Effects of liposomal bupivacaine on opioid use and healthcare resource utilization after outpatient spine surgery: a real-world assessment.

BACKGROUND CONTEXT: Perioperative pain management affects cost and outcomes in elective spine surgery. PURPOSE: This study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization. STUDY DESIGN: This was a retrospective comparative study. PATIENT SAMPLE: Eligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores. OUTCOME MEASURES: Outcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis. METHODS: Deidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc. RESULTS: In total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, -52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, -50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, -31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts. CONCLUSIONS: Use of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery.

Inferior Clinical Outcomes for Patients with Medicaid Insurance After Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients.

BACKGROUND: It remains unclear how type of insurance coverage affects long-term, spine-specific patient-reported outcomes (PROs). This study sought to elucidate the impact of insurance on clinical outcomes after lumbar spondylolisthesis surgery. METHODS: The prospective Quality Outcomes Database registry was queried for patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery. Twenty-four-month PROs were compared and included Oswestry Disability Index, Numeric Rating Scale (NRS) back pain, NRS leg pain, EuroQol-5D, and North American Spine Society Satisfaction. RESULTS: A total of 608 patients undergoing surgery for grade 1 degenerative lumbar spondylolisthesis (mean age, 62.5 ± 11.5 years and 59.2% women) were selected. Insurance types included private insurance (n = 319; 52.5%), Medicare (n = 235; 38.7%), Medicaid (n = 36; 5.9%), and Veterans Affairs (VA)/government (n = 17; 2.8%). One patient (0.2%) was uninsured and was removed from the analyses. Regardless of insurance status, compared to baseline, all 4 cohorts improved significantly regarding ODI, NRS-BP, NRS-LP, and EQ-5D scores (P < 0.001). In adjusted multivariable analyses, compared with patients with private insurance, Medicaid was associated with worse 24-month postoperative Oswestry Disability Index (ß = 10.2; 95% confidence interval [CI], 3.9-16.5; P = 0.002) and NRS leg pain (ß =1.3; 95% CI, 0.3-2.4; P = 0.02). Medicaid was associated with worse EuroQol-5D scores compared with private insurance (ß = -0.07; 95% CI -0.01 to -0.14; P = 0.03), but not compared with Medicare and VA/government insurance (P > 0.05). Medicaid was associated with lower odds of reaching ODI minimal clinically important difference (odds ratio, 0.2; 95% CI, 0.03-0.7; P = 0.02) compared with VA/government insurance. NRS back pain and North American Spine Society satisfaction did not differ by insurance coverage (P > 0.05). CONCLUSIONS: Despite adjusting for potential confounding variables, Medicaid coverage was independently associated with worse 24-month PROs after lumbar spondylolisthesis surgery compared with other payer types. Although all improved postoperatively, those with Medicaid coverage had relatively inferior improvements.

High-impact chronic pain transition in surgical recipients with cervical spondylotic myelopathy.

OBJECTIVE: High-impact chronic pain (HICP) is a recently proposed metric that indicates the presence of a severe and troubling pain-related condition. Surgery for cervical spondylotic myelopathy (CSM) is designed to halt disease transition independent of chronic pain status. To date, the prevalence of HICP in individuals with CSM and their HICP transition from presurgery is unexplored. The authors sought to define HICP prevalence, transition, and outcomes in patients with CSM who underwent surgery and identify predictors of these HICP transition groups. METHODS: CSM surgical recipients were categorized as HICP at presurgery and 3 months if they exhibited pain that lasted 6-12 months or longer with at least one major activity restriction. HICP transition groups were categorized and evaluated for outcomes. Multivariate multinomial modeling was used to predict HICP transition categorization. RESULTS: A majority (56.1%) of individuals exhibited HICP preoperatively; this value declined to 15.9% at 3 months (71.6% reduction). The presence of HICP was also reflective of other self-reported outcomes at 3 and 12 months, as most demonstrated notable improvement. Higher severity in all categories of self-reported outcomes was related to a continued HICP condition at 3 months. Both social and biological factors predicted HICP translation, with social factors being predominant in transitioning to HICP (from none preoperatively). CONCLUSIONS: Many individuals who received CSM surgery changed HICP status at 3 months. In a surgical population where decisions are based on disease progression, most of the changed status went from HICP preoperatively to none at 3 months. Both social and biological risk factors predicted HICP transition assignment.

Social risk factors predicting outcomes of cervical myelopathy surgery.

OBJECTIVE: Combinations of certain social risk factors of race, sex, education, socioeconomic status (SES), insurance, education, employment, and one's housing situation have been associated with poorer pain and disability outcomes after lumbar spine surgery. To date, an exploration of such factors in patients with cervical spine surgery has not been conducted. The objective of the current work was to 1) define the social risk phenotypes of individuals who have undergone cervical spine surgery for myelopathy and 2) analyze their predictive capacity toward disability, pain, quality of life, and patient satisfaction-based outcomes. METHODS: The Cervical Myelopathy Quality Outcomes Database was queried for the period from January 2016 to December 2018. Race/ethnicity, educational attainment, SES, insurance payer, and employment status were modeled into unique social phenotypes using latent class analyses. Proportions of social groups were analyzed for demonstrating a minimal clinically important difference (MCID) of 30% from baseline for disability, neck and arm pain, quality of life, and patient satisfaction at the 3-month and 1-year follow-ups. RESULTS: A total of 730 individuals who had undergone cervical myelopathy surgery were included in the final cohort. Latent class analysis identified 2 subgroups: 1) high risk (non-White race and ethnicity, lower educational attainment, not working, poor insurance, and predominantly lower SES), n = 268, 36.7% (class 1); and 2) low risk (White, employed with good insurance, and higher education and SES), n = 462, 63.3% (class 2). For both 3-month and 1-year outcomes, the high-risk group (class 1) had decreased odds (all p < 0.05) of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Being in the low-risk group (class 2) resulted in an increased odds of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Neither group had increased or decreased odds of being satisfied with surgery. CONCLUSIONS: Although 2 groups underwent similar surgical approaches, the social phenotype involving non-White race/ethnicity, poor insurance, lower SES, and poor employment did not meet MCIDs for a variety of outcome measures. This finding should prompt surgeons to proactively incorporate socially conscience care pathways within healthcare systems, as well as to optimize community-based resources to improve outcomes and personalize care for populations at social risk.

Availability and Variability of Consumer Prices for Lumbar Discectomy Across US Hospitals in 2018.

OBJECTIVE: To determine the availability and variability of consumer pricing data for an elective lumbar discectomy in the USA. METHODS: Hospital representatives were contacted via telephone, hospital websites, and state price-transparency websites. A total of 153 hospitals were contacted via telephone calls under the guise of a patient requesting a self-pay price for elective lumbar discectomy. The same hospitals were then researched for price comparison between those requested by phone and those listed on hospital websites after installment of the price transparency law by the Centers of Medicare and Medicaid Services (CMS) on 1 January 2019. Complete and partial prices were recorded for both datasets when available. Hospitals were grouped based on profit status, teaching status, and geographical region. Statistical analysis compared rates of price availability and mean prices between hospital groups and between datasets. RESULTS: Thirty-four (23.0%) of 148 hospitals included in the final analysis were able to provide complete price information via telephone. An additional 70 (47.3%) were able to provide a partial price. A total of four (2.7%) institutions provided a complete price and an additional 65 (43.9%) provided a partial price via website. The mean complete price for microdiscectomy when provided was $27,342.36 (n = 34). When compared to government and non-profit hospitals combined, private hospitals had significantly lower partial-prices. CONCLUSION: A patient seeking to undergo a common surgical procedure in the USA will likely be met with difficulty and few options if motivated by price. A high degree of variability exists among US hospitals in 2018 with regards to availability and comprehensiveness of pricing information.

Patient Participation With a Mobile Phone Application for Objective Activity Assessment Before and After Spinal Fusion.

Background  Evolution within spine surgery is driven by a surgeon's desire for expertise and significant improvement in their patients' quality of life. As surgeons move away from using subjective patient-reported outcome (PRO) surveys, there must be an alternative objective metric in its place. Modern iPhone (Apple Inc., Cupertino, CA) technology can be used to capture daily activity in a simple, non-user biased manner. These health data can be used to analyze objective functional status in conjunction with PRO surveys to measure surgical outcomes. Methods  Patients who underwent an awake transforaminal lumbar interbody fusion (TLIF) between 2014 and 2018 at our institution were identified. Patients were consented and instructed to download the application "QS Access" (Quantified Self Labs, San Francisco, CA). Following data collection, we analyzed the demographic information of patients who were reached to gauge participation and feasibility of data exportation. Results A total of 177 patients who underwent an awake TLIF at our institution were contacted. Of those who answered, 41 (44.6%) agreed to participate and 51 (55.4%) declined to participate. When comparing those who either participated or declined, there were no significant differences in age (p=0.145), sex (p=0.589), or ethnicity (p=0.686). Conclusion  Our pilot study examined the patient participation in the novel usage of Apple "Health" data, queried from "QS Access" (Quantified Self Labs), to objectively measure relative patient functional status surrounding spinal fusion. We demonstrated that a smartphone-based application was mostly well received by our patient cohort and has the potential to be used as an objective operative metric moving forward.

Reduced Acute Care Costs With the ERAS® Minimally Invasive Transforaminal Lumbar Interbody Fusion Compared With Conventional Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Enhancing Recovery After Surgery (ERAS®) programs have been widely adopted throughout the world, but not in spinal surgery. In this report, we review the implementation of a "fast track" surgery for lumbar fusion and its effect on acute care hospitalization costs. OBJECTIVE: To determine if a "fast track" surgery methodology results in acute care cost savings. METHODS: Thirty-eight consecutive ERAS patients were compared with patients undergoing conventional minimally invasive transforaminal lumbar interbody fusion. Differences between these groups included the use of endoscopic decompression, injections of liposomal bupivacaine, and performing the surgery under sedation in the ERAS® group. RESULTS: Patients had similar medical comorbidities (2.02 vs 2 for ERAS® and comparator groups, respectively; P = .458). Body mass index was similar (26.5 vs 27.0; P = .329). ERAS® patients were older (65 vs 59 yr, P = .031). Both groups had excellent clinical results with an improvement of 23% and 24%, respectively. Intraoperative blood loss was less (68 ± 31 cc vs 231 ± 73, P < 0.001). Length of stay was also less with ERAS® surgery, at a mean of 1.23 ± 0.8 d vs 3.9 ± 1.1 d (P = 0.009). When comparing ERAS® surgery to standard minimally invasive transforaminal lumbar interbody fusion, the total cost for the acute care hospitalization was $19 212 vs $22 656, respectively (P < 0.001). This reflected an average of $3444 in savings, which was a 15.2% reduction. CONCLUSION: ERAS® programs for spinal fusion surgery have the potential to reduce the costs of acute care. This is made possible by leveraging less invasive interventions to minimize soft tissue damage.

Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery.

OBJECTIVE The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery. METHODS Medicare's Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion. RESULTS Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay. CONCLUSIONS Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.

Metals in Spine.

The treatment of spinal disorders requires the consideration of a number of factors and understanding the type of material we are implanting is important. Alloys have different mechanical properties and behave differently under different physiologic conditions. Spinal implants need to have good performance in the characteristics of biofunctionality and biocompatibility. In this review, the alloys titanium, cobalt-chrome, nitinol, and tantalum will be examined closely. Several of the important properties that are considered when selecting an alloy for use in spinal instrumentation are explored and detailed for each. This allows for an assessment and comparison of each alloy and a possible determination of which is the best alloy for specific surgery or the best alloy for use in specific situations.

The clinical and economic impact of the use of diabetes-specific enteral formula on ICU patients with type 2 diabetes.

BACKGROUND & AIMS: Patients admitted to intensive care units (ICUs) often need enteral nutrition (EN) support. For patients with type 2 diabetes (T2D), standard EN formulas may not provide ideal nutrients. The purpose was to investigate whether use of a diabetes-specific formula (DSF) could provide clinical and health economic benefits (compared to standard formulas) in critically ill patients with T2D. METHODS: This study was a retrospective analysis of medical records and expenditure data covering a 5-year period (2009-2013) from the hospitalization database of the National Taiwan University Hospital. Records of ICU patients who had T2D and were receiving enteral feeding with either the DSF or non-diabetes-specific formula (non-DSF) for at least 5 days were included in the analysis. Mortality, ICU length of stay (LOS), diabetes-related medications, and total costs of care (including all costs covered by the National Health Insurance and private expenses) were considered as the primary outcomes. RESULTS: A total of 158 patient records were analyzed in the DSF group and 794 in the non-DSF group. The baseline demographics including age, gender, weight, body mass index (BMI), and comorbidity patterns were mostly comparable between the groups. Compared to those receiving non-DSF, patients with T2D receiving DSF were found to have significantly decreased mortality (5.1% vs. 12.3%, P = 0.0118) and reduced need for insulin prescription (29.1% vs. 38.4%, P = 0.0269). ICU LOS was shorter for DSF patients, but no statistical difference was found (13.0 days vs. 15.1 days, P = 0.1843). However, significantly lower total ICU costs were reported for DSF patients (6700 USD vs. 9200 USD, P < 0.0001). CONCLUSIONS: The use of DSF in ICU patients with T2D is correlated with significant reduction in mortality and improved health economic outcomes.

Economic impact of minimally invasive lumbar surgery.

Cost effectiveness has been demonstrated for traditional lumbar discectomy, lumbar laminectomy as well as for instrumented and noninstrumented arthrodesis. While emerging evidence suggests that minimally invasive spine surgery reduces morbidity, duration of hospitalization, and accelerates return to activites of daily living, data regarding cost effectiveness of these novel techniques is limited. The current study analyzes all available data on minimally invasive techniques for lumbar discectomy, decompression, short-segment fusion and deformity surgery. In general, minimally invasive spine procedures appear to hold promise in quicker patient recovery times and earlier return to work. Thus, minimally invasive lumbar spine surgery appears to have the potential to be a cost-effective intervention. Moreover, novel less invasive procedures are less destabilizing and may therefore be utilized in certain indications that traditionally required arthrodesis procedures. However, there is a lack of studies analyzing the economic impact of minimally invasive spine surgery. Future studies are necessary to confirm the durability and further define indications for minimally invasive lumbar spine procedures.

Is minimal access spine surgery more cost-effective than conventional spine surgery?

STUDY DESIGN: Systematic review. OBJECTIVE: To summarize and critically review the economic literature evaluating the cost-effectiveness of minimal access surgery (MAS) compared with conventional open procedures for the cervical and lumbar spine. SUMMARY OF BACKGROUND DATA: MAS techniques may improve perioperative parameters (length of hospital stay and extent of blood loss) compared with conventional open approaches. However, some have questioned the clinical efficacy of these differences and the associated cost-effectiveness implications. When considering the long-term outcomes, there seem to be no significant differences between MAS and open surgery. METHODS: PubMed, EMBASE, the Cochrane Collaboration database, University of York, Centre for Reviews and Dissemination (NHS-EED and HTA), and the Tufts CEA Registry were reviewed to identify full economic studies comparing MAS with open techniques prior to December 24, 2013, based on the key questions established a priori. Only economic studies that evaluated and synthesized the costs and consequences of MAS compared with conventional open procedures (i.e., cost-minimization, cost-benefit, cost-effectiveness, or cost-utility) were considered for inclusion. Full text of the articles meeting inclusion criteria were reviewed by 2 independent investigators to obtain the final collection of included studies. The Quality of Health Economic Studies instrument was scored by 2 independent reviewers to provide an initial basis for critical appraisal of included economic studies. RESULTS: The search strategy yielded 198 potentially relevant citations, and 6 studies met the inclusion criteria, evaluating the costs and consequences of MAS versus conventional open procedures performed for the lumbar spine; no studies for the cervical spine met the inclusion criteria. Studies compared MAS tubular discectomy with conventional microdiscectomy, minimal access transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion, and multilevel hemilaminectomy via MAS versus open approach. CONCLUSION: Overall, the included cost-effectiveness studies generally supported no significant differences between open surgery and MAS lumbar approaches. However, these conclusions are preliminary because there was a paucity of high-quality evidence. Much of the evidence lacked details on methodology for modeling, related assumptions, justification of economic model chosen, and sources and types of included costs and consequences. The follow-up periods were highly variable, indirect costs were not frequently analyzed or reported, and many of the studies were conducted by a single group, thereby limiting generalizability. Prospective studies are needed to define differences and optimal treatment algorithms. LEVEL OF EVIDENCE: 3.

A comparison of acute hospital charges after tubular versus open microdiskectomy.

OBJECTIVE: To determine if tubular microdiskectomy is associated with differences in hospital charges compared with open microdiskectomy. METHODS: A retrospective review of patients who underwent tubular microdiskectomy or open microdiskectomy performed by the senior authors from 2007-2010 was performed. The primary outcome was inflation-adjusted total hospital charges for each procedure using itemized charge data obtained from the hospital finance department. Secondary outcomes included length of stay, complications, and operative times. RESULTS: There were 76 eligible patients (33 open microdiskectomy and 48 tubular microdiskectomy) identified during the study period. The mean total charge was $27,811 (standard deviation $11,198) in the open group compared with $22,358 (standard deviation $8695) in the tubular group. Total charges in the tubular group were on average $5453 less than in the open group (P = 0.02). There were no significant differences in operative times or complications. Length of stay was significantly shorter in the tubular group (mean 1.5 days open vs. 0.9 days tubular, P = 0.01). CONCLUSIONS: This analysis revealed significantly lower acute hospital charges associated with tubular microdiskectomy versus open microdiskectomy at an academic tertiary care hospital. These differences appear to the related to decreased use of postoperative resources in the tubular group.