A National Snapshot Detailing the Impact of Parkinson's Disease on the Cost and Outcome Profiles of Fusion Procedures for Cervical Myelopathy.

BACKGROUND: Studies suggest a higher prevalence of cervical deformities in Parkinson's Disease (PD) patients who predispose to cervical myelopathy (CM). Despite the profound effect of CM on function and quality of life, no study has assessed the influence of PD on costs and outcomes of fusion procedures for CM. OBJECTIVE: To conduct the first national-level study that provides a snapshot of the current outcome and cost profiles for different fusion procedures for CM in PD and non-PD populations. METHODS: Patients with or without PD who underwent cervical decompression and fusion anteriorly (ACDF), posteriorly (PCDF), or both (Frontback), for CM were identified from the 2013 to 2014 National Inpatient Sample using International Classification of Disease codes. RESULTS: A total of 75 870 CM patients were identified, with 535 patients (0.71%) also having PD. Although no difference existed between in-hospital mortality rates, overall complication rates were higher in PD patients (38.32% vs 22.05%; P < .001). PD patients had higher odds of pulmonary (P = .002), circulatory (P = .020), and hematological complications (P = .035). Following ACDFs, PD patients had higher odds of complications (P = .035), extended hospitalization (P = .026), greater total charges (P = .003), and nonhome discharge (P = .006). Although PCDFs and Frontbacks produced higher overall complication rates for both populations than ACDFs, PD status did not affect complication odds for these procedures. CONCLUSION: PD may increase risk for certain adverse outcomes depending on procedure type. This study provides data with implications in healthcare delivery, policy, and research regarding a patient population that will grow as our population ages and justifies further investigation in future prospective studies.

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.

Scarcity of Implants Has Partially Replaced Cervical Spondylotic Myelopathy Decompression and Instrumented Fusion with Implant-Less Expansile Cervical Laminoplasty: Poverty Teaches all the Arts.

OBJECTIVE: The scarcity of implants during the economic crisis partially has replaced decompression and instrumented fusion for the treatment of cervical spondylotic myelopathy with implant-less expansile cervical laminoplasty (ECL). The aim of the study was to compare the results obtained with instrumented anterior cervical corpectomy and fusion with implant-less ECL. METHODS: Patients suffering from cervical spondylotic myelopathy Nurick 3-5 with preoperative tethering and postoperative untethering were included. Exclusion criterion was kyphosis more than 10°. Patients were assessed according to 30-meter walking track (30mWT), Nurick, and modified Japanese Orthopaedic Association scale scores. Kinematic magnetic resonance imaging 3-dimensional subaxial spinal cord reconstructions were 3 dimensionally modeled to confirm preoperative pincer clamping and follow-up unclamping to measure subaxial spinal cord length and pia envelope area (PEA). RESULTS: A total of 35 patients divided in the ECL (n = 19) and the anterior cervical corpectomy and fusion (n = 16) groups were selected from 534 patients operated on between September 1, 2008, and August 31, 2013 as the result of degenerative cervical disorders. Patients improved according to Nurick and modified Japanese Orthopaedic Association scores without differences between groups. Follow-up 30mWT analysis showed greater decrease in steps number and time in ECL group, creating the basis for further imaging analysis. Magnetic resonance imaging analysis showed that spinal cord length (mm) shortened more (4.47 ± 1.87 vs. 1.5 ± 2.5, t = -4.02; P = 0.0003) and PEA (mm2) shrank more (95.58 ± 43.73 vs. 22.94 ± 33.11, t = -5.45, P < 0.0001) in the ECL group. Multivariate logistic analysis showed that Δ 30mWT-time and Δ PEA were a very predictive model when area under the receiver operating characteristic curve is 0.98. CONCLUSIONS: Our results created a nidus for further research of postdecompression spinal cord relaxation.

Surgery for degenerative cervical myelopathy: a patient-centered quality of life and health economic evaluation.

BACKGROUND CONTEXT: Degenerative cervical myelopathy (DCM) represents the most common cause of non-traumatic spinal cord impairment in adults. Surgery has been shown to improve neurologic symptoms and functional status, but it is costly. As sustainability concerns in the field of health care rise, the value of care has come to the forefront of policy decision-making. Evidence for both health-related quality of life outcomes and financial expenditures is needed to inform resource allocation decisions. PURPOSE: This study aimed to estimate the lifetime incremental cost-utility of surgical treatment for DCM. DESIGN/SETTING: This is a prospective observational cohort study at a Canadian tertiary care facility. PATIENT SAMPLE: We recruited all patients undergoing surgery for DCM at a single center between 2005 and 2011 who were enrolled in either the AOSpine Cervical Spondylotic Myelopathy (CSM)-North America study or the AOSpine CSM-International study. OUTCOME MEASURES: Health utility was measured at baseline and at 6, 12, and 24 months following surgery using the Short Form-6D (SF-6D) health utility score. Resource expenditures were calculated on an individual level, from the hospital payer perspective over the 24-month follow-up period. All costs were obtained from a micro-cost database maintained by the institutional finance department and reported in Canadian dollars, inflated to January 2015 values. METHODS: Quality-adjusted life year (QALY) gains for the study period were determined using an area under the curve calculation with a linear interpolation estimate. Lifetime incremental cost-to-utility ratios (ICUR) for surgery were estimated using a Markov state transition model. Structural uncertainty arising from lifetime extrapolation and the single-arm cohort design of the study were accounted for by constructing two models. The first included a highly conservative assumption that individuals undergoing nonoperative management would not experience any lifetime neurologic decline. This constraint was relaxed in the second model to permit more general parameters based on the established natural history. Deterministic and probabilistic sensitivity analyses were employed to account for parameter uncertainty. All QALY gains and costs were discounted at a base of 3% per annum. Statistical significance was set at the .05 level. RESULTS: The analysis included 171 patients; follow-up was 96.5%. Mean age was 58.2±12.0 years and baseline health utility was 0.56±0.14. Mean QALY gained over the 24-month study period was 0.139 (95% confidence interval: 0.109-0.170, p<.001) and the mean 2-year cost of treatment was $19,217.82±12,404.23. Cost associated with the operation comprised 65.7% of the total. The remainder was apportioned over presurgical preparation and postsurgical recovery. Three patients required a reoperation over the 2-year follow-up period. The costs of revision surgery represented 1.85% of the total costs. Using the conservative model structure, the estimated lifetime ICUR of surgical intervention was $20,547.84/QALY gained, with 94.7% of estimates falling within the World Health Organization definition of "very cost-effective" ($54,000 CAD). Using the more general model structure, the estimated lifetime ICUR of surgical intervention was $11,496.02/QALY gained, with 97.9% of estimates meeting the criteria to be considered "very cost-effective." CONCLUSIONS: Surgery for DCM is associated with a significant quality of life improvement. The intervention is cost-effective and, from the perspective of the hospital payer, should be supported.

The Role of Incentives in Changing the Behavior of Spinal Care Providers: A Primer on Behavioral Economics in Health Care.

As spinal care transitions from individual practitioners working in a volume-based reimbursement system toward multidisciplinary health care organizations working in a population-based model with value-based reimbursement, it is critical that insurance companies, administrators, and spine care provider have a clear understanding of how incentives change physician behavior. This article will introduce the concept of behavior economics, and discuss 9 principles relevant to physician decision-making.

The Impact of Socioeconomic Status on the Utilization of Spinal Imaging.

BACKGROUND: Few studies have examined the general correlation between socioeconomic status and imaging. This study is the first to analyze this relationship in the spine patient population. OBJECTIVE: To assess the effect of socioeconomic status on the frequency with which imaging studies of the lumbar spine are ordered and completed. METHODS: Patients that were diagnosed with lumbar radiculopathy and/or myelopathy and had at least 1 subsequent lumbar magnetic resonance imaging (MRI), computed tomography (CT), or X-ray ordered were retrospectively identified. Demographic information and the number of ordered and completed imaging studies were among the data collected. Patient insurance status and income level (estimated based on zip code) served as representations of socioeconomic status. RESULTS: A total of 24,105 patients met the inclusion criteria for this study. Regression analyses demonstrated that uninsured patients were significantly less likely to have an MRI, CT, or X-ray study ordered (P < .001 for all modalities) and completed (P < .001 for MRI and X-ray, P = .03 for CT). Patients with lower income had higher rates of MRI, CT, and X-ray (P < .001 for all) imaging ordered but were less likely to have an ordered X-ray be completed (P = .009). There was no significant difference in the completion rate of ordered MRIs or CTs. CONCLUSION: Disparities in image utilization based on socioeconomic characteristics such as insurance status and income level highlight a critical gap in access to health care. Physicians should work to mitigate the influence of such factors when deciding whether to order imaging studies, especially in light of the ongoing shift in health policy in the United States.

The role of decision analytic modeling in the health economic assessment of spinal intervention.

STUDY DESIGN: Narrative review. OBJECTIVE: To review the common tenets, strengths, and weaknesses of decision modeling for health economic assessment and to review the use of decision modeling in the spine literature to date. SUMMARY OF BACKGROUND DATA: For the majority of spinal interventions, well-designed prospective, randomized, pragmatic cost-effectiveness studies that address the specific decision-in-need are lacking. Decision analytic modeling allows for the estimation of cost-effectiveness based on data available to date. Given the rising demands for proven value in spine care, the use of decision analytic modeling is rapidly increasing by clinicians and policy makers. METHODS: This narrative review discusses the general components of decision analytic models, how decision analytic models are populated and the trade-offs entailed, makes recommendations for how users of spine intervention decision models might go about appraising the models, and presents an overview of published spine economic models. RESULTS: A proper, integrated, clinical, and economic critical appraisal is necessary in the evaluation of the strength of evidence provided by a modeling evaluation. As is the case with clinical research, all options for collecting health economic or value data are not without their limitations and flaws. There is substantial heterogeneity across the 20 spine intervention health economic modeling studies summarized with respect to study design, models used, reporting, and general quality. There is sparse evidence for populating spine intervention models. Results mostly showed that interventions were cost-effective based on $100,000/quality-adjusted life-year threshold. Spine care providers, as partners with their health economic colleagues, have unique clinical expertise and perspectives that are critical to interpret the strengths and weaknesses of health economic models. CONCLUSION: Health economic models must be critically appraised for both clinical validity and economic quality before altering health care policy, payment strategies, or patient care decisions. LEVEL OF EVIDENCE: 4.

Setting the equation: establishing value in spine care.

STUDY DESIGN: Topic review. OBJECTIVE: Describe value measurement in spine care and discuss the motivation for, methods for, and limitations of such measurement. SUMMARY OF BACKGROUND DATA: Spinal disorders are common and are an important cause of pain and disability. Numerous complementary and competing treatment strategies are used to treat spinal disorders, and the costs of these treatments is substantial and continue to rise despite clear evidence of improved health status as a result of these expenditures. METHODS: The authors present the economic and legislative imperatives forcing the assessment of value in spine care. The definition of value in health care and methods to measure value specifically in spine care are presented. Limitations to the utility of value judgments and caveats to their use are presented. RESULTS: Examples of value calculations in spine care are presented and critiqued. Methods to improve and broaden the measurement of value across spine care are suggested, and the role of prospective registries in measuring value is discussed. CONCLUSION: Value can be measured in spine care through the use of appropriate economic measures and patient-reported outcomes measures. Value must be interpreted in light of the perspective of the assessor, the duration of the assessment period, the degree of appropriate risk stratification, and the relative value of treatment alternatives.

Cervical decompression and reconstruction without intraoperative neurophysiological monitoring.

OBJECT: The primary goal of this study was to review the immediate postoperative neurological function in patients surgically treated for symptomatic cervical spine disease without intraoperative neurophysiological monitoring. The secondary goal was to assess the economic impact of intraoperative monitoring (IOM) in this patient population. METHODS: This study is a retrospective review of 720 consecutively treated patients who underwent cervical spine procedures. The patients were identified and the data were collected by individuals who were not involved in their care. RESULTS: A total of 1534 cervical spine levels were treated in 720 patients using anterior, posterior, and combined (360°) approaches. Myelopathy was present preoperatively in 308 patients. There were 185 patients with increased signal intensity within the spinal cord on preoperative T2-weighted MR images, of whom 43 patients had no clinical evidence of myelopathy. Three patients (0.4%) exhibited a new neurological deficit postoperatively. Of these patients, 1 had a preoperative diagnosis of radiculopathy, while the other 2 were treated for myelopathy. The new postoperative deficits completely resolved in all 3 patients and did not require additional treatment. The Current Procedural Terminology (CPT) codes for IOM during cervical decompression include 95925 and 95926 for somatosensory evoked potential monitoring of the upper and lower extremities, respectively, as well as 95928 and 95929 for motor evoked potential monitoring of the upper and lower extremities. In addition to the charge for the baseline [monitoring] study, patients are charged hourly for ongoing electrophysiology testing and monitoring using the CPT code 95920. Based on these codes and assuming an average of 4 hours of monitoring time per surgical case, the savings realized in this group of patients was estimated to be $1,024,754. CONCLUSIONS: With the continuing increase in health care costs, it is our responsibility as providers to minimize expenses when possible. This should be accomplished without compromising the quality of care to patients. This study demonstrates that decompression and reconstruction for symptomatic cervical spine disease without IOM may reduce the cost of treatment without adversely impacting patient safety.

Is intraoperative CT of posterior cervical spine instrumentation cost-effective and does it reduce complications?

BACKGROUND: Symptomatic multilevel cervical myelopathy is often addressed using posterior decompression using two-dimensional fluoroscopy. Intraoperative three-dimensional fluoroscopy provides more accurate information on the position of instrumentation to prevent screw-related complications. QUESTIONS/PURPOSES: We documented the incidence of hardware-related complications and evaluate cost-effectiveness when using intraoperative three-dimensional fluoroscopy (ISO-C CT) in posterior cervical spine surgery. METHODS: Records from 87 patients who underwent posterior cervical decompression and instrumented fusion for multilevel cervical spondylosis with myelopathy were retrospectively reviewed. Patients in whom a lateral mass, pars, or pedicle screw was removed or revised based on intraoperative ISO-C CT was recorded. Cost analysis was performed using 2008 Medicare reimbursements and was compared against cost estimates for ISO-C CT. RESULTS: Seven patients (8%) had screws changed based on the results of the three-dimensional fluoroscopy: 0.5% of lateral mass screws, 3.1% of thoracic pedicle screws, and 15% of C2 pars screws. No patients who had evaluation of hardware with the ISO-C CT required a return to surgery for complications secondary to hardware failure, malposition, or cutout. CONCLUSIONS: Cost savings are achieved if use of intraoperative ISO-C CT prevents eight patients from requiring a return to the operating room. If every malpositioned screw has the potential to be symptomatic, then 240 patients must have screws placed to be cost-effective. ISO-C CT can safely replace postoperative CT as the standard of care in patients undergoing posterior cervical spinal fusion. LEVEL OF EVIDENCE: Level III, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Análisis de los factores que influyen en el gasto sanitario de los lesionados medulares agudos mediante los grupos relacionados diagnósticos / Analysis to the factors influencing the health-care costs for acute spinal cord injury by diagnosis-related groups

Objetivo. Analizar los factores que influyen en el gasto sanitario de los pacientes con lesión medular en la última década valorado a través de los grupos relacionados diagnósticos (GRD). Material y métodos. Estudio retrospectivo de pacientes dados de alta por la unidad de lesionados medulares desde el año 1997 hasta el año 2006. Se utilizan los datos obtenidos de la base de datos de los GRD de dicho hospital, que incluye los pacientes dados de alta en la unidad de lesionados medulares (n=698). El estudio investiga el número de altas, la estancia media (EM) total y el peso relativo del GRD. Se agrupó según si tenían EM normalizadas o eran outliers (pacientes con una estancia hospitalaria mayor que la media), y se estudiaron las mismas variables. Se realizó un estudio bivariable con el paquete estadístico SPSS® 15. Resultados. La EM fue de 70,3 días. El peso del GRD era de 4,65. La comparación de la EM de los outliers y no outliers mostró diferencias significativas (p<0,05). Existe una correlación entre la EM y el peso del GRD anual (–0,75). Existen 302 outliers. En los últimos 2 años ha habido un descenso importante en el número de outliers. Conclusiones. Descenso de la EM en los últimos años sin cambios en cuanto a la incidencia de ingresos, pero sí en el modelo de atención de la lesión medular aguda. Se ha producido un incremento del peso del GRD anual. Ha habido un descenso importante en el número de outliers en los últimos años (AU)

Objective. To analyze the factors influencing the health-care costs of the patients spinal cord injury in the last decade, valued through the Diagnosis-Related Groups (DRG). Material and methods. A retrospective study of given discharged patients by Spinal Cord Unit following 1997 to 2006. The collected data of the data base of the DRG are used of this hospital, and that includes the given discharged patients in the Spinal Cord Injury unit (ULM) (N=698). The study investigates the number of discharges, the mean of long of stay (LOS) and relative weight DRG's. It was grouped according to if they had LOS standardized or they were outliers, and the same variables studied. It was analyzed using a bivariate study with the statistical package SPSS® 15. Results. The LOS was 70.3 days. Weight DRG was 4,65. The comparison of LOS between of outliers and not outliers patients did not show significant differences (p<0,05). It exists a correlation between the LOS and weight DRG. The outliers were 302. In the last 2 years there has been an important reduction in the number of outliers. Conclusions. Decrease LOS in the last years, without changes as far as the incidence of SCI, but in the model of attention of the SCI patients. An increase of the weight of the annual DRG has taken place. There were important reductions in the number of outliers in the last years (AU)

Physician ownership of specialty spine hospitals.

Patients expect and deserve quality medical care. Physicians, by nature, want what is best for their patients. With the advent of specialty hospitals, physicians can own, run, and control a superior center designed to deliver the highest quality health care. Neurosurgeons who manage their own hospital may set the standards for medical excellence, with patient satisfaction as their primary focus.