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Sheppard WL, Chiou D, Upfill-Brown A, Shah A, Edogun E, Sassoon A, Park DY. Spondylolisthesis and mismatch deformity affect outcomes after total knee arthroplasty. J Orthop Surg Res 2023; 18:157. [PMID: 36864440 PMCID: PMC9979472 DOI: 10.1186/s13018-023-03605-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 02/10/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Little published data currently exist regarding the potential relationships between spondylolisthesis, mismatch deformity, and clinical outcomes following total knee arthroplasty (TKA). We hypothesize that preexisting spondylolisthesis will result in decreased functional outcomes after TKA. METHODS This retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure the degree of spondylolisthesis. Ninety-five TKAs were subsequently available for inclusion and divided into two groups: those with spondylolisthesis and those without. Within the spondylolisthesis cohort, pelvic incidence (PI) and lumbar lordosis (LL) were calculated on lateral radiographs to determine the difference (PI-LL). Radiographs with PI-LL > 10° were then categorized as having mismatch deformity (MD). The following clinical outcomes were compared between the groups: need for manipulation under anesthesia (MUA), total postoperative arc of motion (AOM) both pre-MUA or post-MUA/revision, incidence of flexion contracture, and a need for later revision. RESULTS Forty-nine TKAs met the spondylolisthesis criteria, while 44 did not have spondylolisthesis. There were no significant differences in gender, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with spondylolisthesis and concomitant MD were more likely to have MUA (p = 0.016), ROM < 0-120 (p < 0.014), and a decreased AOM (p < 0.02) without interventions. CONCLUSION Preexisting spondylolisthesis by itself may not have adverse effect clinical results following TKA. However, spondylolisthesis increases the likelihood of developing MD. In those with both spondylolisthesis and concomitant mismatch deformities, patients had statistically and clinically significantly decreased in postoperative ROM/AOM and increased need for MUA. Surgeons should consider clinical/radiographic assessments of patients with chronic back pain who present for total joint arthroplasty. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- William L. Sheppard
- grid.19006.3e0000 0000 9632 6718Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA 90404 USA
| | - Daniel Chiou
- grid.19006.3e0000 0000 9632 6718Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA 90404 USA
| | - Alexander Upfill-Brown
- grid.19006.3e0000 0000 9632 6718Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA 90404 USA
| | - Akash Shah
- grid.19006.3e0000 0000 9632 6718Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA 90404 USA
| | - Eghosa Edogun
- grid.19006.3e0000 0000 9632 6718David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095 USA
| | - Adam Sassoon
- grid.19006.3e0000 0000 9632 6718Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA 90404 USA ,grid.19006.3e0000 0000 9632 6718David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095 USA
| | - Don Y. Park
- grid.19006.3e0000 0000 9632 6718Department of Orthopedic Surgery, University of California, Los Angeles, 1250 16th St Suite 2100, Santa Monica, CA 90404 USA ,grid.19006.3e0000 0000 9632 6718David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Ave, Los Angeles, CA 90095 USA
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Bakaa N, Gross DP, Carlesso LC, MacDermid J, Thomas K, Slomp F, Rushton A, Miciak M, Smeets R, Rampersaud R, Nataraj A, Drew B, Markian P, Guha D, Cenic A, Macedo L. Presurgical rehabilitation program for patients with symptomatic lumbar spinal stenosis: A pilot randomized controlled trial protocol. Can J Pain 2022. [DOI: 10.1080/24740527.2022.2137009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- Nora Bakaa
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Douglas P. Gross
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa C. Carlesso
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Joy MacDermid
- School of Physical Therapy, Western University, London, Ontario, Canada
| | - Kenneth Thomas
- Surgery and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Florence Slomp
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alison Rushton
- School of Physical Therapy, Western University, London, Ontario, Canada
| | - Maxi Miciak
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Rob Smeets
- Maastricht, the Netherlands and CIR Revalidatie, Maastricht University, Eindhoven, The Netherlands
| | - Raja Rampersaud
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Nataraj
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brian Drew
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Pahuta Markian
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Daipayan Guha
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Aleks Cenic
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Luciana Macedo
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
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Crawford EJ, Ravinsky RA, Coyte PC, Rampersaud YR. Lifetime incremental cost-utility ratios for minimally invasive surgery for degenerative lumbar spondylolisthesis relative to failed medical management compared with total hip and knee arthroplasty for osteoarthritis. Can J Surg 2021; 64:E391-E402. [PMID: 34296707 PMCID: PMC8410474 DOI: 10.1503/cjs.015719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: The objective of this study was to compare the cost-effectiveness of minimally invasive surgery (MIS) for patients with degenerative lumbar spondylolisthesis (DLS) relative to failed medical management with the cost-effectiveness of hip and knee arthroplasty for matched cohorts of patients with osteoarthritis. Methods: A cohort of patients with DLS undergoing MIS procedures with decompression alone or decompression and instrumented fusion between 2008 and 2014 was matched to cohorts of patients with hip osteoarthritis (OA) and knee OA undergoing total joint replacement. Incremental cost–utility ratios (ICURs) were calculated from the perspective of the Ontario Ministry of Health, using prospectively collected Short Form–6 Dimension utility data. Costs and quality-adjusted life years (QALYs) were discounted at 3% and sensitivity analyses were performed. Results: Sixty-six patients met the inclusion criteria for the DLS cohort (n = 35 for decompression alone), with a minimum follow-up time of 1 year (mean 1.7 yr). The mean age of patients in the DLS cohort was 64.76 years, and 45 patients (68.2%) were female. For each cohort, utility scores improved from baseline to follow-up and the magnitude of the gain did not differ by group. Lifetime ICURs comparing surgical with nonsurgical care were Can$7946/QALY, Can$7104/QALY and Can$5098/QALY for the DLS, knee OA and hip OA cohorts, respectively. Subgroup analysis yielded an increased ICUR for the patients with DLS who underwent decompression and fusion (Can$9870/QALY) compared with that for the patients with DLS who underwent decompression alone (Can$5045/QALY). The rank order of the ICURs by group did not change with deterministic or probabilistic sensitivity analyses. Conclusion: Lifetime ICURs for MIS procedures for DLS are similar to those for total joint replacement. Future research should adopt a societal perspective and potentially capture further economic benefits of MIS procedures.
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Affiliation(s)
- Eric J Crawford
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Crawford, Rampersaud); the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Crawford, Coyte); the Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Ariz. (Ravinksy); the Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); and the Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud)
| | - Robert A Ravinsky
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Crawford, Rampersaud); the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Crawford, Coyte); the Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Ariz. (Ravinksy); the Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); and the Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud)
| | - Peter C Coyte
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Crawford, Rampersaud); the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Crawford, Coyte); the Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Ariz. (Ravinksy); the Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); and the Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud)
| | - Y Raja Rampersaud
- From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Crawford, Rampersaud); the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Crawford, Coyte); the Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Ariz. (Ravinksy); the Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); and the Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud)
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Glennie RA, Oxner WM, Alant J, Barry SP, Christie S. Case costing in spine surgery: Can surgeons assist with accurate capture of operating room costs? Healthc Manage Forum 2020; 34:158-162. [PMID: 33148024 DOI: 10.1177/0840470420969915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Surgical case costing is critical for health leaders to make decisions about resource utilization. Synoptic reporting offers the potential for surgeons to capture these costs and work with other leaders to make evidence-based decisions. The purpose of this study was to determine whether surgeons documented intra-operative cost drivers as part of their operative report. This article outlines a synoptic reporting system at a quaternary spine care centre. Data were captured from 2015 to 2020. Surgeon rates of documentation for specific devices, bone graft, and surgical adjuncts were evaluated. It is hoped that the results of this survey will help to guide programs to capture costs in other settings.
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Affiliation(s)
- R Andrew Glennie
- Department of Surgery, 12361Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - William M Oxner
- Department of Surgery, 12361Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Jacob Alant
- Department of Surgery, 12361Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Sean P Barry
- Department of Surgery, 12361Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Sean Christie
- Department of Surgery, 12361Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health, Halifax, Nova Scotia, Canada
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5
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Xu Y, Yen D, Whitehead M, Xu J, Johnson AP. Use of instrumented lumbar spinal surgery for degenerative conditions: trends and costs over time in Ontario, Canada. Can J Surg 2020; 62:393-401. [PMID: 31782293 DOI: 10.1503/cjs.017016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Instrumented lumbar surgeries, such as lumbar fusion and lumbar disc replacement, are increasingly being used in the United States for low back pain, with utilization rates approaching those of total joint arthroplasty. It is unknown whether there is a similar pattern in Canada. We sought to determine utilization rates and total medical costs of instrumented lumbar surgeries in a single-payer system and to compare these with the rates and costs of total hip and knee replacements. Methods We included Ontarians aged 20 years and older who underwent instrumented lumbar surgery or total knee or total hip replacement between April 1993 and March 2012. Utilization and medical cost of the procedures were evaluated and compared using linear regression in a time-series analysis. Instrumented lumbar surgical procedures were stratified by age and main indication for surgery. Results Utilization of instrumented lumbar surgeries rose from 6.2 to 14.2 procedures per 100 000 population between 1993 and 2012 (p < 0.001), well below the utilization of knee and hip arthroplasties. Patients were younger than 50 years for 29.2% of all instrumented lumbar surgery cases; annual procedure rates among those older than 80 years rose 7.6-fold. Direct medical costs of instrumented lumbar surgeries from 2002 to 2012 totaled $176 million. Spinal stenosis and spondylolisthesis were the most common indications for instrumented lumbar surgeries. Conclusion Use of instrumented lumbar surgeries in Ontario’s single-payer system has increased rapidly, especially among patients older than 80 years. In contrast to the situation in the United States, these rates were well below those of total joint arthroplasties. These data provide useful insights about resource allocation for surgical treatment of lumbar degenerative disorders.
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Affiliation(s)
- Yan Xu
- From the Department of Medicine, University of Toronto, Toronto, Ont. (Y. Xu); ICES, Queen’s University, Kingston, Ont. (Y. Xu, Whitehead, J. Xu, Johnson); the Division of Orthopaedic Surgery, Department of Surgery, Queen’s University, Kingston, Ont. (Yen); and the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Johnson)
| | - David Yen
- From the Department of Medicine, University of Toronto, Toronto, Ont. (Y. Xu); ICES, Queen’s University, Kingston, Ont. (Y. Xu, Whitehead, J. Xu, Johnson); the Division of Orthopaedic Surgery, Department of Surgery, Queen’s University, Kingston, Ont. (Yen); and the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Johnson)
| | - Marlo Whitehead
- From the Department of Medicine, University of Toronto, Toronto, Ont. (Y. Xu); ICES, Queen’s University, Kingston, Ont. (Y. Xu, Whitehead, J. Xu, Johnson); the Division of Orthopaedic Surgery, Department of Surgery, Queen’s University, Kingston, Ont. (Yen); and the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Johnson)
| | - Jianfeng Xu
- From the Department of Medicine, University of Toronto, Toronto, Ont. (Y. Xu); ICES, Queen’s University, Kingston, Ont. (Y. Xu, Whitehead, J. Xu, Johnson); the Division of Orthopaedic Surgery, Department of Surgery, Queen’s University, Kingston, Ont. (Yen); and the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Johnson)
| | - Ana P. Johnson
- From the Department of Medicine, University of Toronto, Toronto, Ont. (Y. Xu); ICES, Queen’s University, Kingston, Ont. (Y. Xu, Whitehead, J. Xu, Johnson); the Division of Orthopaedic Surgery, Department of Surgery, Queen’s University, Kingston, Ont. (Yen); and the Department of Public Health Sciences, Queen’s University, Kingston, Ont. (Johnson)
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Burgess LC, Arundel J, Wainwright TW. The Effect of Preoperative Education on Psychological, Clinical and Economic Outcomes in Elective Spinal Surgery: A Systematic Review. Healthcare (Basel) 2019; 7:E48. [PMID: 30901875 PMCID: PMC6473918 DOI: 10.3390/healthcare7010048] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 12/26/2022] Open
Abstract
Psychosocial factors related to different degrees of clinical impairment and quality of life in the preoperative period may influence outcomes from elective spine surgery. Patients have expressed a need for individualized information given in sufficient quantities and at the appropriate time. Therefore, this review article aims to determine whether a preoperative education session improves clinical, psychological and economic outcomes in elective spinal surgery. PubMed, Cochrane Library, CINAHL Complete, Medline Complete and PsychINFO were searched in July 2018 for randomized clinical trials to evaluate the effects of a preoperative education intervention on psychological, clinical and economic outcomes in spinal surgery. The search yielded 78 results, of which eleven papers (seven studies) were relevant for inclusion. From these results, there is limited, fair-quality evidence that supports the inclusion of a preoperative education session for improving clinical (pain, function and disability), economic (quality-adjusted life years, healthcare expenditure, direct and indirect costs) and psychological outcomes (anxiety, depression and fear-avoidance beliefs) from spinal surgery. Other benefits are reported to be improved patient knowledge, feelings of better preparation, reduced negative thinking and increased levels of physical activity after the intervention. No differences in quality of life, return to work, physical indicators or postoperative complications were reported. From the limited evidence, it is not possible to conclusively recommend that preoperative education should be delivered as a standalone intervention before elective spine surgery; however, given the low risk profile and promising benefits, future research in this area is warranted.
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Affiliation(s)
- Louise C Burgess
- Orthopaedic Research Institute, Bournemouth University, Bournemouth, Dorset BH8 8EB, UK.
| | - Joe Arundel
- Orthopaedic Research Institute, Bournemouth University, Bournemouth, Dorset BH8 8EB, UK.
| | - Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth University, Bournemouth, Dorset BH8 8EB, UK.
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Swamy G, Lopatina E, Thomas KC, Marshall DA, Johal HS. The cost effectiveness of minimally invasive spine surgery in the treatment of adult degenerative scoliosis: a comparison of transpsoas and open techniques. Spine J 2019; 19:339-348. [PMID: 29859350 DOI: 10.1016/j.spinee.2018.05.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 04/10/2018] [Accepted: 05/24/2018] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Surgical treatment improves quality of life in patients with adult degenerative scoliosis (ADS). However, open ADS surgeries are complex, large magnitude operations associated with a high rate of complications. The lateral transpsoas interbody fusion technique is a less invasive alternative to open ADS surgery, but less invasive techniques tend to be more expensive. The objective of this study was to evaluate the cost effectiveness of the transpsoas technique for patients with ADS over a 12-month time horizon from a public payer perspective. METHODS A cost-effectiveness analysis was performed based on a consecutive case series of patients who underwent ADS surgeries between 2006 and 2012. Effectiveness was expressed as the difference in patient reported preoperative and 12-month postoperative health-related quality of life (HRQOL), which was measured in quality-adjusted life years. Health-care resource use was tabulated based on a clinical chart review on an item-by-item basis. Unit cost data were obtained from published provincial costs in Alberta, Canada. All costs were adjusted to 2015 Canadian dollars. The base case analysis included costs for the surgery, initial hospitalization, and treatment for complications over a 12-month follow-up period. The uncomplicated case analysis included costs for the surgery and initial hospitalization only. The joint uncertainty surrounding the cost and HRQOL differences was estimated using bootstrapping with 10,000 replicates. RESULTS A total of 10 open technique and 12 transpsoas technique T11-pelvis fusions were included in the analysis. In the base case analysis, the transpsoas technique was less costly compared with the open technique, total cost of $83,513 (95% CI: $72,772-$94,253) versus $111,381 (95% CI: $36,340-$186,423), respectively (incremental cost $27,869), and was associated with 0.06 more quality-adjusted life years and/or patient. However, in the uncomplicated case, the open technique was less costly compared with the transpsoas technique ($47,795 [95% CI: $39,003-$56,586] vs $76,510 [95% CI: $72,273-$80,746]), respectively, with an incremental cost of $28,715. Based on the probabilistic analysis of 10,000 bootstrap iterations for the base case analysis, the transpsoas technique was more effective and less costly compared with the open technique 57% of time. One-way deterministic sensitivity analysis by adjusting bone-morphogenetic protein-2 dosage further improved cost effectiveness of the transpsoas technique by lowering overall costs. CONCLUSIONS Transpsoas surgeries were associated with better outcomes in terms of HRQOL and lower costs over 1-year follow-up period compared with more invasive open technique. This study should be viewed as a pilot evaluation and should be replicated in a larger prospective multicenter controlled study.
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Affiliation(s)
- Ganesh Swamy
- University of Calgary Spine Program, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta , Canada, T2N 4N1.
| | - Elena Lopatina
- University of Calgary, Room 3C60, Health Research Innovation Centre, 3280 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4Z6.
| | - Ken C Thomas
- University of Calgary Spine Program, Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta , Canada, T2N 4N1.
| | - Deborah A Marshall
- University of Calgary, Room 3C60, Health Research Innovation Centre, 3280 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4Z6.
| | - Herman S Johal
- Division of Orthopaedic Surgery, McMaster University, Center for Evidence Based Orthopedics, 293 Wellington Street North, Hamilton, Ontario, Canada L8L 8E7.
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8
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Nayak NR, Stephen JH, Piazza MA, Obayemi AA, Stein SC, Malhotra NR. Quality of Life in Patients Undergoing Spine Surgery: Systematic Review and Meta-Analysis. Global Spine J 2019; 9:67-76. [PMID: 30775211 PMCID: PMC6362549 DOI: 10.1177/2192568217701104] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Meta-analysis. OBJECTIVE Despite the increasing importance of tracking clinical outcomes using valid patient-reported outcome measures, most providers do not routinely obtain baseline preoperative health-related quality of life (HRQoL) data in patients undergoing spine surgery, precluding objective outcomes analysis in individual practices. We conducted a meta-analysis of pre- and postoperative HRQoL data obtained from the most commonly published instruments to use as reference values. METHODS We searched PubMed, EMBASE, and an institutional registry for studies reporting EQ-5D, SF-6D, and Short Form-36 Physical Component Summary scores in patients undergoing surgery for degenerative cervical and lumbar spinal conditions published between 2000 and 2014. Observational data was pooled meta-analytically using an inverse variance-weighted, random-effects model, and statistical comparisons were performed. RESULTS Ninety-nine articles were included in the final analysis. Baseline HRQoL scores varied by diagnosis for each of the 3 instruments. On average, postoperative HRQoL scores significantly improved following surgical intervention for each diagnosis using each instrument. There were statistically significant differences in baseline utility values between the EQ-5D and SF-6D instruments for all lumbar diagnoses. CONCLUSIONS The pooled HRQoL values presented in this study may be used by practitioners who would otherwise be precluded from quantifying their surgical outcomes due to a lack of baseline data. The results highlight differences in HRQoL between different degenerative spinal diagnoses, as well as the discrepancy between 2 common utility-based instruments. These findings emphasize the need to be cognizant of the specific instruments used when comparing the results of outcome studies.
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Affiliation(s)
- Nikhil R. Nayak
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - James H. Stephen
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Sherman C. Stein
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Neil R. Malhotra
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Clinical Impact and Economic Burden of Hospital-Acquired Conditions Following Common Surgical Procedures. Spine (Phila Pa 1976) 2018; 43:E1358-E1363. [PMID: 29794588 DOI: 10.1097/brs.0000000000002713] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To assess the clinical impact and economic burden of the three most common hospital-acquired conditions (HACs) that occur within 30-day postoperatively for all spine surgeries and to compare these rates with other common surgical procedures. SUMMARY OF BACKGROUND DATA HACs are part of a non-payment policy by the Centers for Medicare and Medicaid Services and thus prompt hospitals to improve patient outcomes and safety. METHODS Patients more than 18 years who underwent elective spine surgery were identified in American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Primary outcomes were cost associated with the occurrence of three most common HACs. Cost associated with HAC occurrence derived from the PearlDiver database. RESULTS Ninety thousand five hundred fifty one elective spine surgery patients were identified, where 3021 (3.3%) developed at least one HAC. Surgical site infection (SSI) was the most common HAC (1.4%), then urinary tract infection (UTI) (1.3%) and venous thromboembolism (VTE) (0.8%). Length of stay (LOS) was longer for patients who experienced a HAC (5.1 vs. 3.2 d, P < 0.001). When adjusted for age, sex, and Charlson Comorbidity Index, LOS was 1.48 ± 0.04 days longer (P < 0.001) and payments were $8893 ± $148 greater (P < 0.001) for patients with at least one HAC. With the exception of craniotomy, patients undergoing common procedures with HAC had increased LOS and higher payments (P < 0.001). Adjusted additional LOS was 0.44 ± 0.02 and 0.38 ± 0.03 days for total knee arthroplasty and total hip arthroplasty, and payments were $1974 and $1882 greater. HACs following hip fracture repair were associated with 1.30 ± 0.11 days LOS and $4842 in payments (P < 0.001). Compared with elective spine surgery, only bariatric and cardiothoracic surgery demonstrated greater adjusted additional payments for patients with at least one HAC ($9975 and $10,868, respectively). CONCLUSION HACs in elective spine surgery are associated with a substantial cost burden to the health care system. When adjusted for demographic factors and comorbidities, average LOS is 1.48 days longer and episode payments are $8893 greater for patients who experience at least one HAC compared with those who do not. LEVEL OF EVIDENCE 3.
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10
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Comparisons of direct costs, outcomes, and cost-utility of decompression surgery with fusion versus decompression alone for degenerative lumbar spondylolisthesis. J Orthop Sci 2018; 23:653-657. [PMID: 29699906 DOI: 10.1016/j.jos.2018.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 03/23/2018] [Accepted: 04/03/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Cost-utility analysis of surgery for degenerative lumber spondylolisthesis (DS) is essential for healthcare providers and patients to select appropriate treatment. The purpose of this study was to review the cost-utility of decompression alone versus decompression with fusion for DS. METHODS A retrospective review of 99 consecutive patients who were treated for Meyerding grade 1 DS at two representative spine centers was performed. Patients with significant spinal instability were treated by decompression with fusion (F group, 40 patients); all others were treated by decompression surgery alone (D group, 59 patients). All patients were followed for three years. Demographic and radiographic data, health-related quality of life (HRQoL), and the direct cost for surgery were analyzed, and the incremental cost-effectiveness ratio (ICER) was determined using cost/quality-adjusted life years (QALY). RESULTS There were no differences between the groups in baseline demographics (D vs. F: age 68 ± 9 vs. 66 ± 7 years; 37% vs. 40% female) or HRQoL (ODI: D, 41 ± 16 vs. F, 46 ± 13%). The F group had a higher initial-surgery cost ($18,992 ± 2932) but lower reoperation frequency (7%) than the D group ($7660 ± 2182 and 12%, respectively). The three-year total direct cost was higher for F than for D ($19,222 ± 3332 vs. $9668 ± 6,168, p = .01). ICER was higher for F at one year ($136,408 ± 187,911 vs. $237,844 ± 212,049, p < .01), but was comparable for F and D at three years (D, $41,923 ± 44,503 vs. F, $51,313 ± 32,849, p = .17). CONCLUSION At the three-year follow-up, the two methods had comparable cost-utility. Both methods were cost-effective (defined as an ICER within three times the per-capita gross domestic product).
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Chotai S, Sivaganesan A, Parker SL, Wick JB, Stonko DP, McGirt MJ, Devin CJ. Effect of Complications within 90 Days on Cost Per Quality-Adjusted Life Year Gained Following Elective Surgery for Degenerative Lumbar Spine Disease. Neurosurgery 2017; 64:157-164. [PMID: 28899064 DOI: 10.1093/neuros/nyx356] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 06/24/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Silky Chotai
- Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ahilan Sivaganesan
- Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott L Parker
- Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph B Wick
- Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David P Stonko
- Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neuro-surgery and Spine Associates, Charlotte, North Carolina
| | - Clinton J Devin
- Department of Orthopedics Surgery and Department of Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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12
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Quality of life and cost-utility of surgical treatment for patients with spinal metastases: prospective cohort study. INTERNATIONAL ORTHOPAEDICS 2017; 41:1265-1271. [DOI: 10.1007/s00264-017-3463-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 03/22/2017] [Indexed: 10/19/2022]
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Elmallah RK, Chughtai M, Khlopas A, Bhowmik-Stoker M, Bozic KJ, Kurtz SM, Mont MA. Determining Cost-Effectiveness of Total Hip and Knee Arthroplasty Using the Short Form-6D Utility Measure. J Arthroplasty 2017; 32:351-354. [PMID: 27665243 DOI: 10.1016/j.arth.2016.08.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 07/22/2016] [Accepted: 08/02/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND With the implementation of the Patient Protection and Affordable Care Act, cost-effectiveness analyses are becoming increasingly important for resource allocation, and particularly for the justification of costly procedures, such as total knee and total hip arthroplasties (TKAs and THAs). Therefore, using the Short Form-6D (SF-6D) utility values, the purpose of this study was to determine (1) the quality-adjusted life years (QALYs) gained and (2) and the cost-effectiveness of undergoing THA and TKA. METHODS A total of 844 patients (357 men, 487 women) who had a mean age of 65 years (range, 39 to 80 years) underwent primary TKA, and 224 patients who had a mean age of 69 years (range, 44 to 88 years) underwent primary THAs at 7 institutions. The SF-6D values were derived for each patient preoperatively and at 1-year follow-up. QALYs were estimated at 1 year, and lifetime QALYs gained were determined using predicted life-expectancy values, at a discounted rate of 3% per year of life expectancy, to reflect a diminishing gain with time. National-level costs were determined using the 2011 Nationwide Inpatient Sample, and incremental cost-effectiveness ratios (ICER) were deduced for both groups. RESULTS The preoperative SF-6D values for the THA and TKA cohorts were 0.614 (range, 0.37 to 1) and 0.62 (range, 0.3 to 0.93). Postoperatively, SF-6D values improved significantly at 1 year in both groups. One-year QALYs for TKA and THA were 0.768 and 0.799. Lifetime QALYs gained for the groups were 2.07 and 1.85 (1.39 and 1.34 if discounted at a rate of 3% per year). The estimated ICER for TKA vs baseline presurgery was $43,107 per QALY, and $39,453 per QALY for THA vs baseline presurgery. CONCLUSION The ICER showed that THA and TKA are cost-effective, compared to the $50,000 USD/QALY threshold for cost-effectiveness, and justify resources allocated to these surgeries. The SF-6D can utilize existing functional outcome data, which makes these cost calculations considerably easier and more feasible for practicing orthopedists.
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Affiliation(s)
- Randa K Elmallah
- Department of Orthopaedic Surgery, University of Mississippi, Jackson, Mississippi
| | - Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Kevin J Bozic
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas
| | - Steven M Kurtz
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Manchikanti L, Pampati V, Kaye AD, Hirsch JA. Cost Utility Analysis of Cervical Therapeutic Medial Branch Blocks in Managing Chronic Neck Pain. Int J Med Sci 2017; 14:1307-1316. [PMID: 29200944 PMCID: PMC5707747 DOI: 10.7150/ijms.20755] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/06/2017] [Indexed: 02/06/2023] Open
Abstract
Background: Controlled diagnostic studies have established the prevalence of cervical facet joint pain to range from 36% to 67% based on the criterion standard of ≥ 80% pain relief. Treatment of cervical facet joint pain has been described with Level II evidence of effectiveness for therapeutic facet joint nerve blocks and radiofrequency neurotomy and with no significant evidence for intraarticular injections. However, there have not been any cost effectiveness or cost utility analysis studies performed in managing chronic neck pain with or without headaches with cervical facet joint interventions. Study Design: Cost utility analysis based on the results of a double-blind, randomized, controlled trial of cervical therapeutic medial branch blocks in managing chronic neck pain. Objectives: To assess cost utility of therapeutic cervical medial branch blocks in managing chronic neck pain. Methods: A randomized trial was conducted in a specialty referral private practice interventional pain management center in the United States. This trial assessed the clinical effectiveness of therapeutic cervical medial branch blocks with or without steroids for an established diagnosis of cervical facet joint pain by means of controlled diagnostic blocks. Cost utility analysis was performed with direct payment data for the procedures for a total of 120 patients over a period of 2 years from this trial based on reimbursement rates of 2016. The payment data provided direct procedural costs without inclusion of drug treatments. An additional 40% was added to procedural costs with multiplication of a factor of 1.67 to provide estimated total costs including direct and indirect costs, based on highly regarded surgical literature. Outcome measures included significant improvement defined as at least a 50% improvement with reduction in pain and disability status with a combined 50% or more reduction in pain in Neck Disability Index (NDI) scores. Results: The results showed direct procedural costs per one-year improvement in quality adjusted life year (QALY) of United States Dollar (USD) of $2,552, and overall costs of USD $4,261. Overall, each patient on average received 5.7 ± 2.2 procedures over a period of 2 years. Average significant improvement per procedure was 15.6 ± 12.3 weeks and average significant improvement in 2 years per patient was 86.0 ± 24.6 weeks. Limitations: The limitations of this cost utility analysis are that data are based on a single center evaluation. Only costs of therapeutic interventional procedures and physician visits were included, with extrapolation of indirect costs. Conclusion: The cost utility analysis of therapeutic cervical medial branch blocks in the treatment of chronic neck pain non-responsive to conservative management demonstrated clinical effectiveness and cost utility at USD $4,261 per one year of QALY.
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Affiliation(s)
| | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Witiw CD, Tetreault LA, Smieliauskas F, Kopjar B, Massicotte EM, Fehlings MG. Surgery for degenerative cervical myelopathy: a patient-centered quality of life and health economic evaluation. Spine J 2017; 17:15-25. [PMID: 27793760 DOI: 10.1016/j.spinee.2016.10.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 09/02/2016] [Accepted: 10/12/2016] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Christopher D Witiw
- Toronto Western Hospital, 399 Bathurst St, WW 4-437, Toronto, Ontario M5T 2S8, Canada; Department of Public Health Sciences, The University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637, USA
| | - Lindsay A Tetreault
- Faculty of Medicine, University of Toronto Medical Sciences, Building 1 King's College Circle, Room 2374 Toronto, Ontario M5S 1A8, Canada
| | - Fabrice Smieliauskas
- Department of Public Health Sciences, The University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637, USA
| | - Branko Kopjar
- Department of Health Services, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660
| | - Eric M Massicotte
- Toronto Western Hospital, 399 Bathurst St, WW 4-437, Toronto, Ontario M5T 2S8, Canada
| | - Michael G Fehlings
- Toronto Western Hospital, 399 Bathurst St, WW 4-437, Toronto, Ontario M5T 2S8, Canada; McEwen Centre for Regenerative Medicine, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, Ontario M5T 2S8, Canada; Department of Surgery, University of Toronto, Stewart Building, 149 College St, 5th Floor, Toronto, Ontario M5T 1P5, Canada.
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Chotai S, Parker SL, Sielatycki JA, Sivaganesan A, Kay HF, Wick JB, McGirt MJ, Devin CJ. Impact of old age on patient-report outcomes and cost utility for anterior cervical discectomy and fusion surgery for degenerative spine disease. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:1236-1245. [PMID: 27885477 DOI: 10.1007/s00586-016-4835-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 09/21/2016] [Accepted: 10/20/2016] [Indexed: 01/13/2023]
Abstract
PURPOSE With growing older population and increasing rates of cervical spinal surgery, it is vital to understand the value of cervical surgery in this population. We set forth to determine the cost utility following anterior cervical decompression and fusion (ACDF) for degenerative disease in older patients. METHODS Patients undergoing ACDF for degenerative diseases were enrolled into prospective longitudinal registry. Patient-reported outcomes (PROs) were recorded at baseline, 1-year, and 2-year postoperatively. Two-year medical resource utilization, missed work, and health-state values [quality-adjusted life years (QALYs)] were assessed to compute cost per QALY gained. Patients were dichotomized based on age: <65 years (younger) and ≥65 years (older) to compare the cost utility in these age groups. RESULTS Total 218 (87%) younger patients and 33 (13%) older patients who underwent ACDF were analyzed. Both the groups demonstrated a significant improvement in PROs 2-year following surgery. The older patients had a lower mean cumulative gain in QALYs compared to younger patients at 1 year (0.141 vs. 0.28, P = 0.05) and 2 years (0.211 vs. 0.424, P = 0.04). There was no significant difference in the mean total 2-year cost between older [$21,041 (95% CI $18,466-$23,616)] and younger [$22,669 (95% CI $$21,259-$24,079)] patients (P = 0.27). Two-year cost per QALY gained in older vs. younger patients was ($99,720/QALYs gained vs. ($53,464/QALYs gained, P = 0.68). CONCLUSION ACDF surgery provided a significant gain in health-state utility in older patients with degenerative cervical pathology, with a mean cumulative 2-year cost per QALY gained of $99,720/QALY. While older patients have a slightly higher cost utility compared to their younger counterparts, surgery in the older cohort does provide a significant improvement in pain, disability, and quality-of-life outcomes.
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Affiliation(s)
- Silky Chotai
- Department of Orthopedics Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott L Parker
- Department of Orthopedics Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Alex Sielatycki
- Department of Orthopedics Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ahilan Sivaganesan
- Department of Orthopedics Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harrison F Kay
- Department of Orthopedics Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph B Wick
- Department of Orthopedics Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA
| | - Clinton J Devin
- Department of Orthopedics Surgery, Vanderbilt Spine Institute, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA. .,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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Chotai S, Sielatycki JA, Parker SL, Sivaganesan A, Kay HL, Stonko DP, Wick JB, McGirt MJ, Devin CJ. Effect of obesity on cost per quality-adjusted life years gained following anterior cervical discectomy and fusion in elective degenerative pathology. Spine J 2016; 16:1342-1350. [PMID: 27394664 DOI: 10.1016/j.spinee.2016.06.023] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/28/2016] [Accepted: 06/28/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Obese patients have greater comorbidities along with higher risk of complications and greater costs after spine surgery, which may result in increased cost and lower quality of life compared with their non-obese counterparts. PURPOSE The aim of the present study was to determine cost-utility following anterior cervical discectomy and fusion (ACDF) in obese patients. STUDY DESIGN This study analyzed prospectively collected data. PATIENT SAMPLE Patients undergoing elective ACDF for degenerative cervical pathology at a single academic institution were included in the study. OUTCOME MEASURES Cost and quality-adjusted life years (QALYs) were the outcome measures. METHODS One- and two-year medical resource utilization, missed work, and health state values (QALYs) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Total cost (direct+indirect) was used to compute cost per QALY gained. Patients were defined as obese for body mass index (BMI) ≥35 based on the WHO definition of class II obesity. A subgroup analysis was conducted in morbidly obese patients (BMI≥40). RESULTS There were significant improvements in pain (neck pain or arm pain), disability (Neck Disability Index), and quality of life (EuroQol-5D and Short Form-12) at 2 years after surgery (p<.001). There was no significant difference in post-discharge health-care resource utilization, direct cost, indirect cost, and total cost between obese and non-obese patients at postoperative 1-year and 2-year follow-up. Mean 2-year direct cost for obese patients was $19,225±$8,065 and $17,635±$6,413 for non-obese patients (p=.14). There was no significant difference in the mean total 2-year cost between obese ($23,144±$9,216) and non-obese ($22,183±$10,564) patients (p=.48). Obese patients had a lower mean cumulative gain in QALYs versus non-obese patients at 2-years (0.34 vs. 0.42, p=.32). Two-year cost-utility in obese ($68,070/QALY) versus non-obese patients ($52,816/QALY) was not significantly different (p=.11). Morbidly obese patients had lower QALYs gained (0.17) and higher cost per QALYs gained ($138,094/QALY) at 2 years. CONCLUSIONS Anterior cervical discectomy and fusion provided a significant gain in health state utility in obese patients, with a mean 2-year cost-utility of $68,070 per QALYs gained, which can be considered moderately cost-effective. Morbidly obese patients had lower cost-effectiveness; however, surgery does provide a significant improvement in outcomes. Obesity, and specifically morbid obesity, should to be taken into consideration as physician and hospital reimbursements move toward a bundled model.
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Affiliation(s)
- Silky Chotai
- Department of Orthopedics Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Alex Sielatycki
- Department of Orthopedics Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott L Parker
- Department of Orthopedics Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ahilan Sivaganesan
- Department of Orthopedics Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harrison L Kay
- Department of Orthopedics Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David P Stonko
- Department of Orthopedics Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph B Wick
- Department of Orthopedics Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA
| | - Clinton J Devin
- Department of Orthopedics Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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Ramme AJ, Strauss EJ, Jazrawi L, Gold HT. Cost effectiveness of meniscal allograft for torn discoid lateral meniscus in young women. PHYSICIAN SPORTSMED 2016; 44:278-82. [PMID: 27270137 DOI: 10.1080/00913847.2016.1197762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE A discoid meniscus is more prone to tears than a normal meniscus. Patients with a torn discoid lateral meniscus are at increased risk for early onset osteoarthritis requiring total knee arthroplasty (TKA). Optimal management for this condition is controversial given the up-front cost difference between the two treatment options: the more expensive meniscal allograft transplantation compared with standard partial meniscectomy. We hypothesize that meniscal allograft transplantation following excision of a torn discoid lateral meniscus is more cost-effective compared with partial meniscectomy alone because allografts will extend the time to TKA. METHODS A decision analytic Markov model was created to compare the cost effectiveness of two treatments for symptomatic, torn discoid lateral meniscus: meniscal allograft and partial meniscectomy. Probability estimates and event rates were derived from the scientific literature, and costs and benefits were discounted by 3%. One-way sensitivity analyses were performed to test model robustness. RESULTS Over 25 years, the partial meniscectomy strategy cost $10,430, whereas meniscal allograft cost on average $4040 more, at $14,470. Partial meniscectomy postponed TKA an average of 12.5 years, compared with 17.30 years for meniscal allograft, an increase of 4.8 years. Allograft cost $842 per-year-gained in time to TKA. CONCLUSION Meniscal allografts have been shown to reduce pain and improve function in patients with discoid lateral meniscus tears. Though more costly, meniscal allografts may be more effective than partial meniscectomy in delaying TKA in this model. Additional future long term clinical studies will provide more insight into optimal surgical options.
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Affiliation(s)
- Austin J Ramme
- a Department of Orthopaedic Surgery , New York University Hospital for Joint Diseases , New York , NY , USA
| | - Eric J Strauss
- a Department of Orthopaedic Surgery , New York University Hospital for Joint Diseases , New York , NY , USA
| | - Laith Jazrawi
- a Department of Orthopaedic Surgery , New York University Hospital for Joint Diseases , New York , NY , USA
| | - Heather T Gold
- a Department of Orthopaedic Surgery , New York University Hospital for Joint Diseases , New York , NY , USA.,b Department of Population Health , New York University School of Medicine , New York , NY , USA
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Virk SS, Phillips FM, Khan SN. Reimbursement Related to a 90-Day Episode of Care for a One or Two-Level Anterior Cervical Discectomy and Fusion. J Bone Joint Surg Am 2016; 98:1378-84. [PMID: 27535440 DOI: 10.2106/jbjs.15.01169] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A bundled payment represents a single payment for services during an episode of care for a surgical procedure. Anterior cervical discectomy and fusion (ACDF) and associated 90-day costs have been suggested as a bundle amenable to such a payment structure; however, to our knowledge, there are limited available data with regard to costs related to this procedure and subsequent care. METHODS The Medicare 5% National Sample Administrative Database was used to catalog clinical and financial data associated with the day of the surgical procedure and the 90-day postoperative period for patients undergoing a one to two-level ACDF procedure from 2005 to 2012. We simultaneously queried the database for total knee replacement as a means to compare the payments and to verify the reliability of our analysis. RESULTS A total of 4,506 patients underwent an ACDF procedure for cervical radiculopathy. The total 90-day reimbursement was $69,469,550 or a mean cost per patient (and standard deviation) of $15,417 ± $947 (median, $15,589). As a comparison, the mean reimbursement for patients who had undergone a total knee replacement amounted to $17,451 per patient. The physician reimbursement for ACDF represented 20.42% of the total, with the surgeon receiving 18.07% of the total reimbursement. Revision surgery, readmission, and emergency department reimbursement accounted for 0.71% of the total reimbursement. Reimbursement for rehabilitation services, including physical therapy, skilled nursing facilities, and home care, represented 3.11% of the total reimbursement. There was a significant variation in reimbursement among geographic regions in the United States (p < 0.001), with the highest in the West. CONCLUSIONS To our knowledge, this study is the first report on 90-day reimbursement per patient for one to two-level ACDF procedures in a Medicare cohort. Payments varied significantly among geographic locations. Our study provides a reimbursement benchmark for one to two-level ACDF procedures. Clarifying the payments relative to costs will help providers to understand whether a bundled payment for the ACDF procedure is economically viable.
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Affiliation(s)
- Sohrab S Virk
- Department of Orthopaedics, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Frank M Phillips
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Safdar N Khan
- Department of Orthopaedics, Wexner Medical Center at The Ohio State University, Columbus, Ohio
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Risk Factors for Reoperation in Patients Treated Surgically for Lumbar Stenosis: A Subanalysis of the 8-year Data From the SPORT Trial. Spine (Phila Pa 1976) 2016; 41:901-9. [PMID: 26656062 PMCID: PMC5521164 DOI: 10.1097/brs.0000000000001361] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective subgroup analysis was performed on surgically treated patients from the lumbar spinal stenosis (SpS) arm of the Spine Patient Outcomes Research Trial (SPORT), randomized, and observational cohorts. OBJECTIVE To identify risk factors for reoperation in patients treated surgically for SpS and compare outcomes between patients who underwent reoperation with those who did not. SUMMARY OF BACKGROUND DATA SpS is one of the most common indications for surgery in the elderly; however, few long-term studies have identified risk factors for reoperation. METHODS A post-hoc subgroup analysis was performed on patients from the SpS arm of the SPORT, randomized and observational cohorts. Baseline characteristics were analyzed between reoperation and no-reoperation groups using univariate and multivariate analysis on data 8 years postoperation. RESULTS Of the 417 study patients, 88% underwent decompression only, 5% noninstrumented fusion, and 6% instrumented fusion. At the 8-year follow-up, the reoperation rate was 18%; 52% of reoperations were for recurrent stenosis or progressive spondylolisthesis, 25% for complication or other reason, and 16% for new condition. Of patients who underwent a reoperation, 42% did so within 2 years, 70% within 4 years, and 84% within 6 years. Patients who underwent reoperation were less likely to have presented with any neurological deficit (43% reop vs. 57% no reop, P = 0.04). Patients improved less at follow-up in the reoperation group (P < 0.001). CONCLUSION In patients undergoing surgical treatment for SpS, the reoperation rate at 8-year follow-up was 18%. Patients with a reoperation were less likely to have a baseline neurological deficit. Patients who did not undergo reoperation had better patient reported outcomes at 8-year follow-up compared with those who had repeat surgery. LEVEL OF EVIDENCE 2.
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Takura T, Miki K. The future of medical reimbursement for orthopedic surgery in Japan from the viewpoint of the health economy. J Orthop Sci 2016; 21:273-81. [PMID: 27020176 DOI: 10.1016/j.jos.2016.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 01/04/2016] [Accepted: 02/09/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The financial burden of medical insurance on the government of Japan has recently become severe, which has led to the control of outpatient orthopedic reimbursements for common procedures. On the other hand, the overall disease burden for total hip or knee arthroplasty, decompression for cervical myelopathy or lumbar spinal canal stenosis, and new surgical technologies to treat other painful conditions and the post-surgical care related to these procedures has been reduced. METHODS Medical insurance systems in Japan are generally influenced by budget-balancing action. Consequently, the further development of interventional evaluation methods should be promoted. From the viewpoint of health economics, the value (meaning) of medical intervention can partly be explained by its cost-effectiveness. In order for appropriate medical reimbursement levels to be set for orthopedic surgery, the financial status of medical institutions needs to be concurrently reviewed. In particular, the relationship between the expense structure and medical reimbursement must be discussed to evaluate its role in community medicine system. RESULTS Over the past 10 years, medical expenditures have increased by 9.6% in all fields, whereas the monthly medical reimbursements per patient have dropped by an average of 17.5%. Remarkably, surgery-related costs have increased by 36.5%, while other medical costs have decreased by 19.8%. There are a few reports of cost-utility analyses which investigate interventions such as total hip arthroplasty for hip osteoarthritis patients (US$ 4,600-70,500/QALY) and laminectomy for patients with spinal canal stenosis. Interventions may be an inevitable part of relative expense control under the current trend; however, there has been a slight increase in other parameters in response to changes in medical reimbursement evaluations - specifically, in the total income of medical institutions. CONCLUSIONS If medical professionals such as orthopedic surgeons contribute to the economic value of orthopedic surgery, it is crucial to clearly establish interventions among the different performances of medical reimbursement to motivate the increased allocation of management resources. To further develop this concept, discussions between stakeholders should involve the value of medicine based on cost and benefit.
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Affiliation(s)
- Tomoyuki Takura
- Department of Health Care Economics and Industrial Policy, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita-shi, Osaka 565-0871, Japan.
| | - Kenji Miki
- Department of Pain Medicine, Graduate School of Medicine, Osaka University, Japan
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22
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Abraham P, Rennert RC, Martin JR, Ciacci J, Taylor W, Resnick D, Kasper E, Chen CC. The role of surgery for treatment of low back pain: insights from the randomized controlled Spine Patient Outcomes Research Trials. Surg Neurol Int 2016; 7:38. [PMID: 27127703 PMCID: PMC4838923 DOI: 10.4103/2152-7806.180297] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/02/2016] [Indexed: 12/17/2022] Open
Abstract
Low back pain (LBP) is a common medical problem with high morbidity and healthcare costs. The optimal management strategy, including the role of surgical intervention, remains controversial. The Spine Patient Outcomes Research Trials were randomized controlled studies conducted to assess the effectiveness of surgery for three of the most common conditions implicated in LBP: Intervertebral disc herniation, degenerative spondylolisthesis, and spinal stenosis. Despite challenges in data interpretation related to patient cross over, these studies support the efficacy of surgery as treatment for these three common conditions.
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Affiliation(s)
- Peter Abraham
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Joel R Martin
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Joseph Ciacci
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - William Taylor
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Daniel Resnick
- Department of Neurosurgery, University of Wisconsin, Madison, WI, USA
| | - Ekkehard Kasper
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Clark C Chen
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
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Kasch R, Assmann G, Merk S, Barz T, Melloh M, Hofer A, Merk H, Flessa S. Economic analysis of two-stage septic revision after total hip arthroplasty: What are the relevant costs for the hospital's orthopedic department? BMC Musculoskelet Disord 2016; 17:112. [PMID: 26932453 PMCID: PMC4774180 DOI: 10.1186/s12891-016-0962-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 02/23/2016] [Indexed: 02/02/2023] Open
Abstract
Background The number of septic total hip arthroplasty (THA) revisions is increasing continuously, placing a growing financial burden on hospitals. Orthopedic departments performing septic THA revisions have no basis for decision making regarding resource allocation as the costs of this procedure for the departments are unknown. It is widely assumed that septic THA procedures can only be performed at a loss for the department. Therefore, the purpose of this study was to investigate whether this assumption is true by performing a detailed analysis of the costs and revenues for two-stage septic THA revision. Methods Patients who underwent revision THA for septic loosening in two sessions from January 2009 through March 2012 were included in this retrospective, consecutive cost study from the orthopedic department’s point of view. We analyzed variable and case-fixed costs for septic revision THA with special regard to implantation and explantation stay. By using marginal costing approach we neglected hospital-fixed costs. Outcome measures include reimbursement and daily contribution margins. Results The average direct costs (reimbursement) incurred for septic two-stage revision THA was €10,828 (€24,201). The difference in cost and contribution margins per day was significant (p < .001 and p = 0.019) for ex- and implantation (€4147 vs. €6680 and €429 vs. €306) while length of stay and reimbursement were comparable. Conclusions This is the first detailed analysis of the hospital department’s cost for septic revision THA performed in two sessions. Disregarding hospital-fixed costs the included variable and case fixed-costs were covered by revenues. This study provides cost data, which will be guidance for health care decision makers.
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Affiliation(s)
- R Kasch
- Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, Clinic and Outpatient Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany.
| | - G Assmann
- Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, Clinic and Outpatient Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany.,Department of Health Care Management, Faculty of Law and Economics, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - S Merk
- Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, Clinic and Outpatient Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - T Barz
- Department of Orthopedics and Trauma Surgery, Asklepios Hospital Uckermark, Schwedt, Germany
| | - M Melloh
- Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, Clinic and Outpatient Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany.,Center for Health Sciences, School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - A Hofer
- Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, Clinic and Outpatient Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - H Merk
- Center of Orthopaedics, Trauma Surgery and Rehabilitation Medicine, Clinic and Outpatient Clinic for Orthopaedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - S Flessa
- Department of Health Care Management, Faculty of Law and Economics, Ernst-Moritz-Arndt-University, Greifswald, Germany
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Manson NA, Green AJ, Abraham EP. Elevated Patient Body Mass Index Does Not Negatively Affect Self-Reported Outcomes of Thoracolumbar Surgery: Results of a Comparative Observational Study with Minimum 1-Year Follow-Up. Global Spine J 2016; 6:108-17. [PMID: 26933611 PMCID: PMC4771507 DOI: 10.1055/s-0035-1556585] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 05/06/2015] [Indexed: 11/19/2022] Open
Abstract
Study Design Retrospective study. Objective Quantify the effect of obesity on elective thoracolumbar spine surgery patients. Methods Five hundred consecutive adult patients undergoing thoracolumbar spine surgery to treat degenerative pathologies with minimum follow-up of at least 1 year were included. Primary outcome measures included Numerical Rating Scales for back and leg pain, the Short Form 36 Physical Component Summary and Mental Component Summary, the modified Oswestry Disability Index, and patient satisfaction scores collected preoperatively and at 3, 6, 12, and 24 months postoperatively. Secondary outcome measures included perioperative and postoperative adverse events, postoperative emergency department presentation, hospital readmission, and revision surgeries. Patients were grouped according to World Health Organization body mass index (BMI) guidelines to isolate the effect of obesity on primary and secondary outcome measures. Results Mean BMI was 30 kg/m(2), reflecting a significantly overweight population. Each BMI group reported statistically significant improvement on all self-reported outcome measures. Contrary to our hypothesis, however, there was no association between BMI group and primary outcome measures. Patients with BMI of 35 to 39.99 visited the emergency department with complaints of pain significantly more often than the other groups. Otherwise, we did not detect any differences in the secondary outcome measures between BMI groups. Conclusions Patients of all levels of obesity experienced significant improvement following elective thoracolumbar spine surgery. These outcomes were achieved without increased risk of postoperative complications such as infection and reoperation. A risk-benefit algorithm to assist with surgical decision making for obese patients would be valuable to surgeons and patients alike.
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Affiliation(s)
- Neil A. Manson
- Canada East Spine Centre, Saint John, New Brunswick, Canada,Department of Orthopaedic Surgery, Saint John Regional Hospital, Saint John, New Brunswick, Canada,Department of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada,Address for correspondence Neil A. Manson, MD, FRCSC 555 Somerset Street, Suite 200Saint John, New BrunswickCanada E2K 4X2
| | - Alana J. Green
- Canada East Spine Centre, Saint John, New Brunswick, Canada,Department of Orthopaedic Surgery, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | - Edward P. Abraham
- Canada East Spine Centre, Saint John, New Brunswick, Canada,Department of Orthopaedic Surgery, Saint John Regional Hospital, Saint John, New Brunswick, Canada,Department of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Devin CJ, Chotai S, Parker SL, Tetreault L, Fehlings MG, McGirt MJ. A Cost-Utility Analysis of Lumbar Decompression With and Without Fusion for Degenerative Spine Disease in the Elderly. Neurosurgery 2015; 77 Suppl 4:S116-24. [DOI: 10.1227/neu.0000000000000949] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Abstract
Introduction: The heath care system in the United States is in the midst of a transition, in large part to help accommodate an older and more medically complex population. Central to the current evolution is the reassessment of value based on the cost utility of a particular procedure compared to alternatives. The existing contribution of geriatric orthopedics to the societal burden of disease is substantial, and literature focusing on the economic value of treating elderly populations with musculoskeletal injuries is growing. Materials and Methods: A literature review of peer-reviewed publications and abstracts related to the cost-effectiveness of treating geriatric patients with orthopedic injuries was carried out. Results: In our review, we demonstrate that while cost-utility studies generally demonstrate net society savings for most orthopedic procedures, geriatric populations often contribute to negative net society savings due to decreased working years and lower salaries while in the workforce. However, the incremental cost-effective ratio for operative intervention has been shown to be below the financial willingness to treat threshold for common procedures including joint replacement surgery of the knee (ICER US$8551), hip (ICER US$17 115), and shoulder (CE US$957) as well as for spinal procedures and repair of torn rotator cuffs (ICER US$12 024). We also discuss the current trends directed toward improving institutional value and highlight important complementary next steps to help overcome the growing demands of an older, more active society. Conclusion: The geriatric population places a significant burden on the health care system. However, studies have shown that treating this demographic for orthopedic-related injuries is cost effective and profitable for providers under certain scenarios.
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Affiliation(s)
- Jeremy Truntzer
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Christopher Nacca
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - David Paller
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
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Elmallah RK, Cherian JJ, Jauregui JJ, Bhowmik-Stoker M, Beaver WB, Mont MA. Determining Health-Related Quality-of-Life Outcomes Using the SF-6D Preference-Based Measure in Patients Following Total Knee Arthroplasty. J Arthroplasty 2015; 30:1150-3. [PMID: 25683293 DOI: 10.1016/j.arth.2015.01.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/06/2015] [Accepted: 01/31/2015] [Indexed: 02/01/2023] Open
Abstract
The SF-6D, a health-related quality-of-life measure, assigns value to patients' perception of their health. We determined SF-6D values of 844 TKA patients, deduced clinical relevance of value changes using effect size, and compared these to clinical and functional improvements 6weeks, 3months, and 1 through 5years post-operatively. The SF-6D significantly improved at all follow-ups after 6weeks. The effect size indicated clinical relevance at every follow-up. The KSS improved at all follow-ups (+43, +51, +56, +57, +57 points), and LEAS scores improved at follow-ups after 6weeks (+1 point at 3months, +2 points thereafter), correlating with SF-6D changes. Deducing utility scores facilitates cost analyses, allowing clinicians to deduce quality-adjusted life-years and economic impacts of treatments.
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Affiliation(s)
- Randa K Elmallah
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jeffrey J Cherian
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Julio J Jauregui
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Walter B Beaver
- OrthoCarolina Hip and Knee Center, Charlotte, North Carolina
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Manchikanti L, Kaye AD, Manchikanti K, Boswell M, Pampati V, Hirsch J. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med 2015; 5:e23139. [PMID: 25789241 PMCID: PMC4350165 DOI: 10.5812/aapm.23139] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/12/2014] [Indexed: 12/13/2022] Open
Abstract
Context: Lumbar central spinal stenosis is common and often results in chronic persistent pain and disability, which can lead to multiple interventions. After the failure of conservative treatment, either surgical or nonsurgical modalities such as epidural injections are contemplated in the management of lumbar spinal stenosis. Evidence Acquisition: Recent randomized trials, systematic reviews and guidelines have reached varying conclusions about the efficacy of epidural injections in the management of central lumbar spinal stenosis. The aim of this systematic review was to determine the efficacy of all three anatomical epidural injection approaches (caudal, interlaminar, and transforaminal) in the treatment of lumbar central spinal stenosis. A systematic review was performed on randomized trials published from 1966 to July 2014 of all types of epidural injections used in the management of lumbar central spinal stenosis. Methodological quality assessment and grading of the evidence was performed. Results: The evidence in managing lumbar spinal stenosis is Level II for long-term improvement for caudal and lumbar interlaminar epidural injections. For transforaminal epidural injections, the evidence is Level III for short-term improvement only. The interlaminar approach appears to be superior to the caudal approach and the caudal approach appears to be superior to the transforaminal one. Conclusions: The available evidence suggests that epidural injections with local anesthetic alone or with local anesthetic with steroids offer short- and long-term relief of low back and lower extremity pain for patients with lumbar central spinal stenosis. However, the evidence is Level II for the long-term efficacy of caudal and interlaminar epidural injections, whereas it is Level III for short-term improvement only with transforaminal epidural injections.
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Affiliation(s)
- Laxmaiah Manchikanti
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, USA
- Pain Management Center of Paducah, Paducah, USA
- Corresponding author: Laxmaiah Manchikanti, Pain Management Center of Paducah, Paducah, USA. Tel: +1-2705548373, Fax: +1-2705548987, E-mail:
| | - Alan David Kaye
- Department of Anesthesia, LSU Health Science Center, New Orleans, USA
| | - Kavita Manchikanti
- University of Kentucky Medical School, University of Kentucky, Lexington, USA
| | - Mark Boswell
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, USA
| | - Vidyasagar Pampati
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, USA
| | - Joshua Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Cheng I, Ho S, Kennedy DJ. Electrodiagnostic testing before surgery for spinal stenosis. PM R 2014; 6:945-50. [PMID: 25441719 DOI: 10.1016/j.pmrj.2014.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 09/18/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Ivan Cheng
- Department of Orthopaedics, Stanford University, Redwood City, CA(∗)(‡)
| | - Suehun Ho
- Department of Physical Medicine and Rehabilitation, SUNY Upstate Medical University, Syracuse, NY(†)
| | - David J Kennedy
- Department of Orthopaedics, Stanford University, Redwood City, CA(∗)(‡).
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Abstract
STUDY DESIGN Systematic review. OBJECTIVE To identify cost-effective treatment strategies for lumbar spine degenerative diseases. SUMMARY OF BACKGROUND DATA There is a paucity of literature assisting physicians and society regarding the cost-efficiency of management of lumbar spine conditions. Limited articles on selective operative and nonoperative therapies have been published for a variety of lumbar conditions. METHODS A systematic search of PubMed, EMBASE, the Cochrane Collaboration data base, University of York, Centre for Reviews and Dissemination (National Health Services Economic Evaluation Database and health technology assessment), and the Tufts CEA Registry was conducted through December 16, 2013. Three specific questions were addressed for adult patients: (1) What is the evidence that surgery is cost-effective compared with nonsurgical management for lumbar degenerative spondylolisthesis or stenosis? (2) What is the evidence that fusion is cost-effective compared with no fusion for degenerative spondylolisthesis or stenosis? and (3) What is the evidence that instrumentation is cost-effective compared with none for degenerative spondylolisthesis? The Quality of Health Economic Studies instrument was used to provide an initial basis for critical appraisal of included economic studies. Articles were further refined with individual review based on inclusion/exclusion criteria. RESULTS Initial search resulted in 122 potentially relevant citations, 115 of which were excluded at title and abstract levels and 3 at full-text reviews, leaving 5 for analysis. No non-English language text met inclusion/exclusion criteria. All studies illustrated a clinical benefit of surgical treatment as measured by quality-adjusted life year (0.11-8.05). Surgical treatments had a greater financial cost than nonoperative care ($5883-$26,035). Incremental cost-effectiveness ratio calculations noted operative treatment over nonoperative treatment for spondylolisthesis ($59,487-$115,600) per quality-adjusted life year. However, cost for patients without spondylolisthesis varied greatly from nonoperative treat dominating to $77,600 per quality-adjusted life year favoring surgery. Because the articles had heterogeneous methods and patient population, conclusion differed greatly on cost assessment. CONCLUSION Limited quality data exist on cost-effective treatment of degenerative lumbar spinal conditions, despite more recent interest related to this topic. It is important that future research efforts focus on constructing higher quality trials in this area to help determine the most cost-effective care. LEVEL OF EVIDENCE 3.
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Proceedings of the 2014 Autumn Meeting of the Society of British Neurological Surgeons. Br J Neurosurg 2014. [DOI: 10.3109/02688697.2014.946317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Stauff MP, Connolly PJ, Hurwitz EL. Commentary on perioperative variables and minimally invasive surgical techniques: are we asking the right questions? Spine J 2014; 14:1709-11. [PMID: 25085724 DOI: 10.1016/j.spinee.2014.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 03/01/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Michael P Stauff
- Department of Orthopedic Surgery and Physical Rehabilitation, University of Massachusetts Memorial Medical Center, Spine Center, Memorial Campus, 119 Belmont St, Worcester, MA 01605, USA.
| | - Patrick J Connolly
- Department of Orthopedic Surgery and Physical Rehabilitation, University of Massachusetts Memorial Medical Center, Spine Center, Memorial Campus, 119 Belmont St, Worcester, MA 01605, USA
| | - Eric L Hurwitz
- Department of Public Health Services, Office of Public Health Studies, University of Hawaii, Manoa, 1960 East-West Road, Biomed D-104H; Honolulu, HI 96822, USA
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Shaffrey CI, Smith JS. Editorial: Incremental cost-effectiveness of adult spinal deformity surgery. Neurosurg Focus 2014; 36:E4. [DOI: 10.3171/2014.3.focus14115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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