Comparative Review of the Socioeconomic Burden of Lower Back Pain in the United States and Globally.

Internationally, the United States (U.S.) cites the highest cost burden of low back pain (LBP). The cost continues to rise, faster than the rate of inflation and overall growth of health expenditures. We performed a comprehensive literature review of peer-reviewed and non- peer-reviewed literature from PubMed, Scopus, and Google Scholar for contemporary data on prevalence, cost, and projected future costs. Policymakers in the U.S. have long attempted to address the high-cost burden of LBP through limiting low-value services and early imaging. Despite these efforts, costs (~$40 billion; ~$2,000/patient/yr) continue to rise with increasing rates of unindicated imaging, high rates of surgery, and subsequent revision surgery without proper trial of non-pharmacologic measures and no corresponding reduction in LBP prevalence. Globally, the overall prevalence of LBP continues to rise largely secondary to a growing aging population. Cost containment methods should focus on careful and comprehensive clinical assessment of patients to better understand when more resource-intensive interventions are indicated.

Failure in Adult Spinal Deformity Surgery: A Comprehensive Review of Current Rates, Mechanisms, and Prevention Strategies.

STUDY DESIGN: Literature review. OBJECTIVE: The aim of this review is to summarize recent literature on adult spinal deformity (ASD) treatment failure as well as prevention strategies for these failure modes. SUMMARY OF BACKGROUND DATA: There is substantial evidence that ASD surgery can provide significant clinical benefits to patients. The volume of ASD surgery is increasing, and significantly more complex procedures are being performed, especially in the aging population with multiple comorbidities. Although there is potential for significant improvements in pain and disability with ASD surgery, these procedures continue to be associated with major complications and even outright failure. METHODS: A systematic search of the PubMed database was performed for articles relevant to failure after ASD surgery. Institutional review board approval was not needed. RESULTS: Failure and the potential need for revision surgery generally fall into 1 of 4 well-defined phenotypes: clinical failure, radiographic failure, the need for reoperation, and lack of cost-effectiveness. Revision surgery rates remain relatively high, challenging the overall cost-effectiveness of these procedures. CONCLUSION: By consolidating the key evidence regarding failure, further research and innovation may be stimulated with the goal of significantly improving the safety and cost-effectiveness of ASD surgery.

Implementation of Outpatient Minimally Invasive Lumbar Decompression at an Academic Medical Center without Ambulatory Surgery Centers: A Cost Analysis and Systematic Review.

BACKGROUND: Lumbar decompressions are increasingly performed at ambulatory surgery centers (ASCs). We sought to compare costs of open and minimally invasive (MIS) lumbar decompressions performed at a university without dedicated ASCs. METHODS: Lumbar decompressions performed at a tertiary academic hospital or satellite university hospital dedicated to outpatient surgery were retrospectively reviewed. Care pathways were same-day, overnight observation, or inpatient admission. Patient demographics, American Society of Anesthesiologists classification, Charlson Comorbidity Index, surgical characteristics, 30-day readmission, and costs were collected. A systematic review of lumbar decompression cost literature was performed. RESULTS: A total of 354 patients, mean age 55 years with 128 women (36.2%), were reviewed. There was no significant difference in age, gender, body mass index, American Society of Anesthesiologists classification, or Charlson Comorbidity Index between patients treated with open and minimally invasive surgery. Open decompression was associated with higher total cost ($21,280 vs. $14,407; P < 0.001); however, this was driven by care pathway and length of stay. When stratifying by care pathway, there was no difference in total cost between open versus minimally invasive surgery among same-day ($10,609 vs. $11,074; P = 0.556), overnight observation ($14,097 vs. $13,992; P = 0.918), or inpatient admissions ($24,507 vs. $27,929; P = 0.311). CONCLUSIONS: When accounting for care pathway, the cost of open and MIS decompression were no different. Transition from a tertiary academic hospital to a university hospital specializing in outpatient surgery was not associated with lower costs. Academic departments may consider transitioning lumbar decompressions to a dedicated ASC to maximize cost savings; however, additional studies are needed.

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.

Systematic Review of Cost-Effectiveness Analyses in U.S. Spine Surgery.

BACKGROUND: Increasing costs put the value of spine surgery under scrutiny. In health economics, cost-effectiveness analyses (CEA) are used to compare the value of competing procedures. However, inconsistent methodology prevents standardization and implementation of recommendations. The goal of this study is to perform a systematic review of all U.S. CEAs in spine surgery reported to date, highlight their strengths and weaknesses, and define metrics essential for high-quality CEAs. METHODS: We followed AMSTAR systematic review methods, identifying all U.S. spine surgery CEAs reported to March 2019 with a structured, reproducible search of PubMed, Embase, and the Tufts CEA Registry. RESULTS: We identified 40 CEA studies. Twelve (30%) used outcome data from a randomized controlled trial. To calculate costs, 22 (55%) used allowed charges but costing methods were often unclear or imprecise. Studies applying discounting had mean follow-up of 5.92 years compared with 3.00 years for studies without. Eleven of 15 (73%) cervical studies compared cervical disc arthroplasty with anterior cervical discectomy and fusion, finding cervical disc arthroplasty to be cost-effective (<$100,000/quality-adjusted life year) for 1-level and 2-level procedures. Eleven of 25 lumbar studies (44%) compared operative with nonoperative interventions for intervertebral disc herniation, lumbar stenosis, and lumbar spondylolisthesis. Lumbar studies comparing surgical with nonoperative intervention found surgery at least cost-effective for intervertebral disc herniation and lumbar stenosis, but cost-effective only for lumbar spondylolisthesis at 4 years follow-up. Most studies (70%) lacked appropriate sensitivity analyses. CONCLUSIONS: Costing methodology remains obscure and inconsistent and incremental cost-effectiveness ratio results incomparable. The language of costing methodology must be standardized and sensitivity analyses of outcome and cost inputs mandatory for publication.

A pilot study on mobile phones as a means to access maternal health education in eastern rural Uganda.

Maternal mortality in Uganda has remained relatively high since 2006. We studied access to mobile phones and people's interest in receiving audio-based maternal health lessons delivered via a toll-free telephone line. Interviews were conducted, using a male and a female translator, with 42 men and 41 women in four villages located in eastern rural Uganda. Most of the participants were recruited through systematic sampling, but some were recruited through community organizations and antenatal clinics. Ownership of a mobile phone was reported by 79% of men and by 42% of women. Among those who did not own a mobile phone, 67% of men and 88% of women reported regularly borrowing a mobile phone. Among women, 98% reported interest in receiving maternal mobile health lessons, and 100% of men. Providing local communities with mobile maternal health education offers a new potential method of reducing maternal mortality.

Endoscopic versus open resection of tuberculum sellae meningiomas: a decision analysis.

BACKGROUND/AIMS: Tuberculum sellae meningiomas (TSMs) are challenging tumors for surgical resection. Endoscopic endonasal (EE) approaches to these lesions have not been directly compared to open craniotomy in a controlled trial. METHODS: We searched Medline and Embase online databases for English-language articles containing key words related to TSMs. Data were pooled, including 5 of our own patients reported here for the first time. Metaregression was used and a decision-analytical model was constructed to compare outcomes between open microsurgery and EE approaches. RESULTS: The overall quality of life (QOL) was not significantly different between the approaches (p = 0.410); however, there were large differences in individual complication rates. The Monte Carlo simulation yielded an overall average QOL in craniotomy patients of 0.915 and in endoscopic patients of 0.952. Endoscopy had a higher CSF leak rate (26.8 vs. 3.5%, p < 0.001) but a lower rate of injury to the optic apparatus (1.4 vs. 9.2%, p < 0.001) compared with craniotomy. The 3-year recurrence rates were not statistically different (p = 0.529). CONCLUSION: EE resection of TSMs appears to be a comparable alternative to traditional open microsurgical resection with respect to overall QOL based on available publications. A meaningful comparison of recurrence rates will require a longer follow-up.