Cost analysis of primary single-level lumbar discectomies using the Value Driven Outcomes database in a large academic center

No cost difference between single or dual implants for distal femur fractures in the perioperative period

PURPOSE

This study uses a value-driven outcome model to assess the cost-effectiveness of single versus dual implants used in the fixation of distal femur fractures (DFF).

METHODS

A retrospective review identified all DFF treated at a level I trauma center between 2013 and 2023. Patients with open fractures, bilateral fractures, multiple injuries, and less than six months of cost-data or follow-up were excluded. DFF were divided into fixation by an intramedullary nail (IMN), lateral plate (LP), or dual construct (DC) including IMN and plate or dual plating. Cost data included all costs, including implant, facility, and operative costs associated with initial surgery and subsequent admissions associated with the injury. Actual cost data were analyzed via an inverse Gaussian regression model.

RESULTS

Of 293 cases, 123 were treated by IMN, 133 by LP, and 37 by DC. There was no demographic, BMI, Charlson Comorbidity Index (CCI), or Injury Severity score (ISS) differences between groups. DC DFF tended to be AO Type C (27%) or periprosthetic fractures (35%) (p < 0.001). DC was 47% more expensive than IMN and 43% more expensive than LP at initial surgery (p < 0.001) and 46% more expensive than IMN and 40% more costly than LP downstream (p < 0.001). However, when controlling for age, BMI, fracture classification, and ISS, there was no difference in total cost across fixation types.

CONCLUSION

The total cost for dual construct fixation of distal femur fractures was similar to intramedullary nailing or lateral plating despite higher initial costs and use in more complex fracture patterns.

Cost outcomes of pituitary adenoma resection: The use of a hybrid microscopic/endoscopic surgery

Background

The pathogenesis, surgical techniques, and outcomes of pituitary adenomas (PAs) remain variable. We compared our surgical techniques and perioperative/long-term PA outcomes to highlight the hybrid microscopic/endoscopic technique used to optimize efficiency, cost savings, and outcomes in PA surgery.

Methods

Consecutive PA cases performed from January 2017 through February 2020 were evaluated retrospectively. A cost analysis by surgical approach was performed combining this primarily microscopic series, with endoscopic visual assist, and a separate cohort of consecutive intra-institutional endoscopic-only PA resections.

Results

Among 160 patients included in the main cohort analysis (mean age 51.5 ± 16.2; 89 females [55.6%]), a microscope was used in 81.9% of cases, with endoscopic assistance (hybrid) or the endoscope alone used in the remaining cases. Surgical complications occurred in 5 cases (3.1%): postoperative diabetes insipidus in 3 (1.9%), electrolyte imbalances requiring additional drug treatment in 3 (1.9%), and syndrome of inappropriate anti-diuretic hormone release in 2 (1.2%). Thirty-three additional patients were included in the cost analysis (193 total). Patients treated with a microscopic-only approach had the lowest operating time (mean normalized operating room costs 1.00 [95% confidence interval (CI) 0.95, 1.04], P < 0.001; mean normalized total direct costs 5.00 [95%CI 4.69, 5.31], P = 0.008), with hybrid and endoscopic-only approaches having higher comparable operating times and costs.

Conclusion

PA surgery using a primarily microscopic approach (with endoscopic assistance for complex cases) remains a safe, efficient, and cost-effective strategy and results in shorter anesthesia time to reduce patient complications while maintaining excellent endocrinologic outcomes.

Keywords

Endoscope, Hybrid approach, Microscope, Pituitary adenoma, Transnasal surgery, Transsphenoidal surgery.

Post-operative outcomes in Indigenous patients in North America and Oceania: A systematic review and meta-analysis

Indigenous Peoples across North America and Oceania experience worse health outcomes compared to non-Indigenous people, including increased post-operative mortality. Several gaps in data exist regarding global differences in surgical morbidity and mortality for Indigenous populations based on geographic locations and across surgical specialties. The aim of this study is to evaluate disparities in post-operative outcomes between Indigenous and non-Indigenous populations. This systematic review and meta-analysis was conducted in accordance with PRISMA and MOOSE guidelines. Eight electronic databases were searched with no language restriction. Studies reporting on Indigenous populations outside of Canada, the USA, New Zealand, or Australia, or on interventional procedures were excluded. Primary outcomes were post-operative morbidity and mortality. Secondary outcomes included reoperations, readmission rates, and length of hospital stay. The Newcastle Ottawa Scale was used for quality assessment. Eighty-four unique observational studies were included in this review. Of these, 67 studies were included in the meta-analysis (Oceania n = 31, North America n = 36). Extensive heterogeneity existed among studies and 50% were of poor quality. Indigenous patients had 1.26 times odds of post-operative morbidity (OR = 1.26, 95% CI: 1.10-1.44, p<0.01) and 1.34 times odds of post-operative infection (OR = 1.34, 95% CI: 1.12-1.59, p<0.01) than non-Indigenous patients. Indigenous patients also had 1.33 times odds of reoperation (OR = 1.33, 95% CI: 1.02-1.74, p = 0.04). In conclusion, we found that Indigenous patients in North American and Oceania experience significantly poorer surgical outcomes than their non-Indigenous counterparts. Additionally, there is a low proportion of high-quality research focusing on assessing surgical equity for Indigenous patients in these regions, despite multiple international and national calls to action for reconciliation and decolonization to improve quality surgical care for Indigenous populations.

Minimally Invasive Tubular Lumbar Discectomy Versus Conventional Open Lumbar Discectomy: An Observational Study From the Canadian Spine Outcomes and Research Network

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We evaluated the effectiveness of minimally invasive (MIS) tubular discectomy in comparison to conventional open surgery among patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN).

METHODS

We performed an observational analysis of data that was prospectively collected. We implemented Minimum Clinically Important Differences (MCIDs), and we adjusted for potential confounders with multiple logistic regression. Adverse events were collected according to the Spinal Adverse Events Severity (SAVES) protocol.

RESULTS

Three hundred thirty-nine (62%) patients underwent MIS tubular discectomy and 211 (38%) underwent conventional open discectomy. There were no significant differences between groups for improvement of leg pain and disability, but the MIS technique was associated with reduced odds of achieving the MCID for back pain (OR 0.66, 95% CI 0.44 to 0.99, P < 0.05). We identified statistically significant differences in favor of MIS for each of operating time (MIS mean (SD) 72.2 minutes (30.0) vs open 93.5 (40.9)), estimated blood loss (MIS 37.9 mL (36.7) vs open 76.8 (71.4)), length of stay in hospital (MIS 73% same-day discharge vs open 40%), rates of incidental durotomy (MIS 4% vs open 8%), and wound-related complications (MIS 3% vs open 9%); but not for overall rates of reoperation.

CONCLUSIONS

Open and MIS techniques yielded similar improvements of leg pain and disability at up to 12 months of follow-up, but MIS patients were less likely to experience improvement of associated back pain. Small differences favored MIS for operating time, blood loss, and adverse events but may have limited clinical importance.

Improvements in Outcomes and Cost After Adult Spinal Deformity Corrective Surgery Between 2008 and 2019

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To assess whether patient outcomes and cost-effectiveness of adult spinal deformity (ASD) surgery have improved over the past decade.

BACKGROUND

Surgery for ASD is an effective intervention, but one that is also associated with large initial healthcare expenditures. Changes in the cost profile for ASD surgery over the last decade has not been evaluated previously.

MATERIALS AND METHODS

ASD patients who received surgery between 2008 and 2019 were included. Analysis of covariance was used to establish estimated marginal means for outcome measures [complication rates, reoperations, health-related quality of life, total cost, utility gained, quality adjusted life years (QALYs), cost-efficiency (cost per QALY)] by year of initial surgery. Cost was calculated using the PearlDiver database and represented national averages of Medicare reimbursement for services within a 30-day window including length of stay and death differentiated by complication/comorbidity, revision, and surgical approach. Internal cost data was based on individual patient diagnosis-related group codes, limiting revisions to those within two years (2Y) of the initial surgery. Cost per QALY over the course of 2008-2019 were then calculated.

RESULTS

There were 1236 patients included. There was an overall decrease in rates of any complication (0.78 vs . 0.61), any reoperation (0.25 vs . 0.10), and minor complication (0.54 vs . 0.37) between 2009 and 2018 (all P <0.05). National average 2Y cost decreased at an annual rate of $3194 ( R2 =0.6602), 2Y utility gained increased at an annual rate of 0.0041 ( R2 =0.57), 2Y QALYs gained increased annually by 0.008 ( R2 =0.57), and 2Y cost per QALY decreased per year by $39,953 ( R2 =0.6778).

CONCLUSION

Between 2008 and 2019, rates of complications have decreased concurrently with improvements in patient reported outcomes, resulting in improved cost effectiveness according to national Medicare average and individual patient cost data. The value of ASD surgery has improved substantially over the course of the last decade.