Private healthcare sector spine surgery: Patient and surgeon profiles from a large open medical scheme in South Africa

Abstract

Background. It is generally understood that the profile of spine surgery varies by setting, based on factors such as the age profile of the population, the economic context and access to healthcare. Relatively little is known about the profile of spine surgery in South Africa (SA), although one previous report from the public healthcare sector suggested a high burden of trauma and infection-related surgery. To our knowledge, there has been no formal investigation in the private sector. A holistic understanding of spine surgery within our setting may be beneficial for applications such as resource allocation and informing the training needs of future specialists. Objectives. To provide insight into spinal surgery in the SA private healthcare sector by describing spine surgery characteristics within a large open medical scheme, including both patient and surgeon profiles. Methods. This retrospective review included adult inpatient spine surgeries funded by the largest open medical scheme in SA between 2008 and 2017. An anonymised dataset extracted from the scheme records included patient demographics, ICD-10 codes, procedure codes and surgeon specialisation. Descriptive patient and surgery data were presented. Furthermore, the association between patient and surgery factors and surgeon specialisation was investigated using univariate and multivariate analyses. Results. A total of 49 576 index spine surgeries were included. The largest proportion of surgeries involved members aged 40 - 59 years old (n=23 543, 48%), approximately half involved female members (n=25 293, 51%) and most were performed by neurosurgeons (n=35 439, 72%). At least 37 755 (76%) surgeries were for degenerative pathology, 2 100 (4%) for trauma and 242 (0.5%) for infection. Adjusted risk ratios (aRR) significantly associated with orthopaedic surgeon specialisation included cervical spine region (aRR = 0.49; 95% confidence interval (CI) 0.39 - 0.61), trauma (aRR = 1.50; 95% CI 1.20 - 1.88), deformity (aRR = 1.77; 95% CI 1.33 - 2.35) and blood transfusion (aRR = 1.46; 95% CI 1.12 - 1.91). Conclusion. Spine surgery in SA’s largest open medical scheme was dominated by surgery for degenerative pathology in older adults, and was performed largely by neurosurgeons. This constituted a stark contrast to a previous report from the public sector and highlighted a mismatch between exposure during public sector registrar training and private practice post specialisation. The findings support the need for private-public collaboration as well as the importance of spine fellowships for all specialists intending to practise spine surgery.