Reducing the cost and frequency of explantations associated with single-level anterior diskectomy and fusion at a single institution through education

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.

Analysis of Anterior Cervical Discectomy and Fusion Healthcare Costs via the Value-Driven Outcomes Tool

BACKGROUND

Examining the costs of single- and multilevel anterior cervical discectomy and fusion (ACDF) is important for the identification of cost drivers and potentially reducing patient costs. A novel tool at our institution provides direct costs for the identification of potential drivers.

OBJECTIVE

To assess perioperative healthcare costs for patients undergoing an ACDF.

METHODS

Patients who underwent an elective ACDF between July 2011 and January 2017 were identified retrospectively. Factors adding to total cost were placed into subcategories to identify the most significant contributors, and potential drivers of total cost were evaluated using a multivariable linear regression model.

RESULTS

A total of 465 patients (mean, age 53 ± 12 yr, 54% male) met the inclusion criteria for this study. The distribution of total cost was broken down into supplies/implants (39%), facility utilization (37%), physician fees (14%), pharmacy (7%), imaging (2%), and laboratory studies (1%). A multivariable linear regression analysis showed that total cost was significantly affected by the number of levels operated on, operating room time, and length of stay. Costs also showed a narrow distribution with few outliers and did not vary significantly over time.

CONCLUSION

These results suggest that facility utilization and supplies/implants are the predominant cost contributors, accounting for 76% of the total cost of ACDF procedures. Efforts at lowering costs within these categories should make the most impact on providing more cost-effective care.

What is the cost burden of surgical implant waste? An analysis of surgical implant waste in an orthopedics and trauma surgery department of a French university hospital in 2016

BACKGROUND

During an orthopedic or trauma surgery procedure, when an implantable medical device is unpackaged, not implanted and cannot be resterilized, it is considered "waste". The cost burden falls on the hospital. The French Social Security Code provides for add-on reimbursement for certain expensive or very specialized devices (supplementary list of costly implants). To allow its restocking without linking it to a patient or reimbursement request, the wasted implant is tracked in a computerized database. The economic impact of these wasted implants is not known in France. This led us to conduct a retrospective study: 1) to determine the percentage and number of wasted implants, 2) to identify elements related to the surgery that impact implant waste.

HYPOTHESIS

Various elements of the surgical environment (type of procedure, specialty, surgeon experience, time of year) can independently contribute to the non-implantation of a medical device.

METHODS

We carried out a retrospective observational study of data collected prospectively in the database of our teaching hospital in 2016. The primary outcome was the percentage of wasted implants. The secondary outcome was the mean cost of these wasted implants. These parameters were determined for all the implants used in orthopedics and trauma surgery and tracked in this department, then for each variable hypothesized to led to non-implantation. Our analysis was descriptive, then comparative.

RESULTS

In our database, 29,073 devices were tracked (€3,761,180), of which 1995 devices were wasted (6.9%). The total cost of the wasted implants was €179,193 (4.8% of the overall cost). The breakdown of the wasted implants was 430 (4.4%) from the add-on list (average cost of €293.10) versus 1565 implants associated with the hospital's diagnosis-related group payment system (average cost of €33.90). Trauma surgery procedures had significantly more wasted implants than orthopedic surgery (1135 vs. 860 (p<0.01)), although the individual cost was less (€59.20 vs. €130.10 (p<0.01)). Fracture fixation implants were more likely to be wasted than ligament reconstruction or arthroplasty implants, with a lower mean cost. More implants were wasted during hip arthroplasty than during other arthroplasty procedures. Less experienced surgeons wasted more implants than more experienced surgeons (1087 vs. 905 (p<0.01)) but these implants cost less (€69.20 vs. €114.80 (p<0.05)). The percentage of implants wasted was higher during the resident changeover period relative to the other months of the year (772 vs. 1223 (p<0.01)).

DISCUSSION

This study is the first attempt at quantifying the number and cost of wasted implants in the context of orthopedics and trauma surgery at a teaching hospital in France. While trauma surgery is associated with more wasted implants, the cost burden is higher in orthopedics. Surgeons, by virtue of their experience and teaching mandate, have a decisive role managing this cost burden.

TYPE OF STUDY

IV, Retrospective study.

Operative costs, reasons for operative waste, and vendor credit replacement in spinal surgery

BACKGROUND

In 2012, Epstein et al. documented that educating spinal surgeons reduced the cost of operative waste (explanted devices: placed but removed prior to closure) occurring during anterior cervical diskectomy/fusion from 20% to 5.8%.[5] This prompted the development of a two-pronged spine surgeon-education program (2012-2014) aimed at decreasing operative costs for waste, and reducing the nine reasons for operative waste.

METHODS

The spine surgeon-education program involved posting the data for operative costs of waste and the nine reasons for operative waste over the neurosurgery/orthopedic scrub sinks every quarter. These data were compared for 2012 (latter 10 months), 2013 (12 months), and 2014 (first 9 months) (e.g. data were normalized). Savings from a 2013 Vendor Credit Replacement program were also calculated.

RESULTS

From 2012 to 2013 and 2014, spinal operative costs for waste were, respectively reduced by 64.7% and 61% for orthopedics, and 49.4% and 45.2% for neurosurgery. Although reduced by the program, the major reason for operative waste for all 3 years remained surgeon-related factors (e.g. 159.6, to 67, and 96, respectively). Alternatively, the eight other reasons for operative waste were reduced from 68.4 (2012) to 12 (2013) and finally to zero by 2014. Additionally, the Vendor Replacement program for 2013 netted $78,564.

CONCLUSIONS

The spine surgeon-education program reduced the costs/reasons for operative waste for 2012 to lower levels by 2013 and 2014. Although the major cost/reasons for operative waste were attributed to surgeon-related factors, these declined while the other eight reasons for operative waste were reduced to zero by 2014.

A review article on the benefits of early mobilization following spinal surgery and other medical/surgical procedures

Background:

The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in other medical/surgical subspecialties. However, few spinal series have specifically focused on the “pros” of early mobilization for spinal surgery, other than in acute spinal cord injury. Here we reviewed how early mobilization and other adjunctive measures reduced morbidity and LOS in both medical and/or surgical series, and focused on how their treatment strategies could be applied to spinal patients.

Methods:

We reviewed studies citing protocols for early mobilization of hospitalized patients (day of surgery, first postoperative day/other) in various subspecialties, and correlated these with patients’ perioperative morbidity and LOS. As anticipated, multiple comorbid factors (e.g. hypertension, high cholesterol, diabetes, hypothyroidism, obesity/elevated body mass index hypothyroidism, osteoporosis, chronic obstructive pulmonary disease, coronary artery disease and other factors) contribute to the risks and complications of immobilization for any medical/surgical patient, including those undergoing spinal procedures. Some studies additionally offered useful suggestions specific for spinal patients, including prehabilitation (e.g. rehabilitation that starts prior to surgery), preoperative and postoperative high protein supplements/drinks, better preoperative pain control, and early tracheostomy, while others cited more generalized recommendations.

Results:

In many studies, early mobilization protocols reduced the rate of complications/morbidity (e.g. respiratory decompensation/pneumonias, deep venous thrombosis/pulmonary embolism, urinary tract infections, sepsis or infection), along with the average LOS.

Conclusions:

A review of multiple medical/surgical protocols promoting early mobilization of hospitalized patients including those undergoing spinal surgery reduced morbidity and LOS.

Is "mini-invasive" technique for iliac crest harvesting an alternative to cervical cage implant? An overview of a large personal experience

Background:

Autograft bone provides an excellent substrate for multilevel arthrodesis after anterior discectomy and is inexpensive. However, the use of tricortical bone could increase the discomfort for the patient.

Methods:

We reviewed cases of cervical disc diseases operated on by a single neurosurgeon (AS), within the period June 2000-December 2011. A total of 221 patients were considered for the present study; 109 female, 112 male, averaging 49 years of age. Only patients who could be followed up for at least one year were included in the present study. The grafts obtained with the technique described are bi- (and not tri-) cortical, and always of sufficient size in order to fit two spaces if necessary.

Results:

The technique is not associated with long-term significant donor site pain except for a striking minority of patients, it shortens the hospital stay, it offers comparable results to the published surgical series in which cage and/or modern implants are used.

Conclusions:

Autograft bone can be reasonably considered as one of the possible alternatives to be used in the surgical management of cervical disk disease.

Iliac crest autograft versus alternative constructs for anterior cervical spine surgery: Pros, cons, and costs

Background:

Grafting choices available for performing anterior cervical diskectomy/fusion (ACDF) procedures have become a major concern for spinal surgeons, and their institutions. The “gold standard”, iliac crest autograft, may still be the best and least expensive grafting option; it deserves to be reassessed along with the pros, cons, and costs for alternative grafts/spacers.

Methods:

Although single or multilevel ACDF have utilized iliac crest autograft for decades, the implant industry now offers multiple alternative grafting and spacer devices; (allografts, cages, polyether-etherketone (PEEK) amongst others). While most studies have focused on fusion rates and clinical outcomes following ACDF, few have analyzed the “value-added” of these various constructs (e.g. safety/efficacy, risks/complications, costs).

Results:

The majority of studies document 95%-100% fusion rates when iliac crest autograft is utilized to perform single level ACDF (X-ray or CT confirmed at 6-12 postoperative months). Although many allograft studies similarly quote 90%-100% fusion rates (X-ray alone confirmed at 6-12 postoperative months), a recent “post hoc analysis of data from a prospective multicenter trial” (Riew KD et. al., CSRS Abstract Dec. 2011; unpublished) revealed a much higher delayed fusion rate using allografts at one year 55.7%, 2 years 87%, and four years 92%.

Conclusion:

Iliac crest autograft utilized for single or multilevel ACDF is associated with the highest fusion, lowest complication rates, and significantly lower costs compared with allograft, cages, PEEK, or other grafts. As spinal surgeons and institutions become more cost conscious, we will have to account for the “value added” of these increasingly expensive graft constructs.