• The strange tale of back pain and AHCPR

    Austin posted on an interesting paper in Health Affairs that essentially makes the case that the treatment of low back pain is impervious to evidence; once payment for a procedure to address this debilitating condition is begun, it seems impossible to stop. I asked Austin via twitter if he was old enough to remember the AHCPR low back pain dust up from the early 1990s and he said he was not, which made me feel very old. You see, the AHCPR/back pain episode was where my “dream of reason” first ran into power, in this midst of my Ph.D. training.*

    Shannon Brownlee beautifully tells the story of how the Agency for Health Care Policy and Research (AHCPR)–created under President Bush I in 1989 to do evidence-based research designed to improve the functioning of the health care system–was nearly killed during the budget warfare between President Clinton and House Speaker Newt Gingrich during 1995 after Republicans took over the House of Representatives. The primary offense of AHCPR was to publish a series of low back pain guidelines that showed many invasive therapies did not work.

    But when the AHCPR’s panel concluded that there was little evidence to support surgery as a first-line treatment for low back pain, and that doctors and patients would be wise to try nonsurgical interventions first, back surgeons went wild. They knew that once the AHCPR’s guidelines were published, Medicare might limit reimbursement for various back surgeries to patients who were enrolled in a controlled clinical trial designed to test the efficacy of the procedure. If the study showed that a surgery was no better than nonsurgical remedies, or only about as good, there was a chance that Medicare would stop reimbursing for it. If Medicare made a back surgery provisional, private insurers were likely to follow [….]

    The back surgeons’ anger at the AHCPR’s efforts to discipline medical practice resonated with the Republican fervor for reducing government, and with the party’s ideological antipathy for federal interference in what they imagined as a free market. The agency’s name soon appeared on a House Budget Committee “hit list” of 140 federal programs targeted for elimination.

    I paid a great deal of attention to the plight of the AHCPR, because I had been awarded a post-doctoral fellowship by the agency in December of 1994 (predicated on successfully defending my dissertation in May, 1995), and was set to move to England with my wife and two month old baby in August, 1995. This was a terrifying experience for me, because there were serious discussions of eliminating AHCPR, and for me, my post-doc, and only source of income.** There was a deal cut that slashed AHCPR’s budget by around 20% (but not my post-doc!) and the name of the agency was changed to the Agency for Healthcare Research and Quality (AHRQ). The key was to remove the word policy from the title.

    I fully believe that bringing the peer review research evidence to bear on health policy is crucial, and that is why I blog, because it gives us a chance to try and interpret and link research into the policy discussions of the day. We at TIE endeavor to stick to the evidence, and I fully believe in this mission. However, I think I might struggle with cynicism about this more than the other bloggers here at TIE. I think it is because I cut my teeth on health policy research wondering if my post-doc and only source of income would evaporate, simply because someone didn’t like the evidence.


    *The Dream of Reason did not take power into account is the first line of Paul Starr’s brilliant Social Transformation of American Medicine. Basic Books, 1982.

    **My father in law used to ask me “what is your job going to be?” you are going to be paid for that? I truly regret he died before I had a stable job, because I think he worried quite a lot about this.


    • I remember those days also. The back surgeons really were up in arms. Since this was before the era of blogs, I had no idea how they managed to resolve this.


    • The problem of people who are unwilling to accept evidence, because the evidence hurts them individually, is far broader than the practice of medicine. For example, climate change. For example, the sources of urban sprawl. As a society, we need to find a way to let the evidence win in these arguments.

    • @David
      yes, I am sure there are many examples. In fact, I bet if you sent me a paper that showed that tenure was bad for teaching and downstream research productivity I would be quite inclined to poke holes in it, etc. Esp where we have very large amounts of public money, we need to have some agreed upon notion of evidence and to allow it to inform decisions.

    • The speaker at my graduation from nursing school was the head of AHCPR (a nurse, by the way), and so I followed the agency’s fortunes with great interest!

      AHCPR managed to piss off urologists too (pun intended), after they published clinical guidelines on the management of incontinence. Their nursing management and patient education materials were GREAT and showed that, properly managed, medication management for incontinence could be almost completely avoided. Whoo-wee!! The docs didn’t like THAT, especially since the guidelines emphasized nursing intervention.

      I still have those materials in my files and used them with patients for a decade after.

      Killing AHCPR cost us billions in health care expenses since, I’m sure…

    • I attended a speech by Newt Gingrich a few years ago and he was in his transforming health care mode. He talked up the use of comparative effectiveness studies. Fortunately I wasn’t allowed near the microphone during question time or I would have asked him why he participated in the near execution of AHCPR for having dared to do exactly what he claimed was necessary.

    • Thanks for the shout out. The near death experience of AHCPR/AHRQ has fostered a timidity on the part of both that agency and CMS when it comes to reining in medical practice, even when the practice leads to a great deal of unnecessary expense and worse, physical harm to patients, as a great deal of back surgery does. Do you know what the biggest predictor of having a back fusion surgery is? Having had a previous one! And we still don’t have a really good RCT for spinal fusion.

      The death panel-mongers may try to kill AHRQ again because of the U.S. Preventive Services Task Force’s recent recommendations on mammography for women in their 40s (don’t do it) and PSA testing (don’t do it). http://www.nytimes.com/2011/10/09/magazine/can-cancer-ever-be-ignored.html?pagewanted=all