Cost-effectiveness of adult lumbar scoliosis surgery: an as-treated analysis from the adult symptomatic scoliosis surgery trial with 5-year follow-up.

STUDY DESIGN: Longitudinal comparative cohort. OBJECTIVE: The purpose of this study is to report on the cost-effectiveness of surgical versus non-surgical treatment for Adult Symptomatic Lumbar Scoliosis (ASLS) using the as-treated data and provide a comparison to previously reported intent-to-treat (ITT) analysis. Adult spinal deformity is a relatively prevalent condition for which surgical treatment has become increasingly common but concerns surrounding complications, revision rates and cost-effectiveness remain unresolved. Of these issues, cost-effectiveness is perhaps the most difficult to quantify as the requisite data is difficult to obtain. The purpose of this study is to report on the cost-effectiveness of surgical versus non-surgical treatment for ASLS using the as-treated data and provide a comparison to previously reported ITT analysis. METHODS: Patients with at least 5-year follow-up data within the same treatment arm were included. Data collected every 3 months included use of nonoperative modalities, medications and employment status. Costs for surgeries and non-operative modalities were determined using Medicare Allowable rates. Medication costs were determined using the RedBook and indirect costs were calculated based on the reported employment status and income. Quality-Adjusted Life Years (QALY) was determined using the SF-6D. RESULTS: Of 226 patients, 195 patients (73 Non-op, 122 Op) met inclusion criteria. At 5 years, 29 (24%) patients in the Op group had a revision surgery of whom two had two revisions and one had three revisions. The cumulative cost for the Op group was $111,451 with a cumulative QALY gain of 2.3. The cumulative cost for the Non-Op group was $29,124 with a cumulative QALY gain of 0.4. This results in an ICER of $44,033 in favor of Op treatment. CONCLUSION: This as-treated cost-effectiveness analysis demonstrates that surgical treatment for adult lumbar scoliosis becomes favorable at year-three, 1 year earlier than suggested by a previous intent-to-treat analysis. LEVEL OF EVIDENCE: II.

Cost-effectiveness of surgical treatment of adult spinal deformity: comparison of posterior-only versus anteroposterior approach.

BACKGROUND CONTEXT: Considerable debate exists regarding the optimal surgical approach for adult spinal deformity (ASD). It remains unclear which approach, posterior-only or combined anterior-posterior (AP), is more cost-effective. Our goal is to determine the 2-year cost per quality-adjusted life year (QALY) for each approach. PURPOSE: To compare the 2-year cost-effectiveness of surgical treatment for ASD between the posterior-only approach and combined AP approach. STUDY DESIGN: Retrospective economic analysis of a prospective, multicenter database PATIENT SAMPLE: From a prospective, multicenter surgical database of ASD, patients undergoing five or more level fusions through a posterior-only or AP approach were identified and compared. METHODS: QALYs gained were determined using baseline, 1-year, and 2-year postoperative Short Form 6D. Cost was calculated from actual, direct hospital costs including any subsequent readmission or revision. Cost-effectiveness was determined using cost/QALY gained. RESULTS: The AP approach showed significantly higher index cost than the posterior-only approach ($84,329 vs. $64,281). This margin decreased at 2-year follow-up with total costs of $89,824 and $73,904, respectively. QALYs gained at 2 years were similar with 0.21 and 0.17 in the posterior-only and the AP approaches, respectively. The cost/QALY at 2 years after surgery was significantly higher in the AP approach ($525,080) than in the posterior-only approach ($351,086). CONCLUSIONS: We assessed 2-year cost-effectiveness for the surgical treatment through posterior-only and AP approaches. The posterior-only approach is less expensive both for the index surgery and at 2-year follow-up. The QALY gained at 2-years was similar between the two approaches. Thus, posterior-only approach was more cost-effective than the AP approach under our study parameters. However, both approaches were not cost-effective at 2-year follow-up.

Inpatient versus Outpatient Anterior Cervical Discectomy and Fusion: A Perioperative Complication Analysis of 259,414 Patients From the Healthcare Cost and Utilization Project Databases.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is one of the most common operations utilized to address pathology of the cervical spine. Few reports have attempted to compare complications associated with inpatient versus outpatient ACDF. METHODS: The Nationwide Inpatient Sample (NIS) from 2001-2012 and the State Ambulatory Services Database (SASD) for New Jersey (NJ) from 2003-2012 were used for analysis. Patients receiving ACDF (defined as anterior cervical fusion (ICD-0 code=81.02) + excision of intervertebral disc (80.51)) were segmented into an inpatient group derived from the NIS, and an outpatient group derived from the NJ SASD. Patients receiving > 2 levels fused (ICD-9 codes 81.63-81.64), or surgery for cancer (ICD-9 codes 140-239), or trauma (ICD-9 codes=805.0-806.9) were excluded. Propensity score matching (PSM) was used to adjust the analysis for patient age, race, sex, primary payer for care, and number of medical diagnoses. RESULTS: Of the 94,492,438 inpatients comprising the NIS from 2001-2012, 257,398 received ACDF. Of the 4,194,207 outpatients comprising the NJ SASD, 2,016 received ACDF. PSM of 10,080 patients (all 2,016 SASD and 8,064 from NIS) was performed, and subsequent analysis revealed that durotomy (P=0.001;OR=0.81), paraplegia, postoperative infection, hematoma/seroma (OR=0.14), respiratory complications, acute posthemorrhagic anemia and red blood cell transfusion (all P<0.001) were less frequent in outpatient versus inpatient ACDF (p<0.05). These results were similar to an unmatched analysis involving all of the NIS patients. CONCLUSION: Accepting the limitations of the NIS and SASD (inability to distinguish between one and two-level fusions, no long-term follow-up, potential selection bias, disparities between inpatient and outpatient ACDF populations), these findings indicate that for 1-2 level ACDF, perioperative complications, including durotomy, paraplegia, hematoma, and acute posthemorrhagic anemia were more commonly reported following inpatient ACDF. Future studies involving outpatient analysis of several states will be necessary to determine whether these results of outpatient ACDF are applicable nationwide.

Cell Saver for Adult Spinal Deformity Surgery Reduces Cost.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: To determine if the use of cell saver reduces overall blood costs in adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Recent studies have questioned the clinical value of cell saver during spine procedures. METHODS: ASD patients enrolled in a prospective, multicenter surgical database who had complete preoperative and surgical data were identified. Patients were stratified into (1) cell saver available during surgery, but no intraoperative autologous infusion (No Infusion group), or (2) cell saver available and received autologous infusion (Infusion group). RESULTS: There were 427 patients in the Infusion group and 153 in the No infusion group. Patients in both groups had similar demographics. Mean autologous infusion volume was 698 mL. The Infusion group had a higher percentage of EBL relative to the estimated blood volume (42.2%) than the No Infusion group (19.6%, p < .000). Allogeneic transfusion was more common in the Infusion group (255/427, 60%) than the No Infusion group (67/153, 44%, p = .001). The number of allogeneic blood units transfused was also higher in the Infusion group (2.4) than the No Infusion group (1.7, p = .009). Total blood costs ranged from $396 to $2,146 in the No Infusion group and from $1,262 to $5,088 in the Infusion group. If the cost of cell saver blood was transformed into costs of allogeneic blood, total blood costs for the Infusion group would range from $840 to $5,418. Thus, cell saver use yielded a mean cost savings ranging from $330 to $422 (allogeneic blood averted). Linear regression showed that after an EBL of 614 mL, cell saver becomes cost-efficient. CONCLUSION: Compared to transfusing allogeneic blood, cell saver autologous infusion did not reduce the proportion or the volume of allogeneic transfusion for patients undergoing surgery for adult spinal deformity. The use of cell saver becomes cost-efficient above an EBL of 614 mL, producing a cost savings of $330 to $422. LEVEL OF EVIDENCE: Level III.

Impact of Parkinson's disease on perioperative complications and hospital cost in multilevel spine fusion: A population-based analysis.

Parkinson's disease (PD) is a neurodegenerative disorder manifesting over time to result in reduced mobility. The impact of PD on spinal fusion has yet to be addressed on a nationwide level. The Nationwide Inpatient Sample (NIS) from 2001 to 2012 was used for analysis. Admissions with spinal fusion of two or more vertebrae (ICD-9 codes=81.62, 81.63 and 81.64) were included and then stratified based on the presence or absence of PD (ICD-9 code=332.0); patients with cancer (ICD-9 codes=140-239) or trauma (ICD-9 codes=805.0-806.9) were excluded. Propensity score matching adjusted for potential confounding effects introduced by patient age, race, sex, and primary payer for care. 570,858 patients receiving spinal fusion of two or three vertebrae (1-2 levels) were identified, 2648 (0.5%) of whom had PD. Analysis revealed that PD was independently predictive for increased in-hospital mortality, durotomy, paraplegia, postoperative infection, venous thrombotic events, inferior vena cava filter placement, red blood cell transfusion, pulmonary embolism, total hospital charge >$200,000, length of stay >1week, non-routine discharge disposition, acute respiratory distress syndrome, acute posthemorrhagic anemia, multisystem complications (nervous system, cardiac, respiratory, urinary), and device-related complications (all P<0.001). In conclusion, these findings from a nationwide analysis comprising a 12-year period indicate that PD is significantly associated with increased in-hospital morbidity, mortality, and cost following spine fusion of 1-2 levels when compared with the general population. These findings point to the need for risk stratification and adjustment of quality metrics for this growing patient population, and should be integrated into operative decision-making and patient counseling.

Impact of cost valuation on cost-effectiveness in adult spine deformity surgery.

BACKGROUND CONTEXT: Over the past decade, the number of adult spinal deformity (ASD) surgeries has more than doubled in the United States. The complex surgeries needed to manage ASD are associated with significant resource utilization and high cost, making them a primary target for increased scrutiny. Accordingly, it is important to not only demonstrate value in ASD surgery as clinical effectiveness but also to translate outcome assessment to cost-effectiveness. PURPOSE: To compare the difference between Medicare allowable rates and the actual, direct hospital costs for ASD surgeries. STUDY DESIGN: Longitudinal cohort. PATIENT SAMPLE: Consecutive patients enrolled in an ASD database from a single institution. OUTCOME MEASURES: Short Form (SF)-6D. METHODS: Consecutive patients enrolled in an ASD database from a single institution from 2008 to 2013 were identified. Direct hospital costs were collected from hospital administrative records for the entire inpatient episode of surgical care. Medicare allowable rates were calculated for the same inpatient stays using the year-appropriate Center for Medicare-Medicaid Services Inpatient Pricer Payment System Tool. The SF-6D, a utility index derived from the SF-36v1, was used to determine quality-adjusted life years (QALY). Costs and QALYs were discounted at 3.5% annually. RESULTS: Of 580 surgical ASD patients eligible for 2-year follow up, 346 (60%) had complete baseline and 2-year data, and 60 were Medicare beneficiaries comprising the cohort for the present study. Mean SF-6D gained is 0.10 during year 1 after surgery and 0.02 at year 2, resulting in a cumulative SF-6D gain of 0.12 over 2 years. Mean Medicare allowable rate over the 2 years is $82,050 (range $42,383 to $220,749) and mean direct cost is $99,114 (range $28,447 to $217,717). Mean cost per QALY over 2 years is $683,750 using Medicare allowable rates and $825,950 using direct costs. This difference of $17,181 between the 2 cost calculation represents a 17% difference, which was statistically significant (p<.001). CONCLUSIONS: There is a significant difference in direct hospital costs versus Medicare allowable rates in ASD surgery and in turn, there is a similar difference in the cost per QALY calculation. Utilizing Medicare allowable rates not only underestimates (17%) the cost of ASD surgery, but it also creates inaccurate and unrealistic expectations for researchers and policymakers.