The Rise and Fall of Bone Morphogenetic Protein 2 Throughout the United States.

STUDY DESIGN: Retrospective Database Study. OBJECTIVE: Investigate utilization of bone morphogenetic protein (BMP-2) between 2004 and 2014. SUMMARY OF BACKGROUND DATA: The utilization, particularly off-label utilization, of BMP-2 has been controversial and debated in the literature. Given the concerns regarding cancer and potential complications, the risk benefit profile of BMP must be weighed with each surgical case. The debate regarding the costs and potential side effects of BMP-2 compared with autologous iliac crest bone harvest has continued. METHODS: The National Inpatient Sample (NIS) database was queried for the use of BMP-2 (ICD-9-CM 84.52) between 2004 and 2014 across 44 states. The NIS database represents a 20% sample of discharges, weighted to provide national estimates. BMP-2 utilization rates in spine surgery fusion procedures were calculated as a fraction of the total number of thoracic, lumbar, and sacral spinal fusion surgeries performed each year. RESULTS: Between 2004 and 2014, BMP-2 was utilized in 927,275 spinal fusion surgeries. In 2004, BMP-2 was utilized in 28.3% of all cases (N=48,613). The relative use of BMP-2 in spine fusion surgeries peaked in 2008 at 47.0% (N=112,180). Since then, it has continued to steadily decline with an endpoint of 23.6% of cases in 2014 (N=60,863). CONCLUSIONS: Throughout the United States, the utilization of BMP-2 in thoracolumbar fusion surgeries increased from 28.3% to 47.0% between 2004 and 2008. However, from 2008 to 2014, the utilization of BMP-2 in thoracolumbar spine fusion surgeries decreased significantly from 47.0% to 23.4%. While this study provides information on the utilization of BMP-2 for the entire United States over an 11-year period, further research is needed to the determine the factors affecting these trends.

The Expanding Frontier of Outpatient Spine Surgery.

BACKGROUND: In 2014, inpatient spinal fusion surgery had the highest aggregate cost of any inpatient surgery performed in the United States, costing 12 billion dollars. As the national health care system seeks to improve value-based care, there is increased motivation to perform surgery on an outpatient basis. To ensure improved patient outcomes with this transition, patient selection has become increasingly important to identify who would most benefit from outpatient spine fusion, for example. This demands an improved understanding of the demographics of patients who have been receiving outpatient spine fusion on which the spine surgery community can build to improve cost-effective care delivered. METHODS: The Healthcare Cost and Utilization Project, State Ambulatory Surgery Databases, and Agency for Healthcare Research and Quality databases were queried for demographic data regarding all-cause outpatient spine surgery between 2012 and 2014. Outpatient surgery volume was compared with inpatient surgery volume-which was provided by the State Inpatient Databases. RESULTS: A total of 1,164,040 spine fusion procedures were identified between 2012 and 2014, of which 132,900 procedures were performed as outpatient surgery (11.4%). Of all fusion procedures amongst 18- to 44-year-old patients, 18.4% were outpatient. A larger proportion of white patients, rather than black or Hispanic patients, underwent ambulatory procedures (12.14% vs 9.53% vs 7.46%, respectively); 16.54% of spinal fusion procedures for patients with private insurance was performed on an outpatient basis. Based on patient income, 76% of all outpatient fusions were performed on patients who live in "not low" income ZIP codes. CONCLUSIONS: There has been a gradual trend toward performing more outpatient spinal fusion procedures over the studied period. This study has also revealed unique trends in the demographics of patients who have received outpatient spine fusion during this time. LEVEL OF EVIDENCE: 3.

Marked Increase in Spinal Deformity Surgery Throughout the United States.

STUDY DESIGN: Retrospective cohort database study. OBJECTIVE: The aim of this study was to investigate trends in utilization and demographics in Spinal Deformity Surgery. SUMMARY OF BACKGROUND DATA: The aging population in the United States will likely result in increased incidence of adult degenerative scoliosis. With a national focus on resource utilization and value-based care, it is essential for surgeons, researchers, and health care policy makers to know utilization and demographic trends of spinal surgery with long fusion construct. METHODS: The National Inpatient Sample (NIS) database was queried for patients who underwent fusion or refusion of nine or more vertebrae (ICD-9-CM 81.64) between 2004 and 2015 across 44 states. Demographic and economic data include annual number of surgeries, incidence, patient age, sex, region, insurance type, charge, routine discharge, length of stay, and data. The NIS database represents a 20% sample of discharges from US hospitals, excluding rehabilitation and long-term acute care hospitals, which is weighted to provide national estimates. RESULT: In 2014, there were 14,615 fusions involving nine or more vertebrae across the United States. The number of fusions involving nine or more levels has increased 141% from 6072 in 2004. Long fusion constructs increased 460% from 2004 to 2014 among patients 65 to 84 years' old. The mean hospital cost associated with long fusion spine surgery was $69,546 per case in 2015. Between 2004 and 2014, the payer breakdown for individuals receiving spinal deformity surgery is as follows: 54.2% private insurance, 18% Medicare, and 21.2% Medicaid. CONCLUSION: The massive increase (141%) in utilization of long construct spine fusion was primarily driven by 460% rise in incidence of the surgery among those aged 65 to 84. Although the cause is unknown, it is possible that this rise was, at least in part, driven by the implementation of the affordable care act, improved surgical safety, and better knowledge of spinopelvic parameters.Level of Evidence: 3.