Appropriate Use Criteria
Osteoporotic Compression Fracture
Results
Based on inclusion criteria and level of evidence, manuscripts were reviewed in detail and evidentiary tables completed which formed the basis for the level of evidence for each scenario which raters used to inform their rating.2-207 The completed evidentiary tables along with results of all individual final ratings can be found on the NASS website, www.spine.org.
Medical Management
Medical management was rated as appropriate with agreement in all 144 (100%) scenarios (Table 3).
Cement Augmentation
Cement augmentation was rated as Appropriate with Agreement in 7 (4.9%) scenarios, Uncertain or Disagreement in 51 (35.4%) scenarios, and Rarely Appropriate in 86 (59.7%) scenarios. (Table 4). The most important modifiers (in order of importance) determining final rating for appropriateness of cement augmentation included duration, pain, physical function, and spinal stenosis (Figure 1A). Scenarios with a chronic fracture with VAS pain scale ≤ 6 were all rated as Rarely Appropriate (100% probability, Figure 2).
Surgery
Surgery was rated as Appropriate with Agreement in 50 (34.7%) scenarios, Uncertain or Disagreement in 68 (47.2%) scenarios, and Rarely Appropriate in 26 (18.1%) scenarios (Table 5). The most important modifiers (in order of importance) determining final rating for appropriateness of surgery were spinal stenosis, stability, and pain (Figure 1B). Scenarios with spinal stenosis and neurologic changes had an 87% probability of being rated as Appropriate with Agreement and scenarios without neurologic changes, a stable fracture pattern, and a VAS score ≤ 6 or nonmechanical pain had a 72% probability of being rated as Rarely Appropriate (Figure 3).
Disagreement
For surgery as the treatment, 73 scenarios with a median rater score of 7-9 were identified. Of these, 23 (32%) received a final rating of Uncertain or Disagreement due to disagreement among the raters. A multivariable logistic regression model was fit to determine modifiers that were associated with agreement. Modifiers associated with higher adjusted odds of agreement included a pain modifier of VAS: ≥ 6 (aOR, 66.7; 95%CI, 6.7 to 26973.3) or nonmechanical pain (aOR, 13.5; 95%CI, 1.6 to 298.9), and a spinal stenosis modifier of Yes + neurologic changes (aOR, 445.9; 95%CI, 24.5 to 22026.5 (Figure 4). There were no scenarios with disagreement for cement augmentation or for medical management.
Figure 1. Relative modifier importance in determining the final rating for each treatment is shown.
Figure 2. Decision tree for appropriateness of cement augmentation. Duration, pain, physical function and spinal stenosis all contributed to the accuracy of the decision tree. For each terminal node (final rating), the probability of receiving the final rating with the given modifiers is shown.
Figure 3. Decision tree for appropriateness of surgery. Spinal stenosis, stability and pain contributed to the accuracy of the decision tree. For each terminal node (final rating), the probability of receiving the final rating with the given modifiers is shown.
Figure 4. For scenarios with a median score between 7-9 for surgery, the adjusted odds of each modifier resulting in a final rating of “Appropriate with Agreement” rather than “Uncertain or Disagreement,” were computed (eg, compared to scenarios presented with no spinal stenosis, spinal stenosis with neurologic changes was associated with a significant increased odds of receiving a final rating of “Appropriate with Agreement.”) Thus, scenarios with no spinal stenosis were more likely to lead to disagreement among the raters.
