National Variation in Referral and Surgical Management of Incident Cervical Disc Herniation

Abstract Introduction: Cervical disc herniation (CDH) in working-age adults may cause substantial functional impairment. However, little is known about how patients transition from primary care to specialist evaluation, and whether regional differences in referral pathways influence management and outcome. Aim: To examine regional variation in referral pathways, surgical rates, and work capacity outcomes in Denmark’s five healthcare regions. Methods: Using national registry data, we identified 4,322 citizens aged 18–65 diagnosed with incident CDH in 2017. Patients were stratified by region and the type of department first referred to e.g. medical, surgical, or emergency. Work capacity one year prior to diagnosis was categorized as low (<20%), intermediate (20–80%), or high (≥80%) of a standard 37-hour work week and followed for two years after initial specialized health care sector admission the. Results: Admission rates were consistent across regions, ranging from 12 to 13 per 10,000 citizens. Nationally, the surgical rate was 1,296 per 10,000 admitted patients. However, surgical rates varied markedly between regions, from 793 per 10,000 in the Capitol Region to 2,320 per 10,000 in the Region of Northern Denmark. Nationally, 60.5 percent of patients were admitted through medical departments, 30.7 percent through surgical departments, and 8.8 percent through emergency departments, but the pathways differed substantially across the regions of Denmark. The highest surgical rate was observed among those referred through emergency departments, where 95 of 379 admitted patients underwent surgery (2,507 per 10,000 admitted patients). In contrast, medical departments admitted 2,615 patients, of whom 182 received surgery (696 per 10,000 admitted patients), while surgical departments admitted 1,328 patients, with 283 undergoing surgery (2,132 per 10,000 admitted patients). A total of 87 percent of patients with high and 83 percent with intermediate baseline work capacity regained pre-diagnosis work capacity within six months, whereas only 5% of those with low capacity achieved a work capacity of 20% or above within two years. Conclusion: Despite similar national admission rates for CDH, substantial regional disparities were observed in referral practices and surgical intervention rates. The findings suggest a need for more research into the optimal specialized clinical pathway for CDH patients who are refractory to initial conservative treatment in the primary health sector.