This Atlas examined variation in six surgical interventions by Statistical Area Level 3 (SA3). Lumbar spinal fusion showed the largest variation between areas, with a seven-fold difference between the highest and lowest rates. Rates of spinal decompression showed a five-fold difference. A four-fold difference was found for rates of knee replacement, laparoscopic cholecystectomy, appendicectomy and cataract surgery.
For some of these procedures, ‘indication creep’ and differing clinician views of the value of the operation in new patient populations are likely to have contributed to the variation. For example, spinal fusion surgery was initially used primarily to treat fractures and deformities of the spine, but its use has now broadened to include treatment of degenerative spine disorders.1 In the case of cholecystectomy, introduction of the laparoscopic technique was followed by a sharp rise in its use.2 This may have been partly due to a lowering of the threshold for the procedure.2
Wide variation in use of a surgical procedure may reflect a lack of agreement on its indications. For procedures with uncertain benefits outside a small patient population, substantial variation raises the likelihood that rates are too high in some areas. For the interventions in this chapter where the evidence is unclear, determining whether there are subgroups of patients who are more likely to benefit from the procedure should be a priority. Identification of patients who are likely to benefit would be aided by routine collection and analysis of the severity and nature of patients’ presenting symptoms, and patient-reported outcomes after surgery. Limiting spinal fusion procedures undertaken because of low back pain has been recommended in the United Kingdom.3
Ensuring that patients understand the evidence about the likelihood of risks and benefits is particularly important if the degree of benefit from surgical treatment is not clear. Accessible information, improved health literacy and high-quality tools for shared decision-making would support patients to make better informed choices about care.4
The variation in rates of cataract surgery highlights inequity of access. The rate of cataract surgery hospitalisations for Aboriginal and Torres Strait Islander Australians was 80% of the rate for other Australians.
4a. The Medicare Benefits Schedule (MBS) Review Taskforce to ensure that MBS descriptors reflect the care described in the Osteoarthritis of the Knee Clinical Care Standard.
4b. State and territory health departments to use the Osteoarthritis of the Knee Clinical Care Standard to promote appropriate care for the management of people with knee pain, including conservative non-surgical management using a combination of non-pharmacological and pharmacological treatments.
4c. State and territory health departments to promote timely access to joint replacement or joint-conserving surgery when conservative management no longer provides adequate pain relief or maintenance of function.
Lumbar spinal decompression and fusion
4d. The Commission to lead work with relevant professional colleges and societies to develop an Australian guideline for management of low back pain and sciatica, to promote appropriate care for people with these conditions. This should be based on a modification of the 2016 National Institute for Health and Care Excellence guideline Low Back Pain and Sciatica in Over 16s: Assessment and Management, and any other relevant high-quality Australian and international evidence.
4e. State and territory health departments, and relevant colleges and specialist societies to implement the Australian guideline on low back pain and sciatica to promote appropriate care for people with low back pain and sciatica.
4f. The Commission to work with relevant specialists and experts to identify the next steps needed to define and deliver appropriate care for low back pain and sciatica.
4g. The Spine Society of Australia to publish the outcome of the pilot trial of the Australian Spine Registry. The Commission to work with the Spine Society of Australia to develop a business case for the development of a clinical quality registry for all patients undergoing spinal fusion and decompression surgery in Australia. All patients who have spinal fusion and decompression operations in Australia would be entered on this registry unless they opt out. The registry is to be established and operated according to the Framework for Australian Clinical Quality Registries.
Laparoscopic cholecystectomy and appendicectomy
4h. State and territory health departments to lead work with relevant professional colleges and societies to develop clinical guidance on timing, imaging and thresholds for surgery for appendicectomy and laparoscopic cholecystectomy.
4i. State and territory health departments, and relevant colleges and specialist societies to promote, disseminate and implement guidance on surgery thresholds for biliary disease and abdominal pain. To maximise implementation, the guidance should be incorporated within care pathways.
4j. The Commission to work with relevant professional colleges and specialist societies and HealthPACT to develop a technology brief to examine the evidence for the use of intraoperative cholangiography to delineate the biliary anatomy and to detect stones in the common bile duct.
4k. The Commission to develop a clinical care standard for cataract surgery, and the MBS Review Taskforce to ensure that MBS descriptors reflect the care described in the clinical care standard.
4l. State and territory health departments to work with the Aboriginal Community Controlled Health Service sector to ensure culturally appropriate, ongoing and consistent services for cataract assessment and cataract surgery in areas where these are needed.