LAUSR

Over the past 5 decades, the speed of innovation in spine surgery has been nothing short of mindboggling in all arenas, including surgical techniques, implants, biologics, robotics, imaging, analytics, and perhaps most important, global highquality education. With globally tightening health care budgets, the utilization and cost of care relative to return on investment has become a necessity. In developed countries, spine care has become a popular target of concern due to its increasing apportionment of general health care expenditures. In the United States, spine care has ascended to the number 3 position in general health care spending behind diabetes and cancer, ahead of cardiovascular disease. One popular talking point to curb medical spending is to hold our medical community increasingly accountable through application of “evidence-based medicine,” a concept coined by Haynes and Guyatt in 1992, which is based on the integrated trifecta of research, patient preferences, and clinical experience. The increasing availability of increasingly larger data repositories and registries has made it tempting for some to perform something far simpler and readily available—analytics involving data mining and statistical modulations, usually to prove a point. There are, of course, many commonly known limitations to registry-based investigations, but such concerns are usually not well known outside the academic community and are certainly not part of the general public awareness, thus leading to a real potential for manipulation. An interesting case study for the impact of a well-publicized data mining expedition surfaced prominently in Germany in 2017 when a think tank endowed by a media giant trust fund presented its long anticipated Fact check spine (Faktencheck Rücken). The basic premise of their health care series sounds very common-sensical and includes phrases like “ . . . not all diagnostic tests and treatments are medically necessary . . . ,” and “ . . . contribute to match health care utilization with the actual patient needs . . . ,” and perhaps more ominously to “ . . . foster a stronger discourse of the public with their health system to better understand necessary reforms . . . ” Their 2017 report on spine surgery followed a succession of previous spine-related projects concerning popular (mis)conceptions on back pain and spine imaging, so this surgery-related project could be considered to be the latest iteration of a larger agenda driven campaign in the context of German spine care in general. By all means, Germany seems to be the ideal testing ground for such an investigation as it offers not only access to some of most advanced health care technologies in the world but also features the arguably most comprehensive medical utilization data capture for a country of its size with its highly regulated public/private mix of insurance carriers. The key findings of a calculated 71% increase in spine surgery in Germany over a time period from 2007 to 2015 were projected through this media giant’s portals and predictably resonated vociferously in the other German mainstream media—with the theme that Germans better beware of the intentions of their spine surgeons, fueled by headlines like “Operate and cash in” (Süddeutsche Zeitung, June 19, 2017), “90,000 unnecessary spine surgeries in Bavaria” (Wochenblatt, July 18, 2017), and even “Crime scene spinal column” (Die Zeit Online, May 18, 2016) and similar postings in many if not most other conventional, online and television portals. The 2 investigators, who are listed as employees of a private health care data analytics company (IGES Germany), and as far as published are nonphysicians and without specialty qualifications in spine care, identified the need for their project in a 2001 quote by a German government health care committee, which identified “overutiliziation of spine procedures, unclear procedural indications” and “introduction of novel, poorly evaluated and especially minimally invasive surgeries.” From a scientific process standpoint, a formal hypothesis was not presented. The methodology involved a data query to the German diagnosisrelated group (DRG) inpatient hospital discharge database for inpatient spine care of patients with 1 of 4 most prevalent diagnosis codes: “back pain,” “disc related,” “general spondylarthropathies,” “spondylosis.” Furthermore, the 3 most commonly used procedure codes were selected by the authors to study surgical utilization: “discectomies,” “arthrodesis,” “bony decompression.” Inclusion and exclusion criteria among other common features of a proper scientific publication were not listed in their report. They analyzed the 4 selected DRG discharge and procedure utilizations for the 402 health regions and its 16 states in Germany together with basic age-related Global Spine Journal 2018, Vol. 8(5) 437-439 a The Author(s) 2018 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2192568218782480 journals.sagepub.com/home/gsj