouri |
2654 |
16.2% |
3701 |
12.8% |
Montana |
436 |
13.7% |
240 |
3.4% |
Nebraska |
876 |
14.5% |
1281 |
16.1% |
Nevada |
733 |
13.1% |
731 |
16.6% |
New Hampshire |
678 |
22.3% |
640 |
7.2% |
New Jersey |
1416 |
14.4% |
885 |
6.0% |
New Mexico |
378 |
17.0% |
317 |
5.9% |
New York |
3877 |
15.0% |
3011 |
6.7% |
North Carolina |
3630 |
12.6% |
2843 |
9.5% |
North Dakota |
273 |
12.1% |
625 |
6.4% |
Ohio |
5044 |
16.3% |
7099 |
11.1% |
Oklahoma |
1030 |
8.5% |
2421 |
17.9% |
Oregon |
848 |
8.5% |
430 |
2.8% |
Pennsylvania |
5113 |
18.2% |
4030 |
7.7% |
Rhode Island |
349 |
14.6% |
384 |
11.8% |
South Carolina |
1685 |
11.6% |
1457 |
10.0% |
South Dakota |
615 |
16.9% |
499 |
8.3% |
Tennessee |
3399 |
15.7% |
1458 |
8.3% |
Texas |
5864 |
10.4% |
9262 |
14.8% |
Utah |
1066 |
12.1% |
394 |
4.9% |
Vermont |
128 |
17.4% |
99 |
3.0% |
Virginia |
2365 |
13.6% |
2162 |
7.6% |
Washington |
1854 |
11.7% |
1415 |
5.2% |
West Virginia |
641 |
16.1% |
494 |
5.2% |
Wisconsin |
1359 |
13.4% |
2209 |
7.8% |
Wyoming |
99 |
7.5% |
91 |
5.2% |
*Does not count hospitals outside of the 50 US states and DC, or hospitals with missing state information
Breakdown of selected industry payments by category. Includes payments from 2020-22 to physicians with measurable spinal fusion/laminectomy or vertebroplasty overuse. Data sourced from CMS Open Payments with analysis by Conflixis, Inc.
Category |
# of payments |
Total amount |
Consulting fee |
11,761 |
$40.1 million |
Speaker fee |
3,236 |
$11.0 million |
Travel & lodging |
20,949 |
$7.7 million |
Food & Beverage |
107,492 |
$5.2 million |
Other payments & gifts |
1,286 |
$616,000 |
TOTAL |
144,724 |
$64.6 million |
Breakdown of selected industry payments by company. Includes payments from 2020-22 to physicians with measurable spinal fusion/laminectomy or vertebroplasty overuse. Data sourced from CMS Open Payments with analysis by Conflixis, Inc.
Company |
# of payments |
Total amount |
NuVasive, Inc. |
10,122 |
$8.0 million |
Medtronic, Inc. |
21,229 |
$7.5 million |
Stryker Corporation |
13,568 |
$7.3 million |
Globus Medical, Inc. |
4,878 |
$3.5 million |
Alphatec Spine, Inc. |
4,165 |
$3.5 million |
Medtronic USA, Inc. |
7,203 |
$3.0 million |
Medical Device Business Services, Inc. |
1,612 |
$2.3 million |
SI-BONE, Inc. |
4,397 |
$1.4 million |
SeaSpine Orthopedics Corporation |
2,172 |
$1.4 million |
Innovasis Inc. |
476 |
$1.3 million |
What is a spinal fusion or laminectomy?
Spinal fusions and laminectomies are performed to treat back pain, either by fusing vertebrae together (spinal fusion) or removing part of a vertebra (laminectomy). These procedures are frequently performed together.
When is it overuse?
Lumbar spinal fusion is recommended for patients that have low-back pain caused by issues such as traumatic injury, sciatica, slipped spinal bone, or spinal deformity. However, for patients who have low back pain caused by aging, there is not sufficient evidence of a benefit from these procedures compared to non-surgical alternatives. Unlike with vertebroplasty, there have been no randomized controlled trials comparing spinal fusion/laminectomy to a placebo surgery (known as “sham trials”).
For this study, spinal fusion and/or laminectomy was defined as overuse for patients with low-back pain, excluding patients with radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain, scoliosis. Patients with neural claudication and spondylolisthesis were also excluded in certain cases. Our exclusion criteria is based on a previously validated overuse measure (Segal, 2015) and consultations with physicians.
Recent systematic reviews/meta-analyses:
See also:
What are the harms?
What is a vertebroplasty?
Vertebroplasty is a procedure to treat spinal fractures caused by osteoporosis, bone cancer, and other conditions. A medical-grade cement is injected into the fractured vertebra through a needle, under light sedation or general anesthesia, and the cement hardens in the bone space to form an internal cast. Vertebroplasty may include a kyphoplasty, in which a balloon is inserted into the fractured vertebra and inflated to create space before the cement is injected.
When is it overuse?
For this study, vertebroplasty was defined as overuse for patients with spinal fractures caused by osteoporosis, excluding patients with bone cancer, myeloma, or hemangioma. Overuse rates of vertebroplasty were measured as a ratio of low-value procedures as a proportion of total patient visits for osteoporotic spinal fracture. This overuse definition is based on a previously validated overuse measure (Schwartz, 2014).
Relevant research reviews:
After two landmark trials in 2009 found a lack of benefit for vertebroplasty compared to a placebo (“sham”) procedure, the rate of vertebroplasties in Medicare declined by about 60% (Journal of the American College of Radiology, 2017).
What are the harms?
Hospital overuse was measured using Medicare fee-for-service and Medicare Advantage claims data for three years of the most recently available data (2020-2022 for Medicare FFS and 2019-2021 for Medicare Advantage). The nationwide counts of low-value procedures includes all hospitals with Medicare claims data available (n=2,545 for spinal fusion/laminectomy, n=2,417 for vertebroplasty).
The cost of low-value back surgeries was calculated using Medicare’ procedure price lookup tool for outpatient procedures, using the most frequent CPT code for the procedure. The cost of inpatient procedures was calculated using the average Medicare cost of the most frequent Diagnosis Related Group (DRG) code for the procedure, using Medicare FFS claims data. We assume that the cost of these procedures is similar for Medicare FFS and Advantage patients.
The lists of hospitals with highest and lowest overuse rates are limited to hospitals with high volumes, defined as performing at least 500 total spinal fusions/laminectomies (when measuring spinal fusion/laminectomy) or having at least 500 patient visits for osteoporotic fracture (when measuring vertebroplasty) over three years.
Spinal fusion and/or laminectomy was defined as overuse for patients with low-back pain, excluding patients with radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain or scoliosis. For spinal fusion only cases, patients with stenosis with neural claudication and spondylolisthesis were excluded. For laminectomy only cases, patients with stenosis with neural claudication were excluded. Overuse rates of spinal fusion/laminectomy were measured as a ratio of low-value procedures as a proportion of total spinal fusion/laminectomy procedures.
Vertebroplasty was defined as overuse for patients with spinal fractures caused by osteoporosis, excluding patients with bone cancer, myeloma, or hemangioma. Overuse rates of vertebroplasty were measured as a ratio of low-value procedures as a proportion of total patient visits with osteoporotic spinal fracture.
BECKER’S HOSPITAL REVIEW
Media inquiries should be directed to Aaron Toleos, vice president of communications for the Lown Institute, at atoleos@lowninstitute.org.