Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals.

Importance: Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Objectives: To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals. Design, Setting, and Participants: This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021. Main Outcomes and Measures: The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient. Results: There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18). Conclusions and Relevance: This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.

Higher pedicle screw density does not improve curve correction in Lenke 2 adolescent idiopathic scoliosis.

PURPOSE: Higher pedicle screw density posterior spinal fusion (PSF) constructs have not been shown to result in improved curve correction in Lenke 1 and 5 adolescent idiopathic scoliosis (AIS) but do increase cost. The purpose of this study questioned whether higher screw density constructs improved curve correction and maintenance of correction in Lenke 2 AIS. Secondary goals were to identify predictive factors for correction and postoperative magnitude of curves in Lenke 2 AIS. METHODS: We identified patients 11 to 17 years old who underwent primary PSF for Lenke 2 AIS between 2007 and 2017 who had minimum follow-up of 2 years. Demographic and radiographic data were collected to perform regression and elimination analysis. RESULTS: Thirty patients (21 females, 9 males) were analyzed. Average age and SD at time of surgery was 14.0 ± 1.8 years (range, 11-17 years), and median follow-up was 2.8 years (IQR 2.1-4.0 years). Implant density did not predict final postoperative curve magnitude. Predictors of final postoperative curve magnitude were sex and preoperative curve magnitude. Predictors of percentage of correction of major curve were sex and age at the time of surgery. Predictors of final postoperative thoracic kyphosis were sex and percent flexibility preop. Females had lower final postoperative major curve magnitude, a higher percent curve correction, and lower postoperative thoracic kyphosis. CONCLUSIONS: Increased implant density is not predictive of postoperative curve magnitude in Lenke 2 AIS. Predictors of postoperative curve magnitude are sex and preoperative curve magnitude. LEVEL OF EVIDENCE: Level III, retrospective observational.

Cost-effectiveness of adult lumbar scoliosis surgery: an as-treated analysis from the adult symptomatic scoliosis surgery trial with 5-year follow-up.

STUDY DESIGN: Longitudinal comparative cohort. OBJECTIVE: The purpose of this study is to report on the cost-effectiveness of surgical versus non-surgical treatment for Adult Symptomatic Lumbar Scoliosis (ASLS) using the as-treated data and provide a comparison to previously reported intent-to-treat (ITT) analysis. Adult spinal deformity is a relatively prevalent condition for which surgical treatment has become increasingly common but concerns surrounding complications, revision rates and cost-effectiveness remain unresolved. Of these issues, cost-effectiveness is perhaps the most difficult to quantify as the requisite data is difficult to obtain. The purpose of this study is to report on the cost-effectiveness of surgical versus non-surgical treatment for ASLS using the as-treated data and provide a comparison to previously reported ITT analysis. METHODS: Patients with at least 5-year follow-up data within the same treatment arm were included. Data collected every 3 months included use of nonoperative modalities, medications and employment status. Costs for surgeries and non-operative modalities were determined using Medicare Allowable rates. Medication costs were determined using the RedBook and indirect costs were calculated based on the reported employment status and income. Quality-Adjusted Life Years (QALY) was determined using the SF-6D. RESULTS: Of 226 patients, 195 patients (73 Non-op, 122 Op) met inclusion criteria. At 5 years, 29 (24%) patients in the Op group had a revision surgery of whom two had two revisions and one had three revisions. The cumulative cost for the Op group was $111,451 with a cumulative QALY gain of 2.3. The cumulative cost for the Non-Op group was $29,124 with a cumulative QALY gain of 0.4. This results in an ICER of $44,033 in favor of Op treatment. CONCLUSION: This as-treated cost-effectiveness analysis demonstrates that surgical treatment for adult lumbar scoliosis becomes favorable at year-three, 1 year earlier than suggested by a previous intent-to-treat analysis. LEVEL OF EVIDENCE: II.

Controversies with nonoperative management for adolescent idiopathic scoliosis: Study from the APSS Scoliosis Focus Group.

PURPOSE: To determine consensus among Asia-Pacific surgeons regarding nonoperative management for adolescent idiopathic scoliosis (AIS). METHODS: An online REDCap questionnaire was circulated to surgeons in the Asia-Pacific region during the period of July 2019 to September 2019 to inquire about various components of nonoperative treatment for AIS. Aspects under study included access to screening, when MRIs were obtained, quality-of-life assessments used, role of scoliosis-specific exercises, bracing criteria, type of brace used, maturity parameters used, brace wear regimen, follow-up criteria, and how braces were weaned. Comparisons were made between middle-high income and low-income countries, and experience with nonoperative treatment. RESULTS: A total of 103 responses were collected. About half (52.4%) of the responders had scoliosis screening programs and were particularly situated in middle-high income countries. Up to 34% obtained MRIs for all cases, while most would obtain MRIs for neurological problems. The brace criteria were highly variable and was usually based on menarche status (74.7%), age (59%), and Risser staging (92.8%). Up to 52.4% of surgeons elected to brace patients with large curves before offering surgery. Only 28% of responders utilized CAD-CAM techniques for brace fabrication and most (76.8%) still utilized negative molds. There were no standardized criteria for brace weaning. CONCLUSION: There are highly variable practices related to nonoperative treatment for AIS and may be related to availability of resources in certain countries. Relative consensus was achieved for when MRI should be obtained and an acceptable brace compliance should be more than 16 hours a day.

Predictors of cost for posterior spinal fusion in adolescent idiopathic scoliosis.

STUDY DESIGN: Single-center retrospective review of pediatric patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS). OBJECTIVE: To determine what clinical and operative factors influence inflation-adjusted hospital costs of posterior spine fusion surgery for AIS. With rising healthcare costs and the advent of bundled payments, it is essential understand the predictors of costs for surgical procedures. We sought to determine the components of hospital costs for AIS posterior spine fusion surgery using standardized, inflation-adjusted, line-item costs for services and procedures. METHODS: The study population comprised 148 AIS patients who underwent spinal fusion surgery at a large tertiary care center between 2009 and 2016. Data on medical characteristics, curve type, curve magnitude, number of screws and the number of levels was collected through manual chart review of X-rays and medical records. Hospital costs from admission until discharge were retrieved from an institutional database that contained line-item details of all procedures and services billed during the hospital episode. Bottom-up microcosting valuation techniques were used to generate standardized inflation-adjusted estimates of costs and standard deviations in 2016 dollars. RESULTS: Mean cost of AIS surgery was $48,058 ± 9379. Physician fees averaged 15% of the total cost ($7045 ± 1732). Implant costs and surgical/anesthesia/surgeon's fees accounted for over 70% of the hospital costs. Mean number of screws was 16 ± 4.5, mean number of levels fused was 11.2 ± 2.2, and the mean implant density (screws per level fused) was 1.45 ± 0.35. On multivariate analysis, the number of screws per level fused, number of levels fused, curve magnitude and length of stay were all significantly associated with hospital costs (p < 0.01). CONCLUSIONS: Bundled payments for AIS surgery should include adjustments for number of levels fused and curve size. Areas for cost savings include further reduction in implant costs, shortening length of stay, and reducing intraoperative costs. LEVEL OF EVIDENCE: III.

Health and Economic Outcomes of Posterior Spinal Fusion for Children With Neuromuscular Scoliosis.

OBJECTIVES: Neuromuscular scoliosis (NMS) can result in severe disability. Nonoperative management minimally slows scoliosis progression, but operative management with posterior spinal fusion (PSF) carries high risks of morbidity and mortality. In this study, we compare health and economic outcomes of PSF to nonoperative management for children with NMS to identify opportunities to improve care. METHODS: We performed a cost-effectiveness analysis. Our decision analytic model included patients aged 5 to 20 years with NMS and a Cobb angle ≥50°, with a base case of 15-year-old patients. We estimated costs, life expectancy, quality-adjusted life-years (QALYs), and incremental cost-effectiveness from published literature and conducted sensitivity analyses on all model inputs. RESULTS: We estimated that PSF resulted in modestly decreased discounted life expectancy (10.8 years) but longer quality-adjusted life expectancy (4.84 QALYs) than nonoperative management (11.2 years; 3.21 QALYs). PSF costs $75 400 per patient. Under base-case assumptions, PSF costs $50 100 per QALY gained. Our findings were sensitive to quality of life (QoL) and life expectancy, with PSF favored if it significantly increased QoL. CONCLUSIONS: In patients with NMS, whether PSF is cost-effective depends strongly on the degree to which QoL improved, with larger improvements when NMS is the primary cause of debility, but limited data on QoL and life expectancy preclude a definitive assessment. Improved patient-centered outcome assessments are essential to understanding the effectiveness of NMS treatment alternatives. Because the degree to which PSF influences QoL substantially impacts health outcomes and varies by patient, clinicians should consider shared decision-making during PSF-related consultations.

Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

OBJECTIVES: In adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal instrumented fusion (PSIF), we aimed to answer these questions: (1) is there a difference in postoperative urinary retention (UR) rates among patients who had removal of their Foley catheters before vs. after discontinuation of epidural analgesia (EA)? (2) Can the timing of Foley catheter removal be an independent risk factor for postoperative UR requiring recatheterization? (3) Is there an incurred cost related to treating UR? STUDY DESIGN: Retrospective cohort. BACKGROUND: EA has been widely used for postoperative pain control after PSIF for AIS. In these patients, removing the Foley catheter, inserted for intraoperative monitoring of urine output, is indicated in the early postoperative period. However, a controversy exists as to whether it should be removed before or after the EA has been discontinued. METHODS: A single-institution, longitudinally maintained database was queried to identify 297 patients who met specific inclusion and exclusion criteria. Patient characteristics and the order and timing of removing the urinary and epidural catheters were collected. Rates of UR were statistically compared in patients who had early vs. late urinary catheter removal. A univariate and multivariate regression analysis was conducted to identify independent risk factors. Hospital episode costs were analyzed. RESULTS: Patients who had early (n = 66, 22%) vs. late (n = 231, 78%) urinary catheter removal had a significantly higher incidence of UR requiring recatheterization (15 vs. 4.7%, p = 0.007). Patient with early removal were almost 4 times more likely to develop UR requiring recatheterization [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p = 0.005]. UR incurred additional costs averaging $15,000/patient (p = 0.204). CONCLUSION: In patients who had PSIF for AIS, removal of a urinary catheter before discontinuation of EA is an independent risk factor for UR, requiring recatheterization and associated with increased cost. LEVEL OF EVIDENCE: III.

Clinical Outcomes, Complications, and Cost-effectiveness in Surgically Treated Adult Spinal Deformity Over 70 Years: A Propensity score-Matched Analysis.

STUDY DESIGN: This is a multicentered retrospective study. SUMMARY OF BACKGROUND DATA: Surgical correction for the adult spinal deformity (ASD) is effective but carries substantial risks for complications. The diverse pathologies of ASD make it difficult to determine the effect of advanced age on outcomes. OBJECTIVE: The objective of this study was to assess how advanced age affects outcomes and cost-effectiveness for corrective surgery for ASD. MATERIALS AND METHODS: We used data from a multicenter database to conduct propensity score-matched comparisons of 50 patients who were surgically treated for ASD when at least 50 years old and were followed for at least 2 years, to clarify whether advanced age is a risk factor for inferior health-related quality of life and cost-effectiveness. Patients were grouped by age, 50-65 years (M group: 59±4 y) or >70 years (O group: 74±3 y), and were propensity score-matched for sex, body mass index, upper and lower instrumented vertebrae, the use of pedicle-subtraction osteotomy, and sagittal alignment. Cost-effectiveness was determined by cost/quality-adjusted life years. RESULTS: Oswestry Disability Index and Scoliosis Research Society-22 (SRS-22) pain and self-image at the 2-year follow-up were significantly inferior in the O group (Oswestry Disability Index: 32±9% vs. 25±13%, P=0.01; SRS-22 pain: 3.5±0.7 vs. 3.9±0.6, P=0.05; SRS-22 self-image: 3.5±0.6 vs. 3.8±0.9, P=0.03). The O group had more complications than the M group (55% vs. 29%). The odds ratios in the O group were 4.0 for postoperative complications (95% confidence interval: 1.1-12.3) and 4.9 for implant-related complications (95% confidence interval: 1.2-21.1). Cost-utility analysis at 2 years after surgery indicated that the surgery was less cost-effective in the O group (cost/quality-adjusted life year: O group: $211,636 vs. M group: 125,887, P=0.01). CONCLUSIONS: Outcomes for corrective surgery for ASD were inferior in geriatric patients compared with middle-aged patients, in whom the extent of spinal deformity and the operation type were adjusted similarly. Special attention is needed when considering surgical treatment for geriatric ASD patients.

Day of the Week of Surgery Affects Time to Discharge for Patients With Adolescent Idiopathic Scoliosis.

Unnecessary delays in discharge are extraordinarily common in the current US health care system. These delays are even more protracted for patients undergoing orthopedic procedures. A traditional hospital staffing model is heavily weighted toward increased resources on weekdays and minimal coverage on the weekend. This study examined the effect of this traditional staffing model on time to discharge for patients undergoing posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis. Patients undergoing surgery later in the week had a significantly longer hospital stay compared with patients undergoing surgery early in the week (5.5 days vs 4.9 days, respectively; P=.003). This discrepancy resulted in a mean cost increase of $7749.50 for patients undergoing surgery later in the week. A subsequent quality, safety, value initiative (QSVI) was undertaken to balance physical therapy resources alone. Following the QSVI, patients undergoing surgery later in the week had a decreased mean length of stay of 3.78 days (P=.002). Patients undergoing fusion early in the week also had a decreased mean length of stay of 3.66 days (P<.001). There was no longer a significant difference in length of stay between the "early" and the "late" groups (P=.84). This study demonstrates that simply having surgery later in the week in a hospital with a traditional staffing model adversely affects the timing of discharge, resulting in a significantly longer and more costly hospital course. By increasing physical therapy availability on the weekend, the length of stay and the cost of hospitalization decrease precipitously for these patients. [Orthopedics. 2020; 43(1);8-12.].

National Trends in the Surgical Management of Lumbar Spinal Stenosis in Adult Spinal Deformity Patients.

STUDY DESIGN: This is a retrospective analysis of national administrative hospital data. OBJECTIVE: This study examines national trends in the surgical management of lumbar spinal stenosis (LSS) in patients with and without coexisting scoliosis between 2010 and 2014. The study also examines revision rates for LSS procedures. SUMMARY OF BACKGROUND DATA: There is wide variability in the surgical management of patients with LSS, with and without coexisting spinal deformity. METHODS: Data were obtained from the Healthcare Cost and Utilization Project's National Inpatient Sample Database. International Classification of Diseases 9th revision- Clinical Modification codes were used to identify all patients with a primary diagnosis of lumbar spinal stenosis. These patients were divided into two groups: 1) LSS alone and 2) LSS with coexisting scoliosis. The two groups were examined for one of three surgical outcomes: 1) decompression alone (discectomy, laminectomy), 2) simple fusion, and 3) complex fusion (>three vertebrae or 360° fusion). The groups were then further examined for revision operations. National Inpatient Sample discharge weights were applied where relevant. RESULTS: In 2014 national estimates of discharged patients indicated 76,275 patients with a primary diagnosis of LSS (population rate, 23.9; in the elderly (65+) the age-adjusted population rate was 95.4). Of these patients, 88.5% were managed through primary surgery (34.6% decompression, 47.2% simple fusion, 5.7% complex fusion). Between 2010 and 2014, the percentage of decompression decreased from 47.5% to 34.6%, the percent of simple fusion increased from 35.3% to 47.2%, and the percent of complex fusion increased from 5.7% to 7.1% (P < 0.01). In patients with coexisting scoliosis, lumbar spinal stenosis was predominantly managed by simple fusion and complex fusion (15.5% decompression, 51.9% simple fusion, 27.3% complex fusion, in 2014). Revision rates were highest among patients without scoliosis managed with complex fusion (15.8% in 2014) compared with patients with scoliosis (8.8% in 2014). Patients with scoliosis who underwent decompression only had revision rates of 1.7% and 0.62% in 2010 and 2014, respectively. CONCLUSION: We observed a leveling-off of the rate of operation for patients with a primary diagnosis of LSS at around 88%. There was an increase in the rate of fusion and a decrease in the rate of decompression across all patient groups. We report no difference in revision rates between patients with and without scoliosis, except in those undergoing a complex fusion. LEVEL OF EVIDENCE: 3.

Understanding Costs in a 90-Day Episode of Care Following Posterior Spinal Fusions for Adolescent Idiopathic Scoliosis.

OBJECTIVE: To understand cost distribution in a 90-day episode of care following posterior spinal fusions (PSFs) for adolescent idiopathic scoliosis (AIS). METHODS: The 2007-2016 Humana PearlDiver dataset was queried using Current Procedural Terminology codes (22800, 22802, 22804, 22842, 22843, and 22844) to identify patients with AIS, aged 10-19 years, receiving PSFs. The following categories were used to define distribution in 90-day costs: 1) facility costs, 2) surgeon costs, 3) anesthesia costs, 4) intraoperative neuromonitoring, 5) hospital services and investigations, 6) intensive care unit stay, 7) radiology, 8) physical therapy/rehabilitation, 9) office visits, and 10) readmissions. RESULTS: A total of 455 patients with AIS received PSFs, of whom 381 (83.7%) were commercial insurance beneficiaries and 74 (16.3%) were Medicaid beneficiaries. The overall average 90-day cost of surgery was $124,360 with the 90-day stipulated bundled prices being $136,302 and $62,871 for commercial and Medicaid beneficiaries, respectively. Facility costs comprised 85%-92% of the 90-day cost, followed by surgeon costs (5.2%-5.7%). Post-acute care (physical therapy/rehab and office visits) was not a major driver of the 90-day cost (0.2%-0.3%). Significant independent predictors of increased 90-day costs were-increased co-morbidity burden (+$11,284), ≥7 levels fusion (+$65,330), and length of stay (+$5298/day). Medicaid (-$81,957) payer type was associated with lower 90-day costs. CONCLUSIONS: Facility costs are a major determinant of overall 90-day costs following PSFs in AIS. Providers should aim at optimizing the co-morbidity burden and constructing accelerated care-pathways to decrease the length of stay and reduce the cost of the entire episode of care.

Cost-effectiveness of Operative versus Nonoperative Treatment of Adult Symptomatic Lumbar Scoliosis an Intent-to-treat Analysis at 5-year Follow-up.

STUDY DESIGN: Secondary analysis using data from the NIH-sponsored study on adult symptomatic lumbar scoliosis (ASLS) that included randomized and observational arms. OBJECTIVE: The aim of this study was to perform an intent-to-treat cost-effectiveness study comparing operative (Op) versus nonoperative (NonOp) care for ASLS. SUMMARY OF BACKGROUND DATA: The appropriate treatment approach for ASLS continues to be ill-defined. NonOp care has not been shown to improve outcomes. Surgical treatment has been shown to improve outcomes, but is costly with high revision rates. METHODS: Patients with at least 5-year follow-up data were included. Data collected every 3 months included use of NonOp modalities, medications, and employment status. Costs for index and revision surgeries and NonOp modalities were determined using Medicare Allowable rates. Medication costs were determined using the RedBook and indirect costs were calculated based on reported employment status and income. Qualityadjusted life year (QALY) was determined using the SF6D. RESULTS: There were 81 of 95 cases in the Op and 81 of 95 in the NonOp group with complete 5-year follow-up data. Not all patients were eligible 5-year follow-up at the time of the analysis. All patients in the Op and 24 (30%) in the NonOp group had surgery by 5 years. At 5 years, the cumulative cost for Op was $96,000 with a QALY gain of 2.44 and for NonOp the cumulative cost was $49,546 with a QALY gain of 0.75 with an incremental cost-effectiveness ratio (ICER) of $27,480 per QALY gain. CONCLUSION: In an intent-to-treat analysis, neither treatment was dominant, as the greater gains in QALY in the surgery group come at a greater cost. The ICER for Op compared to NonOp treatment was above the threshold generally considered cost-effective in the first 3 years of the study but improved over time and was highly cost-effective at 4 and 5 years. LEVEL OF EVIDENCE: 2.

Cost-Utility Analysis of Operative Versus Nonoperative Treatment of Thoracic Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Cost-utility analysis OBJECTIVE.: To compare the cost utility of operative versus nonoperative treatment of adolescent idiopathic scoliosis (AIS) and identity factors that influence cost-utility estimates. SUMMARY OF BACKGROUND DATA: AIS affects 1% to 3% of children aged 10 to 16 years. When the major coronal curve reaches 50°, operative treatment may be considered. The cost utility of operative treatment of AIS is unknown. METHODS: A decision-analysis model comparing operative versus nonoperative treatment was developed for a hypothetical 15-year-old skeletally mature girl with a 55° right thoracic (Lenke 1) curve. The AIS literature was reviewed to estimate the probability, health utility, and quality-adjusted life years (QALYs) for each event. For the conservative model, we assumed that operative treatment did not result directly in any QALYs gained, and the health utility in AIS patients was the same as the age-matched US population mean. Costs were inflation-adjusted at 3.22% per year to 2015 US dollars. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates. RESULTS: Operative treatment was favored in 98.5% of simulations, with a median ICUR of $20,600/QALY (95% confidence interval, $20,500-$21,900) below the societal willingness-to-pay threshold (WTPT) of $50,000/QALY. The median incremental net monetary benefit associated with operative treatment was $15,100 (95% confidence interval, $14,800-$15,700). Operative treatment produced net monetary benefit across various WTPTs. Factors that most affected the ICUR were net costs associated with uncomplicated operative treatment, undergoing surgery during adulthood, and development of pulmonary complications. CONCLUSION: Cost-utility analysis suggests that operative treatment of AIS is favored over nonoperative treatment and falls below the $50,000/QALY WTPT for patients with Lenke 1 curves. LEVEL OF EVIDENCE: 2.

A National Analysis on Predictors of Discharge to Rehabilitation After Corrective Surgery for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective study of a national database. OBJECTIVE: To identify the incidence and risk factors for discharge to a rehabilitation facility after corrective surgery for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The vast majority of patients who undergo surgery for AIS are discharged home, with limited data on rates and causes for discharge to a rehabilitation facility. METHODS: The United States National Inpatient Sample (NIS) database was queried for the years 2012 to 2014. Inclusion criteria were children aged 10 to 18 who underwent surgery for idiopathic scoliosis. Studied data included patient demographics, operative parameters, length of stay, and hospital charges. Perioperative complications were also examined, along with their association with discharge to an inpatient rehabilitation facility. Statistical analysis was performed via chi-squared testing and multivariate analysis, with significance defined as a P-value <0.05. RESULTS: A total of 17,275 patients were included (76.3% female, mean age 14 yr). Out of the entire cohort, 4.8% of patients developed a complication and 0.6% were discharged to a rehabilitation facility. The most common complications included respiratory failure (2.3%), reintubation (0.8%), and postoperative hematoma (0.8%). Following multivariate analysis, male sex (Odds ratio (OR) 4.7; 95% Confidence Interval (CI), 1.8-12.2; P = 0.002), revision surgery (OR 29.6; 95% CI, 5.7-153.5; P < 0.001), and development of a perioperative complication (OR 12.3; 95% CI, 4.7-32.4; P < 0.001) were found to be significant predictors of discharge to rehabilitation. Average length of stay was 8 ±â€Š6 versus 5 ±â€Š3 days and hospital charges were $254,425 versus $186,273 in the complication and control groups, respectively (both P < 0.001). CONCLUSION: Discharge to rehabilitation after AIS surgery is uncommon. However, patients who are male, undergo revision procedures, or develop a complication may have a higher risk of a non-routine discharge. Complication occurrence also resulted in significantly longer lengths of stay and healthcare costs. LEVEL OF EVIDENCE: 3.

Cost Analysis of Magnet-driven Growing Rods for Early-onset Scoliosis at 5 Years.

STUDY DESIGN: Prospective case series of nine children with early-onset scoliosis (EOS) treated by a single surgeon with a novel implant, the magnet-driven growing rod (MdGR) in a publicly funded health care service accounting for "payer costs" (PC) incurred. OBJECTIVE: The aim of this study was to compare the cost-effectiveness of MdGR versus conventional growing rods (CGRs) with respect to the PC incurred for treating EOS at 5 years. SUMMARY OF BACKGROUND DATA: Cost estimate and mathematical modeling study projections of MdGR have shown despite high insertional costs, it breaks even with CGR by 3 to 4 years. However, no clinical study to date exists either supporting or refuting this hypothesis. METHODS: Nine patients with EOS secondary to idiopathic (two), congenital (one), syndromic (three), and neuromuscular (three) etiologies treated by submuscular insertion of MdGR against stringent inclusion criteria formed the study cohort. We collected costs incurred with all aspects of care over the lifetime of device (or at least 5 years) from payers' perspective to compute and report average PC incurred per patient. We performed this cost analysis by comparing the MdGR PC against literature reported PC for CGR at 5 years. RESULTS: There were five single rod (SR) and two dual rod (DR) de novo MdGR insertions, while two patients had conversion of CGR to MdGR. MdGR alone accounted for at least 50% of overall budget. The MdGR was at least 40% more cost-effective in comparison to the CGR (£34,741 vs. £52,293) and there were seven MdGR graduates. CONCLUSION: The first study reporting direct PC incurred in EOS treated by MdGR that is devoid of any mathematical modeling and deterministic sensitivity analysis is presented. The true societal/human cost savings taking into consideration indirect costs are likely to be significantly higher. MdGR is a promising novel implant that may eventually become the "standard of care" for certain EOS etiologies. LEVEL OF EVIDENCE: 4.

Intraoperative CT Scan Verification of Pedicle Screw Placement in AIS to Prevent Malpositioned Screws: Safety Benefit and Cost.

STUDY DESIGN: Prospective database review. OBJECTIVES: Determine if use of intraoperative 3D imaging of pedicle screw position provides clinical and cost benefit. SUMMARY OF BACKGROUND: Injury or reoperation from malpositioned pedicle screws in adolescent idiopathic scoliosis (AIS) surgery occurs but is increasingly considered to be a never-event. To avoid complications, intraoperative 3D imaging of screw position may be obtained. METHODS: A prospective, consecutive AIS database at a high-volume pediatric spine center was examined three years before and after implementation of an intraoperative low-dose computed tomographic (CT) scan protocol. All screws were placed via freehand technique and corrected if found to be outside optimal trajectory on the postplacement CT scan. Demographic and outcome data were compared between cohorts, along with number, location, and reason for screw change. Cost analysis was based on the average cost of revision surgery for screw malposition versus intraoperative CT use. RESULTS: There were 153 patients in the pre-CT and 153 in the post-CT cohorts with a minimum 2-year follow-up. Two reoperations were needed for revision of improper screw placement in the pre-CT group and none in the post-CT group. Number of patients needed to harm was 76 (absolute risk increase = 1.31% [-0.49%, 3.11%]). Of those who had intraoperative CT scans, 80 (52.3%) needed on average 1.75 screw trajectories/lengths changed. Forty-three percent were medial breaches; of these, 39% were in the concavity. There were no differences between patients who did and did not need screw repositioning with regard to body mass index (BMI), age, curve size, surgeon/trainee side, screw density, or preoperative and one-year postoperative Scoliosis Research Society-22 patient questionnaire (SRS-22) scores. The average cost of reoperation for malposition was $4,900, whereas the cost of a single intraoperative CT was $232. CONCLUSION: Intraoperative CT is an effective tool to prevent reoperation in AIS surgery for incorrect screw placement. Despite high volume, experience, and specialty training, incorrect trajectories occur and systems should be in place for preventable error. LEVEL OF EVIDENCE: Level II.

Blood Loss Trends and Financial Implications in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The primary goal was to evaluate risk factors related to increased blood loss in adolescent idiopathic surgery (AIS) surgery with the secondary goal being to evaluate the financial implications around the use of intraoperative cell salvage (ICS) and the routine preallocation of autogenous blood products. SUMMARY OF BACKGROUND DATA: Deformity correction for AIS is a complex procedure and can be associated with significant blood loss. METHODS: A retrospective cohort study was conducted on consecutive patients between the ages of 10 and 18 years who underwent posterior spinal fusion of 7-12 levels over a 3-year period between January 2013 and December 2015. Demographic information and surgical characteristics were recorded. All patients had a preoperative type and cross of 2 units and ICS was used in all cases. Charges for preoperative type and cross and ICS were also measured. Univariate and multivariable analyses were performed to identify pertinent variables affecting blood loss. RESULTS: In total, 134 patients met inclusion criteria. ICS was used in all cases. In total, 51 patients were transfused cell saver blood intraoperatively/postoperatively at the discretion of the surgeon. On average 133 mL were returned to the patient. No complications related to ICS were observed. Multivariable analysis identified male sex, lower body mass index and higher surgical time to be associated with increased blood loss (P<0.05). All 134 patients had a preoperative type and cross, with an average charge to patient of $311. Patients were charged $1037 for intraoperative use of ICS and $242 for centrifugation. Patients who had allogeneic transfusion were charged $1047. CONCLUSIONS: Several blood conservation strategies, including use of ICS, exist to minimize the consequences of blood loss. Routine use of preoperative type and cross may be avoided except in cases where significant blood loss is anticipated-that is adolescent male individuals, those with a lower body mass index and in whom a longer surgical time is anticipated.

Predictors of adverse discharge disposition in adult spinal deformity and associated costs.

BACKGROUND CONTEXT: With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount. PURPOSE: Using the nationwide and surgeon-created databases, the present study aimed to identify predictors of adverse discharge disposition after ASD surgeries and view the corresponding differences in charges. STUDY DESIGN/SETTING: This is a retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and of cost data from Medicare PearlDiver Database. PATIENT SAMPLE: Patients undergoing thoracolumbar surgery for correction of ASD were included in the study. OUTCOME MEASURES: Primary analysis was performed to compare patients discharged to home with patients who either expired or were discharged to locations other than home. Secondary analysis was performed to determine the cost differences across discharge groups. METHODS: Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x) and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30- and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion. RESULTS: A total of 1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. On multivariate regression analysis, age over 60 years (odds ratio [OR]: 0.28, confidence interval [CI]: 0.22-0.34) and female sex (p=.003) were independent predictors of adverse discharge status. Partially dependent preoperational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR: 0.57, CI: 0.35-0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR: 0.51, CI: 0.40-0.64), interbody device placement (OR: 0.80, CI: 0.64-0.98), and fixation to the iliac (OR: 0.54, CI: 0.41-0.70) increased the likelihood of adverse discharge. Complications most associated with adverse discharge were urinary tract infections (OR: 0.34, CI: 0.21-0.57) and blood transfusions (OR: 0.42, CI: 0.34-0.52). Relative to home discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=.177). The 90-day costs of care were $23,815 in rehab discharges (p<.001), but again not different from skilled nursing facility discharges (+$6,091, p=.212). CONCLUSIONS: Discharge destination to rehabilitation has a significant impact on the cost of thoracolumbar ASD surgeries. Patient selection can predict patients at higher risk of discharges to rehab or skilled nursing facility.

Evidence-Based Thresholds for the Volume-Value Relationship in Adolescent Idiopathic Scoliosis: Outcomes and Economies of Scale.

OBJECTIVES: Increased surgeon and hospital volume has been associated with improved patient outcomes and cost effectiveness for adolescent idiopathic scoliosis (AIS). However, no evidence-based thresholds that clarify the volume at which these strata occur exist. The objective of this study was to establish statistically meaningful thresholds that define high-volume surgeons and hospitals performing spinal fusion for AIS from those that are low volume with respect to length of stay (LOS) and cost. METHODS: Using 3,224 patients undergoing spinal fusion for AIS from an administrative database, we created and applied four models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. We generated four sets of thresholds predictive of adverse outcomes, namely, increased cost and LOS, for both surgeon and hospital volume. RESULTS: For both LOS and cost, surgeon volume produced the same strata with low volume identified as 0-5 annual surgeries and high as greater than 5. LOS and cost decreased significantly (p < .05) between volume strata. For hospital volume in terms of LOS, low volume was identified as 0-10 annual surgeries and high as greater than 10; in terms of cost, low volume was identified as 0-15 annual surgeries and high as greater than 15. LOS decreased significantly (p < .05) and cost was $1,500 less but not statistically significant between volume strata for hospital volume. CONCLUSIONS: Our study of risk-based volume stratification established a direct volume-value relationship for surgeons and hospitals performing fusion for AIS. A meaningful threshold for low- and high-volume surgeons was established at 5 annual surgeries, but no consensus or clinically meaningful conclusion was reached for hospitals, although the threshold approached 10-15 annual surgeries. This analysis should aid patients, surgeons, and administration reach value-based decisions in the optimal delivery of pediatric spinal fusion for AIS.

Variation in Adolescent Idiopathic Scoliosis Surgery: Implications for Improving Healthcare Value.

OBJECTIVES: To investigate the variation in care and cost of spinal fusion for adolescent idiopathic scoliosis (AIS), and to identify opportunities for improving healthcare value. STUDY DESIGN: Retrospective cohort study from the Pediatric Health Information Systems database, including children 11-18 years of age with AIS who underwent spinal fusion surgery between 2004 and 2015. Multivariable regression was used to evaluate the relationships between hospital cost, patient outcomes, and resource use. RESULTS: There were 16 992 cases of AIS surgery identified. There was marked variation across hospitals in rates of intensive care unit admission (0.5%-99.2%), blood transfusions (0%-100%), surgical complications (1.8%-32.3%), and total hospital costs ($31 278-$90 379). Hospital cost was 32% higher at hospitals that most frequently admitted patients to the intensive care unit (P = .009), and 8% higher for each additional 25 operative cases per hospital (P = .003). Hospital duration of stay was shorter for patients admitted to hospitals with highest intensive care unit admission rates and higher surgical volumes. There was no association between cost and duration of stay, 30-day readmission, or surgical complications. The largest contribution to hospital charges was supplies (55%). Review of a single hospital's detailed cost accounting system also found supplies to be the greatest single contributor to cost, the majority of which were for spinal implants, accounting for 39% of total hospital costs. CONCLUSIONS: The greatest contribution to AIS surgery cost was supplies, the majority of which is likely attributed to spinal implant costs. Opportunities for improving healthcare value should focus on controlling costs of spinal instrumentation, and improving quality of care with standardized treatment protocols.