Microdiscectomy Is More Cost-effective Than a 6-Month Nonsurgical Care Regimen for Chronic Radiculopathy.

BACKGROUND: A recent randomized controlled trial (RCT), performed by the authors, comparing early surgical microdiscectomy with 6 months of nonoperative care for chronic lumbar radiculopathy showed that early surgery resulted in improved outcomes. However, estimates of the incremental cost-utility ratio (ICUR), which is often expressed as the cost of gaining one quality-adjusted life year (QALY), of microdiscectomy versus nonsurgical management have varied. Radiculopathy lasting more than 4 months is less likely to improve without surgical intervention and may have a more favorable ICUR than previously reported for acute radiculopathy. QUESTION/PURPOSE: In the setting of chronic radiculopathy caused by lumbar disc herniation, defined as symptoms and/or signs of 4 to 12 months duration, is surgical management more cost-effective than 6 months of nonoperative care from the third-party payer perspective based on a willingness to pay of less than CAD 50,000/QALY? METHODS: A decision analysis model served as the vehicle for the cost-utility analysis. A decision tree was parameterized using data from our single-center RCT that was augmented with institutional microcost data from the Ontario Case Costing Initiative. Bottom-up case costing methodology generates more accurate cost estimates, although institutional costs are known to vary. There were no major surgical cost drivers such as implants or bone graft substitutes, and therefore, the jurisdictional variance would be minimal for tertiary care centers. QALYs derived from the EuroQoL-5D were the health outcome and were derived exclusively from the RCT data, given the paucity of studies evaluating the surgical treatment of lumbar radiculopathy lasting 4 to 12 months. Cost-effectiveness was assessed using the ICUR and a threshold of willingness to pay CAD 50,000 (USD 41,220) per QALY in the base case. Sensitivity analyses were performed to account for the uncertainties within the estimate of cost utility, using both a probabilistic sensitivity analysis and two one-way sensitivity analyses with varying crossover rates after the 6-month nonsurgical treatment had concluded. RESULTS: Early surgical treatment of patients with chronic lumbar radiculopathy (defined as symptoms of 4 to 12 months duration) was cost-effective, in that the cost of one QALY was lower than the CAD 50,000 threshold (note: the purchasing power parity conversion factor between the Canadian dollar (CAD) and the US dollar (USD) for 2019 was 1 USD = 1.213 CAD; therefore, our threshold was USD 41,220). Patients in the early surgical treatment group had higher expected costs (CAD 4118 [95% CI 3429 to 4867]) than those with nonsurgical treatment (CAD 2377 [95% CI 1622 to 3518]), but they had better expected health outcomes (1.48 QALYs [95% CI 1.39 to 1.57] versus 1.30 [95% CI 1.22 to 1.37]). The ICUR was CAD 5822 per QALY gained (95% CI 3029 to 30,461). The 2-year probabilistic sensitivity analysis demonstrated that the likelihood that early surgical treatment was cost-effective was 0.99 at the willingness-to-pay threshold, as did the one-way sensitivity analyses. CONCLUSION: Early surgery is cost-effective compared with nonoperative care in patients who have had chronic sciatica for 4 to 12 months. Decision-makers should ensure adequate funding to allow timely access to surgical care given that it is highly likely that early surgical intervention is potentially cost-effective in single-payer systems. Future work should focus on both the clinical effectiveness of the treatment of chronic radiculopathy and the costs of these treatments from a societal perspective to account for occupational absences and lost patient productivity. Parallel cost-utility analyses are critical so that appropriate decisions about resource allocation can be made. LEVEL OF EVIDENCE: Level III, economic and decision analysis.

Does an enhanced recovery after surgery protocol change costs and outcomes of single-level lumbar microdiscectomy?

OBJECTIVEEnhanced recovery after surgery (ERAS) is a multimodal approach that aims to improve perioperative surgical outcomes. The aim of this study was to evaluate the benefits of ERAS in terms of cost-effectiveness and postoperative outcomes in single-level lumbar microdiscectomy.METHODSThis study was a single-center retrospective comparing costs and outcomes before and after implementation of the ERAS pathway. Data were collected from the electronic medical records of patients who had undergone single-level lumbar microdiscectomy during 2 time periods-during the 2 years preceding implementation of the ERAS pathway (pre-ERAS group) and after implementation of the ERAS pathway (ERAS group). Each group consisted of 60 patients with an American Society of Anesthesiologists (ASA) Physical Status Classification of class 1. Patients were excluded if their physical status was classified as ASA class II-V or if they were younger than 18 years or older than 65.Groups were compared in terms of age, sex, body mass index (BMI), perioperative hemodynamics, operation time, intraoperative blood loss, intraoperative fluid administration, intraoperative opioid administration, time to first oral intake, time to first mobilization, postoperative nausea and vomiting (PONV), difference between preoperative and postoperative visual analog scale (VAS) scores, postoperative analgesic requirements, length of hospital stay, and cost of anesthesia.RESULTSThe ERAS and pre-ERAS groups were comparable with respect to age, sex, and BMI. Operation time, intraoperative blood loss, intraoperative opioid administration, and intraoperative fluid administration were all less in the ERAS group. First oral intake and first mobilization were earlier in the ERAS group. The incidence of PONV was less in the ERAS group. Postoperative analgesic requirements and postoperative VAS scores were significantly less in the ERAS group. The length of hospital stay was found to be shorter in the ERAS group. The ERAS approach was found to be cost-effective.CONCLUSIONSERAS had clinical and economic benefits and is associated with improved outcomes in lumbar microdiscectomy.

Outpatient spine surgery: defining the outcomes, value, and barriers to implementation.

Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

Propensity-matched comparison of outcomes and cost after macroscopic and microscopic lumbar discectomy using a national longitudinal database.

OBJECTIVE There has been considerable debate about the utility of the operating microscope in lumbar discectomy and its effect on outcomes and cost. METHODS A commercially available longitudinal database was used to identify patients undergoing discectomy with or without use of a microscope between 2007 and 2015. Propensity matching was performed to normalize differences between demographics and comorbidities in the 2 cohorts. Outcomes, complications, and cost were subsequently analyzed using bivariate analysis. RESULTS A total of 42,025 patients were identified for the "macroscopic" group, while 11,172 patients were identified for the "microscopic" group. For the propensity-matched analysis, the 11,172 patients in the microscopic discectomy group were compared with a group of 22,340 matched patients who underwent macroscopic discectomy. There were no significant differences in postoperative complications between the groups other than a higher proportion of deep vein thrombosis (DVT) in the macroscopic discectomy cohort versus the microscopic discectomy group (0.4% vs 0.2%, matched OR 0.48 [95% CI 0.26-0.82], p = 0.0045). Length of stay was significantly longer in the macroscopic group compared to the microscopic group (mean 2.13 vs 1.83 days, p < 0.0001). Macroscopic discectomy patients had a higher rate of revision surgery when compared to microscopic discectomy patients (OR 0.92 [95% CI 0.84-1.00], p = 0.0366). Hospital charges were higher in the macroscopic discectomy group (mean $19,490 vs $14,921, p < 0.0001). CONCLUSIONS The present study suggests that the use of the operating microscope in lumbar discectomy is associated with decreased length of stay, lower DVT rate, lower reoperation rate, and decreased overall hospital costs.

Impact of old age on patient-report outcomes and cost utility for anterior cervical discectomy and fusion surgery for degenerative spine disease.

PURPOSE: With growing older population and increasing rates of cervical spinal surgery, it is vital to understand the value of cervical surgery in this population. We set forth to determine the cost utility following anterior cervical decompression and fusion (ACDF) for degenerative disease in older patients. METHODS: Patients undergoing ACDF for degenerative diseases were enrolled into prospective longitudinal registry. Patient-reported outcomes (PROs) were recorded at baseline, 1-year, and 2-year postoperatively. Two-year medical resource utilization, missed work, and health-state values [quality-adjusted life years (QALYs)] were assessed to compute cost per QALY gained. Patients were dichotomized based on age: <65 years (younger) and ≥65 years (older) to compare the cost utility in these age groups. RESULTS: Total 218 (87%) younger patients and 33 (13%) older patients who underwent ACDF were analyzed. Both the groups demonstrated a significant improvement in PROs 2-year following surgery. The older patients had a lower mean cumulative gain in QALYs compared to younger patients at 1 year (0.141 vs. 0.28, P = 0.05) and 2 years (0.211 vs. 0.424, P = 0.04). There was no significant difference in the mean total 2-year cost between older [$21,041 (95% CI $18,466-$23,616)] and younger [$22,669 (95% CI $$21,259-$24,079)] patients (P = 0.27). Two-year cost per QALY gained in older vs. younger patients was ($99,720/QALYs gained vs. ($53,464/QALYs gained, P = 0.68). CONCLUSION: ACDF surgery provided a significant gain in health-state utility in older patients with degenerative cervical pathology, with a mean cumulative 2-year cost per QALY gained of $99,720/QALY. While older patients have a slightly higher cost utility compared to their younger counterparts, surgery in the older cohort does provide a significant improvement in pain, disability, and quality-of-life outcomes.

Routine radiographs one day after anterior cervical discectomy and fusion are neither necessary nor cost-effective.

OBJECTIVES: Anterior cervical discectomy and fusion (ACDF) is a common operative treatment of compressive pathology of the cervical spinal cord, when caused by one or more degenerated intervertebral discs or related osteophytes. In addition to intra-operative radiographs to confirm spinal level before discectomy and implant position after insertion, traditional practice is to obtain post-operative antero-posterior and lateral plain radiographs (XR) before hospital discharge, despite a paucity of evidence supporting their benefit to patient care. Minimising unnecessary radiation to radiosensitive neck structures is desirable, and furthermore, with increasing financial pressure on healthcare resources, routine investigations should be clinically justified and evidence-based. We aim to compare the utility of routine post-operative cervical spine X-rays following ACDF. METHODS: We compare two groups of consecutive patients undergoing ACDF in a single UK neurosurgical centre. The first group (n = 109) received routine post-operative XR imaging, and the second group (n = 113) received radiographs only when clinically indicated. RESULTS: There were no differences in post-operative complication rates (4.6% vs. 5.3%), or requirement for further imaging or of further operative intervention (1.8% vs. 0.9%). The group that did not have routine post-operative radiographs had a significantly shorter stay in hospital (median two days vs. three days). There were no patients in either group where post-operative XR changed clinical management and mandated revision surgery or further imaging. All cases requiring surgery or further imaging were identified by clinical deterioration. CONCLUSIONS: We suggest that the practice of obtaining routine radiographs of the cervical spine following ACDF should be abandoned, unless there is a clear clinical indication.

The Cost Effectiveness of Polyetheretheketone (PEEK) Cages for Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Cost-effectiveness analysis using a Markov model with inputs from published literature. OBJECTIVE: To learn which graft or hardware option used in a single-level anterior cervical discectomy and fusion (ACDF) is most beneficial in terms of cost, quality of life, and overall cost effectiveness. Options studied were autograft, allograft, and polyetheretherketone (PEEK) cages for cervical fusion. SUMMARY OF BACKGROUND DATA: ACDF is commonly used to treat cervical myelopathy and/or radiculopathy. No study has compared the cost effectiveness of autograft, allograft, and PEEK in 1-level ACDF. MATERIALS AND METHODS: A literature review provided inputs into a Markov decision model to determine the most effective graft or hardware option for 1-level ACDF. Data regarding rate of complications, quality-adjusted life years (QALYs) gained, and cost for each procedure type was collected. The Markov model was first run in a base case, using all currently available data. The model was then tested using 1-way and 2-way sensitivity analyses to determine the validity of the model's conclusions if specific aspects of model were changed. This model was run for 10 years postoperatively. RESULTS: The cost per QALY for each option in the base case analysis was $3328/QALY for PEEK, $2492/QALY for autograft, and $2492/QALY for allograft. All graft/hardware options are cost effective ways to improve outcomes for patients living with chronic neck pain. For graft/hardware options the most cost-effective option was allograft. The incremental cost-effectiveness ratio for PEEK compared with autograft or allograft was >$100,000/QALY. CONCLUSIONS: Allograft is the most cost-effective graft/hardware option for ACDF. Compared with living with cervical myelopathy and/or radiculopathy, ACDF using any graft or hardware option is a cost-effective method of improving the quality of life of patients. PEEK is not a cost-effective option compared with allograft or autograft for use in ACDF.

[Minimally invasive surgery in treatment of lumbar intervertebral disc herniation]. / Minimalno invazivna kirurgija slabinske kraljeznice u lijecenju hernije intervertebralnog diska.

Surgical treatment of lumbar intervertebral disc herniation is one of the most common neurosurgical procedures. Besides conventional surgical techniques, in the last more than 30 years, different methods with minimal damage to neuromuscular spine structures are being developed and introduced, all having the purpose of reducing postoperative back pain. The advantages of the minimally invasive spine surgery include: possibility of performing procedures under local anaesthesia, reduced hospital stay, limited blood loss with consecutively reduced fibrous tissue development. Patients are capable of return to work and everyday activities early after surgery. From the economical point of view, this kind of treatment is considered to be a cost-effective intervention. Three methods that are being used for treatment of lumbar intervertebral disc herniation are: percutaneous laser disc decompression (PLDD), microdiscectomy using tubular retractor system and selective endoscopic discectomy (SED). Conducted prospective studies have shown that minimally invasive methods are adequate alternative to classic surgical procedures.

Minimally invasive surgery for lumbar disc herniation: a systematic review and meta-analysis.

PURPOSE: Assessing the benefits of surgical treatments for sciatica is critical for clinical and policy decision-making. To compare minimally invasive (MI) and conventional microdiscectomy (MD) for patients with sciatica due to lumbar disc herniation. METHODS: A systematic review and meta-analysis of controlled clinical trials including patients with sciatica due to lumbar disc herniation. Conventional microdiscectomy was compared separately with: (1) Interlaminar MI discectomy (ILMI vs. MD); (2) Transforaminal MI discectomy (TFMI vs. MD). OUTCOMES: Back pain, leg pain, function, improvement, work status, operative time, blood loss, length of hospital stay, complications, reoperations, analgesics and cost outcomes were extracted and risk of bias assessed. Pooled effect estimates were calculated using random effect meta-analysis. RESULTS: Twenty-nine studies, 16 RCTs and 13 non-randomised studies (n = 4,472), were included. Clinical outcomes were not different between the surgery types. There is low quality evidence that ILMI takes 11 min longer, results in 52 ml less blood loss and reduces mean length of hospital stay by 1.5 days. There were no differences in complications or reoperations. The main limitations were high risk of bias, low number of studies and small sample sizes comparing TF with MD. CONCLUSIONS: There is moderate to low quality evidence of no differences in clinical outcomes between MI surgery and conventional microdiscectomy for patients with sciatica due to lumbar disc herniation. Studies comparing transforaminal MI with conventional surgery with sufficient sample size and methodological robustness are lacking.

How does accounting for worker productivity affect the measured cost-effectiveness of lumbar discectomy?

BACKGROUND: Back pain attributable to lumbar disc herniation is a substantial cause of reduced workplace productivity. Disc herniation surgery is effective in reducing pain and improving function. However, few studies have examined the effects of surgery on worker productivity. QUESTIONS/PURPOSES: We wished to determine the effect of disc herniation surgery on workers' earnings and missed workdays and how accounting for this effect influences the cost-effectiveness of surgery? METHODS: Regression models were estimated using data from the National Health Interview Survey to assess the effects of lower back pain caused by disc herniation on earnings and missed workdays. The results were incorporated into Markov models to compare societal costs associated with surgical and nonsurgical treatments for privately insured, working patients. Clinical outcomes and utilities were based on results from the Spine Patient Outcomes Research Trial and additional clinical literature. RESULTS: We estimate average annual earnings of $47,619 with surgery and $45,694 with nonsurgical treatment. The increased earnings for patients receiving surgery as compared with nonsurgical treatment is equal to $1925 (95% CI, $1121-$2728). After surgery, we also estimate that workers receiving surgery miss, on average, 3 fewer days per year than if workers had received nonsurgical treatment (95% CI, 2.4-3.7 days). However, these fewer missed work days only partially offset the assumed 20 workdays missed to recover from surgery. More fully accounting for the effects of disc herniation surgery on productivity reduced the cost of surgery per quality-adjusted life year (QALY) from $52,416 to $35,146 using a 4-year time horizon and from $27,359 to $4186 using an 8-year time horizon. According to a sensitivity analysis, the 4-year cost per QALY varies between $27,921 and $49,787 depending on model assumptions. CONCLUSIONS: Increased worker earnings resulting from disc herniation surgery may offset the increased direct medical costs associated with surgery. After accounting for the effects on productivity, disc herniation surgery was found to be a highly cost-effective surgery and may yield net societal savings if the benefits of outpatient and inpatient surgery persist beyond 6 and 12 years, respectively. LEVEL OF EVIDENCE: Level II, economic and decision analysis. See the Instructions for Authors for a complete description of levels of evidence.

Cost-effectiveness of lumbar discectomy and single-level fusion for spondylolisthesis: experience with the NeuroPoint-SD registry.

OBJECT: There is significant practice variation and uncertainty as to the value of surgical treatments for lumbar spine disorders. The authors' aim was to establish a multicenter registry to assess the efficacy and costs of common lumbar spinal procedures by using prospectively collected outcomes. METHODS: An observational prospective cohort study was completed at 13 academic and community sites. Patients undergoing single-level fusion for spondylolisthesis or single-level lumbar discectomy were included. The 36-Item Short Form Health Survey (SF-36) and Oswestry Disability Index (ODI) data were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively. Power analysis estimated a sample size of 160 patients: lumbar disc (125 patients) and lumbar listhesis (35 patients). The quality-adjusted life year (QALY) data were calculated using 6-dimension utility index scores. Direct costs and complication costs were estimated using Medicare reimbursement values from 2011, and indirect costs were estimated using the human capital approach with the 2011 US national wage index. Total costs equaled $14,980 for lumbar discectomy and $43,852 for surgery for lumbar spondylolisthesis. RESULTS: There were 198 patients enrolled over 1 year. The mean age was 46 years (49% female) for lumbar discectomy (n = 148) and 58.1 years (60% female) for lumbar spondylolisthesis (n = 50). Ten patients with disc herniation (6.8%) and 1 with listhesis (2%) required repeat operation at 1 year. The overall 1-year follow-up rate was 88%. At 30 days, both lumbar discectomy and single-level fusion procedures were associated with significant improvements in ODI, visual analog scale, and SF-36 scores (p = 0.0002), which persisted at the 1-year evaluation (p < 0.0001). By 1 year, more than 80% of patients in each cohort who were working preoperatively had returned to work. Lumbar discectomy was associated with a gain of 0.225 QALYs over the 1-year study period ($66,578/QALY gained). Lumbar spinal fusion for Grade I listhesis was associated with a gain of 0.195 QALYs over the 1-year study period ($224,420/QALY gained). CONCLUSIONS: This national spine registry demonstrated successful collection of high-quality outcomes data for spinal procedures in actual practice. These data are useful for demonstrating return to work and cost-effectiveness following surgical treatment of single-level lumbar disc herniation or spondylolisthesis. One-year cost per QALY was obtained, and this cost per QALY is expected to improve further by 2 years. This work sets the stage for real-world analysis of the value of health interventions.

Single-level anterior cervical discectomy and fusion versus minimally invasive posterior cervical foraminotomy for patients with cervical radiculopathy: a cost analysis.

OBJECT: Patients suffering from cervical radiculopathy in whom a course of nonoperative treatment has failed are often candidates for a single-level anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF). The objective of this analysis was to identify any significant cost differences between these surgical methods by comparing direct costs to the hospital. Furthermore, patient-specific characteristics were also considered for their effect on component costs. METHODS: After obtaining approval from the medical center institutional review board, the authors conducted a retrospective cross-sectional comparative cohort study, with a sample of 101 patients diagnosed with cervical radiculopathy and who underwent an initial single-level ACDF or minimally invasive PCF during a 3-year period. Using these data, bivariate analyses were conducted to determine significant differences in direct total procedure and component costs between surgical techniques. Factorial ANOVAs were also conducted to determine any relationship between patient sex and smoking status to the component costs per surgery. RESULTS: The mean total direct cost for an ACDF was $8192, and the mean total direct cost for a PCF was $4320. There were significant differences in the cost components for direct costs and operating room supply costs. It was found that there was no statistically significant difference in component costs with regard to patient sex or smoking status. CONCLUSIONS: In the management of single-level cervical radiculopathy, the present analysis has revealed that the average cost of an ACDF is 89% more than a PCF. This increased cost is largely due to the cost of surgical implants. These results do not appear to be dependent on patient sex or smoking status. When combined with results from previous studies highlighting the comparable patient outcomes for either procedure, the authors' findings suggest that from a health care economics standpoint, physicians should consider a minimally invasive PCF in the treatment of cervical radiculopathy.

Does Body Mass Index Influence Intraoperative Costs and Operative Times for Anterior Cervical Discectomy and Fusion? A Time-Driven Activity-Based Costing Analysis.

OBJECTIVE: Spine surgeons are often unaware of drivers of cost variation for anterior cervical discectomy and fusion (ACDF). We used time-driven activity-based costing to assess the relationship between body mass index (BMI), total cost, and operating room (OR) times for ACDFs. METHODS: Total cost was divided into direct and indirect costs. Individual costs were obtained by direct observation, electronic medical records, and through querying multiple departments. Timestamps for all involved personnel and material resources were documented. Total intraoperative costs were estimated for all ACDFs from 2017 to 2022. All patients were categorized into distinct BMI-based cohorts. Linear regression models were performed to assess the relationship between BMI, total cost, and OR times. RESULTS: A total of 959 patients underwent ACDFs between 2017 and 2022. The average age and BMI were 58.1 ± 11.2 years and 30.2 ± 6.4 kg/m2, respectively. The average total intraoperative cost per case was $7120 ± $2963. Multivariable regression analysis revealed that BMI was not significantly associated with total cost (P = 0.36), supply cost (P = 0.39), or personnel cost (P = 0.20). Higher BMI was significantly associated with increased time spent in the OR (P = 0.018); however, it was not a significant factor for the duration of surgery itself (P = 0.755). Rather, higher BMI was significantly associated with nonoperative OR time (P < 0.001). CONCLUSIONS: Time-driven activity-based costing is a feasible and scalable methodology for understanding the true intraoperative costs of ACDF. Although higher BMI was not associated with increased total cost, it was associated with increased preparatory time in the OR.

Transforaminal endoscopic spinal surgery: the future 'gold standard' for discectomy? - A review.

BACKGROUND: Lumbar disc prolapse is common and the primary method of care in most centres is still open discectomy facilitated by microscope or loupe magnification and illumination. Hospitalisation may be less than 24 h, but post-operative pain usually requires an overnight stay. This review describes transforaminal endoscopic spinal surgery (TESS) using HD-video technology, that is generally performed as a day case procedure under sedation or light general anaesthesia, and collates the evidence comparing the technique to microdiscectomy. METHODS: The method of TESS is described and an electronic literature search performed to identify papers reporting clinical outcomes. International data were translated where necessary and proceedings' abstracts included. In addition, papers held by the authors and colleagues in personal libraries were carefully cross-referenced to the obtained database. RESULTS: Analysis of the data supports the use of a transforaminal endoscopic approach to the lumbar intervertebral disc and suggests that outcomes following surgery are at least equivalent to those following microdiscectomy. Significant cost-savings in terms of in-patient stay may be generated. In addition, there is also some evidence supporting endoscopic surgery for relief of foraminal stenosis. CONCLUSION: Based on current evidence there are good arguments supporting a more wide-spread adoption of transforaminal endoscopic surgery for the treatment of lumbar disc prolapse with or without foraminal stenosis.

Patient Out-of-Pocket Cost Burden With Elective Orthopaedic Surgery.

INTRODUCTION: Out-of-pocket (OOP) costs for medical and surgical care can result in substantial financial burden for patients and families. Relatively little is known regarding OOP costs for commercially insured patients receiving orthopaedic surgery. The aim of this study is to analyze the trends in OOP costs for common, elective orthopaedic surgeries performed in the hospital inpatient setting. METHODS: This study used an employer-sponsored insurance claims database to analyze billing data of commercially insured patients who underwent elective orthopaedic surgery between 2014 and 2019. Patients who received single-level anterior cervical diskectomy and fusion (ACDF), single-level posterior lumbar fusion (PLF), total knee arthroplasty (TKA), and total hip arthroplasty (THA) were identified. OOP costs associated with the surgical episode were calculated as the sum of deductible payments, copayments, and coinsurance. Monetary data were adjusted to 2019 dollars. General linear regression, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests were used for analysis, as appropriate. RESULTS: In total, 10,225 ACDF, 28,841 PLF, 70,815 THA, and 108,940 TKA patients were analyzed. Most patients in our study sample had preferred provider organization insurance plans (ACDF 70.3%, PLF 66.9%, THA 66.2%, and TKA 67.0%). The mean OOP costs for patients, by procedure, were as follows: ACDF $3,180 (SD = 2,495), PLF $3,166 (SD = 2,529), THA $2,884 (SD = 2,100), and TKA $2,733 (SD = 1,994). Total OOP costs increased significantly from 2014 to 2019 for all procedures (P < 0.0001). Among the insurance plans examined, patients with high-deductible health plans had the highest episodic OOP costs. The ratio of patient contribution (OOP costs) to total insurer contribution (payments from insurers to providers) was 0.07 for ACDF, 0.04 for PLF, 0.07 for THA, and 0.07 for TKA. CONCLUSION: Among commercially insured patients who underwent elective spinal fusion and major lower extremity joint arthroplasty surgery, OOP costs increased from 2014 to 2019. The OOP costs for elective orthopaedic surgery represent a substantial and increasing financial burden for patients.

Cost and Complications of Single-Level Lumbar Decompression in Those Over and Under 75: A Matched Comparison.

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 (n = 44,694 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, P = 0.042) and dural tear (OR 1.560, P = 0.043), and a lower rate of seroma complicating the procedure (OR 0.419, P = 0.009). 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%, P = 0.051), although the 75 and older age group had a greater rate of laminectomy without discectomy (CPT-63047; OR 1.175, P < 0.001), while having a lower rate of laminotomy with discectomy (CPT-63042 and CPT-63030; OR 0.727 and 0.867, respectively, P = 0.013 and <0.001, respectively). The 75 and older age group had greater same day ($3329.24 vs. $3138.05, P < 0.001) and 90-day ($5014.82 vs. $4749.44, P < 0.001) 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.

Anterior Cervical Discectomy and Fusion Versus Laminoplasty for Multilevel Cervical Spondylotic Myelopathy: A National Administrative Database Analysis.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is effective for the treatment of single-level cervical spondylotic myelopathy (CSM). However, the data surrounding multilevel CSM have remained controversial. One alternative is laminoplasty, although evidence comparing these strategies has remained sparse. In the present report, we retrospectively reviewed the readmission and reoperation rates for patients who had undergone ACDF or laminoplasty for multilevel CSM from a national longitudinal administrative claims database. METHODS: We queried the MarketScan Commercial Claims and Encounters database to identify patients who had undergone ACDF or laminoplasty for multilevel CSM from 2007 to 2016. The patients were stratified by operation type. Patients aged <18 years, patients with a history of tumor or trauma, and patients who had undergone anteroposterior approach were excluded from the present study. RESULTS: A total of 5445 patients were included, of whom 1521 had undergone laminoplasty. A matched cohort who had undergone ACDF was identified. The overall 90-day postoperative complication rate was greater in the laminoplasty cohort (odds ratio, 1.48; 95% confidence interval, 1.18-1.86; P < 0.0001). The mean length of stay and 90-day readmission rates were greater in the laminoplasty cohort. The hospital and total payments of the index hospitalization were greater in the ACDF cohort, as were the total payments for ≤2 years after the index hospitalization. CONCLUSIONS: In the present administrative claims database study, no difference was found in the reoperation rate between ACDF and laminoplasty. ACDF resulted in fewer complications and readmissions compared with laminoplasty but was associated with greater costs. Additional prospective research is required to investigate the factors driving the higher costs of ACDF in this population and the long-term clinical outcomes.

Evaluation of Benefit and Cost Utility of Immediate Postanesthesia Care Unit Radiographs to Predict Airway Compromise After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective review. OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure that may be complicated by airway compromise postoperatively. This life-threatening complication may necessitate reintubation and reoperation. We evaluated the cost utility of conventional postoperative x-ray. SUMMARY OF BACKGROUND DATA: Studies have demonstrated minimal benefit in obtaining an x-ray on postoperative day 1, but there is some utility of postanesthesia care unit (PACU) x-rays for predicting the likelihood of reoperation. METHODS: We retrospectively reviewed the records of consecutive patients who underwent ACDF between September 2013 and February 2017. Patients were dichotomized into those who received PACU x-rays and those who did not (control group). Primary outcomes were reoperation, reintubation, mortality, and health care costs. RESULTS: Eight-hundred and fifteen patients were included in our analysis: 558 had PACU x-rays; 257 did not. In those who received PACU x-rays, mean age was 53.7 ±â€Š11.3 years, mean levels operated on were 2.0 ±â€Š0.79, and mean body mass index (BMI) was 30.3 ±â€Š6.9. In those who did not, mean age was 51.8 ±â€Š10.9 years, mean levels operated on were 1.48 ±â€Š0.65, and mean BMI was 29.9 ±â€Š6.3. Complications in the PACU x-ray group were reintubation-0.4%, reoperation-0.7%, and death-0.3% (due to prevertebral swelling causing airway compromise). Complications in the control group were reintubation-0.4%, reoperation-0.8%, and death-0. There were no differences between groups with respect to reoperation (P = 0.92), reintubation (P = 0.94), or mortality (P = 0.49). The mean per-patient cost was significantly higher (P = 0.009) in those who received PACU x-rays, $1031.76 ±â€Š948.67, versus those in the control group, $700.26 ±â€Š634.48. Mean length of stay was significantly longer in those who had PACU x-rays (P = 0.01). CONCLUSION: Although there were no differences in reoperation, reintubation, or mortality, there was a significantly higher cost for care and hospitalization in those who received PACU x-rays. Further studies are warranted to validate the results of the presented study.Level of Evidence: 3.

Cost Analysis of Outpatient Anterior Cervical Discectomy and Fusion at an Academic Medical Center without Dedicated Ambulatory Surgery Centers.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) are increasingly performed at ambulatory surgical centers (ASCs). Academic centers lacking dedicated ASCs must perform these at large university hospitals, which pose unique challenges to cost savings and efficiency. OBJECTIVE: To describe the safety and cost of outpatient ACDF at a major academic medical center without a dedicated ASC. METHODS: ACDFs performed from 2015 to 2018 were retrospectively reviewed. Cases were performed at the major tertiary university hospital or a satellite university hospital dedicated to outpatient surgery. Patient demographics, surgical characteristics, perioperative complications, fusion at 12 months, and cost were collected. RESULTS: A total of 470 patients were included. The mean age was 56 years, with 255 women (54.3%). When comparing same-day discharge, overnight observation, or inpatient admission, there were no differences in age, gender, or number of levels fused. Same-day and overnight observation cases were associated with shorter procedure duration and less estimated blood loss. There were no differences in perioperative complications, 30-day readmissions, or fusion at 12 months. Direct and total costs were lowest for same-day cases, followed by overnight observation and inpatient admissions (P < 0.001). CONCLUSION: Academic centers without dedicated ASCs can safely perform ACDF as a same-day or overnight observation procedure with significant reductions in cost. The lack of a dedicated ASC should not preclude academic centers from allocating appropriately selected patients into same-day or overnight observation care pathways. This strategy can improve resource utilization and preserve precious hospital resources for the most critically ill patients while also allowing these centers to build viable outpatient spine practices.

Factors Associated With Progression to Surgical Intervention for Lumbar Disc Herniation in the Military Health System.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To determine surgery-free survival of patients receiving conservative management of lumbar disc herniation (LDH) in the military healthcare system (MHS) and risk factors for surgical intervention. SUMMARY OF BACKGROUND DATA: Radiculopathy from LDH is a major cause of morbidity and cost. METHODS: The Military Data Repository was queried for all patients diagnosed with LDH from FY2011-2018; the earliest such diagnosis in a military treatment facility (MTF) was kept for each patient as the initial diagnosis. Follow-up time to surgical intervention was defined as the time from diagnosis to first encounter for lumbar microdiscectomy or lumbar decompression in either a MTF or in the civilian sector. The Military Data Repository was also queried for history of tobacco use at any time during MHS care, age at the time of diagnosis, sex, MHS beneficiary category, and diagnosing facility characteristics. Multivariable Cox proportional hazards models were used to evaluate the associations of patient and diagnosing facility characteristics with time to surgical intervention. RESULTS: A total of 84,985 MHS beneficiaries including 62,771 active duty service members were diagnosed with LDH in a MTF during the 8-year study period. A total of 10,532 (12.4%) MHS beneficiaries, including 7650 (10.9%) active duty, failed conservative management onto surgical intervention with lumbar microdiscectomy or lumbar decompression. Median follow-up time of the cohort was 5.2 (interquartile range 2.6, 7.5) years. Among all healthcare beneficiaries, several patient-level (younger age, male sex, and history of tobacco use) and facility-level characteristics (hospital vs. clinic and surgical care vs. primary care clinic) were independently associated with higher risk of surgical intervention. CONCLUSION: LDH compromises military readiness and negatively impacts healthcare costs. MHS beneficiaries with LDH have a good prognosis with approximately 88% of patients successfully completing conservative management. However, strategies to improve outcomes of conservative management in LDH should address risks associated with both patient and facility characteristics.Level of Evidence: 4.