Factors Associated With the Maintenance of Cost-effectiveness at Five Years in Adult Spinal Deformity Corrective Surgery.

ABSTRACT

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To evaluate factors associated with the long-term durability of cost-effectiveness (CE) in ASD patients. BACKGROUND: A substantial increase in costs associated with the surgical treatment for adult spinal deformity (ASD) has given precedence to scrutinize the value and utility it provides. METHODS: We included 327 operative ASD patients with five-year (5 yr) follow-up. Published methods were used to determine costs based on CMS.gov definitions and were based on the average DRG reimbursement rates. The utility was calculated using quality-adjusted life-years (QALY) utilizing the Oswestry Disability Index (ODI) converted to Short-Form Six-Dimension (SF-6D), with a 3% discount applied for its decline in life expectancy. The CE threshold of $150,000 was used for primary analysis. RESULTS: Major and minor complication rates were 11% and 47%, respectively, with 26% undergoing reoperation by five years. The mean cost associated with surgery was $91,095±$47,003, with a utility gain of 0.091±0.086 at one years, QALY gained at 2 years of 0.171±0.183, and at five years of 0.42±0.43. The cost per QALY at two years was $414,885, which decreased to $142,058 at five years.With the threshold of $150,000 for CE, 19% met CE at two years and 56% at five years. In those in which revision was avoided, 87% met cumulative CE till life expectancy. Controlling analysis depicted higher baseline CCI and pelvic tilt (PT) to be the strongest predictors for not maintaining durable CE to five years [CCI OR 1.821 (1.159-2.862), P =0.009] [PT OR 1.079 (1.007-1.155), P =0.030]. CONCLUSIONS: Most patients achieved cost-effectiveness after four years postoperatively, with 56% meeting at five years postoperatively. When revision was avoided, 87% of patients met cumulative cost-effectiveness till life expectancy. Mechanical complications were predictive of failure to achieve cost-effectiveness at two years, while comorbidity burden and medical complications were at five years.