Workers' Compensation Status and Outcomes Following Lumbar Surgery.

OBJECTIVE: To determine the influence of preoperative workers' compensation (WC) status on patient-reported outcome measures following lumbar decompression with or without fusion. METHODS: All patients undergoing lumbar decompression with or without fusion at a single academic institution between 2013 and 2017 were identified. Patients were split into groups based on WC status: no workers' compensation (NWC), WC), or retired. Intragroup analysis used paired t tests. Outcomes between groups were compared using Kruskal-Wallis H test. Multiple linear regression analysis determined if WC status was a predictor of change in patient-reported outcome measures. Subgroup analysis was conducted for WC patients who returned to work. RESULTS: Of 571 included patients, 242 (43.4%) had NWC, 83 (14.5%) had WC, and 246 (43.1%) were retired. Comparing within groups, WC patients showed significant improvement in Short Form-12 Health Survey Physical Component Score, Oswestry Disability Index, visual analog scale (VAS) back pain, and VAS leg pain (all P < 0.001) after surgery. However, WC patients improved less than NWC or retired patients in Short Form-12 Health Survey Physical Component Score (P = 0.010), VAS back pain (P = 0.028), and VAS leg pain (P = 0.015). WC was an independent predictor of decreased improvement in Short Form-12 Health Survey Physical Component Score (ß = -4.31, P = 0.001), VAS back pain (ß = 0.90, P = 0.034), and VAS leg pain (ß = 1.50, P = 0.002) on multivariate analysis. WC patients who did not return to work was an independent predictor of decreased improvement in VAS back pain (ß = 1.39, P = 0.016) and VAS leg pain (ß = 2.11, P = 0.001). CONCLUSIONS: WC patients improve less than NWC patients. However, WC patients who return to work have similar VAS back and neck pain improvements as NWC patients.

Processing and Handling Cost of Single-use Versus Traditional Instrumentation for 1 Level Lumbar Fusions.

STUDY DESIGN: A single center, observational prospective clinical study. OBJECTIVE: The aim of this study was to compare the instrumentation-related cost and efficiency of single-use instrumentation versus traditional reusable instrument trays. SUMMARY OF BACKGROUND DATA: Single-use instrumentation provides the opportunity to reduce costs associated with cleaning and sterilizing instrumentation after surgery. Although previous studies have shown single-use instrumentation is effective in other orthopedic specialties, it is unclear if single-use instrumentation could provide economic advantages in spine surgery. MATERIALS AND METHODS: A total of 40 (20 reusable instrumentation and 20 single-use instrumentation) lumbar decompression (1-3 level) and fusion (1 level) spine surgeries were collected. Instrument handling, opening, setup, re-stocking, cleaning, sterilization, inspection, packaging, and storage were recorded by direct observation for both reusable and single-use instrumentation. The rate of infection was noted for each group. RESULTS: Mean time of handling instruments by the scrub nurse was 11.6 (±3.9) minutes for reusable instrumentation and 2.1 (±0.5) minutes for single-use instrumentation. Mean cost of handling reusable instruments was estimated to be $8.52 (±$2.96) per case, and the average cost to reprocess a single tray by Sterilization Processing Department (SPD) was $58. Thus, the median cost for sterilizing 2 reusable trays per case was $116, resulting in an average total Costresuable of $124.52 (±$2.96). Mean cost of handling single-use instrumentation was estimated to be $1.57 ($0.38) per case. CONCLUSION: Single-use instrumentation provided greater cost savings and reduced time from the opening of instrumentation to use in surgery when compared with reusable instrumentation.

Economics of Cervical Disc Replacement.

BACKGROUND: Although extensive reports of clinical outcome after cervical disc replacement (CDR) and anterior cervical discectomy and fusion exist, few reviews of the cost-effectiveness research in cervical spine surgery exist. The purpose of this study was to review the concepts of cost-effectiveness research, the various approaches to cost-effectiveness studies in the context of cervical spine surgery, and some of the literature results. METHODS: Review article describing cost-effectiveness research concepts, methodology, and results. The article reviews the concept of value, cost, utility, incremental cost-effectiveness ratio, and recent research. RESULTS: Mixed data on cost-effectiveness of CDR compared with fusion exist. Notably, several studies performed within the last 5 years that use prospectively collected utility scores, costs, and adverse event calculations demonstrate a significant cost savings associated with CDR compared with fusion. CONCLUSIONS: The recent literature confirms that, in properly selected patients, CDR is more effective and less costly over a 7-year time horizon for patients with symptomatic degenerative disc disease. The primary driver of the differential in cost effectiveness is the difference in secondary surgery rates. LEVEL OF EVIDENCE: Level 5 CLINICAL RELEVANCE: In properly selected patients, CDR is more effective and less costly over a 7-year time horizon for patients with symptomatic degenerative disc disease.

Medicaid Reimbursement for Common Spine Procedures: Are Compensation Rates Consistent?

STUDY DESIGN: Health Services Research. OBJECTIVE: The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery. SUMMARY OF BACKGROUND DATA: The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively. METHODS: MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement. RESULTS: The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR. CONCLUSION: Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care. LEVEL OF EVIDENCE: 4.

Value of Cervical Disk Arthroplasty.

Over the last decade, several of the Food and Drug Administration-regulated investigational device exemption (IDE) trials have compared multiple cervical disk arthroplasty (CDA) devices to anterior cervical decompression and fusion (ACDF) showing comparable and even superior patient-reported outcomes. CDA has been an increasingly attractive option because of the positive outcomes and the motion-preserving technology. However, with the large burden that health care expenditures place on the economy, the focus is now on the value of treatment options. Cost-effectiveness studies assess value by evaluating both outcomes and cost, and recently several have been conducted comparing CDA and ACDF. The results have consistently shown that CDA is a cost-effective alternative, however, in comparison to ACDF the results remain inconclusive. The lack of incorporation of disease specific measures into health state utility values, the inconsistent methods of calculating cost, and the fact that a vast majority of the results have come from industry-sponsored studies makes it difficult to form a definitive conclusion. Despite these limitations, both procedures have proven to be safe, effective, and cost-efficient alternatives.

The Total Cost to the Health Care System in Medicare and Medicaid Patients for the Treatment of Cervical Myelopathy.

INTRODUCTION: Cervical myelopathy is a common indication for spine surgery. Modern medicine demands high quality, cost-effective treatment. Most cost analyses fail to account for complication costs from nonoperative treatment. The purpose is to compare the total health care costs for operative versus nonoperative treatment of cervical myelopathy. METHODS: The Center for Medicare and Medicaid Services Carrier File from 2005 to 2012 was reviewed using the PearlDiver database, representing a 5% sampling of Medicare billings which diagnosed patients with cervical myelopathy by International Classification of Diseases 9 code. Patients were separated into operative and nonoperative cohorts, and the total health care expenditures per patient normalized to 2012 dollars were collected. RESULTS: A total of 3209 patients were included, and 1755 (55.87%) underwent surgery. A 6-year cost analysis performed on 309 patients over the age of 65 from 2006 undergoing surgery resulted in a nonsignificant increase in total health care expenditures ($166,192 vs. $153,556; P=0.45). Operative treatment had a net decrease in total health care costs following the first year of surgery. CONCLUSIONS: There is no significant difference in the total health care expenditures for operative versus nonoperative treatment of cervical myelopathy after 3 years. It is critical to understand that nonoperative treatment of this progressive disease leads to a substantial increase in total health care expenditures with increased risk of falls, injury, and further morbidity.

Utilization of Time-driven Activity-based Costing to Determine the True Cost of a Single or 2-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This is a prospective case series. OBJECTIVE: To determine the actual cost of performing 1- or 2-level anterior cervical discectomy and fusion (ACDF) using actual patient data and the time-driven activity-based cost methodology. SUMMARY OF BACKGROUND DATA: As health care shifts to use value-based reimbursement, it is imperative to determine the true cost of surgical procedures. Time-driven activity-based costing determines the cost of care by determining the actual resources used in each step of the care cycle. MATERIALS AND METHODS: In total, 30 patients who underwent a 1- or 2-level ACDF by 3 surgeons at a specialty hospital were prospectively enrolled. To build an accurate process map, a research assistant accompanied the patient to every step in the care cycle including the preoperative visit, the preadmission testing, the surgery, and the postoperative visits for the first 90 days. All resources utilized and the time spent with every member of the care team was recorded. RESULTS: In total, 27 patients were analyzed. Eleven patients underwent a single-level ACDF and 16 underwent a 2-level fusion. The total cost for the episode of care was $29,299±$5048. The overwhelming cost driver was the hospital disposable costs ($13,920±$6325) which includes every item used during the hospital stay. Intraoperative personnel costs including fees for the surgeon, resident/fellow, anesthesia, nursing, surgical technician, neuromonitoring, radiology technician and orderlies, accounted for the second largest cost at $6066±$1540. The total cost excluding hospital overhead and disposables was $9071±$1939. CONCLUSIONS: Reimbursement for a bundle of care surrounding a 1- or 2-level ACDF should be no less than $29,299 to cover the true costs of the care for the entire care cycle. However, this cost may not include the true cost of all capital expenditures, and therefore may underestimate the cost.

The Effect of Hospital Ownership on Health Care Utilization in Orthopedic Surgery.

PURPOSE: To determine if ownership of a specialty hospital or ambulatory surgery centers (ASC) affects surgical volume. MATERIALS AND METHODS: All surgeries performed by 75 orthopedic surgeons at a single practice between January 1, 2010 and March 1, 2015 were identified. During this time, the practice purchased an ownership stake in 1 hospital and 3 ASC. The total surgical volume by partnership status and location was collected and analyzed. RESULTS: A total of 104,661 surgical surgeries were performed by 75 surgeons. Over the 62 months, there was an average increase in the number of surgical cases performed per surgeon per year of 2.82±0.48 cases; however, the average increase in cases per year was lower for equity partners by 1.51 cases per year (P<0.0001). In the 2 years before purchasing the specialty hospital, the increase in the number of surgical cases per surgeon per month was 0.093±0.087 cases. In the 2 years after investing in the physician-owned specialty hospital, there was a decrease in the number of cases performed per surgeon per month by 0.027±0.110 (P=0.92). CONCLUSIONS: In a well-established large orthopedic practice, surgeon ownership of a hospital or ASC does not lead to an increase in surgical volume. LEVEL OF EVIDENCE: Level 4.

Cervical Spine Surgery Complications and Risks in the Elderly.

STUDY DESIGN: Cervical decompression (CD) and cervical fusion (CF) patients in 5% Medicare Part B claims data. OBJECTIVE: Evaluate the complication rate and associated risk factors after cervical spine surgery using a national sample of elderly patients. SUMMARY OF BACKGROUND DATA: The number of cervical spine procedures in the United States has risen along with associated hospital costs. Postoperative complications lead to longer hospitalizations and greater costs. METHODS: Demographic information and postoperative complications (90 days) were evaluated. Multivariate Cox regression was used to evaluate the risk factors for the complications, while adjusting for age, socioeconomic status, Charlson comorbidity index, race, census region, sex, and year of surgery. RESULTS: Between 2010 and 2012, 1519 CD and 1273 CF Medicare patients were identified in the dataset. Respiratory complications (CD: 12.1% and CF: 14.6%), urinary retention (CD: 8.2% and CF: 9.1%), acute delirium (CD: 5.3% and CF: 6.0%), and nausea/vomiting (CD: 2.8% and CF: 3.1%) were the most commonly diagnosed complications. All other complications had an incidence of less than 1.5%. Older patients had higher risks of respiratory complications for both procedures, and CD patients with Charlson scores of 1 to 2 and 5+ were also at higher risk of respiratory complications. Males (P <0.001) were at higher risk of urinary retention. Patients with dementia (P <0.001) had a higher risk of acute delirium after both CD and CF. For CD patients, those aged 85 years and over had higher risk of acute delirium, along with patients with transient ischemic attack/stroke. Age was also a significant risk factor (P = 0.019) for acute delirium for CF patients. Females were at a significantly higher risk of nausea/vomiting after CD and CF. CONCLUSION: These data help to provide baseline information regarding the complication rates in the elderly CD and CF patient population in the United States, and will serve to help minimize these complications. LEVEL OF EVIDENCE: 3.

The Economic Implications of an Incidental Durotomy.

STUDY DESIGN: Case-control. OBJECTIVE: The aim of this study was to determine the economic impact of an incidental durotomy in spine surgery. SUMMARY OF BACKGROUND DATA: An incidental durotomy during spine surgery does not affect long-term outcomes, but as reimbursement moves toward bundled payments, it may substantially affect the profitability of spine surgery. METHODS: A retrospective review of a prospectively collected morbidity and mortality database identified all patients with an incidental durotomy between January 1, 2012, and January 11, 2013. Subjects with a dural tear were matched to controls (1 : 2) without a dural tear, and the total charges for one year were collected. Controls were required to meet the following criteria: Age ±5 years; Charlson Comorbidity Index (CCI) ±1; Date of surgery ±2 years; Exact region of the spine, but not the exact level (i.e., lumbar → lumbar); Exact type of fusion (i.e., approach, instrumentation); Exact number of levels fused; Use of rhBMP-2; Number of levels decompressed ±1. RESULTS: Two controls without a dural tear could be identified for 57 patients who sustained an incidental durotomy. No difference in demographic data, emergency room visits, hospital readmissions, or revision surgeries between the groups was identified. Patients with an incidental durotomy had a longer operative time by 30.6 ±â€Š8.5 minutes (P < 0.01), longer length of stay by 0.89 ±â€Š0.27 days (P = 0.0001), and an increase in their average initial hospital charge by 18%. No increase in surgeon-based charges or hospital-based charges after the initial visit was identified. CONCLUSION: An incidental durotomy significantly increases the initial hospital charges for patients undergoing spine surgery; however, in this study it has no effect on surgeon-based charges or on hospital-based charges after discharge. LEVEL OF EVIDENCE: 3.

Seven-year cost-effectiveness of ProDisc-C total disc replacement: results from investigational device exemption and post-approval studies.

OBJECTIVE The purpose of this study was to evaluate the 7-year cost-effectiveness of cervical total disc replacement (CTDR) versus anterior cervical discectomy and fusion (ACDF) for the treatment of patients with single-level symptomatic degenerative disc disease. A change in the spending trajectory for spine care is to be achieved, in part, through the selection of interventions that have been proven effective yet cost less than other options. This analysis complements and builds upon findings from other cost-effectiveness evaluations of CTDR through the use of long-term, patient-level data from a randomized study. METHODS This was a 7-year health economic evaluation comparing CTDR versus ACDF from the US commercial payer perspective. Prospectively collected health care resource utilization and treatment effects (quality-adjusted life years [QALYs]) were obtained from individual patient-level adverse event reports and SF-36 data, respectively, from the randomized, multicenter ProDisc-C total disc replacement investigational device exemption (IDE) study and post-approval study. Statistical distributions for unit costs were derived from a commercial claims database and applied using Monte Carlo simulation. Patient-level costs and effects were modeled via multivariate probabilistic analysis. Confidence intervals for 7-year costs, effects, and net monetary benefit (NMB) were obtained using the nonparametric percentile method from results of 10,000 bootstrap simulations. The robustness of results was assessed through scenario analysis and within a parametric regression model controlling for baseline variables. RESULTS Seven-year follow-up data were available for more than 70% of the 209 randomized patients. In the base-case analysis, CTDR resulted in mean per-patient cost savings of $12,789 (95% CI $5362-$20,856) and per-patient QALY gains of 0.16 (95% CI -0.073 to 0.39) compared with ACDF over 7 years. CTDR was more effective and less costly in 90.8% of probabilistic simulations. CTDR was cost-effective in 99.8% of sensitivity analysis simulations and generated a mean incremental NMB of $20,679 (95% CI $6053-$35,377) per patient at a willingness-to-pay threshold of $50,000/QALY. CONCLUSIONS Based on this modeling evaluation, CTDR was found to be more effective and less costly over a 7-year time horizon for patients with single-level symptomatic degenerative disc disease. These results are robust across a range of scenarios and perspectives and are intended to support value-based decision making.

Costs of cervical disc replacement versus anterior cervical discectomy and fusion for treatment of single-level cervical disc disease: an analysis of the Blue Health Intelligence database for acute and long-term costs and complications.

STUDY DESIGN: Retrospective review of prospectively collective administrative data. OBJECTIVE: The purpose of this study was to determine the reoperation rates, adverse event rate, as well as the direct and follow-on costs of cervical disc arthroplasty (CDA) compared with anterior cervical discectomy and fusion (ACDF) in a "real-world" population of patients with single-level symptomatic cervical disc disease. SUMMARY OF BACKGROUND DATA: Until very recently, there was a paucity of human clinical data to demonstrate that CDA lowers the rate of adjacent segment disease over ACDF. METHODS: This was a retrospective, matched cohort analysis of a prospectively collected database of costs and outcomes for patients aged 18 to 60 years, who were continuously enrolled in a Blue Cross Plan contributing data to a claims database. Inclusion criteria were as follows: all patients who were treated surgically with either CDA or ACDF between January 2008 and December 2009, with single-level cervical pathology and claims reflecting at least 6 weeks of nonsurgical preoperative care without claims history of prior surgery. RESULTS: There were 6635 ACDF patients and 327 CDA patients. There were no significant differences in the incidence of comorbidities or mean follow-up time (ACDF 25.7 mo vs. CDA 26.1 mo) between groups. By 36 months postoperatively, the reoperation rate was significantly increased in the ACDF group (10.5%) versus the CDA group (5.7%) (hazard ratio, P = 0.0214). The index surgery and 90-day global window costs were significantly lower in the CDA groups. At final follow-up, there was a statistically significant reduction in total costs paid by insurer in CDA patients (CDA $34,979 vs. ACDF $39,820). CONCLUSION: Patients who underwent CDA for single-level degenerative disease had lower readmission rates, lower reoperation rates, and reduced index and total costs than those treated with ACDF. CDA was effective in reducing the monthly cost of care compared with ACDF. LEVEL OF EVIDENCE: 2.

Cost and value of spinal deformity surgery.

STUDY DESIGN: Literature review. OBJECTIVE: To assess (1) quality of life in patients with adult scoliosis who underwent nonoperative and/or surgical treatment, and (2) cost-effectiveness of different scoliosis treatment modalities. SUMMARY OF BACKGROUND DATA: Recently, there has been an interest in examining quality of life of patients undergoing treatment for adult scoliosis, comparing the value of nonoperative versus operative management. This article reviews the current literature on treatment of adult scoliosis, in the hopes of drawing conclusions for the best approach to these patients. METHODS: MEDLINE and PubMed databases were searched to identify articles. Health-related quality of life measures included Oswestry Disability Index scores, Scoliosis Research Society (SRS) instrument scores, 12-Item Short Form Health Survey, and numerical rating scale for leg and/or back pain. Studies included were those involving patients with adult scoliosis who underwent primary surgery or nonoperative management. The studies that focused on the change in validated outcome scores from the onset of the study to final follow-up were found to be valuable. Studies on predominantly adolescent scoliosis and those that only measured postoperative outcomes scores were excluded. RESULTS: The SRS-22, Oswestry Disability Index, 12-Item Short Form Health Survey, and numerical rating scale were found to be validated for measuring quality of life in patients with scoliosis. Thirteen studies were included, which evaluated changes in health-related quality of life outcomes from baseline in surgical and nonsurgical treatment of adult scoliosis. There was a trend toward improved quality of life measures in patients undergoing surgical treatment for adult scoliosis. CONCLUSION: Adults with painful and disabling scoliosis may benefit from surgical treatment compared with nonsurgical treatment, given the proper indications. Nonsurgical treatment does not seem to be cost-effective and has not shown to have a positive impact on quality of life, although there is a possibility that patients' health may have deteriorated if they did not receive the nonsurgical treatment. Future prospective studies focusing on the cost-effectiveness of adult scoliosis treatment and improvement of quality of life are needed to confirm the assertion of the current retrospective literature that surgery provides better quality of life than nonoperative treatment. LEVEL OF EVIDENCE: N/A.