RESUMO
BACKGROUND: Although posterior decompression with fusion (PDF) are effective for treating thoracic myelopathy, surgical treatment has a high risk of various complications. There is currently no information available on the perioperative complications in thoracic ossification of the longitudinal ligament (T-OPLL) and thoracic ossification of the ligamentum flavum (T-OLF). We evaluate the perioperative complication rate and cost between T-OPLL and T-OLF for patients underwent PDF. METHODS: Patients undergoing PDF for T-OPLL and T-OLF from 2012 to 2018 were detected in Japanese nationwide inpatient database. One-to-one propensity score matching between T-OPLL and T-OLF was performed based on patient characteristics and preoperative comorbidities. We examined systemic and local complication rate, reoperation rate, length of hospital stays, costs, discharge destination, and mortality after matching. RESULTS: In a total of 2,660 patients, 828 pairs of T-OPLL and T-OLF patients were included after matching. The incidence of systemic complications did not differ significantly between the T-OPLL and OLF groups. However, local complications were more frequently occurred in T-OPLL than in T-OLF groups (11.4% vs. 7.7% P = 0.012). Transfusion rates was also significantly higher in the T-OPLL group (14.1% vs. 9.4%, P = 0.003). T-OPLL group had longer hospital stay (42.2 days vs. 36.2 days, P = 0.004) and higher medical costs (USD 32,805 vs. USD 25,134, P < 0.001). In both T-OPLL and T-OLF, the occurrence of perioperative complications led to longer hospital stay and higher medical costs. While fewer patients in T-OPLL were discharged home (51.6% vs. 65.1%, P < 0.001), patients were transferred to other hospitals more frequently (47.5% vs. 33.5%, P = 0.001). CONCLUSION: This research identified the perioperative complications of T-OPLL and T-OLF in PDF using a large national database, which revealed that the incidence of local complications was higher in the T-OPLL patients. Perioperative complications resulted in longer hospital stays and higher medical costs.
Assuntos
Bases de Dados Factuais , Descompressão Cirúrgica , Ligamento Amarelo , Ossificação do Ligamento Longitudinal Posterior , Complicações Pós-Operatórias , Fusão Vertebral , Vértebras Torácicas , Humanos , Masculino , Feminino , Vértebras Torácicas/cirurgia , Ligamento Amarelo/cirurgia , Fusão Vertebral/economia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/métodos , Pessoa de Meia-Idade , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/métodos , Idoso , Ossificação do Ligamento Longitudinal Posterior/cirurgia , Ossificação do Ligamento Longitudinal Posterior/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/economia , Japão/epidemiologia , Ossificação Heterotópica/cirurgia , Ossificação Heterotópica/economia , Ossificação Heterotópica/epidemiologia , Tempo de Internação/economia , Reoperação/economia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Pacientes Internados , Resultado do TratamentoRESUMO
BACKGROUND CONTEXT: Isolated decompression and decompression with instrumented fusion are accepted surgical treatments for lumbar spondylolisthesis. Although isolated decompression is a less costly solution with similar patient-reported outcomes, it is associated with higher rates of reoperation than primary fusion. PURPOSE: To determine the costs associated with primary decompression, primary fusion, and decompression and fusion for degenerative spondylolisthesis. We further sought to establish at what revision rate is primary decompression still a less costly surgical treatment for degenerative lumbar spondylolisthesis. STUDY DESIGN/SETTING: A retrospective database study of the Medicare Provider Analysis and Review (MEDPAR) limited data set. PATIENT SAMPLE: Patients who underwent single-level fusion or decompression for degenerative spondylolisthesis. OUTCOME MEASURES: Cost of surgical care. METHODS: All inpatient stays that underwent surgery for single-level lumbar/lumbosacral degenerative spondylolisthesis in the 2019 calendar year (n=6,653) were queried from the MEDPAR limited data set. Patients were stratified into three cohorts: primary decompression (n=300), primary fusion (n=5,757), and revision fusion (n=566). Univariate analysis was conducted to determine cost differences between these groups and results were confirmed with multivariable regression. An economic analysis was then done to determine at what revision rate would primary decompression still be a less costly treatment choice. RESULTS: on univariate analysis, the cost of primary single-level decompression for spondylolisthesis was $14,690±9,484, the cost of primary single-level fusion was $26,376±11,967, and revision fusion was $26,686±11,309 (p<0.001). on multivariate analysis, primary fusion was associated with an increased cost of $3,751, and revision fusion was associated with increased cost of $7,502 (95%ci: 2,990-4,512, p<0.001). economic analysis found that a revision rate less than or equal to 43.8% would still result in primary decompression being less costly for a practice than primary fusion for all patients. CONCLUSIONS: Isolated decompression for degenerative lumbar spondylolisthesis is a less costly treatment choice even with rates of revision fusion as high as 43.8%. This was true even with an assumed revision rate of 0% after primary fusion. This study solely looks at cost data, however, and many patients may still benefit from primary fusion when appropriately indicated.
Assuntos
Descompressão Cirúrgica , Vértebras Lombares , Reoperação , Fusão Vertebral , Espondilolistese , Humanos , Espondilolistese/cirurgia , Espondilolistese/economia , Fusão Vertebral/economia , Fusão Vertebral/métodos , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/métodos , Masculino , Idoso , Feminino , Reoperação/economia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Vértebras Lombares/cirurgia , Idoso de 80 Anos ou mais , Medicare/economia , Pessoa de Meia-Idade , Estados UnidosRESUMO
STUDY DESIGN: Observational cohort study. OBJECTIVE: Cauda equina syndrome (CES) is a rare neurologic condition with potentially devastating consequences. The objective of this study was to compare the 2-year postoperative cost-associated treatments after posterior spinal decompression between patients with and without CES. METHODS: By analyzing a commercial insurance claims database, patients who underwent posterior spinal decompression with a concurrent diagnosis of lumbar spinal stenosis, radiculopathy, or disk herniation in 2017 were identified and included in the study. The primary outcome was the cost of payments for identified treatments in the 2-year period after surgery. Treatments included were (1) physical therapy (PT), (2) pain medication, (3) injections, (4) bladder management, (5) bowel management, (6) sexual dysfunction treatment, and (7) psychological treatment. RESULTS: In total, 3,140 patients (age, 55.3 ± 12.0 years; male, 62.2%) were included in the study. The average total cost of treatments identified was $2,996 ± 6,368 per patient. The overall cost of identified procedures was $2,969 ± 6,356 in non-CES patients, compared with $4,535 ± 6,898 in patients with CES ( P = 0.079). Among identified treatments, only PT and bladder management costs were significantly higher for patients with CES (PT: +115%, P < 0.001; bladder management: +697%, P < 0.001). The difference in overall cost was significant between patients (non-CES: $1,824 ± 3,667; CES: $3,022 ± 4,679; P = 0.020) in the first year. No difference was found in the second year. DISCUSSION: A short-term difference was observed in costs occurring in the first postoperative year. Cost of treatments was similar between patients apart from PT and bladder management.
Assuntos
Síndrome da Cauda Equina , Descompressão Cirúrgica , Humanos , Síndrome da Cauda Equina/cirurgia , Síndrome da Cauda Equina/economia , Masculino , Pessoa de Meia-Idade , Feminino , Descompressão Cirúrgica/economia , Idoso , Adulto , Efeitos Psicossociais da Doença , Estenose Espinal/cirurgia , Estenose Espinal/economia , Estudos de Coortes , Custos de Cuidados de Saúde , Deslocamento do Disco Intervertebral/cirurgia , Deslocamento do Disco Intervertebral/economia , Vértebras Lombares/cirurgia , Estudos RetrospectivosRESUMO
INTRODUCTION: To improve the delivery of value-based health care, a deeper understanding of the cost drivers in hand surgery is warranted. Time-driven activity-based costing (TDABC) offers a more accurate estimation of resource utilization compared with top-down accounting methods. This study used TDABC to compare the facility costs of open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR). METHODS: We identified 845 consecutive, unilateral carpal tunnel release (516 open, 329 endoscopic) surgeries performed at an orthopaedic specialty hospital between 2015 and 2021. Itemized facility costs were calculated using a TDABC algorithm. Patient demographics, comorbidities, surgical characteristics, and itemized costs were compared between OCTR and ECTR. Multivariate regression was used to determine the independent effect of endoscopic surgery on true facility costs. RESULTS: Total facility costs were $352 higher in ECTR compared with OCTR ($882 versus $530). ECTR cases had higher personnel costs ($499 versus $420), likely because of longer surgical time (15 versus 11 minutes) and total operating room time (35 versus 27 minutes). ECTR cases also had higher supply costs ($383 versus $110). Controlling for demographics and comorbidities, ECTR was associated with an increase in personnel costs of $35.74 (95% CI, $26.32 to $45.15), supply costs of $230.28 (95% CI, $205.17 to $255.39), and total facility costs of $265.99 (95% CI, $237.01 to $294.97) per case. DISCUSSION: Using TDABC, ECTR was 66% more costly to the facility compared with OCTR. To reduce the costs related to endoscopic surgery, efforts to decrease surgical time and negotiate lower ECTR-specific supply costs are warranted. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II.
Assuntos
Síndrome do Túnel Carpal , Endoscopia , Humanos , Síndrome do Túnel Carpal/cirurgia , Síndrome do Túnel Carpal/economia , Endoscopia/economia , Masculino , Feminino , Pessoa de Meia-Idade , Duração da Cirurgia , Custos e Análise de Custo , Idoso , Procedimentos Ortopédicos/economia , Fatores de Tempo , Adulto , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/métodos , Estudos RetrospectivosRESUMO
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to compare the impact of anterior cervical decompression and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for the treatment of acute traumatic central cord syndrome (CCS) on hospital episodes of care in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination. SUMMARY OF BACKGROUND DATA: Acute traumatic CCS is the most common form of spinal cord injury in the United States. CCS is commonly treated with surgical decompression and fusion. Hospital resource utilization based on surgical approach remains unclear. METHODS: Patients undergoing ACDF and PCDF for acute traumatic CCS were identified using the 2019 Medicare Provider Analysis and Review Limited Data Set and Centers for Medicare and Medicaid Services 2019 Impact File. Multivariate models for hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. Subanalysis of accommodation and revenue center cost drivers was performed. RESULTS: There were 1474 cases that met inclusion criteria: 673 ACDF (45.7%) and 801 PCDF (54.3%). ACDF was independently associated with a decreased cost of $9802 ( P <0.001) and a 59.2% decreased risk of discharge to nonhome destinations (adjusted odds ratio: 0.408, P <0.001). The difference in length of stay was not statistically significant. On subanalysis of cost drivers, ACDF was associated with decreased charges ($55,736, P <0.001) compared with PCDF, the largest drivers being the intensive care unit ($15,873, 28% of total charges, P <0.001) and medical/surgical supply charges ($19,651, 35% of total charges, P <0.001). CONCLUSIONS: For treatment of acute traumatic CCS, ACDF was associated with almost $10,000 less expensive cost of care and a 60% decreased risk of discharge to nonhome destination compared with PCDF. The largest cost drivers appear to be ICU and medical/surgical-related. These findings may inform value-based decisions regarding the treatment of acute traumatic CCS. However, injury and patient clinical factors should always be prioritized in surgical decision-making, and increased granularity in reimbursement policies is needed to prevent financial disincentives in the treatment of patients with CCS better addressed with posterior approach-surgery.
Assuntos
Síndrome Medular Central , Vértebras Cervicais , Descompressão Cirúrgica , Fusão Vertebral , Humanos , Descompressão Cirúrgica/economia , Fusão Vertebral/economia , Masculino , Feminino , Síndrome Medular Central/cirurgia , Vértebras Cervicais/cirurgia , Pessoa de Meia-Idade , Idoso , Tempo de Internação/economia , Estudos Retrospectivos , Recursos em Saúde/economia , Doença AgudaRESUMO
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare elective single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for degenerative cervical myelopathy (DCM) in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination in Medicare patients. A sub-analysis of potential cost drivers was also performed. BACKGROUND: In the era of value-based medicine, there is substantial interest in reducing the cost of care. Both ACDF and PCDF are used to treat DCM but carry different morbidity and risk profiles that can impact hospital resource utilization. However, this has not been assessed on a national level. METHODS: Patients undergoing single-level elective ACDF and PCDF surgery were identified using the 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File. Multivariate models of hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. A univariate sub-analysis of 9 revenue centers was performed. RESULTS: In all, 3942 patients met the inclusion criteria. The mean cost of elective single-level cervical fusion for myelopathy was $18,084±10,783, and the mean length of stay was 2.45±2.95 d. On multivariate analysis, ACDF was independently associated with decreased cost of $5,814 ( P <0.001), shorter length of stay by 1.1 days ( P <0.001), and decreased risk of nonhome discharge destination by 58% (adjusted odds ratio: 0.422, P <0.001).On sub-analysis of 9 revenue centers, medical/surgical supply ($10,497, 44%), operating room charges ($5401, 23%), and accommodations ($3999, 17%) were the largest drivers of charge differences. CONCLUSIONS: Single-level elective primary ACDF for DCM was independently associated with decreased cost, decreased hospital length of stay, and a lower rate of nonhome discharge compared with PCDF. Medical and surgical supply, operating room, and accommodation differences between ACDF and PCDF are potential areas for intervention. Increased granularity in reimbursement structures is warranted to prevent the creation of disincentives to the treatment of patients with DCM with pathology that is better addressed with PCDF. LEVEL OF EVIDENCE: Level-III Retrospective Cohort Study.
Assuntos
Vértebras Cervicais , Descompressão Cirúrgica , Procedimentos Cirúrgicos Eletivos , Tempo de Internação , Fusão Vertebral , Espondilose , Humanos , Fusão Vertebral/economia , Descompressão Cirúrgica/economia , Masculino , Feminino , Vértebras Cervicais/cirurgia , Espondilose/cirurgia , Idoso , Pessoa de Meia-Idade , Doenças da Medula Espinal/cirurgia , Estudos Retrospectivos , Recursos em Saúde/economia , Discotomia/economia , Medicare , Estados UnidosRESUMO
STUDY DESIGN: Markov model. OBJECTIVE: To compare the cost-effectiveness of lumbar decompression alone (DA) with lumbar decompression with fusion (DF) for the management of adults undergoing surgery for lumbar stenosis with associated degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: Rates of lumbar fusion have increased for all indications in the United States over the last 20 years. Recent randomized controlled trial data, however, have suggested comparable functional outcomes and lower reoperation rates for lumbar decompression and fusion as compared with DA in the treatment of lumbar stenosis with degenerative spondylolisthesis. MATERIALS AND METHODS: A multistate Markov model was constructed from the US payer perspective of a hypothetical cohort of patients with lumbar stenosis with associated spondylolisthesis requiring surgery. Data regarding clinical improvement, costs, and reoperation were generated from contemporary randomized trial evidence, meta-analyses of recent prospective studies, and large retrospective cohorts. Base case, one-way sensitivity analysis, and probabilistic sensitivity analyses were conducted, and the results were compared with a WTP threshold of $100,000 (in 2022 USD) over a two-year time horizon. A discount rate of 3% was utilized. RESULTS: The incremental cost and utility of DF relative to DA were $12,778 and 0.00529 aggregated quality adjusted life years. The corresponding incremental cost-effectiveness ratio of $2,416,281 far exceeded the willingness to pay threshold of $100,000. In sensitivity analysis, the results varied the most with respect to rate of improvement after DA, rate of improvement after lumbar decompression and fusion, and odds ratio of reoperation between the two groups. Zero percent of one-way and probabilistic sensitivity analyses achieved cost-effectiveness at the willingness-to-pay threshold. CONCLUSIONS: Within the context of contemporary surgical data, DF is not cost-effective compared with DA in the surgical management of lumbar stenosis with associated spondylolisthesis over a two-year time horizon.
Assuntos
Análise Custo-Benefício , Descompressão Cirúrgica , Vértebras Lombares , Fusão Vertebral , Estenose Espinal , Espondilolistese , Humanos , Espondilolistese/cirurgia , Espondilolistese/economia , Estenose Espinal/cirurgia , Estenose Espinal/economia , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/métodos , Fusão Vertebral/economia , Fusão Vertebral/métodos , Vértebras Lombares/cirurgia , Cadeias de Markov , Anos de Vida Ajustados por Qualidade de Vida , Resultado do TratamentoRESUMO
BACKGROUND: Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy. METHODS: 2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs. RESULTS: 842 patients were included, of which 409 (48.6 â%) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 â% vs 0.0 â%, p â= â0.045), reduced ostomy rate (38.3 â% vs 29.4 â%, p â= â0.013), an increased overall length of stay (12 days vs 8 days, p â< â0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p â< â0.001). CONCLUSION: In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.
Assuntos
Colectomia , Volvo Intestinal , Doenças do Colo Sigmoide , Humanos , Volvo Intestinal/cirurgia , Idoso , Feminino , Masculino , Colectomia/métodos , Colectomia/economia , Doenças do Colo Sigmoide/cirurgia , Idoso de 80 Anos ou mais , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/métodos , Tempo de Internação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Fatores de TempoRESUMO
OBJECTIVE/BACKGROUND: Thoracic outlet syndrome (TOS) is most often referred to vascular surgeons. However, there is a lack of understanding of the malpractice cases involving TOS. The goal of this study is to better understand the medicolegal landscape related to the care of TOS. METHODS: The Westlaw Edge AI-powered proprietary system was retrospectively reviewed for malpractice cases involving TOS. A Boolean search strategy was used to identify target cases under the case category of "Jury Verdicts & Settlements" for all state and federal jurisdictions from 1970 to September 2020. The settled case was described but not included in the statistical analysis. Descriptive statistics were used to report our findings, and when appropriate. The P ≤ .05 decision rule was established a priori as the null hypothesis rejection criterion to determine associations between jury verdicts outcomes and state's tort reform status. RESULTS: In this study, 39 cases were identified and met the study's inclusion criteria from the entire Westlaw Edge database. Among plaintiffs who disclosed age and/or gender, median age was 35.0 years with a female majority (67.6%). Cases involving TOS were noted to be steadily decreasing since the mid-1990s. The cases were unevenly spread across 18 states, with the highest number of cases (14, 35.9%) from California and the second highest (4, 10.3%) from Pennsylvania. A similar uneven distribution was seen among U.S. census regions, in which the West had the highest cases (39.5%). The study revealed that more cases were brought to trials in tort reform states (26, 68.4%) than in non-tort reform states (12, 31.6%). A total of 24 of 39 (61.5%) plaintiffs had one specific claim, which resulted in their economic and noneconomic damages. Negligent operation and treatment complication represented an overwhelming majority of claims brought by 38 of 39 plaintiffs (97.4%). Misdiagnosis and lack of informed consent were both brought nine times (23.1%) by the group. Intraoperative nerve injury (20 patients, 51.3%) was the most commonly reported complication. Excluding one case with a settlement of $965,000, 30 of 38 (78.9%) cases went to trials and received defense verdicts. Eight cases (20.5%) were found in favor of plaintiffs with a median payout of $725,581. CONCLUSIONS: This study highlighted higher than average payouts to plaintiffs and risk factors that may result in malpractice lawsuits for surgeons undertaking TOS treatment. Future studies are needed to further clarify the relationships between tort reform and outcomes of malpractice cases involving TOS.
Assuntos
Compensação e Reparação , Descompressão Cirúrgica/economia , Seguro de Responsabilidade Civil/economia , Responsabilidade Legal/economia , Imperícia/economia , Erros Médicos/economia , Complicações Pós-Operatórias/economia , Síndrome do Desfiladeiro Torácico/cirurgia , Procedimentos Cirúrgicos Vasculares/economia , Adulto , Compensação e Reparação/legislação & jurisprudência , Bases de Dados Factuais , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/legislação & jurisprudência , Feminino , Humanos , Seguro de Responsabilidade Civil/legislação & jurisprudência , Masculino , Imperícia/legislação & jurisprudência , Erros Médicos/legislação & jurisprudência , Formulação de Políticas , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Síndrome do Desfiladeiro Torácico/economia , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/legislação & jurisprudênciaRESUMO
BACKGROUND: The costs and health effects associated with lower extremity complications in diabetes mellitus are an increasing burden to society. In selected patients, lower extremity nerve decompression is able to reduce symptoms of neuropathy and the concomitant risks of diabetic foot ulcers and amputations. To estimate the health and economic effects of this type of surgery, the cost-effectiveness of this intervention compared to current nonsurgical care was studied. METHODS: To estimate the incremental cost-effectiveness of lower extremity nerve decompression over a 10-year period, a Markov model was developed to simulate the onset and progression of diabetic foot disease in patients with diabetes and neuropathy who underwent lower extremity nerve decompression surgery, compared to a group undergoing current nonsurgical care. Mean survival time, health-related quality of life, presence or risk of lower extremity complications, and in-hospital costs were the outcome measures assessed. Data from the Rotterdam Diabetic Foot Study were used as current care, complemented with information from international studies on the epidemiology of diabetic foot disease, resource use, and costs, to feed the model. RESULTS: Lower extremity nerve decompression surgery resulted in improved life expectancy (88,369.5 life-years versus 86,513.6 life-years), gain of quality-adjusted life-years (67,652.5 versus 64,082.3), and reduced incidence of foot complications compared to current care (490 versus 1087). The incremental cost-effectiveness analysis was -59,279.6 per quality-adjusted life-year gained, which is below the Dutch critical threshold of less than 80,000 per quality-adjusted life-year. CONCLUSIONS: Decompression surgery of lower extremity nerves improves survival, reduces diabetic foot complications, and is cost saving and cost-effective compared with current care, suggesting considerable socioeconomic benefit for society.
Assuntos
Tratamento Conservador/economia , Análise Custo-Benefício , Descompressão Cirúrgica/economia , Neuropatias Diabéticas/cirurgia , Amputação Cirúrgica/economia , Amputação Cirúrgica/estatística & dados numéricos , Tratamento Conservador/estatística & dados numéricos , Descompressão Cirúrgica/estatística & dados numéricos , Pé Diabético/economia , Pé Diabético/epidemiologia , Pé Diabético/prevenção & controle , Neuropatias Diabéticas/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Extremidade Inferior/inervação , Extremidade Inferior/cirurgia , Cadeias de Markov , Pessoa de Meia-Idade , Modelos Econômicos , Países Baixos/epidemiologia , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Resultado do TratamentoRESUMO
Background: The objective of this study was to compare the cost-effectiveness of minimally invasive surgery (MIS) for patients with degenerative lumbar spondylolisthesis (DLS) relative to failed medical management with the cost-effectiveness of hip and knee arthroplasty for matched cohorts of patients with osteoarthritis. Methods: A cohort of patients with DLS undergoing MIS procedures with decompression alone or decompression and instrumented fusion between 2008 and 2014 was matched to cohorts of patients with hip osteoarthritis (OA) and knee OA undergoing total joint replacement. Incremental cost-utility ratios (ICURs) were calculated from the perspective of the Ontario Ministry of Health, using prospectively collected Short Form-6 Dimension utility data. Costs and quality-adjusted life years (QALYs) were discounted at 3% and sensitivity analyses were performed. Results: Sixty-six patients met the inclusion criteria for the DLS cohort (n = 35 for decompression alone), with a minimum follow-up time of 1 year (mean 1.7 yr). The mean age of patients in the DLS cohort was 64.76 years, and 45 patients (68.2%) were female. For each cohort, utility scores improved from baseline to follow-up and the magnitude of the gain did not differ by group. Lifetime ICURs comparing surgical with nonsurgical care were Can$7946/QALY, Can$7104/QALY and Can$5098/QALY for the DLS, knee OA and hip OA cohorts, respectively. Subgroup analysis yielded an increased ICUR for the patients with DLS who underwent decompression and fusion (Can$9870/QALY) compared with that for the patients with DLS who underwent decompression alone (Can$5045/QALY). The rank order of the ICURs by group did not change with deterministic or probabilistic sensitivity analyses. Conclusion: Lifetime ICURs for MIS procedures for DLS are similar to those for total joint replacement. Future research should adopt a societal perspective and potentially capture further economic benefits of MIS procedures.
Contexte: L'objectif de cette étude était de comparer le rapport coûtefficacité de la chirurgie minimalement effractive (CME) chez les patients atteints de spondylolisthésis lombaire dégénératif (SLD) en lien avec un échec de la prise en charge médicale à celui de l'arthroplastie de la hanche et du genou pour des cohortes assorties de patients atteints d'arthrose. Méthodes: Une cohorte de patients atteints de SLD soumis à une CME avec décompression seule ou décompression avec arthrodèse entre 2008 et 2014 a été assortie à des cohortes de patients soumis à une arthroplastie totale pour arthrose de la hanche et du genou. Les rapports coûtutilité différentiels (RCUD) ont été calculés du point de vue du ministère de la Santé de l'Ontario à l'aide des données d'utilité du questionnaire Short Form6 Dimension recueillies de manière prospective. Les coûts et les années de vie ajustées en fonction de la qualité (AVAQ) ont été actualisés à un taux de 3 % et des analyses de sensibilité ont été effectuées. Résultats: Soixante-six patients répondaient aux critères d'inclusion pour la cohorte SLD (n = 35, décompression seule), avec un suivi d'une durée minimale de 1 an (moyenne 1,7 an). L'âge moyen des gens de la cohorte SLD était de 64,76 ans, et 45 patients (68,2 %) étaient de sexe féminin. Pour chaque cohorte, les scores d'utilité se sont améliorés entre les valeurs de départ et les valeurs de suivi et l'ampleur du gain n'a pas différé entre les groupes. Les RCUD pour la vie entière entre les soins chirurgicaux et non chirurgicaux ont été 7946 $CA/QALY, 7104 $CA/QALY et 5098 $CA/QALY pour les cohortes SLD, arthrose du genou et de la hanche, respectivement. L'analyse de sous-groupes a généré un RCUD accru pour les patients atteints de SLD qui ont subi la décompression avec arthrodèse (9870 $CA/QALY) comparativement à la décompression seule (5045 $CA/QALY). Le classement des RCUD par groupe n'a pas changé en fonction des analyses de sensibilité déterministes ou probabilistes. Conclusion: Les RCUD pour la vie entière associés à la CME dans les cas de SLD sont similaires à ceux de l'arthroplastie totale. Les recherches futures devraient adopter une perspective sociétale et refléter davantage les bienfaits économiques de la CME.
Assuntos
Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Descompressão Cirúrgica/economia , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Fusão Vertebral/economia , Canadá , Estudos de Coortes , Análise Custo-Benefício , Descompressão Cirúrgica/métodos , Feminino , Humanos , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Osteoartrite do Quadril/cirurgia , Osteoartrite do Joelho/cirurgia , Anos de Vida Ajustados por Qualidade de Vida , Fusão Vertebral/métodos , Estenose Espinal/cirurgia , Espondilolistese/cirurgiaRESUMO
BACKGROUND: Carpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR. METHODS: We developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs). RESULTS: ECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations. CONCLUSIONS: From a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Síndrome do Túnel Carpal/cirurgia , Descompressão Cirúrgica/métodos , Endoscopia/métodos , Análise Custo-Benefício , Descompressão Cirúrgica/economia , Endoscopia/economia , Humanos , Cadeias de Markov , Medicare , Anos de Vida Ajustados por Qualidade de Vida , Estados UnidosRESUMO
BACKGROUND: The Alliance of Dedicated Cancer Centers is an organization of 11 leading cancer institutions and affiliated hospitals that are exempt from the Medicare prospective system hospital reimbursement policies. Because of their focus on cancer care and participation in innovative cancer treatment methods and protocols, these hospitals are reimbursed based on their actual billings. The perceived lack of incentive to meet a predetermined target price and reduce costs has spurred criticism of the value of cancer care at these institutions. The rationale of our study was to better understand whether dedicated cancer centers (DCCs) deliver high-value care for patients undergoing surgical treatment of spinal metastases. QUESTION/PURPOSE: Is there a difference in 90-day complications and reimbursements between patients undergoing surgical treatment (decompression or fusion) for spinal metastases at DCCs and those treated at nonDCC hospitals? METHODS: The 2005 to 2014 100% Medicare Standard Analytical Files database was queried using ICD-9 procedure and diagnosis codes to identify patients undergoing decompression (03.0, 03.09, and 03.4) and/or fusion (81.0X) for spinal metastases (198.5). The database does not allow us to exclude the possibility that some patients were treated with fusion for stabilization of the spine without decompression, although this is likely an uncommon event. Patients undergoing vertebroplasty or kyphoplasty for metastatic disease were excluded. The Medicare hospital provider identification numbers were used to identify the 11 DCCs. The study cohort was categorized into two groups: DCCs and nonDCCs. Although spinal metastases are known to occur among nonMedicare and younger patients, the payment policies of these DCCs are only applicable to Medicare beneficiaries. Therefore, to keep the study objective relevant to current policy and value-based discussions, we performed the analysis using the Medicare dataset. After applying the inclusion and exclusion criteria, we included 17,776 patients in the study, 6% (1138 of 17,776) of whom underwent surgery at one of the 11 DCCs. Compared with the nonDCC group, DCC group hospitals operated on a younger patient population and on more patients with primary renal cancers. In addition, DCCs were more likely to be high-volume facilities with National Cancer Institute designations and have a voluntary or government ownership model. Patients undergoing surgery for spinal metastases at DCCs were more likely to have spinal decompression with fusion than those at nonDCCs (40% versus 22%; p < 0.001) and had a greater length and extent of fusion (at least four levels of fusion; 34% versus 29%; p = 0.001). Patients at DCCs were also more likely than those at nonDCCs to receive postoperative adjunct treatments such as radiation (16% versus 13.5%; p = 0.008) and chemotherapy (17% versus 9%; p < 0.001), although this difference is small and we do not know if this meets a minimum clinically important difference. To account for differences in patients presenting at both types of facilities, multivariate logistic regression mixed-model analyses were used to compare rates of 90-day complications and 90-day mortality between DCC and nonDCC hospitals. Controls were implemented for baseline clinical characteristics, procedural factors, and hospital-level factors (such as random effects). Generalized linear regression mixed-modeling was used to evaluate differences in total 90-day reimbursements between DCCs and nonDCCs. RESULTS: After adjusting for differences in baseline demographics, procedural factors, and hospital-level factors, patients undergoing surgery at DCCs had lower odds of experiencing sepsis (6.5% versus 10%; odds ratio 0.54 [95% confidence interval 0.40 to 0.74]; p < 0.001), urinary tract infections (19% versus 28%; OR 0.61 [95% CI 0.50 to 0.74]; p < 0.001), renal complications (9% versus 13%; OR 0.55 [95% CI 0.42 to 0.72]; p < 0.001), emergency department visits (27% versus 31%; OR 0.78 [95% CI 0.64 to 0.93]; p = 0.01), and mortality (39% versus 49%; OR 0.75 [95% CI 0.62 to 0.89]; p = 0.001) within 90 days of the procedure compared with patients treated at nonDCCs. Undergoing surgery at a DCC (90-day reimbursement of USD 54,588 ± USD 42,914) compared with nonDCCs (90-day reimbursement of USD 49,454 ± USD 38,174) was also associated with reduced 90-day risk-adjusted reimbursements (USD -14,802 [standard error 1362] ; p < 0.001). CONCLUSION: Based on our findings, it appears that DCCs offer high-value care, as evidenced by lower complication rates and reduced reimbursements after surgery for spinal metastases. A better understanding of the processes of care adopted at these institutions is needed so that additional cancer centers may also be able to deliver similar care for patients with metastatic spine disease. LEVEL OF EVIDENCE: Level III, therapeutic study.
Assuntos
Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Hospitais Especializados/economia , Oncologia/economia , Medicare/estatística & dados numéricos , Procedimentos Ortopédicos/economia , Neoplasias da Coluna Vertebral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/métodos , Feminino , Humanos , Masculino , Procedimentos Ortopédicos/métodos , Complicações Pós-Operatórias/economia , Estudos Retrospectivos , Fusão Vertebral/economia , Fusão Vertebral/métodos , Estados UnidosRESUMO
STUDY DESIGN: Cost-effectiveness analysis. OBJECTIVE: To determine if bariatric surgery prior to posterior lumbar decompression and fusion (PLDF) for degenerative spondylolisthesis (DS) is a cost-effective strategy. SUMMARY OF BACKGROUND DATA: Obesity poses significant perioperative challenges for DS. Treated operatively, obese patients achieve worse outcomes relative to non-obese peers. Concomitantly, they fare better with surgery than with nonoperative measures. These competing facts create uncertainty in determining optimal treatment algorithms for obese patients with DS. The role of bariatric surgery merits investigation as a potentially cost-effective optimization strategy prior to PLDF. METHODS: We simulated a Markov model with two cohorts of obese individuals with DS. 10,000 patients with body mass index (BMI) more than or equal to 30 in both arms were candidates for both bariatric surgery and PLDF. Subjects were assigned either to (1) no weight loss intervention with immediate operative or nonoperative management ("traditional arm") or (2) bariatric surgery 2 years prior to entering the same management options ("combined protocol").Published costs, utilities, and transition probabilities from the literature were applied. A willingness to pay threshold of $100,000/QALY was used. Sensitivity analyses were run for all variables to assess the robustness of the model. RESULTS: Over a 10-year horizon, the combined protocol was dominant ($13,500 cheaper, 1.15 QALY more effective). Changes in utilities of operative and nonoperative treatments in non-obese patients, the obesity cost-multiplier, cost of bariatric surgery, and the probability of success of nonoperative treatment in obese patients led to decision changes. However, all thresholds occurred outside published bounds for these variables. CONCLUSION: The combined protocol was less costly and more effective than the traditional protocol. Results were robust with thresholds occurring outside published ranges. Bariatric surgery is a viable, cost-effective preoperative strategy in obese patients considering elective PLDF for DS.Level of Evidence: 3.
Assuntos
Cirurgia Bariátrica , Descompressão Cirúrgica , Obesidade , Fusão Vertebral , Espondilolistese , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/economia , Cirurgia Bariátrica/estatística & dados numéricos , Análise Custo-Benefício , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/estatística & dados numéricos , Humanos , Obesidade/complicações , Obesidade/epidemiologia , Obesidade/cirurgia , Fusão Vertebral/efeitos adversos , Fusão Vertebral/economia , Fusão Vertebral/estatística & dados numéricos , Espondilolistese/complicações , Espondilolistese/epidemiologia , Espondilolistese/cirurgia , Redução de PesoRESUMO
BACKGROUND: Thoracic outlet syndrome (TOS) surgery is relatively rare and controversial, given the challenges in diagnosis as well as wide variation in symptomatic and functional recovery. Our aims were to measure trends in utilization of TOS surgery, complications, and mortality rates in a nationally representative cohort and compare higher versus lower volume centers. METHODS: The National Inpatient Sample was queried using International Classification of Diseases, Ninth Revision, codes for rib resection and scalenectomy paired with axillo-subclavian aneurysm (arterial [aTOS]), subclavian deep vein thrombosis (venous [vTOS]), or brachial plexus lesions (neurogenic [nTOS]). Basic descriptive statistics, nonparametric tests for trend, and multivariable hierarchical regression models with random intercept for center were used to compare outcomes for TOS types, trends over time, and higher and lower volume hospitals, respectively. RESULTS: There were 3,547 TOS operations (for an estimated 18,210 TOS operations nationally) performed between 2010 and 2015 (89.2% nTOS, 9.9% vTOS, and 0.9% aTOS) with annual case volume increasing significantly over time (P = 0.03). Higher volume centers (≥10 cases per year) represented 5.2% of hospitals and 37.0% of cases, and these centers achieved significantly lower overall major complication (defined as neurologic injury, arterial or venous injury, vascular graft complication, pneumothorax, hemorrhage/hematoma, or lymphatic leak) rates (adjusted odds ratio [OR] 0.71 [95% confidence interval 0.52-0.98]; P = 0.04], but no difference in neurologic complications such as brachial plexus injury (aOR 0.69 [0.20-2.43]; P = 0.56) or vascular injuries/graft complications (aOR 0.71 [0.0.33-1.54]; P = 0.39). Overall mortality was 0.6%, neurologic injury was rare (0.3%), and the proportion of patients experiencing complications decreased over time (P = 0.03). However, vTOS and aTOS had >2.5 times the odds of major complication compared with nTOS (OR 2.68 [1.88-3.82] and aOR 4.26 [1.78-10.17]; P < 0.001), and â¼10 times the odds of a vascular complication (aOR 10.37 [5.33-20.19] and aOR 12.93 [3.54-47.37]; P < 0.001], respectively. As the number of complications decreased, average hospital charges also significantly decreased over time (P < 0.001). Total hospital charges were on average higher when surgery was performed in lower volume centers (<10 cases per year) compared with higher volume centers (mean $65,634 [standard deviation 98,796] vs. $45,850 [59,285]; P < 0.001). CONCLUSIONS: The annual number of TOS operations has increased in the United States from 2010 to 2015, whereas complications and average hospital charges have decreased. Mortality and neurologic injury remain rare. Higher volume centers delivered higher value care: less or similar operative morbidity with lower total hospital charges.
Assuntos
Descompressão Cirúrgica/tendências , Osteotomia/tendências , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica/tendências , Síndrome do Desfiladeiro Torácico/cirurgia , Procedimentos Cirúrgicos Vasculares/tendências , Adulto , Idoso , Bases de Dados Factuais , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/mortalidade , Feminino , Preços Hospitalares/tendências , Custos Hospitalares/tendências , Hospitais com Alto Volume de Atendimentos/tendências , Hospitais com Baixo Volume de Atendimentos/tendências , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Osteotomia/efeitos adversos , Osteotomia/economia , Osteotomia/mortalidade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Padrões de Prática Médica/economia , Estudos Retrospectivos , Costelas/cirurgia , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/economia , Síndrome do Desfiladeiro Torácico/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/economia , Procedimentos Cirúrgicos Vasculares/mortalidade , Adulto JovemRESUMO
BACKGROUND: Lumbar decompressions are increasingly performed at ambulatory surgery centers (ASCs). We sought to compare costs of open and minimally invasive (MIS) lumbar decompressions performed at a university without dedicated ASCs. METHODS: Lumbar decompressions performed at a tertiary academic hospital or satellite university hospital dedicated to outpatient surgery were retrospectively reviewed. Care pathways were same-day, overnight observation, or inpatient admission. Patient demographics, American Society of Anesthesiologists classification, Charlson Comorbidity Index, surgical characteristics, 30-day readmission, and costs were collected. A systematic review of lumbar decompression cost literature was performed. RESULTS: A total of 354 patients, mean age 55 years with 128 women (36.2%), were reviewed. There was no significant difference in age, gender, body mass index, American Society of Anesthesiologists classification, or Charlson Comorbidity Index between patients treated with open and minimally invasive surgery. Open decompression was associated with higher total cost ($21,280 vs. $14,407; P < 0.001); however, this was driven by care pathway and length of stay. When stratifying by care pathway, there was no difference in total cost between open versus minimally invasive surgery among same-day ($10,609 vs. $11,074; P = 0.556), overnight observation ($14,097 vs. $13,992; P = 0.918), or inpatient admissions ($24,507 vs. $27,929; P = 0.311). CONCLUSIONS: When accounting for care pathway, the cost of open and MIS decompression were no different. Transition from a tertiary academic hospital to a university hospital specializing in outpatient surgery was not associated with lower costs. Academic departments may consider transitioning lumbar decompressions to a dedicated ASC to maximize cost savings; however, additional studies are needed.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Descompressão Cirúrgica/economia , Degeneração do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Centros Médicos Acadêmicos/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/métodos , Custos e Análise de Custo , Descompressão Cirúrgica/métodos , Feminino , Hospitalização/economia , Hospitais Universitários/economia , Humanos , Ciência da Implementação , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Centros Cirúrgicos/economia , Adulto JovemRESUMO
STUDY DESIGN: Retrospective database analysis. OBJECTIVE: This study aimed to compare costs and complication rates following single-level lumbar decompression in patients under age 75 versus patients aged 75 and older. SUMMARY OF BACKGROUND DATA: Lumbar decompression is a common surgical treatment for lumbar pathology; however, its effectiveness can be debated in elderly patients because complication rates and costs by age group are not well-defined. METHODS: The Medicare database was queried through the PearlDiver server for patients who underwent single-level lumbar decompression without fusion as an index procedure. The 90-day complication and reoperation rates were compared between age groups after matching for sex and comorbidity burden. Same day and 90-day costs are compared. RESULTS: The matched cohort included 89,388 total patients (nâ=â44,694 for each study arm). Compared to the under 75 age group, the 75 and older age group had greater rates of deep venous thrombosis (odds ratio [OR] 1.443, Pâ=â0.042) and dural tear (OR 1.560, Pâ=â0.043), and a lower rate of seroma complicating the procedure (OR 0.419, Pâ=â0.009). There was no difference in overall 90-day reoperation rate in patients under age 75 versus patients aged 75 and older (9.66% vs. 9.28%, Pâ=â0.051), although the 75 and older age group had a greater rate of laminectomy without discectomy (CPT-63047; OR 1.175, Pâ<â0.001), while having a lower rate of laminotomy with discectomy (CPT-63042 and CPT-63030; OR 0.727 and 0.867, respectively, Pâ=â0.013 and <0.001, respectively). The 75 and older age group had greater same day ($3329.24 vs. $3138.05, Pâ<â0.001) and 90-day ($5014.82 vs. $4749.44, Pâ<â0.001) mean reimbursement. CONCLUSION: Elderly patients experience greater rates of select perioperative complications, with mildly increased costs. There is no significant difference in overall 90-day reoperation rates. LEVEL OF EVIDENCE: 3.
Assuntos
Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/economia , Vértebras Lombares/cirurgia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Comorbidade , Bases de Dados Factuais , Discotomia/efeitos adversos , Discotomia/economia , Feminino , Humanos , Laminectomia/efeitos adversos , Laminectomia/economia , Região Lombossacral/cirurgia , Masculino , Medicare , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Reoperação/economia , Estudos Retrospectivos , Fusão Vertebral , Estados UnidosRESUMO
STUDY DESIGN: A retrospective comparative study. OBJECTIVE: To compare the perioperative complications and costs of anterior decompression with fusion (ADF) and posterior decompression with fusion (PDF) for patients with cervical ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA: Surgical treatment of cervical OPLL has a high risk of various complications. ADF and PDF are effective for the treatment of cervical OPLL; however, few studies have compared the two procedures in terms of the perioperative surgical complications. METHODS: Patients undergoing ADF and PDF for cervical OPLL from 2010 to 2016 were identified in a nation-wide inpatient database. We investigated systemic and local complications, length of hospital stay, costs for hospitalization, reoperation, and mortality. Propensity score was calculated from patients' characteristics and preoperative comorbidities, and one to one matching was performed. RESULTS: Propensity score-matching produced 854 pairs of patients who underwent ADF and PDF. The rate of at least one systemic complication was significantly higher in the ADF group (Pâ=â0.004). The incidence rates of postoperative respiratory failure (Pâ=â0.034) and dysphagia (Pâ=â0.008) were significantly higher in the ADF group. The rates of pneumonia (Pâ=â0.06) and hoarseness (Pâ=â0.08) also tended to be higher in the ADF group. However, no difference was found in the mortality rate (Pâ=â0.22). In the local complications, spinal fluid leakage was significantly higher in the ADF group (Pâ<â0.001). However, blood transfusion rate was significantly higher in the PDF group (Pâ=â0.001). Hospital stay was significantly longer in the PDF group (Pâ<â0.001) and the cost for hospitalization was greater in the PDF group (Pâ<â0.001). CONCLUSION: The present study demonstrated that perioperative complications, such as respiratory failure, dysphagia, and spinal fluid leakage, were more common in the ADF group. However, hospital stay was longer in the PDF group, and the cost for hospitalization was greater in the PDF group. LEVEL OF EVIDENCE: 3.
Assuntos
Vértebras Cervicais/cirurgia , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/economia , Ligamentos Longitudinais/cirurgia , Ossificação do Ligamento Longitudinal Posterior/cirurgia , Pontuação de Propensão , Adulto , Idoso , Vazamento de Líquido Cefalorraquidiano/etiologia , Descompressão Cirúrgica/mortalidade , Transtornos de Deglutição/etiologia , Feminino , Humanos , Pacientes Internados , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Fusão Vertebral , Resultado do TratamentoRESUMO
STUDY DESIGN: Retrospective database review. OBJECTIVE: Compare 1-year episode of care costs between single-level decompression and decompression plus fusion for lumbar stenosis. SUMMARY OF BACKGROUND DATA: Lumbar stenosis is the most common indication for surgery in patients over 65. Medicare direct hospital costs for lumbar surgery reached $1.65 billion in 2007. Despite stenosis being a common indication for surgery, there is debate as to the preferred surgical treatment. Cost-minimization analysis is a framework that identifies potential cost savings between treatment options that have similar outcomes. We performed a cost-minimization analysis of decompression versus decompression with fusion for lumbar stenosis from the payer perspective. METHODS: An administrative claims database of privately insured patients (Humana) identified patients who underwent decompression (nâ=â5349) or decompression with fusion (nâ=â8540) for lumbar stenosis with and without spondylolisthesis and compared overall costs. All patients were identified and costs identified for a 1-year period. Complication rates and costs were described using summary statistics. RESULTS: Mean treatment costs at 1 year after surgery were higher for patients who underwent decompression and fusion compared to patients who underwent decompression alone ($20,892 for fusion vs. $6329 for decompression; Pâ<â0.001). Facility costs (Pâ<â0.001), surgeon costs (Pâ<â0.001), and physical therapy costs (Pâ<â0.001) were higher in the fusion group. Cost differences related to infection or durotomy reached significance (Pâ<â0.04). No difference in cost was identified for supplies. CONCLUSION: Decompression had significantly lower costs for the treatment of lumbar stenosis, including treatment for postoperative complications. If cost minimization is the primary goal, decompression is favored for surgical treatment of lumbar stenosis. Other factors including shared decision-making directed toward patient's values, patient-reported outcomes, and preferences should also be recognized as drivers of healthcare decisions. LEVEL OF EVIDENCE: 3.
Assuntos
Custos e Análise de Custo/métodos , Descompressão Cirúrgica/economia , Vértebras Lombares/cirurgia , Fusão Vertebral/economia , Estenose Espinal/economia , Estenose Espinal/cirurgia , Adulto , Idoso , Descompressão Cirúrgica/métodos , Feminino , Humanos , Masculino , Medicare/economia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fusão Vertebral/métodos , Estenose Espinal/epidemiologia , Estados Unidos/epidemiologiaRESUMO
BACKGROUND CONTEXT: Current bundled payment programs in spine surgery, such as the bundled payment for care improvement rely on the use of diagnosis-related groups (DRG) to define payments. However, these DRGs may not be adequate enough to appropriately capture the large amount of variation seen in spine procedures. For example, DRG 459 (spinal fusion except cervical with major comorbidity or complication) and DRG 460 (spinal fusion except cervical without major comorbidity or complication) do not differentiate between the type of fusion (anterior or posterior), the levels/extent of fusion, the use of interbody/graft/BMP, indication of surgery (primary vs. revision) or even if the surgery was being performed for a vertebral fracture. PURPOSE: We carried out a comprehensive analysis to report the factors responsible for cost-variation in a bundled payment model for spinal fusions. STUDY DESIGN: Retrospective review of a 5% national sample of Medicare claims from 2008 to 2014 (SAF5). OUTCOME MEASURES: To understand the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day costs for patients undergoing spinal fusions under DRG 459 and 460. METHODS: The 2008 to 2014 Medicare 5% standard analytical files (SAF) were used to retrieve patients undergoing spinal fusions under DRG 459 and DRG 460 only. Patients with missing gender, age, and/or state-level data were excluded. Only those patients who had complete data, with regard to payments/costs/reimbursements, starting from day 0 of surgery up to 90 days postoperatively were included to prevent erroneous collection. Multivariate linear regression models were built to assess the independent marginal cost impact (decrease/increase) of each patient-level, state-level, and procedure-level characteristics on the average 90-day cost while controlling for other covariates. RESULTS: A total of 21,367 patients (DRG-460=20,154; DRG-459=1,213) were included in the study. The average 90-day cost for all lumbar fusions was $31,716±$18,124, with the individual 90-day payments being $54,607±$30,643 (DRG-459) and $30,338±$16,074 (DRG-460). Increasing age was associated with significant marginal increases in 90-day payments (70-74 years: +$2,387, 75-79 years: +$3,389, 80-84 years: +$2,872, ≥85: +$1,627). With regards to procedure-level factors-undergoing an anterior fusion (+$3,118), >3 level fusion (+$5,648) vs. 1 to 3 level fusion, use of interbody device (+$581), intraoperative neuromonitoring (+$1,413), concurrent decompression (+$768) and undergoing surgery for thoracolumbar fracture (+$6,169) were associated with higher 90-day costs. Most individual comorbidities were associated with higher 90-day costs, with malnutrition (+$12,264), CVA/stroke (+$5,886), Alzheimer's (+$4,968), Parkinson's disease (+$4,415), and coagulopathy (+$3,810) having the highest marginal 90-day cost-increases. The top five states with the highest marginal cost-increase, in comparison to Michigan (reference), were Maryland (+$12,657), Alaska (+$11,292), California (+$10,040), Massachusetts (+$8,800), and the District of Columbia (+$8,315). CONCLUSIONS: Under the proposed DRG-based bundled payment model, providers would be reimbursed the same amount for lumbar fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion (1-3 level vs. >3 level), use of adjunct procedures (decompressions) and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated costs. When defining and developing future bundled payments for spinal fusions, health-policy makers should strive to account for the individual patient-level, state-level, and procedure-level variation seen within DRGs to prevent the creation of a financial dis-incentive in taking care of sicker patients and/or performing more extensive complex spinal fusions.