Intersurgeon Cost Variability in Anterior Cervical Discectomy and Fusion

A Five-Year Cost-Utility Analysis Comparing Synthetic Cage Versus Allograft Use in Anterior Cervical Discectomy and Fusion Surgery for Cervical Spondylotic Myelopathy

STUDY DESIGN

Retrospective cost-utility analysis.

OBJECTIVE

To conduct a cost-analysis comparing synthetic cage (SC) versus allograft (Allo) over a five-year time horizon.

SUMMARY OF BACKGROUND DATA

SC and Allo are two commonly used interbody choices for anterior cervical discectomy and fusion (ACDF) surgery. Previous analyses comparative analyses have reached mixed conclusions regarding their cost-effectiveness, yet recent estimates provide high-quality evidence.

MATERIALS AND METHODS

A decision-analysis model comparing the use of Allo versus SC was developed for a hypothetical 60-year-old patient with cervical spondylotic myelopathy undergoing single-level ACDF surgery. A comprehensive literature review was performed to estimate probabilities, costs (2020 USD) and quality-adjusted life years (QALYs) gained over a five-year period. A probabilistic sensitivity analysis using a Monte Carlo simulation of 1000 patients was carried out to calculate incremental cost-effectiveness ratio and net monetary benefits. One-way deterministic sensitivity analysis was performed to estimate the contribution of individual parameters to uncertainty in the model.

RESULTS

The use of Allo was favored in 81.6% of the iterations at a societal willing-to-pay threshold of 50,000 USD/QALY. Allo dominated (higher net QALYs and lower net costs) in 67.8% of the iterations. The incremental net monetary benefits in the Allo group was 2650 USD at a willing-to-pay threshold of 50,000 USD/QALY. One-way deterministic sensitivity analysis revealed that the cost of the index surgery was the only factor which significantly contributed to uncertainty.

CONCLUSION

Cost-utility analysis suggests that Allo maybe a more cost-effective option compared with SCs in adult patients undergoing ACDF for cervical spondylotic myelopathy.

Prediction of Admission Costs Following Anterior Cervical Discectomy and Fusion Utilizing Machine Learning

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Predict cost following anterior cervical discectomy and fusion (ACDF) within the 90-day global period using machine learning models.

BACKGROUND

The incidence of ACDF has been increasing with a disproportionate decrease in reimbursement. As bundled payment models become common, it is imperative to identify factors that impact the cost of care.

MATERIALS AND METHODS

The Nationwide Readmissions Database (NRD) was accessed in 2018 for all primary ACDFs by the International Classification of Diseases 10th Revision (ICD-10) procedure codes. Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics, such as volume of procedures performed and wage index, were also queried. Readmissions within 90 days were identified, and cost of readmissions was added to the total admission cost to represent the 90-day healthcare cost. Machine learning algorithms were used to predict patients with 90-day admission costs >1 SD from the mean.

RESULTS

There were 42,485 procedures included in this investigation with an average age of 57.7±12.3 years with 50.6% males. The average cost of the operative admission was $24,874±25,610, the average cost of readmission was $25,371±11,476, and the average total cost was $26,977±28,947 including readmissions costs. There were 10,624 patients who were categorized as high cost. Wage index, hospital volume, age, and diagnosis-related group severity were most correlated with the total cost of care. Gradient boosting trees algorithm was most predictive of the total cost of care (area under the curve=0.86).

CONCLUSIONS

Bundled payment models utilize wage index and diagnosis-related groups to determine reimbursement of ACDF. However, machine learning algorithms identified additional variables, such as hospital volume, readmission, and patient age, that are also important for determining the cost of care. Machine learning can improve cost-effectiveness and reduce the financial burden placed upon physicians and hospitals by implementing patient-specific reimbursement.

Spine Instrumented Surgery on a Budget-Tools for Lowering Cost Without Changing Outcome

STUDY DESIGN

Review article.

OBJECTIVES

There have been substantial increases in the utilization of complex spinal surgery in the last 20 years. Spinal instrumented surgery is associated with high costs as well as significant variation in approach and care. The objective of this manuscript is to identify and review drivers of instrumented spine surgery cost and explain how surgeons can reduce costs without compromising outcome.

METHODS

A literature search was conducted using PubMed. The literature review returned 217 citations. 27 publications were found to meet the inclusion criteria. The relevant literature on drivers of spine instrumented surgery cost is reviewed.

RESULTS

The drivers of cost in instrumented spine surgery are varied and include implant costs, complications, readmissions, facility-based costs, surgeon-driven preferences, and patient comorbidities. Each major cost driver represents an opportunity for potential reductions in cost. With high resource utilization and often uncertain outcomes, spinal surgery has been heavily scrutinized by payers and hospital systems, with efforts to reduce costs and standardize surgical approach and care pathways.

CONCLUSIONS

Education about cost and commitment to standardization would be useful strategies to reduce cost without compromising patient-reported outcomes after instrumented spinal fusion.

Health Care Resource Utilization in Commercially Insured Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Pathology

STUDY DESIGN

Retrospective review of an administrative database.

OBJECTIVES

The aim of our study was to investigate the distribution of spending for the entire episode of care among nonelderly, commercially insured patients undergoing elective, inpatient anterior cervical discectomy and fusion (ACDF) surgeries for degenerative cervical pathology.

METHODS

Using a private insurance claims database, we identified patients who underwent single-level, inpatient ACDF for degenerative spinal disease. Patients were selected using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Entire episode of care was defined as 6-months before (preoperative) to 6 months after (postoperative) the surgical admission.

RESULTS

In our cohort containing 33 209 patients, perioperative median spending per patient (MSPP) within the year encompassing surgery totaled $37 020 (interquartile range [IQR] $28 363-$49 206), with preoperative, surgical admission, and postoperative spending accounting for 9.8%, 80.7%, and 9.5% of total spending, respectively. Preoperatively, MSPP was $3109 (IQR $1806-$5215), 48% of patients underwent physical therapy, and 31% underwent injections in the 6 months period prior to surgery. Postoperatively, MSPP was $1416 (IQR $398-$3962), and unplanned hospital readmission (6% incidence) accounted for 33% of the overall postoperative spending. Discharge to a nonhome discharge disposition was associated with higher postoperative spending ($14 216) compared with patients discharged home ($1468) and home with home care ($2903), P < .001.

CONCLUSION

Understanding the elements and distribution of perioperative spending for the episode of care in patients undergoing ACDF surgery for degenerative conditions is important for health care planning and resource allocation.

Low Socioeconomic Status Is Associated With Increased Complication Rates: Are Risk Adjustment Models Necessary in Cervical Spine Surgery?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The objective of this study was to determine whether lower socioeconomic status was associated with increased resource utilization following anterior discectomy and fusion (ACDF).

METHODS

The National Inpatient Sample database was queried for patients who underwent a primary, 1- to 2-level ACDF between 2005 and 2014. Trauma, malignancy, infection, and revision surgery were excluded. The top and bottom income quartiles were compared. Demographics, medical comorbidities, length of stay, complications, and hospital cost were compared between patients of top and bottom income quartiles.

RESULTS

A total of 69 844 cases were included. The bottom income quartile had a similar mean hospital stay (2.04 vs 1.77 days, P = .412), more complications (2.45% vs 1.77%, P < .001), and a higher mortality rate (0.18% vs 0.11%, P = .016). Multivariate analysis revealed bottom income quartile was an independent risk factor for complications (odds ratio = 1.135, confidence interval = 1.02-1.26). Interestingly, the bottom income quartile experienced lower mean hospital costs ($17 041 vs $17 958, P < .001).

CONCLUSION

Patients in the lowest income group experienced more complications even after adjusting for comorbidities. Therefore, risk adjustment models, including socioeconomic status, may be necessary to avoid potential problems with access to orthopedic spine care for this patient population.

Outcomes and value in elective cervical spine surgery: an introductory and practical narrative review

How we determine a successful clinical outcome and the value of a spine intervention are two major questions surrounding clinical spine research. Patient-reported outcomes (PROs), both LEGACY and Patient-Reported Outcomes Measurement Information System (PROMIS) measures, are becoming ubiquitous throughout the literature. Spine surgeons need a facile understanding of the financial landscape of their environment to influence change. In the current introductory, narrative review on outcomes and value in cervical spine surgery, we aim to: (I) define relevant outcome and cost terminology, (II) review recent cervical spine surgery literature, divided by specific pathology with a focus on LEGACY and PROMIS measures, and (III) discuss value and cost as they pertain to postoperative return to work and ambulatory surgery centers surgeries.

The Effect of Tobacco Use on Postoperative Pain Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

To identify the differences in inpatient pain scores, narcotic consumption, and patient-reported outcomes (PROs) between tobacco users and nonusers following an anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Previous studies have investigated tobacco use as a risk factor for negative postsurgical outcomes following spine surgery; however, few studies have analyzed the effects of tobacco on pain following ACDF.

METHODS

Patients undergoing primary, 1-level, or 2-level ACDF were retrospectively reviewed and stratified by tobacco use at the time of surgery. Inpatient pain scores and narcotic consumption were collected. Neck Disability Index and Visual Analogue Scale (VAS) neck and arm pain scores were collected preoperatively and at 6-week, 3-month, and 6-month follow-up visits. Differences in demographics and perioperative characteristics were assessed using χ analysis and multivariate linear regression. An association between immediate postoperative pain, narcotics consumption, and long-term PROs was tested for using multivariate linear regression.

RESULTS

A total of 192 patients were included and stratified by tobacco use: tobacco (n=25) and nontobacco (n=167). There were no significant differences in demographic and perioperative characteristics. No statistical differences were observed in inpatient VAS pain scores and narcotic consumption on postoperative day 0 and postoperative day 1. Preoperative VAS neck pain and arm pain was greater in tobacco users, however, improvements in neck and arm pain were similar in the postoperative period through 6-month follow-up. In addition, no statistical differences in Neck Disability Index were observed preoperatively or at any postoperative time points.

CONCLUSIONS

Our study suggests that tobacco use does not influence inpatient pain scores, narcotic consumption, and improvements in PROs following ACDF. As such, tobacco users and nonusers should receive similar postoperative pain management protocols following surgery.

LEVEL OF EVIDENCE

Level III.

Reduction of direct costs in high-risk lumbar discectomy patients during the 90-day post-operative period through annular closure

Purpose

Despite being an extremely successful procedure, recurrent disc herniation is one of the most common post-discectomy complications in the lumbar spine and contributes significant health care and socioeconomic costs. Patients with large annular defects are at a high risk for reherniation, but an annular closure device (ACD) has been designed to reduce reherniation risk in this population and may, in turn, help control direct health care costs after discectomy.

Patients and methods

This analysis examined the 90-day post-discectomy cost estimates among ACD-treated (n=272) and control (discectomy alone; n=278) patients in a randomized controlled trial (RCT). Direct medical costs were estimated based on 2017 Humana and Medicare claims. Index discectomies were assumed to occur in an outpatient (OP) setting, whereas repeat discectomies were assumed to be 60% in OP and 40% in inpatient (IP). A sensitivity analysis was performed on this assumption. The device cost was not included in the analysis in order to focus on costs in the 90-day post-operative period.

Results

Within 90 days of follow-up, post-operative complications occurred in 3.3% of the ACD patients and 8.6% of the control patients (P=0.01). The average 90-day cost to treat an ACD patient was $10,257 compared to $11,299 per control patient for a 80:20 distribution of Commercial:Medicare coverage ($1,042 difference). This difference varied from $687 with 100% Medicare to $1,132 with 100% Commercial coverage. Varying the IP vs OP distribution resulted in a cost difference range of $968 to $1,156 with the ACD.

Conclusion

Augmenting discectomy with an ACD in high-risk patients with a large annular defect reduced reherniation and reoperation rates, which translated to a reduction of direct health care costs between $687 and $1,156 per patient during the 90-day post-operative period. Large annular defect patients are an easily identifiable high-risk population. Operative strategies that reduce complication risks in these patients, such as the ACD, could be advantageous from both patient care and economic perspectives.