Defining Appropriate Spine Care for the Patient as well as Society David W. Polly Jr, MD,* ,† Charles Gerald T. Ledonio, MD,* Jonathan N. Sembrano, MD,* ,‡ and Robert A. Morgan, MD* ,§,¶ In this era of constrained resources, spine care professionals are challenged to provide value and justification of resource allocation. For surgeons, this requires demonstration of clinical superiority that is both significant and durable compared with nonsurgical man- agement and/or with other forms of surgical treatment. Value concepts such as the cost per quality-adjusted life year allow for more objective comparisons of treatment both for the same condition and for different conditions across a variety of disciplines. It thus becomes imperative that these concepts are learned and used in the design of future studies in the treatment of spinal disorders. Semin Spine Surg 24:123-126 © 2012 Elsevier Inc. All rights reserved. KEYWORDS Spine surgery, value, cost effectiveness, low back pain I n the current resource-constrained health care environ- ment, spine care must compete with the treatment of other conditions. Because the problem is so prevalent and so costly, it has garnered significant attention. In addition, there is sub- stantial practice variation in both the nonoperative and op- erative spine treatment domains that leads to questions of the which strategies are optimal. In this environment, policy makers, patients, and physicians are looking for better an- swers about what to do and when to do it for the treatment of spinal disorders. In an environment of practice variation, comparative effec- tiveness research (CER) is a way to try to determine best treatments. The Agency for Healthcare Research and Quality has defined CER as follows: CER is designed to inform health care decisions by provid- ing evidence on the effectiveness, benefits, and harms of dif- ferent treatment options. The evidence is generated from re- search studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care. 1 There are 2 ways by which this evidence is found: ● Researchers look at all the available evidence about the benefits and harms of each choice for different groups of people from existing clinical trials, clinical studies, and other research. If done in a systematic fashion these are either systematic reviews, or if quantitative methods are applied then they are called meta-analyses. If it is put into a guideline format, then it is a clinical practice guideline. ● Researchers conduct studies that generate new evidence of effectiveness or comparative effectiveness of a test, treatment, procedure, or health care service. 1 CER requires the development, expansion, and use of a variety of data sources and methods to conduct timely and relevant research and disseminate the results in a form that is quickly usable by clinicians, patients, policymakers, and health plans and other payers. In a perfect world, there would be sufficient high-quality data to compare all the different treatment strategies for all spinal pathologies. This would then allow the selection of the “best” treatment. Unfortunately, this scenario does not exist. However, for the treatment of acute low back pain, there is a wealth of literature providing reasonable guidance for the primary care provider treating a patient with an initial com- plaint of low back pain, including 45 systematic reviews in the Cochrane Library. 2 In the surgical arena, there are emerging high-quality data comparing the operative with nonoperative treatment of common spinal problems, including lumbar disk herniation, degenerative spondylolisthesis, and spinal stenosis. These *Department of Orthopaedic Surgery, University of Minnesota, Minneapo- lis, MN. †Department of Neurosurgery, University of Minnesota, Minneapolis, MN. ‡Minneapolis VA Health Care System, Minneapolis, MN. §Orthopaedic Trauma Surgery, Regions Hospital, St. Paul, MN. ¶Center for Spine and Spinal Cord Injury, Regions Hospital, St. Paul, MN. Address reprint requests to David W. Polly Jr, MD, Department of Ortho- paedic Surgery, University of Minnesota Medical School, 2450 Riverside Avenue, South Suite R200, Minneapolis, MN 55454. E-mail: pollydw@ umn.edu 123 1040-7383/$-see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1053/j.semss.2011.11.019