Impact of a second medical opinion on the therapeutic and costs management of lumbar pathologies : a study based on a French cohort

Impact of a second medical opinion on the therapeutic and costs management of lumbar pathologies : a study based on a French cohort | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of a second medical opinion on the therapeutic and costs management of lumbar pathologies : a study based on a French cohort Stéphane Billon, Hélène Barberousse, Jean Sibilia, Jérôme Allain This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6653339/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Introduction: It is increasingly common for a patient to seek a second opinion after a therapeutic proposal, particularly surgical, for a spinal pathology. We studied the impact of this second opinion, obtained via a platform specialized in this approach, on the final therapeutic decision. Methods & Materials: Between 2019 and 2021, 309 second medical opinions (SMO) were obtained on the deuxiemeavis.fr platform for degenerative lumbar pathologies (hernias, discopathies, stenoses). The referring physicians studied the patients' disabilities using personalized questionnaires and their additional examinations. We analysed the concordance rate between the two opinions. Patients were asked about their degree of satisfaction. The costs of care were studied according to a cost minimization principle: all medical costs were considered based on treatment protocols, as well as the costs of insurance, relating to work stoppages. Any additional costs or savings generated were evaluated by opinion, convergent or divergent, and for divergent opinions only. The average cost of the converging arm was considered as the reference cost. We then compared the cost of the care recommended by the SMOs to this reference cost. Those of compulsory health insurance (AMO) have been distinguished from those of supplementary health insurance (AMC). Results: 69% of the SMOs (212 opinions) were convergent and 31% (97 opinions) divergent, differing mainly on the therapeutic strategies as recommended by the High Authority of Health (HAS): contraindication or recommendation of surgery, proposal of infiltrations, pain management, rehabilitation or referral to another specialist (rheumatologist, surgeon). Some divergences concerned the diagnosis, or the examinations carried out. Regardless of the convergent or divergent direction resulting from the second opinion, out of 309 patients, the health insurance system sees on average all medical and welfare costs per patient decrease by €550, including €322 for AMO and €228 for AMC (excluding deuxième.avis.fr costs). When the second opinion diverges from the initial opinion, the savings observed in terms of medical and welfare expenses are on average €1,751 per file including €1,025 for AMO and €726 for AMC. Conclusion: Using a second medical opinion service via a dedicated platform allows patients to seek the advice of a referring physician in lumbar pathology, without the aim of directly interfering in the patient's care. In more than two-thirds of cases, it allows the patient to be reassured about the initially proposed treatment by confirming the first opinion. In divergent cases, the referring physician generally suggests a less invasive treatment, thus resulting in real healthcare savings, estimated at €1,751 per case. Lumbar pathologies Second medical opinions Cost minimization Cost rationalization Relevance of care financing of care Figures Figure 1 Figure 2 Introduction Lumbar pathologies refer to all diseases affecting the back or the spine. The prevalence of lower back pain in a working-age population is more than 2 out of 3 employees. Lower back pain represents 20% of work accidents and 7% of occupational diseases. According to the French Society of General Medicine, in 2017, significant gaps were noted between recommendations and practices, including an overly systematic recourse to surgery. In this context, it is increasingly common for a patient to seek a second medical opinion after a therapeutic proposal, particularly surgical, for a spinal pathology. The systematic use of second opinions is not new. Already in the 1970s and 1980s, American health insurance groups introduced “second medical opinion” programs as part of initial referrals for elective surgical interventions or certain pathologies, resulting in unnecessary procedures being avoided and overall treatment costs being minimized[1]. This directive constitutes a new legal framework in the management of illness, with the obligation placed on doctors issuing the first initial opinion, to remind the patient of their legal right to consult an approved second opinion provider and in the context of specific interventions such as tonsillectomy, hysterectomy and shoulder arthroscopy.[2]. In a US study of a second opinion program (Best Doctors, Inc. Boston) that allowed beneficiary employees to request a free second opinion, it was observed that patients sought a second opinion for assistance in choosing treatment options and for diagnostic questions. The resulting second opinions included changes in diagnosis (14.8%), treatment (37.4%), or both (10.6%)[3]. Regarding the cost-effectiveness of such programs, a study by Antonioli et al. demonstrated that after 2 years of treatment, a second opinion program provided potential cost compensation associated with improved quality of life. This program resulted in financial savings of $6,705 per patient, with an Incremental Cost-Effectiveness Ratio (ICER) reduced by $87,066 per additional patient[4]. A Brazilian study of a second opinion program for spine surgery aimed at reducing unnecessary care for patients with lower back pain highlighted that the criteria for determining which patients should undergo surgery are interpreted heterogeneously by surgeons. Surgical interventions are often planned based on diagnostic inaccuracies from poor clinical and imaging examinations, which can lead to unnecessary interventions. There is no consensus on the best criteria for recommending surgery in patients with lower back pain. Our study is part of this continuity of analyses and therefore aims to identify whether the request for a second medical opinion, in the context of lumbar pathologies and before the final therapeutic decision, could have a significant impact on the management of the disease, particularly in terms of reducing the number of recourses to surgery. This is a medico-economic study of cost minimization whose point of view is that of health insurers in France. Methods Ethics approval and consent to participate. The SMO platform deuxiemeavis.fr received approval from the French National Commission for Data Privacy (Commission Nationale Informatique et Libertés, CNIL - The CNIL has an institutional ethics committee) and patients provided informed consent that their anonymous data may be used for research and quality improvement purposes. No additional approvals were required according to the French legislation as this was an observational study based on medical records. All methods were performed in accordance with the relevant guidelines and regulations (Declarations of Helsinki). SMO Platform Process Overall, the SMO request process via deuxiemeavis.fr involved five main steps. These steps have recently been reported by Sanchez et al[5] (x). In short, after selecting the category of disease, a medical questionnaire related to the condition in question is completed with the patient’s main inquiries for the physician, selected from a list of SMO experts. A designated expert is then notified and can either accept or decline the patient’s request. If the physician accepts the request, they proceed to perform a medical analysis of the case, and a written medical report is generated within seven days. With patient consent, this SMO report can be communicated to their general practitioner, or the specialist doctor consulted for the first opinion. In the case of lumbar pathologies, the panel of experts is composed of eight surgeons who gave the opinions studied. These experts were selected according to their academic position, clinical experience, and international activities and were approved by a scientific jury. Study Population A prospective observational cohort study was conducted using nationwide data from the French SMO platform deuxiemeavis.fr (https://www.deuxiemeavis.fr/) between 01/01/2019 and 31/12/2021. The study population is based on anonymous data from patients who submitted a SMO request through the platform for an issue relating to lumbar pathologies: lumbar disc herniation, lumbar spinal stenosis (or narrowing of the lumbar spinal canal), sciatica, Lumbar osteoarthritis, lower back pain, cruralgia, disc disease. 309 SMOs were analysed in this study. Data Collection and exploitation The 309 anonymized files were sorted by separating those convergent, which only validated the initial medical opinion, and those divergent, which made changes to either diagnoses, treatment, or additional treatment. The collected data was entered into two Excel spreadsheets, one for each convergent or divergent orientation. Within these spreadsheets, each row corresponds to an anonymization code per patient, each column to a variable (diagnosis and treatment). We listed all the therapeutic orientations observed in the 309 files, placing each at the head of a column. We then developed a dichotomous response coding system using the values 0/1 (false/true), to validate or not the existence of the therapeutic orientation for this patient. Analysis Between 2019 and 2021, 309 second opinions were obtained on the deuxiemeavis.fr platform for degenerative lumbar pathology (hernias, disc disease, stenosis). The referring physicians studied the patients' disabilities using personalized questionnaires and their additional examinations. We analysed the concordance rate between the two opinions. The costs of care were studied according to a cost-minimization principle, which compares only the costs of two distinct groups of patients: the "initial opinion" group and the "second opinion" group obtained via the deuxiemeavis.fr platform. The evaluation consisted of examining the difference in costs between a therapeutic strategy with the initial opinion alone and a therapeutic strategy combining two opinions, the second of which diverges from the first and leads to changes in patient care, including the contraindication of surgery. All medical costs were taken into account on the basis of treatment protocols, as well as the costs of insurance, relating to sick leave. The average cost of the convergent arm was considered as the reference cost. We then compared that of the care recommended by the second opinion to this reference cost. Any additional costs or savings generated were evaluated by opinion, convergent or divergent, and for divergent opinions only. Those of compulsory health insurance (AMO) were distinguished from those of supplementary health insurance (AMC). The costs that were taken into account are of two types. First, we addressed the direct medical costs; secondly, the costs associated with insurance, particularly those incurred by covering sick leave, all daily allowances (IJ) and their corollary. Regarding the "surgery" item, which is the most cost-sensitive variable in our study, the frequency of complications was sought in meta-analyses and randomized trials which specified it[6]. This frequency was studied separately for arthrodesis and disc prosthesis. In order to introduce into our analysis, the notion of avoided costs related to surgical contraindications resulting from "second opinions", we relied on the "good practice recommendations for chronic lower back pain in adults". In this context, we used the complications after spinal surgery observed by the HAS, selecting only those with a high level of evidence (level 2). Arthrodesis, excisions, and disc prostheses lead to general complications, reinterventions and degeneration of adjacent levels. The analyses were carried out based on direct public and private medical costs (healthcare, medicines, GHS hospital stays, primary medical procedures, the general nomenclature of professional procedures NGAP, and CCAM hospital technical procedures) for the years 2019 to 2021. The following price bases were used as references: the public database of medicines[7] , MCO (Medicine, Surgery, Obstetrics) hospital rates from the ATIH (Hospital Information Technology Agency databases)[8] , the NGAP (General Nomenclature of Professional Acts) and the rates of the CCAM (Common Classification of Medical Acts)[9]. Regarding work stoppages, the Mandatory Professional Pension Scheme (RPO) automatically provides employees with a salary supplement after 45 or 90 days of absence. During these periods, the employer, through its pension obligation, pays the salary. It maintains the latter after deduction of daily social security benefits for the entire period. The employee must have 1 year of seniority in the company at the time of the work stoppage[10]. The average duration of work stoppages for lower back pathologies is 2 months [11] . The costs inherent in forethought come from the Frenche “Ameli database” of compulsory health insurance [12]. The point of view of the study is that of health insurers, with compulsory health insurance (AMO), also called the general scheme, and supplementary health insurance (AMC). Results Of these 309 requests processed, 97 SMOs (31% of the cohort), resulted in a different opinion from the initial one, either regarding the diagnosis or the therapeutic strategy to adopt. Second opinions were issued on average in 2.9 days. The main lumbar pathologies observed were: Herniated disc, for almost a third of the requests from deuxiemeavis.fr (28%); discopathy (20%); sciatica (12%); and chronic lower back pain (11%). Expert opinions concerned more than 28 different directions towards treatments and therapeutic care, which we found mainly in the HAS good practice recommendations.[13][14][15]. It should be noted that we found several therapeutic orientations per opinion. Thus, 226 therapeutic orientations for the divergent files (n=97) and 207 orientations were proposed for the convergent files (n=212). In these divergent files, there were 10 new diagnoses, 38 contraindications for surgery, 31 referrals to treatment by scan-guided epidural infiltration, 28 referrals to pain management, 26 re-referrals to another specialist (mainly a rheumatologist) or to another surgeon (neurosurgeon or an orthopaedic surgeon specializing in the spine), or 12 to lumbar physiotherapy. The other major pieces of advice regarding these divergent opinions were: Surgery (30 referrals out of 226, or 13%), or reorientation to other specialist surgeons or rheumatologists for 12% of referrals (26 SMOs). In these opinions, we also noted the recommendation of additional examinations to perfect the diagnosis and establish the right therapeutic strategy such as: 10 requests for lumbar MRI without and with injection, 3 multimodal radiological assessments (scanner), electrophysiological and radiographic test analysing the overall balance of the spine (tele-spine), and 4 complete physical and biological examinations (perform a Lyme serology). 1. Analysis of direct medical costs Of the 212 converging cases, the main opinionswere broken down as follows: Treatment by scan-guided epidural infiltration – Homogeneous Stay Group - GHM 08M291 - Other spinal pathologies requiring medical treatment, level 1 – (23%); Surgical intervention - (Microsurgical excision of herniated disc / replacement of the pathological disc with a lumbar prosthesis) - GHM - 8C272 - Other interventions on the spine, level 2 are therapeutic orientations towards pain management – (23%); Contraindication to surgical intervention – GHM - 8C272 - Other interventions on the spine, level 2 - (14%); Lumbar physiotherapy (Mac Kenzie technique, spinal pain physiotherapy - exercise retraining) (9%) Lifestyle rules: Diet for essential weight loss, physical exercises with core strengthening and spinal flexibility work (9%). Of the 97 patient cases that received a divergent opinion, the main second opinions given by the experts were broken down as follows: Contraindications to surgery (39%); Treatment by scan-guided epidural infiltration - GHM 08M291 - Other spinal pathologies requiring medical treatment, level 1 - (13%); Surgical intervention - (Microsurgical excision of herniated disc/via unilateral inter-myolaminar approach / radicular release with excision of the articular cyst - replacement of the pathological disc - Insertion of a disc prosthesis (13%); Pain management (29%); Redirections to another specialist (mainly a rheumatologist) or to another surgeon (neurosurgeon or an orthopaedic surgeon specializing in the spine) (12%); Lumbar physiotherapy (5%); Lifestyle rules: Diet for essential weight loss, physical exercises with work on core strength and spinal flexibility (5%). The impact of surgical contraindications has a significant impact on costs. Since post-operative complications are numerous, if we only consider re-interventions and only the median and high assumptions (Table 1), we can identify significant avoided costs: Out of 38 contraindications for surgery, compulsory health insurance (AMO) avoided, thanks to the request for a second opinion, €113,873 in health expenses, or nearly €2,996 per “contraindication” and €1,174 for all 97 patients redirected. Out of 38 contraindications for surgery, supplementary health insurance (AMC) avoids, thanks to the request for a second opinion, €53,533 in health expenses linked to avoided surgeries, i.e. almost €1,409 per "contraindication" and per patient and €552 for all 97 patients redirected. All of these avoided costs should be highlighted alongside those not measured, such as “general complications” and “degeneration of adjacent levels”. As shown in the following figures 1 and 2 and Table 2, compulsory health insurance (AMO) sees its costs decrease by €569 on average per redirected patient (97 divergent opinions - excluding deuxiemeavis.fr costs). Overall, the health insurance system, compulsory and supplementary combined (AMO and AMC), saves €765/redirected patient due to the request for a second medical opinion. The direct medical costs avoided for supplementary insurance, following a second medical opinion are although lower than those of compulsory health insurance, which, by nature, assumes the majority of hospital costs. However, AMC sees its costs decrease by €196 on average per redirected patient (divergent opinions - excluding deuxième.avis.fr costs). 2. Financial impact of work stoppages - Mandatory Professional Pension Scheme (RPO) According to our observations of deuxiemeavis.fr patient files, only 60 out of 97 divergent opinions characterize a work stoppage (two months), or 62%. Regarding initial opinions, we noted 189 out of 212 work stoppages, or 89%. Beyond the paradigm shift from entirely curative to preventive and participatory, this leads to a difference in costs in the overall care of patients, with an average reduction of 27% in work stoppages (89%-62%=27%) when a second opinion is sought, i.e. a reduction in costs of around 9% in terms of foresight (table 4 – €95,680). As shown in Tables 3 and 4, the avoided insurance costs per patient due to the use of deuxiemeavis.fr are €3,680 per patient, including €1,702 for AMO and €1,978 for AMC. This analysis does not highlight the overall costs for society as a whole, particularly non-medical direct costs and the impact on businesses, particularly in terms of reduced productivity. The divergent opinions only lead to 62% of patients being on sick leave versus 89% for the initial opinions – i.e. 26 sick leave cases avoided out of 309 cases treated and therefore €44,252 in costs avoided for the general scheme (26 * €1,702) and €51,428 for the supplementary scheme (26 * €1,978). The costs avoided under the insurance scheme, by divergent opinion, are therefore €456 for the general AMO scheme (26*1702/97 divergent patients) and €530 for the supplementary AMC scheme (26*1978/97). All opinions combined (divergent and convergent), the costs avoided under the insurance scheme are therefore €143 for the general scheme (26*1702/309 convergent and divergent patients) and €166 for the supplementary scheme (26*1978/309 convergent and divergent patients). Summary of average costs avoided - medical and welfare. Regardless of the convergent or divergent direction resulting from the second opinion, out of 309 patients, the health insurance system sees its medical and welfare costs per patient decrease by an average of €550, including €322 for AMO and €228 for AMC (excluding deuxième.avis.fr costs - See table 5). In the event of a second divergent opinion, the observed savings are on average €1,751 per file, including €1,025 for the AMO and €726 for the AMC – (excluding the cost of deuxième.avis.fr - See table 6). Discussion Lumbar pathologies are pathologies that are particularly sensitive to second opinions from specialized experts, because too systematic recourse to surgery has serious consequences on the quality of care and its consequences in terms of costs. The benefits of this support strategy are numerous: For the patient - The platform's doctors, all specialists in spinal pathologies, are more compliant with best practice recommendations and thus operate less (surgery contraindications in more than 39% of referrals), maintain activity and prioritize pain treatment, which is often underestimated in initial opinions. The management of spinal pathologies is primarily characterized by the relevance of care. The expert has no financial benefit from operating on the patient, so he will give a neutral opinion. He is also undoubtedly more aware of the latest medical practices and recommendations from learned societies, which are for the benefit of patients. Similarly, if the reduction in surgical procedures leads to a reduction in sick leave, the "digital" consultation is carried out without pressure from the patient and their requests for sick leave. Thus, benefiting from a second opinion for back pain, beyond the savings identified for the various stakeholders (AMO, AMC and insurance), a patient who benefits from a second opinion, whatever their situation (standard of living, geographical origin, mobility, etc.) is: ✓ Receive medical expertise within an average of 2.9 days, compared to 45 days for an in-person appointment with a rheumatologist or orthopaedic surgeon in mainland France. ✓ Avoid additional travel while their mobility is restricted. ✓ Benefit from a written and documented report, which they can reread at their leisure and share with their medical team or loved ones. ✓ Gain reassurance and peace of mind, knowing they're receiving the best care pathway. ✓ Be better informed and therefore take control of their own health. For the treating team – The second opinion is written and shared with the treating team, with the aim of sharing knowledge and expertise, and in a collaborative approach. For the company – A better-treated patient is one who is kept active. In this case, there is a major difference in strategic choices among the Deuxiemeavis.fr experts. They more often recommend, as a therapeutic basis, maintaining activity and improving lifestyle (weight loss, physical exercises with core strength and spinal flexibility). For healthcare financiers - Mandatory health insurance (AMO) partially covers healthcare costs. Supplementary health insurance (AMC), whether individual or corporate, can partially cover the remaining costs. The second opinion is covered by the AMC, which allows them to escape the imposed role of blind payer, by offering a service that streamlines care and therefore costs (in this case €1,751 per patient in the event of reorientation). Limitations of the study: First, the medical analysis remains subject to the quality of the files submitted by patients, which can sometimes be incomplete. The second point is that we do not have follow-up with patients after the second opinion. We therefore have no certainty that the latter will be followed up. We therefore limit ourselves to the assumption that this second opinion will be fully followed. It is difficult to fully examine the cost of surgical complications without an ad hoc longitudinal study. We therefore limited ourselves to the observable, that is, re-operations. These are only direct costs, to which it might be appropriate to add indirect costs such as travel, insurance, and convalescence costs. We have 38 contraindications observed in 309 medical files. Conclusions In conclusion of this study on the impact of the use of a second medical opinion in the management of lumbar pathologies, we can retain the following elements: 31% of the opinions given by deuxiemeavis.fr experts differ from the initial opinions presented by patients (97/309) The main lumbar pathologies observed are herniated discs (nearly a third of second opinion requests), discopathy (20%), sciatica (12%), and chronic lower back pain (11%) The main therapeutic orientations observed are treatment by CT-guided epidural infiltration; surgical intervention (microsurgical excision of herniated disc/replacement of the pathological disc with a lumbar prosthesis) – GHM. Average direct medical costs avoided. Regardless of the convergent or divergent referral resulting from the second opinion, for 309 patients, mandatory health insurance saw its average direct medical costs decrease by €55,154, with a reduction of €179 per patient; supplementary health insurance saw its costs decrease by €19,039, with a reduction of €62 per patient (excluding deuxième.avis.fr costs). (See Table 2). In the event of reorientation following a second divergent opinion, for 97 patients, the average direct medical costs avoided were €765, including €569 for the AMO and €196 for the AMC (excluding deuxieme.avis.fr costs and provident insurance - See Table 2). Direct costs of foresight avoided. The insurance costs avoided by using deuxieme.avis.fr are €95,680 for all schemes combined, including €44,252 for AMO (€1,702/divergent patient) and €51,428 (€1,978/divergent patient) for AMC. This analysis does not highlight the overall costs for society as a whole, in particular the direct non-medical costs and the impact on businesses, particularly in terms of reduced productivity (see table 4). Summary of average costs avoided - medical and welfare. Regardless of the convergent or divergent direction resulting from the second opinion, out of 309 patients, the health insurance system sees its medical and welfare costs per patient decrease by an average of €550, including €322 for AMO and €228 for AMC (excluding deuxième.avis.fr costs - see Table 5). In the event of a divergent second opinion, the observed savings are on average €1,751 per case, including €1,025 for AMO and €726 for AMC (excluding deuxième.avis.fr costs - see Table 6). Abbreviations AMC: Supplementary Health Insurance AMO: Mandatory Health Insurance AT: Workplace Accidents ATIH: Hospital Information Technology Agency CCAM: Common Classification of Medical Procedures GHM: Homogeneous Group of Patients (GHM) GHS: Homogeneous Group of Stays HAS: French National Authority for Health ICER: Incremental Cost-Effectiveness Ratio MRI: Magnetic Resonance Imaging MCO: Medicine, Surgery, Obstetrics MP: Occupational Illnesses NGAP: General Classification of Medical Procedures AIDS: Acquired Immunodeficiency Syndrome RPO: Mandatory Professional Insurance Plan Declarations Ethics approval and consent to participate: Ethics approval and consent to participate. The SMO platform deuxiemeavis.fr received approval from the French National Commission for Data Privacy (Commission Nationale Informatique et Libertés, CNIL - The CNIL has an institutional ethics committee) and patients provided informed consent that their anonymous data may be used for research and quality improvement purposes. No additional approvals were required according to the French legislation as this was an observational study based on medical records. All methods were performed in accordance with the relevant guidelines and regulations (Declarations of Helsinki). Consent for publication Not applicable Availability of data and materials All tables used in these analyses are available upon request from the lead author. All data generated and analysed during the current study are not publicly available due to medical confidentiality but are available from the corresponding author upon reasonable request. Competing Interests The company Carians (deuxiemeavis.fr) financed the experts who signed this study, JA and SB. Funding Deuxièmeavis.fr funded this study and participated in the conceptualization, design, data collection, analysis, publication decision, and manuscript preparation. Author contributions SB and JA analysed and interpreted data from patient records. Acknowledgements Not applicable References May et al. Does the second opinion directive in Germany reach the patient? A parallel-convergent mixed-methods study . BMC Health Services Research (2023) 23:1198 Bruch D, May S, Prediger B, et al. Second opinion programmes in Germany: a mixed-methods study protocol. BMJ Open 2021;11:e045264. doi:10.1136/ bmjopen-2020-045264 Meyer et al. Evaluation of Outcomes From a National Patient-initiated Second-opinion Program The American Journal of Medicine, Vol 128, No 10, October 2015. http://dx.doi.org/10.1016/j.amjmed.2015.04.020 Antonioli, E., Tavares Malheiro, D., Damazio Teich, V. et al. Cost-effectiveness of a second opinion program on spine surgeries: an economic analysis. BMC Health Serv Res 23, 1441 (2023). https://doi.org/10.1186/s12913-023-10405-x Sanchez et al. BMC Health Services Research (2021) 21:902 https://doi.org/10.1186/s12913-021-06936-w HAS. Lombalgie chronique de l’adulte et chirurgie. Paris. 2015 http://base-donnees-publique.medicaments.gouv.fr https://www.atih.sante.fr/tarifs-mco-et-had https://www.ameli.fr/accueil-de-la-ccam/outils/actes-frequents/index.php https://code.travail.gouv.fr/contribution/1266-en-cas-darret-maladie-du-salarie-lemployeur-doit-il-assurer-le-maintien-de-salaire INRS - Travail et Lombalgie - 2019 https://www.ameli.fr/paris/assure/remboursements/indemnites-journalieres-maladie-maternite-paternite/arret-maladie-salarie HAS. Prise en charge du patient présentant une lombalgie commune. Rapport d’élaboration Mars 2019. Paris. https://www.has-sante.fr/upload/docs/application/pdf/2019-04/reco315_rapport_lombalgie_2019_04_02.pdf Caisse nationale de l'assurance maladie des travailleurs salariés. Améliorer la qualité du système de santé et maîtriser les dépenses. Propositions de l’Assurance Maladie pour 2017. Paris: CNAMTS; 2016. https://assurance-maladie.ameli.fr/sites/default/files/rapport-activite-charges-produits-17_assurance-maladie.pdf HAS. Lombalgie chronique de l’adulte et chirurgie. Paris. 2015. https://www.has-sante.fr/upload/docs/application/pdf/2016- 03/arg_pertinence_chir-lombalgie.pdf Tables Tables 1-6 are available in the Supplementary Files section. Additional Declarations Competing interest reported. Les auteurs de l'étude sont financés par la société deuxiemeavis.fr dont l'activité est de produire des deuxièmes avis médicaux Supplementary Files LumbarDiscHerniationQuestionnaire.xlsx Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Jan, 2026 Reviews received at journal 13 Jul, 2025 Reviews received at journal 18 Jun, 2025 Reviewers agreed at journal 18 Jun, 2025 Reviewers agreed at journal 15 Jun, 2025 Reviewers invited by journal 13 Jun, 2025 Editor assigned by journal 11 Jun, 2025 Editor invited by journal 20 May, 2025 Submission checks completed at journal 19 May, 2025 First submitted to journal 19 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6653339","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471559164,"identity":"e30dc341-b7e1-4bd8-a0d2-5f7e7e5d7021","order_by":0,"name":"Stéphane Billon","email":"data:image/png;base64,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","orcid":"","institution":"Paris-Dauphine University","correspondingAuthor":true,"prefix":"","firstName":"Stéphane","middleName":"","lastName":"Billon","suffix":""},{"id":471559165,"identity":"9d577e9d-8b6c-4af1-8737-f19ef7285346","order_by":1,"name":"Hélène Barberousse","email":"","orcid":"","institution":"deuxiemeavis.fr","correspondingAuthor":false,"prefix":"","firstName":"Hélène","middleName":"","lastName":"Barberousse","suffix":""},{"id":471559166,"identity":"efbe34d3-36e3-46b8-8896-f6a79f2963ab","order_by":2,"name":"Jean Sibilia","email":"","orcid":"","institution":"CHU Strasbourg - Hôpitaux Universitaires","correspondingAuthor":false,"prefix":"","firstName":"Jean","middleName":"","lastName":"Sibilia","suffix":""},{"id":471559167,"identity":"2e951090-1604-4919-94b2-1924013fdcc1","order_by":3,"name":"Jérôme Allain","email":"","orcid":"","institution":"Hôpital privé Geoffroy Saint-Hilaire","correspondingAuthor":false,"prefix":"","firstName":"Jérôme","middleName":"","lastName":"Allain","suffix":""}],"badges":[],"createdAt":"2025-05-13 08:38:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6653339/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6653339/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84855662,"identity":"ac1bf1e9-cfe3-4002-b48e-b894a7c1da15","added_by":"auto","created_at":"2025-06-18 06:04:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":668231,"visible":true,"origin":"","legend":"\u003cp\u003eDiagram 1: Compulsory Health Insurance (AMO) cost analysis model\u003c/p\u003e\n\u003cp\u003eDecision tree aiming at the distribution between divergent and convergent medical opinions with the associated costs per patient and per therapeutic strategy chosen for compulsory health insurance.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSources: Impact of a second opinion on the costs of treating lumbar pathologies\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture1.png","url":"https://assets-eu.researchsquare.com/files/rs-6653339/v1/818e049267c0467083f39c3f.png"},{"id":84855663,"identity":"197efe97-f981-46f7-aab9-5e2bfb96311d","added_by":"auto","created_at":"2025-06-18 06:04:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":652921,"visible":true,"origin":"","legend":"\u003cp\u003eDiagram 2: Supplementary Health Insurance (AMC) cost analysis model\u003c/p\u003e\n\u003cp\u003eDecision tree targeting distributions between divergent and convergent medical opinions with the associated costs per patient and per therapeutic strategy chosen for supplementary health insurance.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSources: Impact of a second opinion on the costs of treating lumbar pathologies\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture2.png","url":"https://assets-eu.researchsquare.com/files/rs-6653339/v1/18c61d0ff57fb8b7e54a134a.png"},{"id":84858047,"identity":"7645cc23-54f2-4079-ab4e-3d7cca1d09c2","added_by":"auto","created_at":"2025-06-18 06:28:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1906720,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6653339/v1/63799758-d759-4daf-8249-cea2d24cc1c5.pdf"},{"id":84856178,"identity":"dc0bebd7-ea72-44ff-aa9c-dc36e416af41","added_by":"auto","created_at":"2025-06-18 06:12:51","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27252,"visible":true,"origin":"","legend":"","description":"","filename":"LumbarDiscHerniationQuestionnaire.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6653339/v1/aec52de94d3c842bbf9efd38.xlsx"},{"id":84855638,"identity":"3ffeb0e2-667a-44b9-8969-ccb5b9db627f","added_by":"auto","created_at":"2025-06-18 06:04:50","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":34531,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6653339/v1/3cb60a322122cc728dd1fffa.docx"}],"financialInterests":"Competing interest reported. Les auteurs de l'étude sont financés par la société deuxiemeavis.fr dont l'activité est de produire des deuxièmes avis médicaux","formattedTitle":"Impact of a second medical opinion on the therapeutic and costs management of lumbar pathologies : a study based on a French cohort","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLumbar pathologies refer to all diseases affecting the back or the spine. The prevalence of lower back pain in a working-age population is more than 2 out of 3 employees. Lower back pain represents 20% of work accidents and 7% of occupational diseases. According to the French Society of General Medicine, in 2017, significant gaps were noted between recommendations and practices, including an overly systematic recourse to surgery. In this context, it is increasingly common for a patient to seek a second medical opinion after a therapeutic proposal, particularly surgical, for a spinal pathology.\u003c/p\u003e\n\u003cp\u003eThe systematic use of second opinions is not new. Already in the 1970s and 1980s, American health insurance groups introduced \u0026ldquo;second medical opinion\u0026rdquo; programs as part of initial referrals for elective surgical interventions or certain pathologies, resulting in unnecessary procedures being avoided and overall treatment costs being minimized[1]. This directive constitutes a new legal framework in the management of illness, with the obligation placed on doctors issuing the first initial opinion, to remind the patient of their legal right to consult an approved second opinion provider and in the context of specific interventions such as tonsillectomy, hysterectomy and shoulder arthroscopy.[2]. In a US study of a second opinion program (Best Doctors, Inc. Boston) that allowed beneficiary employees to request a free second opinion, it was observed that patients sought a second opinion for assistance in choosing treatment options and for diagnostic questions. The resulting second opinions included changes in diagnosis (14.8%), treatment (37.4%), or both (10.6%)[3]. Regarding the cost-effectiveness of such programs, a study by Antonioli et al. demonstrated that after 2 years of treatment, a second opinion program provided potential cost compensation associated with improved quality of life. This program resulted in financial savings of $6,705 per patient, with an Incremental Cost-Effectiveness Ratio (ICER) reduced by $87,066 per additional patient[4].\u003c/p\u003e\n\u003cp\u003eA Brazilian study of a second opinion program for spine surgery aimed at reducing unnecessary care for patients with lower back pain highlighted that the criteria for determining which patients should undergo surgery are interpreted heterogeneously by surgeons. Surgical interventions are often planned based on diagnostic inaccuracies from poor clinical and imaging examinations, which can lead to unnecessary interventions. There is no consensus on the best criteria for recommending surgery in patients with lower back pain.\u003c/p\u003e\n\u003cp\u003eOur study is part of this continuity of analyses and therefore aims to identify whether the request for a second medical opinion, in the context of lumbar pathologies and before the final therapeutic decision, could have a significant impact on the management of the disease, particularly in terms of reducing the number of recourses to surgery. This is a medico-economic study of cost minimization whose point of view is that of health insurers in France.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eEthics approval and consent to participate. The SMO platform deuxiemeavis.fr received approval from the French National Commission for Data Privacy (Commission Nationale Informatique et Libertés, CNIL - The CNIL has an institutional ethics committee) and patients provided informed consent that their anonymous data may be used for research and quality improvement purposes. \u003c/p\u003e\n\u003cp\u003eNo additional approvals were required according to the French legislation as this was an observational study based on medical records. All methods were performed in accordance with the relevant guidelines and regulations (Declarations of Helsinki).\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eSMO Platform Process \u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eOverall, the SMO request process via deuxiemeavis.fr involved five main steps. These steps have recently been reported by Sanchez et al[5] (x). In short, after selecting the category of disease, a medical questionnaire related to the condition in question is completed with the patient\u0026rsquo;s main inquiries for the physician, selected from a list of SMO experts. A designated expert is then notified and can either accept or decline the patient\u0026rsquo;s request. If the physician accepts the request, they proceed to perform a medical analysis of the case, and a written medical report is generated within seven days. With patient consent, this SMO report can be communicated to their general practitioner, or the specialist doctor consulted for the first opinion.\u003c/p\u003e\n\u003cp\u003eIn the case of lumbar pathologies, the panel of experts is composed of eight surgeons who gave the opinions studied. These experts were selected according to their academic position, clinical experience, and international activities and were approved by a scientific jury.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA prospective observational cohort study was conducted using nationwide data from the French SMO platform deuxiemeavis.fr (https://www.deuxiemeavis.fr/) between 01/01/2019 and 31/12/2021. The study population is based on anonymous data from patients who submitted a SMO request through the platform for an issue relating to lumbar pathologies: lumbar disc herniation, lumbar spinal stenosis (or narrowing of the lumbar spinal canal), sciatica, Lumbar osteoarthritis, lower back pain, cruralgia, disc disease. 309 SMOs were analysed in this study.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData Collection and exploitation\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe 309 anonymized files were sorted by separating those convergent, which only validated the initial medical opinion, and those divergent, which made changes to either diagnoses, treatment, or additional treatment. The collected data was entered into two Excel spreadsheets, one for each convergent or divergent orientation. Within these spreadsheets, each row corresponds to an anonymization code per patient, each column to a variable (diagnosis and treatment). We listed all the therapeutic orientations observed in the 309 files, placing each at the head of a column. We then developed a dichotomous response coding system using the values 0/1 (false/true), to validate or not the existence of the therapeutic orientation for this patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween 2019 and 2021, 309 second opinions were obtained on the deuxiemeavis.fr platform for degenerative lumbar pathology (hernias, disc disease, stenosis). The referring physicians studied the patients\u0026apos; disabilities using personalized questionnaires and their additional examinations. We analysed the concordance rate between the two opinions. The costs of care were studied according to a cost-minimization principle, which compares only the costs of two distinct groups of patients: the \u0026quot;initial opinion\u0026quot; group and the \u0026quot;second opinion\u0026quot; group obtained via the deuxiemeavis.fr platform. The evaluation consisted of examining the difference in costs between a therapeutic strategy with the initial opinion alone and a therapeutic strategy combining two opinions, the second of which diverges from the first and leads to changes in patient care, including the contraindication of surgery. All medical costs were taken into account on the basis of treatment protocols, as well as the costs of insurance, relating to sick leave. The average cost of the convergent arm was considered as the reference cost. We then compared that of the care recommended by the second opinion to this reference cost. Any additional costs or savings generated were evaluated by opinion, convergent or divergent, and for divergent opinions only. Those of compulsory health insurance (AMO) were distinguished from those of supplementary health insurance (AMC). The costs that were taken into account are of two types. First, we addressed the direct medical costs; secondly, the costs associated with insurance, particularly those incurred by covering sick leave, all daily allowances (IJ) and their corollary.\u003c/p\u003e\n\u003cp\u003eRegarding the \u0026quot;surgery\u0026quot; item, which is the most cost-sensitive variable in our study, the frequency of complications was sought in meta-analyses and randomized trials which specified it[6]. This frequency was studied separately for arthrodesis and disc prosthesis.\u003c/p\u003e\n\u003cp\u003eIn order to introduce into our analysis, the notion of avoided costs related to surgical contraindications resulting from \u0026quot;second opinions\u0026quot;, we relied on the \u0026quot;good practice recommendations for chronic lower back pain in adults\u0026quot;. In this context, we used the complications after spinal surgery observed by the HAS, selecting only those with a high level of evidence (level 2). Arthrodesis, excisions, and disc prostheses lead to general complications, reinterventions and degeneration of adjacent levels.\u003c/p\u003e\n\u003cp\u003eThe analyses were carried out based on direct public and private medical costs (healthcare, medicines, GHS hospital stays, primary medical procedures, the general nomenclature of professional procedures NGAP, and CCAM hospital technical procedures) for the years 2019 to 2021. The following price bases were used as references: the public database of medicines[7] , MCO (Medicine, Surgery, Obstetrics) hospital rates from the ATIH (Hospital Information Technology Agency databases)[8] , the NGAP (General Nomenclature of Professional Acts) and the rates of the CCAM (Common Classification of Medical Acts)[9].\u003c/p\u003e\n\u003cp\u003eRegarding work stoppages, the Mandatory Professional Pension Scheme (RPO) automatically provides employees with a salary supplement after 45 or 90 days of absence. During these periods, the employer, through its pension obligation, pays the salary. It maintains the latter after deduction of daily social security benefits for the entire period. The employee must have 1 year of seniority in the company at the time of the work stoppage[10]. The average duration of work stoppages for lower back pathologies is 2 months\u003csup\u003e\u003csup\u003e[11]\u003c/sup\u003e\u003c/sup\u003e. The costs inherent in forethought come from the Frenche \u0026ldquo;Ameli database\u0026rdquo; of compulsory health insurance [12].\u003c/p\u003e\n\u003cp\u003eThe point of view of the study is that of health insurers, with compulsory health insurance (AMO), also called the general scheme, and supplementary health insurance (AMC).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf these 309 requests processed, 97 SMOs (31% of the cohort), resulted in a different opinion from the initial one, either regarding the diagnosis or the therapeutic strategy to adopt. Second opinions were issued on average in 2.9 days.\u003c/p\u003e\n\u003cp\u003eThe main lumbar pathologies observed were: Herniated disc, for almost a third of the requests from deuxiemeavis.fr (28%); discopathy (20%); sciatica (12%); and chronic lower back pain (11%).\u003c/p\u003e\n\u003cp\u003eExpert opinions concerned more than 28 different directions towards treatments and therapeutic care, which we found mainly in the HAS good practice recommendations.[13][14][15]. It should be noted that we found several therapeutic orientations per opinion. Thus, 226 therapeutic orientations for the divergent files (n=97) and 207 orientations were proposed for the convergent files (n=212).\u003c/p\u003e\n\u003cp\u003eIn these divergent files, there were 10 new diagnoses, 38 contraindications for surgery, 31 referrals to treatment by scan-guided epidural infiltration, 28 referrals to pain management, 26 re-referrals to another specialist (mainly a rheumatologist) or to another surgeon (neurosurgeon or an orthopaedic surgeon specializing in the spine), or 12 to lumbar physiotherapy.\u003c/p\u003e\n\u003cp\u003eThe other major pieces of advice regarding these divergent opinions were: Surgery (30 referrals out of 226, or 13%), or reorientation to other specialist surgeons or rheumatologists for 12% of referrals (26 SMOs). In these opinions, we also noted the recommendation of additional examinations to perfect the diagnosis and establish the right therapeutic strategy such as: 10 requests for lumbar MRI without and with injection, 3 multimodal radiological assessments (scanner), electrophysiological and radiographic test analysing the overall balance of the spine (tele-spine), and 4 complete physical and biological examinations (perform a Lyme serology).\u003c/p\u003e\n\u003ch3\u003e1. Analysis of direct medical costs\u003c/h3\u003e\n\u003cp\u003eOf the 212 converging cases, the main opinionswere broken down as follows: Treatment by scan-guided epidural infiltration \u0026ndash; Homogeneous Stay Group - GHM 08M291 - Other spinal pathologies requiring medical treatment, level 1 \u0026ndash; (23%); Surgical intervention - (Microsurgical excision of herniated disc / replacement of the pathological disc with a lumbar prosthesis) - GHM - 8C272 - Other interventions on the spine, level 2 are therapeutic orientations towards pain management \u0026ndash; (23%); Contraindication to surgical intervention \u0026ndash; GHM - 8C272 - Other interventions on the spine, level 2 - (14%); Lumbar physiotherapy (Mac Kenzie technique, spinal pain physiotherapy - exercise retraining) (9%) Lifestyle rules: Diet for essential weight loss, physical exercises with core strengthening and spinal flexibility work (9%).\u003c/p\u003e\n\u003cp\u003eOf the 97 patient cases that received a divergent opinion, the main second opinions given by the experts were broken down as follows: Contraindications to surgery (39%); Treatment by scan-guided epidural infiltration - GHM 08M291 - Other spinal pathologies requiring medical treatment, level 1 - (13%); Surgical intervention - (Microsurgical excision of herniated disc/via unilateral inter-myolaminar approach / radicular release with excision of the articular cyst - replacement of the pathological disc - Insertion of a disc prosthesis (13%); Pain management (29%); Redirections to another specialist (mainly a rheumatologist) or to another surgeon (neurosurgeon or an orthopaedic surgeon specializing in the spine) (12%); Lumbar physiotherapy (5%); Lifestyle rules: Diet for essential weight loss, physical exercises with work on core strength and spinal flexibility (5%).\u003c/p\u003e\n\u003cp\u003eThe impact of surgical contraindications has a significant impact on costs. Since post-operative complications are numerous, if we only consider re-interventions and only the median and high assumptions (Table 1), we can identify significant avoided costs:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eOut of 38 contraindications for surgery, compulsory health insurance (AMO) avoided, thanks to the request for a second opinion, \u0026euro;113,873 in health expenses, or nearly \u0026euro;2,996 per \u0026ldquo;contraindication\u0026rdquo; and \u0026euro;1,174 for all 97 patients redirected.\u003c/li\u003e\n \u003cli\u003eOut of 38 contraindications for surgery, supplementary health insurance (AMC) avoids, thanks to the request for a second opinion, \u0026euro;53,533 in health expenses linked to avoided surgeries, i.e. almost \u0026euro;1,409 per \u0026quot;contraindication\u0026quot; and per patient and \u0026euro;552 for all 97 patients redirected.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll of these avoided costs should be highlighted alongside those not measured, such as \u0026ldquo;general complications\u0026rdquo; and \u0026ldquo;degeneration of adjacent levels\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eAs shown in the following figures 1 and 2 and Table 2, compulsory health insurance (AMO) sees its costs decrease by \u0026euro;569 on average per redirected patient (97 divergent opinions - excluding deuxiemeavis.fr costs). Overall, the health insurance system, compulsory and supplementary combined (AMO and AMC), saves \u0026euro;765/redirected patient due to the request for a second medical opinion. The direct medical costs avoided for supplementary insurance, following a second medical opinion are although lower than those of compulsory health insurance, which, by nature, assumes the majority of hospital costs. However, AMC sees its costs decrease by \u0026euro;196 on average per redirected patient (divergent opinions - excluding deuxi\u0026egrave;me.avis.fr costs).\u003c/p\u003e\n\u003ch3\u003e2. Financial impact of work stoppages - Mandatory Professional Pension Scheme (RPO)\u003c/h3\u003e\n\u003cp\u003eAccording to our observations of deuxiemeavis.fr patient files, only 60 out of 97 divergent opinions characterize a work stoppage (two months), or 62%. Regarding initial opinions, we noted 189 out of 212 work stoppages, or 89%.\u003c/p\u003e\n\u003cp\u003eBeyond the paradigm shift from entirely curative to preventive and participatory, this leads to a difference in costs in the overall care of patients, with an average reduction of 27% in work stoppages (89%-62%=27%) when a second opinion is sought, i.e. a reduction in costs of around 9% in terms of foresight (table 4 \u0026ndash; \u0026euro;95,680).\u003c/p\u003e\n\u003cp\u003eAs shown in Tables 3 and 4, the avoided insurance costs per patient due to the use of deuxiemeavis.fr are \u0026euro;3,680 per patient, including \u0026euro;1,702 for AMO and \u0026euro;1,978 for AMC. This analysis does not highlight the overall costs for society as a whole, particularly non-medical direct costs and the impact on businesses, particularly in terms of reduced productivity.\u003c/p\u003e\n\u003cp\u003eThe divergent opinions only lead to 62% of patients being on sick leave versus 89% for the initial opinions \u0026ndash; i.e. 26 sick leave cases avoided out of 309 cases treated and therefore \u0026euro;44,252 in costs avoided for the general scheme (26 * \u0026euro;1,702) and \u0026euro;51,428 for the supplementary scheme (26 * \u0026euro;1,978).\u003c/p\u003e\n\u003cp\u003eThe costs avoided under the insurance scheme, by divergent opinion, are therefore \u0026euro;456 for the general AMO scheme (26*1702/97 divergent patients) and \u0026euro;530 for the supplementary AMC scheme (26*1978/97). All opinions combined (divergent and convergent), the costs avoided under the insurance scheme are therefore \u0026euro;143 for the general scheme (26*1702/309 convergent and divergent patients) and \u0026euro;166 for the supplementary scheme (26*1978/309 convergent and divergent patients).\u003c/p\u003e\n\u003ch4\u003eSummary of average costs avoided - medical and welfare.\u003c/h4\u003e\n\u003cp\u003eRegardless of the convergent or divergent direction resulting from the second opinion, out of 309 patients, the health insurance system sees its medical and welfare costs per patient decrease by an average of \u0026euro;550, including \u0026euro;322 for AMO and \u0026euro;228 for AMC (excluding deuxi\u0026egrave;me.avis.fr costs - See table 5).\u003c/p\u003e\n\u003cp\u003eIn the event of a second divergent opinion, the observed savings are on average \u0026euro;1,751 per file, including \u0026euro;1,025 for the AMO and \u0026euro;726 for the AMC \u0026ndash; (excluding the cost of deuxi\u0026egrave;me.avis.fr - See table 6).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLumbar pathologies are pathologies that are particularly sensitive to second opinions from specialized experts, because too systematic recourse to surgery has serious consequences on the quality of care and its consequences in terms of costs.\u003c/p\u003e\n\u003cp\u003eThe benefits of this support strategy are numerous:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eFor the patient - The platform\u0026apos;s doctors, all specialists in spinal pathologies, are more compliant with best practice recommendations and thus operate less (surgery contraindications in more than 39% of referrals), maintain activity and prioritize pain treatment, which is often underestimated in initial opinions. The management of spinal pathologies is primarily characterized by the relevance of care. The expert has no financial benefit from operating on the patient, so he will give a neutral opinion. He is also undoubtedly more aware of the latest medical practices and recommendations from learned societies, which are for the benefit of patients. Similarly, if the reduction in surgical procedures leads to a reduction in sick leave, the \u0026quot;digital\u0026quot; consultation is carried out without pressure from the patient and their requests for sick leave. Thus, benefiting from a second opinion for back pain, beyond the savings identified for the various stakeholders (AMO, AMC and insurance), a patient who benefits from a second opinion, whatever their situation (standard of living, geographical origin, mobility, etc.) is:\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e✓ Receive medical expertise within an average of 2.9 days, compared to 45 days for an in-person appointment with a rheumatologist or orthopaedic surgeon in mainland France.\u003c/p\u003e\n\u003cp\u003e✓ Avoid additional travel while their mobility is restricted.\u003c/p\u003e\n\u003cp\u003e✓ Benefit from a written and documented report, which they can reread at their leisure and share with their medical team or loved ones.\u003c/p\u003e\n\u003cp\u003e✓ Gain reassurance and peace of mind, knowing they\u0026apos;re receiving the best care pathway.\u003c/p\u003e\n\u003cp\u003e✓ Be better informed and therefore take control of their own health.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eFor the treating team \u0026ndash; The second opinion is written and shared with the treating team, with the aim of sharing knowledge and expertise, and in a collaborative approach.\u003c/li\u003e\n \u003cli\u003eFor the company \u0026ndash; A better-treated patient is one who is kept active. In this case, there is a major difference in strategic choices among the Deuxiemeavis.fr experts. They more often recommend, as a therapeutic basis, maintaining activity and improving lifestyle (weight loss, physical exercises with core strength and spinal flexibility).\u003c/li\u003e\n \u003cli\u003eFor healthcare financiers - Mandatory health insurance (AMO) partially covers healthcare costs. Supplementary health insurance (AMC), whether individual or corporate, can partially cover the remaining costs. The second opinion is covered by the AMC, which allows them to escape the imposed role of blind payer, by offering a service that streamlines care and therefore costs (in this case \u0026euro;1,751 per patient in the event of reorientation).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eLimitations of the study:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eFirst, the medical analysis remains subject to the quality of the files submitted by patients, which can sometimes be incomplete.\u003c/li\u003e\n \u003cli\u003eThe second point is that we do not have follow-up with patients after the second opinion. We therefore have no certainty that the latter will be followed up. We therefore limit ourselves to the assumption that this second opinion will be fully followed.\u003c/li\u003e\n \u003cli\u003eIt is difficult to fully examine the cost of surgical complications without an ad hoc longitudinal study. We therefore limited ourselves to the observable, that is, re-operations. These are only direct costs, to which it might be appropriate to add indirect costs such as travel, insurance, and convalescence costs. We have 38 contraindications observed in 309 medical files.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion of this study on the impact of the use of a second medical opinion in the management of lumbar pathologies, we can retain the following elements:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e31% of the opinions given by deuxiemeavis.fr experts differ from the initial opinions presented by patients (97/309)\u003c/li\u003e\n \u003cli\u003eThe main lumbar pathologies observed are herniated discs (nearly a third of second opinion requests), discopathy (20%), sciatica (12%), and chronic lower back pain (11%)\u003c/li\u003e\n \u003cli\u003eThe main therapeutic orientations observed are treatment by CT-guided epidural infiltration; surgical intervention (microsurgical excision of herniated disc/replacement of the pathological disc with a lumbar prosthesis) \u0026ndash; GHM.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003eAverage direct medical costs avoided.\u003c/h4\u003e\n\u003cul\u003e\n \u003cli\u003eRegardless of the convergent or divergent referral resulting from the second opinion, for 309 patients, mandatory health insurance saw its average direct medical costs decrease by \u0026euro;55,154, with a reduction of \u0026euro;179 per patient; supplementary health insurance saw its costs decrease by \u0026euro;19,039, with a reduction of \u0026euro;62 per patient (excluding deuxi\u0026egrave;me.avis.fr costs). (See Table 2).\u003c/li\u003e\n \u003cli\u003eIn the event of reorientation following a second divergent opinion, for 97 patients, the average direct medical costs avoided were \u0026euro;765, including \u0026euro;569 for the AMO and \u0026euro;196 for the AMC (excluding deuxieme.avis.fr costs and provident insurance - See Table 2).\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003eDirect costs of foresight avoided.\u003c/h4\u003e\n\u003cul\u003e\n \u003cli\u003eThe insurance costs avoided by using deuxieme.avis.fr are \u0026euro;95,680 for all schemes combined, including \u0026euro;44,252 for AMO (\u0026euro;1,702/divergent patient) and \u0026euro;51,428 (\u0026euro;1,978/divergent patient) for AMC. This analysis does not highlight the overall costs for society as a whole, in particular the direct non-medical costs and the impact on businesses, particularly in terms of reduced productivity (see table 4).\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003eSummary of average costs avoided - medical and welfare.\u003c/h4\u003e\n\u003cul\u003e\n \u003cli\u003eRegardless of the convergent or divergent direction resulting from the second opinion, out of 309 patients, the health insurance system sees its medical and welfare costs per patient decrease by an average of \u0026euro;550, including \u0026euro;322 for AMO and \u0026euro;228 for AMC (excluding deuxi\u0026egrave;me.avis.fr costs - see Table 5).\u003c/li\u003e\n \u003cli\u003eIn the event of a divergent second opinion, the observed savings are on average \u0026euro;1,751 per case, including \u0026euro;1,025 for AMO and \u0026euro;726 for AMC (excluding deuxi\u0026egrave;me.avis.fr costs - see Table 6).\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAMC: Supplementary Health Insurance\u003c/p\u003e\n\u003cp\u003eAMO: Mandatory Health Insurance\u003c/p\u003e\n\u003cp\u003eAT: Workplace Accidents\u003c/p\u003e\n\u003cp\u003eATIH: Hospital Information Technology Agency\u003c/p\u003e\n\u003cp\u003eCCAM: Common Classification of Medical Procedures\u003c/p\u003e\n\u003cp\u003eGHM: Homogeneous Group of Patients (GHM)\u003c/p\u003e\n\u003cp\u003eGHS: Homogeneous Group of Stays\u003c/p\u003e\n\u003cp\u003eHAS: French National Authority for Health\u003c/p\u003e\n\u003cp\u003eICER: Incremental Cost-Effectiveness Ratio\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic Resonance Imaging\u003c/p\u003e\n\u003cp\u003eMCO: Medicine, Surgery, Obstetrics\u003c/p\u003e\n\u003cp\u003eMP: Occupational Illnesses\u003c/p\u003e\n\u003cp\u003eNGAP: General Classification of Medical Procedures\u003c/p\u003e\n\u003cp\u003eAIDS: Acquired Immunodeficiency Syndrome\u003c/p\u003e\n\u003cp\u003eRPO: Mandatory Professional Insurance Plan\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch4\u003eEthics approval and consent to participate:\u003c/h4\u003e\n\u003cp\u003eEthics approval and consent to participate. The SMO platform deuxiemeavis.fr received approval from the French National Commission for Data Privacy (Commission Nationale Informatique et Libertés, CNIL - The CNIL has an institutional ethics committee) and patients provided informed consent that their anonymous data may be used for research and quality improvement purposes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo additional approvals were required according to the French legislation as this was an observational study based on medical records. All methods were performed in accordance with the relevant guidelines and regulations (Declarations of Helsinki).\u003c/p\u003e\n\u003ch4\u003eConsent for publication\u003c/h4\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch4\u003eAvailability of data and materials\u003c/h4\u003e\n\u003cp\u003eAll tables used in these analyses are available upon request from the lead author.\u003c/p\u003e\n\u003cp\u003eAll data generated and analysed during the current study are not publicly available due to medical confidentiality but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch4\u003eCompeting Interests\u003c/h4\u003e\n\u003cp\u003eThe company Carians (deuxiemeavis.fr) financed the experts who signed this study, JA and SB.\u003c/p\u003e\n\u003ch4\u003eFunding\u003c/h4\u003e\n\u003cp\u003eDeuxi\u0026egrave;meavis.fr funded this study and participated in the conceptualization, design, data collection, analysis, publication decision, and manuscript preparation.\u003c/p\u003e\n\u003ch4\u003eAuthor contributions\u003c/h4\u003e\n\u003cp\u003eSB and JA analysed and interpreted data from patient records.\u003c/p\u003e\n\u003ch4\u003eAcknowledgements\u003c/h4\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMay et al. Does the second opinion directive in Germany reach the patient? A parallel-convergent mixed-methods study . BMC Health Services Research (2023) 23:1198\u003c/li\u003e\n\u003cli\u003eBruch D, May S, Prediger B, et al. Second opinion programmes in Germany: a mixed-methods study protocol. BMJ Open 2021;11:e045264. doi:10.1136/ bmjopen-2020-045264\u003c/li\u003e\n\u003cli\u003eMeyer et al. Evaluation of Outcomes From a National Patient-initiated Second-opinion Program The American Journal of Medicine, Vol 128, No 10, October 2015. http://dx.doi.org/10.1016/j.amjmed.2015.04.020\u003c/li\u003e\n\u003cli\u003eAntonioli, E., Tavares Malheiro, D., Damazio Teich, V. et al. Cost-effectiveness of a second opinion program on spine surgeries: an economic analysis. BMC Health Serv Res 23, 1441 (2023). https://doi.org/10.1186/s12913-023-10405-x\u003c/li\u003e\n\u003cli\u003eSanchez et al. BMC Health Services Research (2021) 21:902 https://doi.org/10.1186/s12913-021-06936-w\u003c/li\u003e\n\u003cli\u003eHAS. Lombalgie chronique de l\u0026rsquo;adulte et chirurgie. Paris. 2015\u003c/li\u003e\n\u003cli\u003ehttp://base-donnees-publique.medicaments.gouv.fr\u003c/li\u003e\n\u003cli\u003ehttps://www.atih.sante.fr/tarifs-mco-et-had\u003c/li\u003e\n\u003cli\u003ehttps://www.ameli.fr/accueil-de-la-ccam/outils/actes-frequents/index.php\u003c/li\u003e\n\u003cli\u003ehttps://code.travail.gouv.fr/contribution/1266-en-cas-darret-maladie-du-salarie-lemployeur-doit-il-assurer-le-maintien-de-salaire\u003c/li\u003e\n\u003cli\u003eINRS - Travail et Lombalgie - 2019\u003c/li\u003e\n\u003cli\u003ehttps://www.ameli.fr/paris/assure/remboursements/indemnites-journalieres-maladie-maternite-paternite/arret-maladie-salarie\u003c/li\u003e\n\u003cli\u003eHAS. Prise en charge du patient pr\u0026eacute;sentant une lombalgie commune. Rapport d\u0026rsquo;\u0026eacute;laboration Mars 2019. Paris. https://www.has-sante.fr/upload/docs/application/pdf/2019-04/reco315_rapport_lombalgie_2019_04_02.pdf\u003c/li\u003e\n\u003cli\u003eCaisse nationale de l\u0026apos;assurance maladie des travailleurs salari\u0026eacute;s. Am\u0026eacute;liorer la qualit\u0026eacute; du syst\u0026egrave;me de sant\u0026eacute; et ma\u0026icirc;triser les d\u0026eacute;penses. Propositions de l\u0026rsquo;Assurance Maladie pour 2017. Paris: CNAMTS; 2016. https://assurance-maladie.ameli.fr/sites/default/files/rapport-activite-charges-produits-17_assurance-maladie.pdf\u003c/li\u003e\n\u003cli\u003eHAS. Lombalgie chronique de l\u0026rsquo;adulte et chirurgie. Paris. 2015. https://www.has-sante.fr/upload/docs/application/pdf/2016- 03/arg_pertinence_chir-lombalgie.pdf\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lumbar pathologies, Second medical opinions, Cost minimization, Cost rationalization, Relevance of care, financing of care","lastPublishedDoi":"10.21203/rs.3.rs-6653339/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6653339/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: It is increasingly common for a patient to seek a second opinion after a therapeutic proposal, particularly surgical, for a spinal pathology. We studied the impact of this second opinion, obtained via a platform specialized in this approach, on the final therapeutic decision.\u003c/p\u003e \u003cp\u003eMethods \u0026amp; Materials: Between 2019 and 2021, 309 second medical opinions (SMO) were obtained on the deuxiemeavis.fr platform for degenerative lumbar pathologies (hernias, discopathies, stenoses). The referring physicians studied the patients' disabilities using personalized questionnaires and their additional examinations. We analysed the concordance rate between the two opinions. Patients were asked about their degree of satisfaction. The costs of care were studied according to a cost minimization principle: all medical costs were considered based on treatment protocols, as well as the costs of insurance, relating to work stoppages. Any additional costs or savings generated were evaluated by opinion, convergent or divergent, and for divergent opinions only. The average cost of the converging arm was considered as the reference cost. We then compared the cost of the care recommended by the SMOs to this reference cost. Those of compulsory health insurance (AMO) have been distinguished from those of supplementary health insurance (AMC).\u003c/p\u003e \u003cp\u003eResults: 69% of the SMOs (212 opinions) were convergent and 31% (97 opinions) divergent, differing mainly on the therapeutic strategies as recommended by the High Authority of Health (HAS): contraindication or recommendation of surgery, proposal of infiltrations, pain management, rehabilitation or referral to another specialist (rheumatologist, surgeon). Some divergences concerned the diagnosis, or the examinations carried out.\u003c/p\u003e \u003cp\u003eRegardless of the convergent or divergent direction resulting from the second opinion, out of 309 patients, the health insurance system sees on average all medical and welfare costs per patient decrease by \u0026euro;550, including \u0026euro;322 for AMO and \u0026euro;228 for AMC (excluding deuxi\u0026egrave;me.avis.fr costs). When the second opinion diverges from the initial opinion, the savings observed in terms of medical and welfare expenses are on average \u0026euro;1,751 per file including \u0026euro;1,025 for AMO and \u0026euro;726 for AMC.\u003c/p\u003e \u003cp\u003eConclusion: Using a second medical opinion service via a dedicated platform allows patients to seek the advice of a referring physician in lumbar pathology, without the aim of directly interfering in the patient's care. In more than two-thirds of cases, it allows the patient to be reassured about the initially proposed treatment by confirming the first opinion. In divergent cases, the referring physician generally suggests a less invasive treatment, thus resulting in real healthcare savings, estimated at \u0026euro;1,751 per case.\u003c/p\u003e","manuscriptTitle":"Impact of a second medical opinion on the therapeutic and costs management of lumbar pathologies : a study based on a French cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-18 06:04:46","doi":"10.21203/rs.3.rs-6653339/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-06T11:57:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-13T09:29:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-18T11:18:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314451064971429568095660229391722896508","date":"2025-06-18T09:29:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89208763421816849773776744655450666417","date":"2025-06-15T19:19:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-13T07:33:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T09:57:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-20T07:17:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-19T11:59:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-19T11:57:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c986627c-8f8b-4e48-ba60-bbf29ff74c90","owner":[],"postedDate":"June 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T11:06:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-18 06:04:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6653339","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6653339","identity":"rs-6653339","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}