An Economic Analysis of SC24 in Canada: A Randomized Study of SBRT Compared With Conventional Palliative RT for Spinal Metastases.

PURPOSE: The Canadian Cancer Trials Group (CCTG) Symptom Control 24 protocol (SC.24) was a multicenter randomized controlled phase 2/3 trial conducted in Canada and Australia. Patients with painful spinal metastases were randomized to either 24 Gy/2 stereotactic body radiation therapy (SBRT) or 20 Gy/5 conventional external beam radiation therapy (CRT). The study met its primary endpoint and demonstrated superior complete pain response rates at 3 months following SBRT (35%) versus CRT (14%). SBRT planning and delivery is resource intensive. Given its benefits in SC.24, we performed an economic analysis to determine the incremental cost-effectiveness of SBRT compared with CRT. METHODS AND MATERIALS: The trial recruited 229 patients. Cost-effectiveness was assessed using a Markov model taking into account observed survival, treatments costs, retreatment, and quality of life over the lifetime of the patient. The EORTC-QLU-C10D was used to determine quality of life values. Transition probabilities for outcomes were from available patient data. Health system costs were from the Canadian health care perspective and were based on 2021 Canadian dollars (CAD). The incremental cost-effectiveness ratio (ICER) was expressed as the ratio of incremental cost to quality-adjusted life years (QALY). The impact of parameter uncertainty was investigated using deterministic and probabilistic sensitivity analyses. RESULTS: The base case for SBRT compared with CRT had an ICER of $9,040CAD per QALY gained. Sensitivity analyses demonstrated that the ICER was most sensitive to variations in the utility assigned to "No local failure" ($5,457CAD to $241,051CAD per QALY), adopting low and high estimates of utility and the cost of the SBRT (ICERs ranging from $7345-$123,361CAD per QALY). It was more robust to variations in assumptions around survival and response rate. CONCLUSIONS: SBRT is associated with higher upfront costs than CRT. The ICER shows that, within the Canadian health care system, SBRT with 2 fractions is likely to be more cost-effective than CRT.

Financial Toxicity in Patients with Brain and Spine Metastases.

OBJECTIVE: Financial toxicity associated with cancer treatment has a deleterious impact on patient outcomes but has not been well characterized among patients with metastatic cancers. We characterize the extent of financial toxicity among this population and identify factors associated with financial toxicity. METHODS: We prospectively surveyed adult patients with brain and spine metastases who received radiosurgery at a large academic medical center between January 2018 and December 2019. Financial toxicity was measured with the Personal Financial Wellness (PFW) scale. RESULTS: In total, 93 patients were included, with a median survival of 17.7 months. Most patients had private insurance (47%) or Medicare with supplementary insurance (42%), whereas 11% of patients were uninsured or insured by Medicaid/Medicare/Veterans Affairs. Of patients, 60% were primary income earners, of whom 52% had dependents. The median PFW score was 7.0 (interquartile range, 5.1-9.1), with financial toxicity reported in 23 patients (25%). After adjusting for age and education level, private insurance (odds ratio [OR], 0.28; P = 0.080) was associated with a lower likelihood of financial toxicity. Having ≥1 emergency department visit (OR, 3.87; P = 0.024) and a cancer-related change in employment status (OR, 3.63; P = 0.036) were associated with greater likelihood of reporting financial toxicity. CONCLUSIONS: Most patients with cancer with brain and spine metastases with a poor prognosis treated at a tertiary center are primary income earners and experience financial toxicity. Further studies are warranted to assess the longitudinal impact of financial toxicity in patients with metastatic cancer, particularly those with ≥1 emergency department visit and a cancer-related change in employment status.

Cost and Health Care Resource Utilization Differences After Spine Surgery for Bony Spine versus Primary Intradural Spine Tumors.

OBJECTIVE: The aim of this study was to compare complication rates, length of stay (LOS), and hospital costs after spine surgery for bony spine tumors and intradural spinal neoplasms. METHODS: A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult inpatients who underwent surgical intervention for a primary intradural spinal tumor or primary/metastatic bony spine tumor were identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis/procedural coding systems. Patient demographics, comorbidities, intraoperative variables, complications, LOS, discharge disposition, and total cost of hospitalization were assessed. Backward stepwise multivariable logistic regression analyses were used to identify independent predictors of perioperative complication, extended LOS (≥75th percentile), and increased cost (≥75th percentile). RESULTS: A total of 9855 adult patients were included in the study; 3850 (39.1%) were identified as having a primary intradural spinal tumor and 6005 (60.9%) had a primary or metastatic bony spine tumor. Those treated for bony tumors had more comorbidities (≥3, 67.8% vs. 29.2%) and more commonly experienced ≥1 complications (29.9% vs. 7.9%). Multivariate analyses also showed those in the bony spine cohort had a higher odds of experiencing ≥1 complications (odds ratio [OR], 4.26; 95% confidence interval [CI], 3.04-5.97; P < 0.001), extended LOS (OR, 2.44; 95% CI, 1.75-3.38; P < 0.001), and increased cost (OR, 5.32; 95% CI, 3.67-7.71; P < 0.001). CONCLUSIONS: Relative to patients being treated for primary intradural tumors, those undergoing spine surgery for bony spine tumors experience significantly higher risk for perioperative complications, extended LOS, and increased cost of hospital admission. Further identification of patient and treatment characteristics that may optimize management of spine oncology may reduce adverse outcomes, improve patient care, and reduce health care resources.

Surgery and Radiotherapy for Symptomatic Spinal Metastases Is More Cost Effective Than Radiotherapy Alone: A Cost Utility Analysis in a U.K. Spinal Center.

BACKGROUND: Surgery for symptomatic spinal metastases is effective at prolonging ambulation and life, but it can appear costly at first glance. We have studied the difference between the cost of surgery and reimbursement received, and the cost-effectiveness of surgery in a U.K. tertiary referral spinal center. METHODS: A cost-versus-reimbursement and cost-utility analysis was performed in a prospective cohort of patients admitted for surgical treatment of spinal metastases. Outcome measures were health-related quality of life using the EuroQol EQ-5D-3L, Frankel score, quality-adjusted life years (QALYs), and treatment and reimbursement costs. RESULTS: One hundred thirty consecutive patients were prospectively recruited, of whom 92 had information available for cost and reimbursement comparison, and 100 had information to complete cost-utility analysis. Median cost of hospital treatment per patient was £20,752; median reimbursement received was £18,291, with a median shortfall of £1,967. Surgery in addition to radiotherapy over a lifetime horizon was both more effective and less costly than radiotherapy alone, and therefore was found to be cost-effective. CONCLUSIONS: Our results demonstrate that reimbursement to hospitals for surgical management of symptomatic spinal metastases in the United Kingdom is broadly in line with costs, and that there was an overall saving as a result of community care costs being mitigated by patients walking for longer, which is within the expected National Health Service threshold. Surgery for metastatic spinal tumors is effective and a good value for the money.

Healthcare Resource Utilization and Patient-Reported Outcomes Following Elective Surgery for Intradural Extramedullary Spinal Tumors.

BACKGROUND: Healthcare resource utilization and patient-reported outcomes (PROs) for intradural extramedullary (IDEM) spine tumors are not well reported. OBJECTIVE: To analyze the PROs, costs, and resource utilization 1 year following surgical resection of IDEM tumors. METHODS: Patients undergoing elective spine surgery for IDEM tumors and enrolled in a single-center, prospective, longitudinal registry were analyzed. Baseline and postoperative 1-year PROs were recorded. One-year spine-related direct and indirect healthcare resource utilization was assessed. One-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). RESULTS: A total of 38 IDEM tumor patients were included in this analysis. There was significant improvement in quality of life (EuroQol-5D), disability (Oswestry and Neck Disability Indices), pain (Numeric rating scale pain scores for back/neck pain and leg/arm pain), and general physical and mental health (Short-form-12 health survey, physical and mental component scores) in both groups 1 year after surgery (P < .0001). Eighty-seven percent (n = 33) of patients were satisfied with surgery. The 1-year postdischarge resource utilization including healthcare visits, medication, and diagnostic cost was $4111 ± $3596. The mean total direct cost was $23 717 ± $7412 and indirect cost was $5544 ± $4336, resulting in total 1-year cost $29 177 ± $9314. CONCLUSION: Surgical resection of the IDEM provides improvement in patient-reported quality of life, disability, pain, general health, and satisfaction at 1 year following surgery. Furthermore, we report the granular costs of surgical resection and healthcare resource utilization in this population.

Quality of life and cost-utility of surgical treatment for patients with spinal metastases: prospective cohort study.

PURPOSE: Palliative surgery for patients with spinal metastasis provides good clinical outcomes. However, there have been few studies on quality of life (QOL) and cost-utility of this surgery. We aimed to elucidate QOL and cost-utility of surgical treatment for spinal metastasis. METHODS: We prospectively analyzed 47 patients with spinal metastasis from 2010 to 2014 who had a surgical indication. Thirty-one patients who desired surgery underwent spinal surgery (surgery group). Sixteen patients who did not want to undergo spinal surgery (non-surgery group). The EuroQol 5D (EQ-5D) and relevant costs were measured at one, three, six, and 12 months after study enrollment. Health state values were obtained by Japanese EQ-5D scoring and quality-adjusted life years (QALY) gained were calculated for each group. Cost-utility was expressed as the incremental cost-utility ratio (ICUR). RESULTS: Health state values improved from 0.036 at study enrollment to 0.448 at 12 months in the surgery group, but deteriorated from 0.056 to 0.019 in the non-surgery group, with a significant difference between groups (P < 0.05). The mean QALY gained at 12 months were 0.433 in the surgery group and 0.024 in the non-surgery group. The mean total cost per patient in the surgery group was $25,770 compared with $8615 in the non-surgery group. The ICUR using oneyear follow-up data was $42,003/QALY gained. CONCLUSIONS: Surgical treatment for spinal metastases is associated with significant improvement in health state value. In orthopaedic surgery, an ICUR less than $50,000/QALY gained is considered acceptable cost-effectiveness. Our results indicate that surgical treatment could be cost-effective.

Costs and readmission rates for the resection of primary and metastatic spinal tumors: a comparative analysis of 181 patients.

OBJECTIVE Because the surgical strategies for primary and metastatic spinal tumors are different, the respective associated costs and morbidities associated with those treatments likely vary. This study compares the direct costs and 90-day readmission rates between the resection of extradural metastatic and primary spinal tumors. The factors associated with cost and readmission are identified. METHODS Adults (age 18 years or older) who underwent the resection of spinal tumors between 2008 and 2013 were included in the study. Patients with intradural tumors were excluded. The direct costs of index hospitalization and 90-day readmission hospitalization were evaluated. The direct costs were compared between patients who were treated surgically for primary and metastatic spinal tumors. The independent factors associated with costs and readmissions were identified using multivariate analysis. RESULTS A total of 181 patients with spinal tumors were included (63 primary and 118 metastatic tumors). Overall, the mean index hospital admission cost for the surgical management of spinal tumors was $52,083. There was no significant difference in the cost of hospitalization between primary ($55,801) and metastatic ($50,098) tumors (p = 0.426). The independent factors associated with higher cost were male sex (p = 0.032), preoperative inability to ambulate (p = 0.002), having more than 3 comorbidities (p = 0.037), undergoing corpectomy (p = 0.021), instrumentation greater than 7 levels (p < 0.001), combined anterior-posterior approach (p < 0.001), presence of a perioperative complication (p < 0.001), and longer hospital stay (p < 0.001). The perioperative complication rate was 21.0%. Of this cohort, 11.6% of patients were readmitted within 90 days, and the mean hospitalization cost of that readmission was $20,078. Readmission rates after surgical treatment for primary and metastatic tumors were similar (11.1% vs 11.9%, respectively) (p = 0.880). Prior hospital stay greater than 15 days (OR 6.62, p = 0.016) and diagnosis of lung metastasis (OR 52.99, p = 0.007) were independent predictors of readmission. CONCLUSIONS Primary and metastatic spinal tumors are comparable with regard to the direct costs of the index surgical hospitalization and readmission rate within 90 days. The factors independently associated with costs are related to preoperative health status, type and complexity of surgery, and postoperative course.

Cost of Surgery for Symptomatic Spinal Metastases in the United Kingdom.

BACKGROUND: Spinal metastases represent a significant health and economic burden. The average cost of surgical management varies between institutions and countries, partially a result of differences in health care system billing. This study assessed hospital costs from a single institute in the United Kingdom National Healthcare Service and identified patient factors associated with these costs. METHODS: This prospective study recruited patients with confirmed symptomatic spinal metastases who presented for surgical treatment. The primary outcome was cost of inpatient treatment collected using the Patient Level Costing and Information System; preoperative details collected included patient demographics, primary tumor type, Tomita and Tokuhashi scores, pain level, EuroQol 5 dimension score, Frankel, Karnofsky, and American Society of Anesthesiologists' physical status classification system scores, and operative details. RESULTS: Costs were analyzed for 74 patients. The mean cost of treatment (standard deviation, SD) per patient was £ 16,885 (£ 10,687); which was mainly comprised of operating theater (25% of the total) and ward costs (27%). Better health status at presentation significantly increased total and ward costs (Frankel score P = 0.006, and EuroQol 5 dimension index P = 0.014 respectively); male sex also increased total and ward costs (P < 0.01 and P = 0.06). Operation cost showed a trend to increased costs with less impairment on American Society of Anesthesiologists' physical status classification system scores. CONCLUSION: The cost of surgical management of spinal metastases is associated with several factors but is greater in patients presenting with better health status, probably because of their suitability for larger operations, whereas those with poor health status undergo smaller, palliative operations, resulting in shorter inpatient postoperative recovery.

Healthcare costs attributable to the treatment of patients with spinal metastases: a cohort study with up to 8 years follow-up.

BACKGROUND: Cancer treatment, and in particular end-of-life treatment, is associated with substantial healthcare costs. The purpose of this study was to analyse healthcare costs attributable to the treatment of patients with spinal metastases. METHODS: The study population (n = 629) was identified from clinical databases in Denmark. Patients undergoing spinal metastasis treatment from January 2005 through June 2012 were included. Clinical data were merged with national register data on healthcare resource use, costs and death date. The analytic period ranged from treatment initiation until death or administrative censoring in October 2013. Analysis of both survival and costs were stratified into four treatment regimens of increasing invasiveness: radiotherapy (T1), decompression (T2), decompression + instrumentation (T3) and decompression + instrumentation + reconstruction (T4). Survival was analysed using Kaplan-Meier curves. Costs were estimated from a healthcare perspective. Lifetime costs were defined as accumulated costs from treatment initiation until death. The Kaplan-Meier Sampling Average method was used to estimate these costs; 95% CIs were estimated using nonparametric bootstrapping. RESULTS: Mean age of the study population was 65.2 years (range: 19-95). During a mean follow-up period of 9.2 months (range: 0.1-94.5 months), post treatment survival ranged from 4.4 months (95% CI 2.5-7.5) in the T1 group to 8.7 months (95% CI 6.7-14.1) in the T4 group. Inpatient hospitalisation accounted for 65% and outpatient services for 31% of the healthcare costs followed by hospice placements 3% and primary care 1%. Lifetime healthcare costs accounted for €36,616 (95% CI 33,835-39,583) per T1 patients, €49,632 (95% CI 42,287-57,767) per T2 patient, €70997 (95% CI 62,244-82,354) per T3 patient and €87,814 (95% CI 76,638-101,528) per T4 patient. Overall, 45% of costs were utilised within the first month. T1 and T4 patients had almost identical distributions of costs: inpatient hospitalisation averaged 59% and 36% for outpatient services. Costs of T2 and T3 were very similarly distributed with an average of 71% for inpatient hospitalisation and 25% for outpatient services. CONCLUSION: The index treatment accounts for almost half of lifetime health care costs from treatment initiation until death. As expected, lifetime healthcare costs are positively association with invasiveness of treatment.

Clinical long-term outcome, technical success, and cost analysis of radiofrequency ablation for the treatment of osteoblastomas and spinal osteoid osteomas in comparison to open surgical resection.

OBJECTIVE: To assess the clinical success and costs of computed tomography (CT)-guided radiofrequency ablation (RFA) of osteoblastoma (OB) and spinal osteoid osteoma (OO). MATERIALS AND METHODS: Nineteen patients with OB and eight patients with spinal OO were treated with CT-guided RFA. The OBs were localized in the extremities (n = 10), the vertebral column (n = 2), and (juxta-)articular (n = 7). Dedicated procedural techniques included three-dimensional CT-guided access planning in all cases, overlapping RFA needle positions (median, two positions; range, 1-6 RF-electrode positions) within the OB nidus (multiple ablation technique, n = 15), and thermal protection in case of adjacent neural structure in four spinal OO. The data of eight operated OB and ten operated spinal OO patients were used for comparison. Long-term success was assessed by clinical examination and using a questionnaire sent to all operated and RFA-treated patients including visual analogue scales (VAS) regarding the effect of RFA on severity of pain and limitations of daily activities (0-10, with 0 = no pain/limitation up to 10 = maximum or most imaginable pain/limitation). RESULTS: All patients had a clear and persistent pain reduction until the end of follow-up. The mean VAS score for all spinal OO patients and all OB patients treated either with RFA or with surgical excision significantly decreased for severity of pain at night, severity of pain during the day, and both for limitations of daily and of sports activities. CONCLUSIONS: RFA is an efficient method for treating OB and spinal OO and should be regarded as the first-line therapy after interdisciplinary individual case discussion.

The impact of insurance status on outcomes after surgery for spinal metastases.

BACKGROUND: Disparities based on insurance status in the American health care system are well established. However, to the authors' knowledge, this is the first study to evaluate variables that may explain differences based on payer type in the outcomes after surgery for spinal metastases. METHODS: Data from the Nationwide Inpatient Sample (2005-2008) were retrospectively extracted. Patients ages 18 to 64 years who underwent surgery for spinal metastases were included. Multivariate logistic regression was performed to calculate the adjusted odds of in-hospital death and the development of a complication for Medicaid recipients and for those without insurance compared with privately insured patients. All analyses were adjusted for differences in patient age, gender, primary tumor histology, socioeconomic status, hospital bed size, and hospital teaching status. RESULTS: A total of 2157 hospital admissions were evaluated. The adjusted odds of in-hospital death were significantly higher for Medicaid recipients (crude rate: 6.5%; odds ratio [OR], 1.79; 95% confidence interval [95% CI], 1.11-2.88 [P = .02]) and uninsured patients (crude rate: 7.7%; OR, 2.15; 95% CI, 1.04-4.46 [P = .04]) compared with privately insured patients (crude rate: 3.8%). Complication rates were also significantly higher for Medicaid recipients (OR, 1.34; 95% CI, 1.04-1.72 [P = .02]). However, after also adjusting for acuity of presentation, the odds of in-hospital death were not significantly different for Medicaid (OR, 1.38; 95% CI, 0.86-2.21 [P = .18]) or uninsured patients (OR, 1.86; 95% CI, 0.90-3.83 [P = .09]); in addition, complication rates did not appear to differ significantly. CONCLUSIONS: This nationwide study suggests that disparities based on insurance status for patients undergoing surgery for spinal metastases may be attributable to a higher acuity of presentation.

[Direct cost of spinal cord injuries]. / Costo directo de las lesiones en la columna.

BACKGROUND: High prevalence and high costs in the treatment of spine injuries make a cost study necessary. The objective of this paper is to analyze, from the economic point of view, the behavior of traumatic and non-traumatic spinal pathologies in relation to hospital stay. METHODS: Analysis of economic cost per hospital stay (January 2000 to May 2010). RESULTS: 4,173 cases studied, 45% women and 55% men, predominantly elderly and a mean age of 48.9, standard deviation 16.8 years, with a notable increase in hospital expenses in prevalence and peak months: January, February and April; and a decrease in July, October and December. Total expenses for hospital stay were estimated as $85,565,288.00. Traumatic entities consumed $40,404,477.00, and degenerative $21,866,815.00. The months of highest spending were: April, $11,072,683.00, December, $8,423,773.00 and February $8,154,152.00; whereas July showed the lowest spending: $4,874,261.00. Inflation up to July 2011 remained at 3.55% on average, down 2.98 percentage points from 2008 figures. DISCUSSION: there is a clear increase in spending connected with spine condition treatment at hospitals, in particular those resulting from traumatic events. The definition of risk groups for preventive measures is also reflected in the spending records. Spending on hospital treatment of spinal conditions of the elderly reflects an increment in degenerative conditions. CONCLUSION: It is necessary to plan a timely resource distribution by month and year in order to achieve a better and more efficient scheme for health services. The epidemiological basis for the reorientation of the current models is now clear.

Efficacy and cost-effectiveness analysis of external beam and stereotactic body radiation therapy in the treatment of spine metastases: a matched-pair analysis.

OBJECT: The objective of this study was to compare the palliative efficacy and cost effectiveness of external beam radiation therapy (EBRT) to stereotactic body radiation therapy (SBRT) as primary treatment for bone metastatic disease of the spinal column. METHODS: Forty-four patients were matched based on age, primary tumor site, year of treatment, and location of metastasis. Outcomes of interest were pain relief, cost-effectiveness, toxicities, and need for further intervention. Pain relief was rated as excellent, good, fair, or poor, using a radiosurgical pain scale to combine visual analog scale and verbal descriptor ordinal scale scores. Medicare fee schedules were used to compute the charges for both the technical and professional components of care. Patients in the EBRT group were treated using a linear accelerator while patients in the SBRT group were treated with the CyberKnife robotic radiosurgery system. Patients received regular follow-up evaluations by a radiation oncologist and neurosurgeon. RESULTS: Forty-four patients (22 pairs) were analyzed. At a follow-up of 1 month, there was no statistically significant difference in pain between the 2 groups (p = 0.11). Patients who underwent SBRT had the highest total gross charge; depending on technique, EBRT treatments ranged from 29% to 71% of the SBRT charge. Patients treated using EBRT had more acute toxicities, and more of these patients underwent further intervention at the treated spinal level. There were no late complications attributed to either treatment modality. CONCLUSIONS: External beam radiation therapy remains an efficacious and cost-effective method of palliation of spine metastases. In this study, patients treated with EBRT had more acute toxicities and were more likely to require additional interventions at the treated sites. Stereotactic body radiation therapy, although more costly, resulted in comparable rates of pain relief and late treatment-related toxicity, and continues to show promise as an emerging modality for selected patients with spine metastases.

Outcome and cost of spinal fractures and spinal tumors.

The aim of the study was to delineate rates of surgery, length of hospital stay, return to work, iterative surgery rates and cost to society of spinal tumor (ST) and spinal fracture (SF) surgery in Belgium. Overall surgery rates were obtained from the National Institute for Health Care and Disability Insurance. Medical and financial claims data were abstracted from the administrative database of the Alliance of Christian Sickness Funds which includes data of 42% of the mandatory insured Belgian population. All records including the reimbursement codes for ST and SF surgery in 2005 were identified. A logistic regression model was developed to determine the socio-demographic, surgery-related and sick leave predictors of return to work. Our database contained information about 3.791 patients who underwent surgery for SF and 2.322 patients who had surgery for ST. Year-to-year surgery rate growth for SF was estimated at 15%. The yearly increase in surgery rates for ST was calculated at 11%. The return to work rate was 90% 1 year after surgery for both SF and ST. Sixty percent of patients who underwent radiotherapy and surgery for ST were still alive 1 year after surgery. Length of hospital stay ranged from 1 to 27 days after surgery for ST and from 1 to 16 days after surgery for SF. Repeat surgery was performed in 8% of the ST cases and in 12% of the SF patients. Return to work rate remained significantly lower for blue collar workers, self-employed workers and patients with a longer sick leave before surgery. Patients who were absent from work for more than 3 months at time of surgery represent a high-risk group with regard to successful functional recovery.

Cost-utility analysis of the cyberknife system for metastatic spinal tumors.

OBJECTIVE: Using decision analysis, a cost-utility study evaluated the cost-effectiveness of CyberKnife (Accuray, Inc., Sunnyvale, CA) stereotactic radiosurgery (SRS) in comparison to external beam radiation therapy in the treatment of metastatic spinal malignancies. METHODS: The published literature provided evidence on the effectiveness of the comparator interventions in the absence of primary outcomes data. Costs of care were derived from Centers for Medicare and Medicaid Services fee schedules. A Markov model was constructed from the payer perspective to simulate the outcomes of patients undergoing nonchemotherapeutic interventions for metastatic spinal tumors. Because cancer therapies bear significant health and economic consequences, the impact of treatment-related toxicities was integrated into the model. Given the terminal nature of these conditions and the limited life expectancy of the patient population, the time horizon for the analysis was limited to 12 months. RESULTS: Patients treated with CyberKnife SRS gained an additional net health benefit of 0.08 quality-adjusted life year; the calculated cost of CyberKnife SRS was $1933 less than external beam radiation therapy for comparable effectiveness. The incremental cost per benefit for this strategy ($41 500 per quality-adjusted life year) met payers' willingness-to-pay criteria. CONCLUSION: Cost-utility analysis demonstrated that CyberKnife SRS was a superior, cost-effective primary intervention for patients with metastatic spinal tumors compared with conventional external beam radiation therapy.

Level-adjusted perioperative risk of sacral amputations.

BACKGROUND AND OBJECTIVES: Sacral amputations above the S2 body often involve increased surgical complexity leading to long-term morbidity. The purpose of this study was to determine whether proximal sacral amputations have substantially higher perioperative morbidity compared with more distal sacral amputations. METHODS: We evaluated the effect of sacral amputation level on perioperative outcomes within 90 days of surgery. Outcome measures included blood loss, intensive care unit (ICU) and hospital stay, hospital cost, and incidence of a major and minor morbidity. Survival analyses were adjusted for the level of resection and histological appearance. RESULTS: Thirteen proximal and 14 distal resections were performed. In comparing proximal versus distal resections, median estimated blood loss was 4 L versus 1 L (P < 0.001), ICU stay was 4 days versus 0 days (P = 0.012), hospital stay was 19 days versus 8 days (P = 0.001), hospital cost was 28,800 dollars versus 7,500 dollars (P = 0.003), with one or more major complications in 85% versus 29% (P = 0.011). Survival analysis demonstrated that the sacral resection level did not influence survival (P = 0.936), whereas the type of tumor did influence survival (P = 0.012). CONCLUSION: Tumor resections above S2 demonstrate increased perioperative morbidity, suggesting that proximal osteotomies be reserved for patients with a realistic cure potential.

Rapid magnetic resonance imaging for diagnosing cancer-related low back pain.

OBJECTIVES: This study compared the relative efficiency of lumbar x-ray and rapid magnetic resonance (MR) imaging for diagnosing cancer-related low back pain (LBP) in primary care patients. DESIGN: We developed a decision model with Markov state transitions to calculate the cost per case detected and cost per quality-adjusted life year (QALY) of rapid MR imaging. Model parameters were estimated from the medical literature. The costs of x-ray and rapid MR were calculated in an activity-based costing study. SETTING AND PATIENTS: A hypothetical cohort of primary care patients with LBP referred for imaging to exclude cancer as the cause of their pain. MAIN RESULTS: The rapid MR strategy was more expensive due to higher initial imaging costs and larger numbers of patients requiring conventional MR and biopsy. The overall sensitivity of the rapid MR strategy was higher than that of the x-ray strategy (62% vs 55%). However, because of low pre-imaging prevalence of cancer-related LBP, this generates <1 extra case per 1,000 patients imaged. Therefore, the incremental cost per case detected using rapid MR was high ($213,927). The rapid MR strategy resulted in a small increase in quality-adjusted survival (0.00043 QALYs). The estimated incremental cost per QALY for the rapid MR strategy was $296,176. CONCLUSIONS: There is currently not enough evidence to support the routine use of rapid MR to detect cancer as a cause of LBP in primary care patients.

[The value of magnetic resonance tomography (MRI) with reference to economic aspects of radiotherapy planning of vertebral metastases. A cost benefit analysis]. / Die Wertigkeit der Magnetresonanztomographie (MRT) unter ökonomischen Aspekten bei der Bestrahlungsplanung von Wirbelkörpermetastasen. Eine Kosten-Nutzen-Analyse.

Is magnetic resonance imaging (MRI) based target volume definition for treatment planning of vertebral metastasis effective under economic considerations. From 1994 to 1999, a total of 137 patients with bone metastases affecting the vertebral column underwent MRI of the cervical, thoracic, or lumbar spine for the treatment planning of palliative radiation therapy. The following radiation treatment consisted in a irradiation of the affected vertebral region up to a total dose of 30-40 Gy. The cost calculation for radiotherapy and magnetic resonance tomography was done using the common tariff model (EBM) of the German Health Insurances. In 73% of patients (101 patients), magnetic resonance imaging resulted in marked corrections of the irradiation fields which would have resulted in the necessity of treatment for recurrence in the case of treatment planning without MRI. Consequently, the higher cost of MRI of 345.00 DEM (176,40 EUR) lead to a saving of 497.00 DEM (254,11 EUR) compared to a recurrence treatment of 10 fractions and of 1,428.00 DEM (730,12 EUR) compared to 20 fractions. The transport expenses for the second treatment could be saved as well. Even under economic considerations MRI is effective.