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Delameilleure M, Timmerman S, Vandoren C, Ledger A, Vansteenkiste N, Dewilde K, Page AS, Housmans S, Van den Bosch T, Deprest J, Froyman W. Approaches for hysterectomy and implementation of robot-assisted surgery in benign gynaecological disease: A cost analysis study in a large university hospital. Eur J Obstet Gynecol Reprod Biol 2024; 301:105-113. [PMID: 39116478 DOI: 10.1016/j.ejogrb.2024.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 07/16/2024] [Accepted: 07/26/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND As a minimally invasive technique, robot-assisted hysterectomy (RAH) offers surgical advantages and significant reduction in morbidity compared to open surgery. Despite the increasing use of RAH in benign gynaecology, there is limited data on its cost-effectiveness, especially in a European context. Our goal is to assess the costs of the different hysterectomy approaches, to describe their clinical outcomes, and to evaluate the impact of introduction of RAH on the rates of different types of hysterectomy. METHODS A retrospective single-centre cost-analysis was performed for patients undergoing a hysterectomy for benign indications. Abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), laparoscopically assisted vaginal hysterectomy (LAVH) and RAH were included. We considered the costs of operating room and hospital stay for the different hysterectomy techniques using the "Activity Centre-Care program model". We report on intra- and postoperative complications for the different approaches as well as their cost relationship. RESULTS Between January 2014 and December 2021, 830 patients were operated; 67 underwent VH (8%), 108 LAVH (13%), 351 LH (42%), 148 RAH (18%) and 156 AH (19%). After the implementation and learning curve of a dedicated program for RAH in 2018, AH declined from 27.3% in 2014-2017, to 22.1% in 2018 and 6.9 % in 2019-2021. The reintervention rate was 3-4% for all surgical techniques. Pharmacological interventions and blood transfusions were performed after AH in 28%, and in 17-22% of the other approaches. AH had the highest hospital stay cost with an average of €2236.40. Mean cost of the hospital stay ranged from €1136.77-€1560.66 for minimally invasive techniques. The average total costs for RAH were €6528.10 compared to €4400.95 for AH. CONCLUSION Implementation of RAH resulted in a substantial decrease of open surgery rate. However, RAH remains the most expensive technique in our cohort, mainly due to high material and depreciation costs. Therefore, RAH should not be considered for every patient, but for those who would otherwise need more invasive surgery, with higher risk of complications. Future prospective studies should focus on the societal costs and patient reported outcomes, in order to do cost-benefit analysis and further evaluate the exact value of RAH in the current healthcare setting.
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Affiliation(s)
- Mieke Delameilleure
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium
| | - Stefan Timmerman
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium
| | | | - Ashleigh Ledger
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Kobe Dewilde
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium
| | - Ann-Sophie Page
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium
| | - Susanne Housmans
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium
| | - Thierry Van den Bosch
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium
| | - Wouter Froyman
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium.
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Hsieh H, Yen H, Tseng T, Pan Y, Liao M, Fu S, Yen M, Jaw F, Lin W, Hu M, Yang S, Groot OQ, Schoenfeld AJ. Determining patients with spinal metastases suitable for surgical intervention: A cost-effective analysis. Cancer Med 2023; 12:20059-20069. [PMID: 37749979 PMCID: PMC10587930 DOI: 10.1002/cam4.6576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Both nonoperative and operative treatments for spinal metastasis are expensive interventions. Patients' expected 3-month survival is believed to be a key factor to determine the most suitable treatment. However, to the best of our knowledge, no previous study lends support to the hypothesis. We sought to determine the cost-effectiveness of operative and nonoperative interventions, stratified by patients' predicted probability of 3-month survival. METHODS A Markov model with four defined health states was used to estimate the quality-adjusted life years (QALYs) and costs for operative intervention with postoperative radiotherapy and radiotherapy alone (palliative low-dose external beam radiotherapy) of spine metastases. Transition probabilities for the model, including the risks of mortality and functional deterioration, were obtained from secondary and our institutional data. Willingness to pay thresholds were prespecified at $100,000 and $150,000. The analyses were censored after 5-year simulation from a health system perspective and discounted outcomes at 3% per year. Sensitivity analyses were conducted to test the robustness of the study design. RESULTS The incremental cost-effectiveness ratios were $140,907 per QALY for patients with a 3-month survival probability >50%, $3,178,510 per QALY for patients with a 3-month survival probability <50%, and $168,385 per QALY for patients with independent ambulatory and 3-month survival probability >50%. CONCLUSIONS This study emphasizes the need to choose patients carefully and estimate preoperative survival for those with spinal metastases. In addition to reaffirming previous research regarding the influence of ambulatory status on cost-effectiveness, our study goes a step further by highlighting that operative intervention with postoperative radiotherapy could be more cost-effective than radiotherapy alone for patients with a better survival outlook. Accurate survival prediction tools and larger future studies could offer more detailed insights for clinical decisions.
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Affiliation(s)
- Hsiang‐Chieh Hsieh
- Institute of Biomedical Engineering, National Taiwan UniversityTaipeiTaiwan
- Department of Orthopaedic SurgeryNational Taiwan University HospitalTaipeiTaiwan
- Department of Orthopaedic SurgeryNational Taiwan University HospitalHsinchuTaiwan
| | - Hung‐Kuan Yen
- Department of Orthopaedic SurgeryNational Taiwan University HospitalTaipeiTaiwan
- Department of Orthopaedic SurgeryNational Taiwan University HospitalHsinchuTaiwan
- Department of Medical EducationNational Taiwan University HospitalHsinchuTaiwan
| | - Ting‐En Tseng
- Department of Orthopaedic SurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Yu‐Ting Pan
- Department of Medical EducationNational Taiwan University HospitalTaipeiTaiwan
| | - Min‐Tsun Liao
- Division of Cardiology, Department of Internal MedicineNational Taiwan University HospitalHsinchuTaiwan
| | - Shau‐Huai Fu
- Department of Orthopaedic SurgeryNational Taiwan University HospitalDouliuTaiwan
| | - Mao‐Hsu Yen
- Department of Computer Science and EngineeringNational Taiwan Ocean UniversityKeelungTaiwan
| | - Fu‐Shan Jaw
- Institute of Biomedical Engineering, National Taiwan UniversityTaipeiTaiwan
| | - Wei‐Hsin Lin
- Department of Orthopaedic SurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Ming‐Hsiao Hu
- Department of Orthopaedic SurgeryNational Taiwan University HospitalTaipeiTaiwan
- Department of Orthopaedics, College of medicine, National Taiwan UniversityTaipeiTaiwan
| | - Shu‐Hua Yang
- Department of Orthopaedic SurgeryNational Taiwan University HospitalTaipeiTaiwan
- Department of Orthopaedics, College of medicine, National Taiwan UniversityTaipeiTaiwan
| | - Olivier Q. Groot
- Department of Orthopaedic SurgeryMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
- Department of OrthopaedicsUniversity Medical Center UtrechtUtrechtNetherlands
| | - Andrew J. Schoenfeld
- Department of Orthopaedic SurgeryBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Wu LC, Hsieh YY, Chen IC, Chiang CJ. Life-threatening perioperative complications among older adults with spinal metastases: An analysis based on a nationwide inpatient sample of the US. J Geriatr Oncol 2023; 14:101597. [PMID: 37542948 DOI: 10.1016/j.jgo.2023.101597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/20/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION We aimed to investigate the prognostic determinants of life-threatening and fatal complications in patients <80 and ≥ 20 years of age and those ≥80 years who were undergoing surgery for spinal metastases. MATERIALS AND METHODS Based on data between 2005 and 2018 extracted from National Inpatient Sample as the largest longitudinal hospital inpatient databases in the United States, statistical analyses were performed to identify prognostic factors (age, sex, household income, insurance status, major comorbidities, primary site of malignancy, types of surgery, surgical approaches, types of hospital admission, and hospital-related characteristics) for major and fatal perioperative complications among older adult patients. RESULTS A total of 31,925 patients aged ≥ 20y who were undergoing surgery for spinal metastasis were identified (< 80 y: n = 28,448; ≥ 80 y: n = 35,37). After adjustment, age ≥80 y was significantly associated with greater risk of perioperative cardiac arrest (adjusted odds ratio [aOR]: 1.34, 95% confidence interval [CI]: 1.03-1.73) and acute kidney injury (AKI) (aOR: 1.23, 95% CI: 1.07-1.41) but lower risk of venous thromboembolic event (VTE) (aOR: 0.80, 95% CI: 0.66-0.96) than <80y. Factors predicting life-threatening complications among patients ≥ 80y were: male sex (<80 y: aOR = 1.14; ≥ 80 y: aOR = 1.35), higher score on Charlson Comorbidity Index (CCI) (80 y, aOR = 1.21-2.67; ≥ 80 y: aOR = 1.25-2.55), open surgery (<80 y: aOR = 1.24; ≥ 80 y: aOR = 1.35), and greater Metastatic Spinal Tumor Frailty Index (MSTFI) (<80 y: aOR = 2.48-10.03; ≥ 80 y: aOR = 2.69-11.21). Among patients <80y, factors predicting life-threatening complications were: male sex, Black race, greater CCI score, primary tumor at kidney, hematologic cancer, other/unspecified primary site, certain surgical procedures, open surgery, greater MSTFI, emergent admission, and low hospital volume. DISCUSSION This study identifies a list of independent risk factors for the presence of life-threatening complications among patients <80 and ≥ 80y who were undergoing surgery for spinal metastasis. The findings contribute to the development of clinical strategies for the surgical management of spinal metastasis, especially for octogenarians, and lower the risk of unfavorable inpatient outcomes.
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Affiliation(s)
- Lien-Chen Wu
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan; Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 110, Taiwan
| | - Yueh-Ying Hsieh
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - IChun Chen
- Hospice and Home care of Snohomish County, Providence Health & services, Washington 98203, USA
| | - Chang-Jung Chiang
- Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan.
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Droeghaag R, Schuermans VNE, Hermans SMM, Smeets AYJM, Caelers IJMH, Hiligsmann M, Evers S, van Hemert WLW, van Santbrink H. Methodology of economic evaluations in spine surgery: a systematic review and qualitative assessment. BMJ Open 2023; 13:e067871. [PMID: 36958779 PMCID: PMC10040072 DOI: 10.1136/bmjopen-2022-067871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
OBJECTIVES The present study is a systematic review conducted as part of a methodological approach to develop evidence-based recommendations for economic evaluations in spine surgery. The aim of this systematic review is to evaluate the methodology and quality of currently available clinical cost-effectiveness studies in spine surgery. STUDY DESIGN Systematic literature review. DATA SOURCES PubMed, Web of Science, Embase, Cochrane, Cumulative Index to Nursing and Allied Health Literature, EconLit and The National Institute for Health Research Economic Evaluation Database were searched through 8 December 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies were included if they met all of the following eligibility criteria: (1) spine surgery, (2) the study cost-effectiveness and (3) clinical study. Model-based studies were excluded. DATA EXTRACTION AND SYNTHESIS The following data items were extracted and evaluated: pathology, number of participants, intervention(s), year, country, study design, time horizon, comparator(s), utility measurement, effectivity measurement, costs measured, perspective, main result and study quality. RESULTS 130 economic evaluations were included. Seventy-four of these studies were retrospective studies. The majority of the studies had a time horizon shorter than 2 years. Utility measures varied between the EuroQol 5 dimensions and variations of the Short-Form Health Survey. Effect measures varied widely between Visual Analogue Scale for pain, Neck Disability Index, Oswestry Disability Index, reoperation rates and adverse events. All studies included direct costs from a healthcare perspective. Indirect costs were included in 47 studies. Total Consensus Health Economic Criteria scores ranged from 2 to 18, with a mean score of 12.0 over all 130 studies. CONCLUSIONS The comparability of economic evaluations in spine surgery is extremely low due to different study designs, follow-up duration and outcome measurements such as utility, effectiveness and costs. This illustrates the need for uniformity in conducting and reporting economic evaluations in spine surgery.
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Affiliation(s)
- Ruud Droeghaag
- Orthopedic Surgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Valérie N E Schuermans
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Neurosurgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Neurosurgery, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Sem M M Hermans
- Orthopedic Surgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Anouk Y J M Smeets
- Neurosurgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Neurosurgery, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Inge J M H Caelers
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Neurosurgery, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Mickaël Hiligsmann
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Silvia Evers
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Health Services Research, Maastricht University, Maastricht, The Netherlands
- Centre of Economic Evaluation & Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | | | - Henk van Santbrink
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Neurosurgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Neurosurgery, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
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Xiong GX, Collins JE, Ferrone ML, Schoenfeld AJ. Prospective comparison of one-year survival in patients treated operatively and nonoperatively for spinal metastatic disease: results of the prospective observational study of spinal metastasis treatment (POST). Spine J 2023; 23:14-17. [PMID: 35181541 PMCID: PMC9378762 DOI: 10.1016/j.spinee.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopedic Residency Program, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Jamie E Collins
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Marco L Ferrone
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
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Katzir M, Rustagi T, Hatef J, Mendel E. Cost Analysis With Use of Expandable Cage or Cement in Single level Thoracic Vertebrectomy in Metastasis. Global Spine J 2022; 12:858-865. [PMID: 33307822 PMCID: PMC9344502 DOI: 10.1177/2192568220975375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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 Retrospective case series. OBJECTIVE Patient with metastatic cancer frequently require spinal operations for neural decompression and stabilization, most commonly thoracic vertebrectomy with reconstruction. Objective of the study was to assess economic aspects associated with use of cement versus expandable cage in patients with single level thoracic metastatic disease. We also looked at the differences in the clinical, radiological, complications and survival differences to assess non-inferiority of PMMA over cages. METHODS The electronic medical records of patients undergoing single level thoracic vertebrectomy and reconstruction were reviewed. Two groups were made: PMMA and EC. Totals surgical cost, implant costs was analyzed. We also looked at the clinical/ radiological outcome, complication and survival analysis. RESULTS 96 patients were identified including 70 one-level resections. For 1-level surgeries, Implant costs for use of cement-$75 compared to $9000 for cages. Overall surgical cost was significantly less for PMMA compared to use of EC. No difference was seen in clinical outcome or complication was seen. We noticed significantly better kyphosis correction in the PMMA group. CONCLUSIONS Polymethylmethacrylate cement offers significant cost advantage for reconstruction after thoracic vertebrectomy. It also allows for better kyphosis correction and comparable clinical outcomes and non-inferior to cages.
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Affiliation(s)
- Miki Katzir
- Department of Neurological Surgery, Ohio State University Wexner Medical
Center, The James Cancer Hospital & Solove Research Institute,
Columbus, OH, USA
| | - Tarush Rustagi
- Department of Neurological Surgery, Ohio State University Wexner Medical
Center, The James Cancer Hospital & Solove Research Institute,
Columbus, OH, USA,Department of Spine Surgery, Indian
Spinal Injuries Centre, New Delhi, India,Tarush Rustagi, MD, Department of
Neurological Surgery, Ohio State University Wexner Medical Center, 410 W 10th
Ave, Columbus, OH 110070, USA.
| | - Jeffrey Hatef
- Department of Neurological Surgery, Ohio State University Wexner Medical
Center, The James Cancer Hospital & Solove Research Institute,
Columbus, OH, USA
| | - Ehud Mendel
- Department of Neurological Surgery, Ohio State University Wexner Medical
Center, The James Cancer Hospital & Solove Research Institute,
Columbus, OH, USA
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Taechalertpaisarn P, Wilartratsami S, Phisalprapa P, Kositamongkol C, Teyateeti A, Luksanapruksa P. Cost-Utility Analysis Compared Between Radiotherapy Alone and Combined Surgery and Radiotherapy for Symptomatic Spinal Metastases in Thailand. Neurospine 2022; 19:334-347. [PMID: 35577341 PMCID: PMC9260553 DOI: 10.14245/ns.2142948.474] [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] [Received: 12/15/2021] [Accepted: 03/22/2022] [Indexed: 11/19/2022] Open
Abstract
Objective To investigate the patient quality of life and cost-utility compared between radiotherapy alone and combined surgery and radiotherapy for spinal metastasis (SM) in Thailand.
Methods Patients with SM with an indication for surgery during 2018–2020 were prospectively recruited. Patients were assigned to either the combination surgery and radiotherapy group or the radiotherapy alone group. Quality of life was assessed by EuroQol-5D-5L (EQ-5D-5L) questionnaire, and relevant healthcare costs were collected pretreatment, and at 3-month and 6-month posttreatment. Total lifetime cost and quality-adjusted life-years (QALYs) were estimated for each group.
Results Twenty-four SM patients (18 females, 6 males) were included. Of those, 12 patients underwent combination treatment, and 12 underwent radiotherapy alone. At 6-month posttreatment, 10 patients in the surgery group, and 11 patients in the nonsurgery group remained alive for a survival rate of 83.3% and 91.7%, retrospectively. At 6-month posttreatment, the mean utility in the combination treatment group was significantly better than in the radiotherapy alone group (0.804 ± 0.264 vs. 0.518 ± 0.282, respectively; p = 0.011). Total lifetime costs were 59,863.14 United States dollar (USD) in the combination treatment group and 24,526.97 USD in the radiation-only group. The incremental cost-effectiveness ratio using 6-month follow-up data was 57,074.01 USD per QALY gained.
Conclusion Surgical treatment combined with radiotherapy to treat SM significantly improved patient quality of life compared to radiotherapy alone during the 6-month posttreatment period. However, combination treatment was found not to be cost-effective compared to radiotherapy alone for SM at the Thailand willingness-to-pay threshold of 5,113 USD/QALY.
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Affiliation(s)
- Pasawat Taechalertpaisarn
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirichai Wilartratsami
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pochamana Phisalprapa
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chayanis Kositamongkol
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Achiraya Teyateeti
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Panya Luksanapruksa
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Corresponding Author Panya Luksanapruksa Division of Spine Surgery, Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand
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8
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Xiong GX, Fisher MWA, Schwab JH, Simpson AK, Nguyen L, Tobert DG, Balboni TA, Shin JH, Ferrone ML, Schoenfeld AJ. A Natural History of Patients Treated Operatively and Nonoperatively for Spinal Metastases Over 2 Years Following Treatment: Survival and Functional Outcomes. Spine (Phila Pa 1976) 2022; 47:515-522. [PMID: 35066537 PMCID: PMC8923973 DOI: 10.1097/brs.0000000000004322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE We present the natural history, including survival and function, among participants in the prospective observational study of spinal metastases treatment investigation. SUMMARY OF BACKGROUND DATA Surgical treatment has been touted as a means to preserve functional independence, quality of life, and survival. Nearly all prior investigations have been limited by retrospective design and relatively short-periods of post-treatment surveillance. METHODS This natural history study was conducted using the records of patients who were enrolled in the prospective observational study of spinal metastases treatment study (2017-2019). Eligible participants were 18 or older and presenting for treatment of spinal metastatic disease. Patients were followed at predetermined intervals (1, 3, 6, 12, and 24-mo) following treatment. We conducted cox proportional hazard regression analysis adjusting for confounders including age, biologic sex, number of comorbidities, type of metastatic lesion, neurologic symptoms at presentation, number of metastases involving the vertebral body, vertebral body collapse, New England Spinal Metastasis Score (NESMS) at presentation, and treatment strategy. RESULTS We included 202 patients. Twenty-three percent of the population had died by 3 months following treatment initiation, 51% by 1 year, and 70% at 2 years. There was no significant difference in survival between patients treated operatively and nonoperatively (P = 0.16). No significant difference in HRQL between groups was appreciated beyond 3 months following treatment initiation. NESMS at presentation (scores of 0 [HR 5.61; 95% CI 2.83, 11.13] and 1 [HR 3.00; 95% CI 1.60, 5.63]) was significantly associated with mortality. CONCLUSION We found that patients treated operatively and nonoperatively for spinal metastases benefitted from treatment in terms of HRQL. Two-year mortality for the cohort as a whole was 70%. When prognosticating survival, the NESMS appears to be an effective utility, particularly among patients with scores of 0 or 1.Level of Evidence: 2.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Miles W A Fisher
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Lananh Nguyen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tracy A Balboni
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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9
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Schoenfeld AJ, Ferrone ML, Blucher JA, Agaronnik N, Nguyen L, Tobert DG, Balboni TA, Schwab JH, Shin JH, Sciubba DM, Harris MB. Prospective comparison of the accuracy of the New England Spinal Metastasis Score (NESMS) to legacy scoring systems in prognosticating outcomes following treatment of spinal metastases. Spine J 2022; 22:39-48. [PMID: 33741509 PMCID: PMC8443703 DOI: 10.1016/j.spinee.2021.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/16/2021] [Accepted: 03/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT We developed the New England Spinal Metastasis Score (NESMS) as a simple, informative, scoring scheme that could be applied to both operative and non-operative patients. The performance of the NESMS to other legacy scoring systems has not previously been compared using appropriately powered, prospectively collected, longitudinal data. PURPOSE To compare the predictive capacity of the NESMS to the Tokuhashi, Tomita and Spinal Instability Neoplastic Score (SINS) in a prospective cohort, where all scores were assigned at the time of baseline enrollment. PATIENT SAMPLE We enrolled 202 patients with spinal metastases who met inclusion criteria between 2017-2019. OUTCOME MEASURES One-year survival (primary); 3-month mortality and ambulatory function at 3- and 6-months were considered secondarily. METHODS All prognostic scores were assigned based on enrollment data, which was also assigned as time-zero. Patients were followed until death or survival at 365 days after enrollment. Survival was assessed using Kaplan-Meier curves and score performance was determined via logistic regression testing and observed to expected plots. The discriminative capacity (c-statistic) of the scoring measures were compared via the z-score. RESULTS When comparing the discriminative capacity of the predictive scores, the NESMS had the highest c-statistic (0.79), followed by the Tomita (0.69), the Tokuhashi (0.67) and the SINS (0.54). The discriminative capacity of the NESMS was significantly greater (p-value range: 0.02 to <0.001) than any of the other predictive tools. The NESMS was also able to inform independent ambulatory function at 3- and 6-months, a function that was only uniformly replicated by the Tokuhashi score. CONCLUSIONS The results of this prospective validation study indicate that the NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS. We believe that these findings endorse the utilization of the NESMS as a prognostic tool capable of informing care for patients with spinal metastases.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Justin A Blucher
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Nicole Agaronnik
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Lananh Nguyen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Tracy A Balboni
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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Spinal metastasis: The rise of minimally invasive surgery. Surgeon 2021; 20:328-333. [PMID: 34563452 DOI: 10.1016/j.surge.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 07/31/2021] [Accepted: 08/20/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Bone is the third most common site of metastatic cancer, of which the spine is the most frequently involved. As metastatic cancer prevalence rises and surgical techniques advance, operative intervention for spinal metastases is expected to rise. In the first operative cohort of spinal metastasis in Ireland, we describe the move towards less invasive surgery, the causative primary types and post-operative survival. METHODS This is a retrospective cohort study of all operative interventions for spinal metastasis in a tertiary referral centre over eight years. Primary spinal tumours and local invasion to the spine were excluded. Median follow up was 1895 days. RESULTS 225 operative procedures in 196 patients with spinal metastasis were performed over eight years. Average cases per year increased form 20 per year to 29 per year. Percutaneous procedures became more common, accounting for the majority (53%) in the final two years. The most common primary types were breast, myeloma, lung, prostate and renal. Overall survival at 1 year was 51%. Primary type was a major determinant of survival, with breast and the haematological cancers demonstrating good survival, while lung had the worst prognosis. CONCLUSION This is the first descriptive cohort of operative interventions for spinal metastasis in an Irish context. Surgery for spinal metastasis is performed at an increasing rate, especially through minimally-invasive means. The majority of patients survive for at least one year post-operatively. Prudent resource planning is necessary to prepare for this growing need.
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11
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Schoenfeld AJ, Bensen GP, Blucher JA, Ferrone ML, Balboni TA, Schwab JH, Harris MB, Katz JN, Losina E. The Cost-Effectiveness of Surgical Intervention for Spinal Metastases: A Model-Based Evaluation. J Bone Joint Surg Am 2021; 103:00004623-990000000-00293. [PMID: 34288901 PMCID: PMC8776911 DOI: 10.2106/jbjs.21.00023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Operative and nonoperative treatments for spinal metastases are expensive interventions with a high rate of complications. We sought to determine the cost-effectiveness of a surgical procedure compared with nonoperative management as treatment for spinal metastases. METHODS We constructed a Markov state-transition model with health states defined by ambulatory status and estimated the quality-adjusted life-years (QALYs) and costs for operative and nonoperative management of spine metastases. We considered 2 populations: 1 in which patients presented with independent ambulatory status and 1 in which patients presented with nonambulatory status due to acute (e.g., <48 hours) metastatic epidural compression. We defined the efficacy of each treatment as a likelihood of maintaining, or returning to, independent ambulation. Transition probabilities for the model, including the risks of mortality and becoming dependent or nonambulatory, were obtained from secondary data analysis and published literature. Costs were determined from Medicare reimbursement schedules. We conducted analyses over patients' remaining life expectancy from a health system perspective and discounted outcomes at 3% per year. We conducted sensitivity analyses to account for uncertainty in data inputs. RESULTS Among patients presenting as independently ambulatory, QALYs were 0.823 for operative treatment and 0.800 for nonoperative treatment. The incremental cost-effectiveness ratio (ICER) for a surgical procedure was $899,700 per QALY. Among patients presenting with nonambulatory status, those undergoing surgical intervention accumulated 0.813 lifetime QALY, and those treated nonoperatively accumulated 0.089 lifetime QALY. The incremental cost-effectiveness ratio for a surgical procedure was $48,600 per QALY. The cost-effectiveness of a surgical procedure was most sensitive to the variability of its efficacy. CONCLUSIONS Our data suggest that the value to society of a surgical procedure for spinal metastases varies according to the features of the patient population. In patients presenting as nonambulatory due to acute neurologic compromise, surgical intervention provides good value (ICER, $48,600 per QALY). There is a low value for a surgical procedure performed for patients who are ambulatory at presentation (ICER, $899,700 per QALY). LEVEL OF EVIDENCE Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gordon P Bensen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin A Blucher
- Rutgers Institute for Translational Medicine and Science, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracy A Balboni
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey N Katz
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elena Losina
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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