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Tan H, Elkholy MA, Raslan AM. Combined cervical and thoracic spinal cord stimulation for chronic pain: A systematic literature review. Pain Pract 2023; 23:933-941. [PMID: 37409553 DOI: 10.1111/papr.13264] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/18/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) is conventionally placed at either cervical or thoracic spinal regions to treat chronic pain. However, for patients with multiarea pain, concomitant cervical and thoracic SCS (ctSCS) may be necessary to provide sufficient coverage. It remains unknown whether ctSCS is effective and safe. Thus, we aimed to survey the existing literature and assess the efficacy and safety of ctSCS. METHODS A systematic review of the literature was performed according to the 2020 PRISMA guidelines to investigate pain, functional, and safety outcomes related to ctSCS. Articles between 1990 and 2022 available through PubMed, Web of Science, Scopus, and Cochrane Library databases were included if they assessed these outcomes in the context of ctSCS. Data extracted from articles included study type, number of ctSCS implantations, stimulation parameters, indications for implantation, complications, and frequency. The Newcastle-Ottawa scale was used to assess risk of bias. RESULTS Three primary studies met our inclusion criteria. Overall, ctSCS was effective in providing analgesia. Pain severity was captured with patient-reported pain scales and changes in analgesic requirements. Various metrics were used to quantify quality of life and functional outcomes. Failed back surgery syndrome was the most common indication for ctSCS implantation. Implanted pulse generator pocket pain was the most common postoperative adverse event. CONCLUSIONS Despite the limited evidence available, ctSCS seems to be effective and generally well tolerated. The dearth of relevant primary literature illustrates a knowledge gap, and future studies are needed to better clarify the efficacy and safety profile of this SCS variant.
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Affiliation(s)
- Hao Tan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
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2
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Beletsky A, Liu C, Alexander E, Hassanin SW, Vickery K, Loomba M, Winston N, Chen J, Gabriel RA. The Association of Psychiatric Comorbidities With Short-Term and Long-Term Outcomes Following Spinal Cord Stimulator Placement. Neuromodulation 2023:S1094-7159(22)01432-5. [PMID: 36720669 DOI: 10.1016/j.neurom.2022.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/28/2022] [Accepted: 12/19/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Outcomes after spinal cord stimulator (SCS) placement are affected by psychologic comorbidities. It is part of routine practice to do psychologic assessments prior to SCS trials to assess for the presence of maladaptive behavioral patterns. However, few studies have sought to quantify the effect of psychiatric comorbidities on complications, reoperation, and readmission rates. The purpose of this study was to assess the association of psychiatric comorbidities with postprocedural outcomes after SCS implantation. MATERIALS AND METHODS Inclusion criteria included SCS placement between 2015 and 2020 (percutaneous approach or an open laminectomy-based approach) using Healthcare Corporation of America National Database. Data on psychiatric comorbidities present at the time of SCS implantation surgery were collected. Outcomes of interest included complication rates (defined as lead migration, fracture, malfunction, battery failure, postoperative pain, infection, dural puncture, or neurological injury), reoperation rates (defined as either revision or explant [ie, removal]), and readmission rates within 30-day and 1-year time after SCS implantation. We measured the association between psychiatric comorbidities and outcomes using multivariable regression and reported odds ratio (OR) and respective 95% confidence intervals. RESULTS A total of 12,751 cases were included. The most common psychiatric comorbidities were major depressive disorder (16.1%) and anxiety disorder (13.4%). In unadjusted univariate analysis, patients with any psychiatric comorbidity had heightened rates of any complication (27.1% vs 19.4%), infection (5.9% vs 1.9%), lead displacement (2.2% vs 1.3%), surgical pain (2.1% vs 1.2%), explant (14.7% vs 8.8%), and readmission rates at one year (54.2% vs 33.8%) (all p < 0.001). In multivariable logistic regression, with each additional psychiatric comorbidity, a patient had increased odds of experiencing any complication (OR = 1.5, 95% CI = 1.36-1.57, p < 0.001), requiring a reoperation (OR = 1.5, 95% CI = 1.37-1.6, p < 0.001), and requiring readmission (OR = 1.7, 99% CI = 1.6-1.8, p < 0.001). CONCLUSIONS The presence of psychiatric comorbidities was found to be associated with postoperative complication rates, reoperation, and readmission rates after SCS placement. Furthermore, each consecutive increase in psychiatric comorbidity burden was associated with increased odds of complications, reoperation, and readmission. Future studies might consider examining the role of presurgical mental health screening (ie, patient selection, psychologic testing) and treatment in optimizing outcomes for patients with psychiatric comorbidities.
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Affiliation(s)
- Alexander Beletsky
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA.
| | - Cherry Liu
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Evan Alexander
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Samir W Hassanin
- Rutgers Robert Wood Johnson Medical School, School of Medicine, Rutgers the State University of New Jersey, Picataway, NJ, USA
| | - Kim Vickery
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Munish Loomba
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Nutan Winston
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Jeffrey Chen
- Division of Pain, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Division of Pain, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA; Division of Regional Anesthesia, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, San Diego, CA, USA
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3
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Health Care Disparity in Pain. Neurosurg Clin N Am 2022; 33:251-260. [DOI: 10.1016/j.nec.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lee JM, Woon R, Ramsum M, Halperin DS, Jain R. Improved User Engagement and Assessment of Treatment Effectiveness in Patients Utilizing a Novel Digital Mobile Health Application During Spinal Cord Stimulation Screening Trials (Preprint). JMIR Hum Factors 2021; 9:e35134. [PMID: 35167484 PMCID: PMC8987952 DOI: 10.2196/35134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background Patient outcomes and experience during a Spinal Cord Stimulation (SCS) screening trial can have a significant effect on whether to proceed with long-term, permanent implantation of an SCS device for the treatment of chronic pain. Enhancing the ability to track and assess patients during this initial trial evaluation offers the potential for improved understanding regarding the suitability of permanent device implantation as well as identification of the SCS-based neurostimulative modalities and parameters that may provide substantial analgesia in a patient-specific manner. Objective In this report, we aimed to describe a preliminary, real-world assessment of a new, real time tracking, smart, device-based digital app used by patients with chronic pain undergoing trial screening for SCS therapy. Methods This is a real-world, retrospective evaluation of 13,331 patients diagnosed with chronic pain who used the new “mySCS” mobile app during an SCS screening trial. The app design is health insurance portability and accountability act (HIPAA)-compliant and compatible with most commercially available smartphones (eg, Apple, iPhone, and Android). The app enables tracking of user-inputted health-related responses (ie, pain relief, activity level, and sleep quality) in addition to personal trial goals and a summary of overall experience during the SCS trial. A deidentified, aggregate analysis of user engagement, user-submitted responses, and overall trial success was conducted. Results When provided the opportunity, the percentage of users who engaged with the tracking app for ≥50% of the time during their trial was found to be 64.43% (n=8589). Among the 13,331 patients who used the app, 58.24% (n=7764) entered a trial goal. Most patients underwent SCS screening with a trial duration of at least 7 days (n=7739, 58.05%). Of those patients who undertook a 7-day SCS trial, 62.30% (n=3456) engaged the app for 4 days or more. In addition, among all who submitted descriptive responses using the app, health-related improvements were reported by 77.84% (n=10,377) of patients who reached day 3 of the screening phase assessment and by 83.04% (n=11,070) of those who reached trial completion. A trial success rate of 91% was determined for those who used the app (versus 85% success rate for nonusers). Conclusions Data from this initial, real-world examination of a mobile, digital-health–based tracking app (“mySCS”), as used during the SCS screening phase, demonstrate that substantial patient engagement can be achieved while also providing for the acquisition of more real time patient-outcome measures that may help facilitate improved SCS trial success.
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Affiliation(s)
| | - Rex Woon
- Boston Scientific Neuromodulation, Valencia, CA, United States
| | - Mandy Ramsum
- Boston Scientific Neuromodulation, Valencia, CA, United States
| | | | - Roshini Jain
- Boston Scientific Neuromodulation, Valencia, CA, United States
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Cardinal T, Bonney PA, Strickland BA, Lechtholz-Zey E, Mendoza J, Pangal DJ, Liu J, Attenello F, Mack W, Giannotta S, Zada G. Disparities in the Surgical Treatment of Adult Spine Diseases: A Systematic Review. World Neurosurg 2021; 158:290-304.e1. [PMID: 34688939 DOI: 10.1016/j.wneu.2021.10.121] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Our goal was to systematically review the literature on racial/ethnic, insurance, and socioeconomic disparities in adult spine surgery in the United States and analyze potential areas for improvement. METHODS We conducted a database search of literature published between January 1990 and July 2020 using PRISMA guidelines for all studies investigating a disparity in any aspect of adult spine surgery care analyzed based on race/ethnicity, insurance status/payer, or socioeconomic status (SES). RESULTS Of 2679 articles identified through database searching, 775 were identified for full-text independent review by 3 authors, from which a final list of 60 studies were analyzed. Forty-three studies analyzed disparities based on patient race/ethnicity, 32 based on insurance status, and 8 based on SES. Five studies assessed disparities in access to care, 15 examined surgical treatment, 35 investigated in-hospital outcomes, and 25 explored after-discharge outcomes. Minority patients were less likely to undergo surgery but more likely to receive surgery from a low-volume provider and experience postoperative complications. White and privately insured patients generally had shorter hospital length of stay, were more likely to undergo favorable/routine discharge, and had lower rates of in-hospital mortality. After discharge, white patients reported better outcomes than did black patients. Thirty-three studies (55%) reported no disparities within at least 1 examined metric. CONCLUSIONS This comprehensive systematic review underscores ongoing potential for health care disparities among adult patients in spinal surgery. We show a need for continued efforts to promote equity and cultural competency within neurologic surgery.
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Affiliation(s)
- Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - John Liu
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Frank Attenello
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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Abstract
BACKGROUND Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. METHODS This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. RESULTS Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. CONCLUSION WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Jones MR, Orhurhu V, O'Gara B, Brovman EY, Rao N, Vanterpool SG, Poree L, Gulati A, Urman RD. Racial and Socioeconomic Disparities in Spinal Cord Stimulation Among the Medicare Population. Neuromodulation 2021; 24:434-440. [PMID: 33723896 DOI: 10.1111/ner.13373] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Spinal cord stimulation (SCS) is used in the treatment of many chronic pain conditions. This study investigates racial and socioeconomic disparities in SCS among Medicare patients with chronic pain. MATERIALS AND METHODS Patients over the age of 18 with a primary diagnosis of postlaminectomy syndrome (ICD-10 M96.1) or chronic pain syndrome (ICD-10 G89.4) were identified in the Center for Medicare and Medicaid Services (CMS) Medicare Claims Limited Data Set. We defined our outcome as SCS therapy by race and socioeconomic status. Multivariable logistic regression was used to determine the variables associated with SCS. RESULTS We identified 1,244,927 patients treated between 2016 and 2019 with a primary diagnosis of postlaminectomy syndrome (PLS) or chronic pain syndrome (CPS). Of these patients, 59,182 (4.8%) received SCS. Multivariable logistic regression analysis revealed that, compared with White patients, Black (OR [95%CI], 0.62 [0.6-0.65], p < 0.001), Asian (0.66 [0.56-0.76], p < 0.001), Hispanic (0.86 [0.8-0.93], p < 0.001), and North American Native (0.62 [0.56-0.69], p < 0.001) patients were significantly less likely to receive SCS. In addition, patients who were dual-eligible for Medicare and Medicaid were significantly less likely to receive SCS than those eligible for Medicare only (OR = 0.38 [95% CI: 0.37-0.39], p < 0.001). CONCLUSIONS This study suggests that racial and socioeconomic disparities exist in SCS among Medicare and Medicaid patients with PLS and CPS. Further work is required to elucidate the complex etiology underlying these findings.
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Affiliation(s)
- Mark R Jones
- Weill Cornell Medical College, Department of Anesthesiology, New York, NY, USA
| | - Vwaire Orhurhu
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian O'Gara
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ethan Y Brovman
- Tufts Medical Center and University School of Medicine, Boston, MA, USA
| | | | | | - Lawrence Poree
- Pain Management Center, UCSF Health, San Francisco, CA, USA
| | - Amitabh Gulati
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard D Urman
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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8
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Goyal A, Bhandarkar AR, Kerezoudis P, Lamer TJ, Gazelka HM, Belzberg AJ, North RB, Bydon M. Trends in Utilization and Cost of Inpatient Spinal Cord Stimulation: Analysis of Data from 2008 to 2014. World Neurosurg 2020; 147:e171-e188. [PMID: 33359880 DOI: 10.1016/j.wneu.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In this study, we sought to characterize contemporary trends in cost and utilization of spinal cord stimulation (SCS). METHODS The Healthcare Cost and Utilization Project-National Inpatient Sample was queried for inpatient admissions from 2008 to 2014 where SCS was performed. We then determined the rates and costs of SCS performed in this time frame to treat diagnoses that we classified as device-related complications, degenerative spine disease, pain syndromes, and neuropathies/neuritis/nerve lesions. Least-squares regression was performed to determine the yearly trends for each indication adjusted by the total number of yearly hospitalizations for that diagnosis. RESULTS We identified a total of 6876 admissions in whom an SCS was performed. The overall rate of inpatient SCS procedures performed has decreased by 45% from 2008 to 2014 (14.0 to 7.7 procedures per 100,000 admissions). Adjusted analysis for yearly trends also demonstrated a declining trend for all indications; however, this was not found to be statistically significant, except for device-related complications (P = 0.004). The median inflation-adjusted cost of an admission where SCS was performed increased slightly by 7.4% from $26,200 (IQR: $16,700-$33,800) in 2008 to $28,100 (IQR: $19,600-$36,900) in 2014. Billed hospital charges demonstrated a significant increase with median inflation-adjusted admission charge of $66,068 in 2008 to $110,672 in 2014. CONCLUSIONS Despite a declining contemporary trend in inpatient SCS, an increase was noted in admission costs and hospital charges. A significant declining trend was noted in revision SCS implantations due to device-related complications.
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Affiliation(s)
- Anshit Goyal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Tim J Lamer
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Halena M Gazelka
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard B North
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Orhurhu V, Gao C, Agudile E, Monegro W, Urits I, Orhurhu MS, Olatoye D, Viswanath O, Hirji S, Jones M, Ngo A, Aiudi C, Simopoulos T, Gill J. Socioeconomic Disparities in the Utilization of Spinal Cord Stimulation Therapy in Patients with Chronic Pain. Pain Pract 2020; 21:75-82. [PMID: 32654360 DOI: 10.1111/papr.12936] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/25/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Spinal cord stimulation (SCS) therapies are used in the management of patients with complex regional pain syndrome I (CRPS I) and failed back surgery syndrome (FBSS). The purpose of this study was to investigate the racial and health insurance inequalities with SCS therapy in patients with chronic pain who had CRPS I and FBSS. METHODS Patients with chronic pain who had a discharge diagnosis of FBSS and CRPS I were identified using the National Inpatient Sample database. Our primary outcome was defined as the history of SCS utilization by race/ethnicity, income quartile, and insurance status. Multivariable logistic regression was used to determine the variables associated with utilization of SCS therapy. RESULTS Between 2011 and 2015, 40,858 patients who were hospitalized with a primary diagnosis of FBSS and/or CRPS I were identified. Of these patients, 1,082 (2.7%) had a history of SCS therapy. Multivariable regression analysis revealed that compared to White patients, Black and Hispanic patients had higher odds of having SCS therapy (Black patients: odds ratio [OR] = 1.41; 95% confidence interval [CI], 1.12 to 1.77; P = 0.003; Hispanic patients: OR = 1.41; 95% CI, 1.10 to 1.81; P = 0.007). Patients with private insurance had significantly higher odds of having SCS therapy compared with those with Medicare (OR = 1.24; 95% CI, 1.08 to 1.43; P = 0.003). Compared to patients with Medicare, Medicaid patients had lower odds of having SCS therapy (OR = 0.50; 95% CI, 0.36 to 0.70; P < 0.001). CONCLUSIONS Our study suggests that socioeconomic disparities may exist in the utilization of SCS among hospitalized patients with CRPS I and FBSS the United States. However, confirming these data from other administrative databases, in the outpatient setting, may shed more insight.
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Affiliation(s)
- Vwaire Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Catherine Gao
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, U.S.A
| | - Emeka Agudile
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, U.S.A
| | - Wendy Monegro
- Department of Nursing, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ivan Urits
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mariam Salisu Orhurhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Dare Olatoye
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Omar Viswanath
- Department of Anesthesiology, Valley Anesthesiology and Pain Consultants, Phoenix, Arizona, U.S.A.,Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, U.S.A.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, Nebraska, U.S.A
| | - Sameer Hirji
- Departments of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mark Jones
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Anh Ngo
- Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Pain Medicine, Pain Specialty Group, Newington, New Hampshire, U.S.A
| | - Christopher Aiudi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Thomas Simopoulos
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Jatinder Gill
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
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Odonkor CA, Orman S, Orhurhu V, Stone ME, Ahmed S. Spinal Cord Stimulation vs Conventional Therapies for the Treatment of Chronic Low Back and Leg Pain: A Systematic Review of Health Care Resource Utilization and Outcomes in the Last Decade. PAIN MEDICINE 2019; 20:2479-2494. [DOI: 10.1093/pm/pnz185] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
The purpose of this review is to critically appraise the literature for evidence supporting the health care resource utilization and cost-effectiveness of spinal cord stimulation (SCS) compared with conventional therapies (CTs) for chronic low back and leg pain.
Methods
The PubMed, MEDLINE, Embase, CINAHL, and Rehabilitation & Sports Medicine databases were searched for studies published from January 2008 through October 2018, using the following MeSH terms: “spinal cord stimulation,” “chronic pain,” “back pain,” “patient readmission,” “economics,” and “costs and cost analysis.” Additional sources were added based on bibliographies and consultation with experts. The following data were extracted and analyzed: demographic information, study design, objectives, sample sizes, outcome measures, SCS indications, complications, costs, readmissions, and resource utilization data.
Results
Of 204 studies screened, 11 studies met inclusion criteria, representing 31,439 SCS patients and 299,182 CT patients. The mean age was 53.5 years for SCS and 55.6 years for CT. In eight of 11 studies, SCS was associated with favorable outcomes and found to be more cost-effective than CT for chronic low back pain. Compared with CT, SCS resulted in shorter hospital stays and lower complication rates and health care costs at 90 days. SCS was associated with significant improvement in health-related quality of life, health status, and quality-adjusted life-years.
Conclusions
For the treatment of chronic low back and leg pain, the majority of studies are of fair quality, with level 3 or 4 evidence in support of SCS as potentially more cost-effective than CT, with less resource expenditure but higher complication rates. SCS therapy may yet play a role in mitigating the financial burden associated with chronic low back and leg pain.
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Affiliation(s)
- Charles A Odonkor
- Division of Pain, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Sebastian Orman
- Department of Orthopaedics, Georgetown University School of Medicine, Washington, DC
| | - Vwaire Orhurhu
- Department of Anesthesiology, Critical Care and Pain, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martha E Stone
- Treadwell Library, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shihab Ahmed
- Division of Pain, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
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11
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12
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Abstract
STUDY DESIGN Review of published literature pertaining to spinal cord stimulation (SCS) cost data analysis. OBJECTIVE To acquire, organize, and succinctly summarize the available literature regarding the costs associated with, and the cost-effectiveness of, SCS. SUMMARY OF BACKGROUND DATA Chronic back and limb pain is a pervasive complaint in modern society, with estimated annual costs of medical care greater than $100 billion. The traditional standard medical management with or without intermittent surgical decompression/fusion has been plagued by high costs and inconsistent results, leading to poor patient satisfaction and functional outcome, and questions from policy makers regarding use of limited healthcare resources. Neuromodulation techniques, including SCS have recently become more common in the treatment of chronic back/leg pain, with clinical studies showing a high degree of efficacy in alleviating otherwise intractable pain. Given the relatively high upfront costs associated with the hardware and implantation, policy makers have, however, questioned their use in the framework of cost-containment and resource utilization. We reviewed the available literature summarizing cost data of SCS in chronic back and limb pain, as an understanding of these data will be vital to justify continued payment for this expensive, but often very effective, treatment modality. METHODS We performed a PubMed literature search utilizing the following terms: "spinal cord stimulation," "SCS," "financial," "cost," "cost-effectiveness," and "cost-utility." All studies published in English and containing complete or partial cost evaluations of SCS for chronic back and limb pain were included. RESULTS The search revealed 21 studies that evaluated cost data, with or without outcomes analysis and cost-utility analysis, for patients with chronic back and limb pain. The overwhelming majority of data presented shows that SCS is not only an effective treatment option for these patients, but also represents cost savings and efficient use of healthcare resources relative to current standards of care. Although not all studies performed cost-utility analyses, those that did tended to show SCS falling well within accepted thresholds of "willingness-to-pay" on the part of third-party payers. That being said, the articles included in this review were almost all small, retrospective, single-institution studies. In addition, many of them relied on modeling for their analyses, and published literature values for cost and/or outcomes data rather than prospectively collected patient data. Although the data presented in this review are encouraging, it should serve as a foundation for a thorough, prospective, cost-utility analysis of SCS in chronic back and limb pain so that the role of this important treatment modality may be cemented in the treatment paradigm for these patients without questions from third-party payers. CONCLUSION The large majority of data covering costs of SCS argue in favor of the cost-effectiveness of this treatment modality for chronic neuropathic pain, especially in comparison to reoperation and medical management. Although most of the higher-quality evidence is relatively short-term, clinical experience with the durability of treatment benefit of SCS in these patients is promising. Given the pushback regarding high upfront costs of implantation, longer-term, prospective, randomized studies evaluating this topic will be important to help maintain third-party payer reimbursements for SCS. LEVEL OF EVIDENCE 5.
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Elsamadicy AA, Farber SH, Yang S, Hussaini SMQ, Murphy KR, Sergesketter A, Suryadevara CM, Pagadala P, Parente B, Xie J, Lad SP. Impact of Insurance Provider on Overall Costs in Failed Back Surgery Syndrome: A Cost Study of 122,827 Patients. Neuromodulation 2017; 20:354-360. [PMID: 28322477 DOI: 10.1111/ner.12584] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 12/05/2016] [Accepted: 01/03/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Failed back surgery syndrome (FBSS) affects 40% of patients following spine surgery with estimated costs of $20 billion to the US health care system. The aim of this study was to assess the cost differences across the different insurance providers for FBSS patients. METHODS A retrospective longitudinal study was performed using the Truven MarketScan® database to identify FBSS patients from 2001 to 2012. Patients were grouped into Commercial, Medicaid, or Medicare cohorts. We collected one-year prior to FBSS diagnosis (baseline), then at year of spinal cord stimulation (SCS)-implantation and nine-year post-SCS implantation cost outcomes. RESULTS We identified 122,827 FBSS patients, with 117,499 patients who did not undergo an SCS-implantation (Commercial: n = 49,075, Medicaid: n = 23,180, Medicare: n = 45,244) and 5328 who did undergo an SCS implantation (Commercial: n = 2279, Medicaid: n = 1003, Medicare: n = 2046). Baseline characteristics were similar between the cohorts, with the Medicare-cohort being significantly older. Over the study period, there were significant differences in overall cost metrics between the cohorts who did not undergo SCS implantation with the Medicaid-cohort had the lowest annual median (interquartile range) total cost (Medicaid: $4530.4 [$1440.6, $11,973.5], Medicare: $7292.0 [$3371.4, $13,989.4], Commercial: $4944.3 [$363.8, $13,294.0], p < 0.0001). However, when comparing the patients who underwent SCS implantation, the commercial-cohort had the lowest annual median (interquartile range) total costs (Medicaid: $4045.6 [$1146.9, $11,533.9], Medicare: $7158.1 [$3160.4, $13,916.6], Commercial: $2098.1 [$0.0, $8919.6], p < 0.0001). CONCLUSIONS Our study demonstrates a significant difference in overall costs between various insurance providers in the management of FBSS, with Medicaid-insured patients having lower overall costs compared to Commercial- and Medicare-patients. SCS is cost-effective across all insurance groups (Commercial > Medicaid > Medicare) beginning at two years and continuing through nine-year follow-up. Further studies are necessary to understand the cost differences between these insurance providers, in hopes of reducing unnecessary health care expenditures for patients with FBSS.
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Affiliation(s)
| | | | - Siyun Yang
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | | | - Kelly R Murphy
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | | | | | - Promila Pagadala
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jichun Xie
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Murphy KR, Han JL, Hussaini SMQ, Yang S, Parente B, Xie J, Lad SP. The Volume-Outcome Effect: Impact on Trial-to-Permanent Conversion Rates in Spinal Cord Stimulation. Neuromodulation 2016; 20:256-262. [PMID: 27696607 DOI: 10.1111/ner.12526] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 08/08/2016] [Accepted: 08/16/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Conversion rates from trial leads to permanent spinal cord stimulation (SCS) systems have important implications for healthcare resource utilization (HCRU) and pain management. We hypothesized that there is a volume-outcome effect, with chronic pain patients who visit high volume SCS implanters will have higher trial-to-permanent conversion rates. MATERIALS AND METHODS We designed a large, retrospective analysis using the Truven MarketScan database analyzing adult SCS patients with provider information available, with or without IPG implantation from the years 2007 to 2012 was designed. Patients were divided into three provider-based groups: high (>25), medium (9-24), and low (3-8) volume providers. Univariate and multivariate models identified factors associated with successful conversion. RESULTS A total of 17,850 unique trial implants were performed by 3028 providers. Of 13,879 patients with baseline data available, 8981 (64.7%) progressed to permanent SCS. Higher volume providers were associated with slightly higher conversion rates (65.9% vs. 63.3% low volume, p = 0.029), explant rates (9.2% vs. 7.7% medium volume, p = 0.026), younger age (52.0 ± 13.4 years vs. 53.0 ± 13.4 years, p = 0.0026), Medicare/Medicaid (47.8% vs. 35.0% low volume, p < 0.0001), Southern region (53.5% vs. 38.9% low volume, p < 0.0001), and higher Charlson comorbidity scores (1.0 [SD = 1.4], p = 0.0002). Multivariate regression results showed female gender (1.13 [95% CI: 1.05-1.22], p < 0.001) and high volume providers associated with higher odds of successful trial conversion (1.12 [95% CI: 1.02-1.22], p = 0.014). CONCLUSIONS In this nationwide analysis, high volume providers achieved higher trial-to-permanent SCS conversion rates than lower volume providers. The study has implications for both training requirements and referral patterns to delineate minimum implant experience necessary for provider proficiency. Future studies may be useful to understand HCRU differences.
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Affiliation(s)
- Kelly Ryan Murphy
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jing L Han
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | | | - Siyun Yang
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jichun Xie
- Department of Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Chen EY, Fox BT, Suzo A, Greenberg JA, Campos GM, Garren MJ, Funk LM. One-year Surgical Outcomes and Costs for Medicaid Versus Non-Medicaid Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass: A Single-Center Study. Surg Laparosc Endosc Percutan Tech 2016; 26:38-43. [PMID: 26836627 PMCID: PMC4742364 DOI: 10.1097/sle.0000000000000219] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare 1-year outcomes and costs between severely obese Medicaid and non-Medicaid patients who underwent laparoscopic Roux-en-Y gastric bypass surgery. METHODS This is a single-institution retrospective review comparing 33 Medicaid patients to 99 randomly selected non-Medicaid patients (1:3 case-control). Ninety-day and 1-year outcomes were extracted from the electronic health record. Costs were obtained from the UW information technology division. Bivariate analyses were used to compare study variables. RESULTS Emergency department visits (48.2% vs. 27.4%; P=0.06) and readmissions (37.0% vs. 14.7%; P=0.01) were more common for Medicaid patients. Medicaid patients had less excess body weight loss (50.7% vs. 65.6%; P=0.001) but similar comorbidity resolution and complication rates. One-year median costs were similar between Medicaid and non-Medicaid patients ($21,160 vs. $24,215; P=0.92). CONCLUSIONS One-year comorbidity resolution, complications, and costs following laparoscopic Roux-en-Y gastric bypass were similar between Medicaid and non-Medicaid patients. Focusing on reducing emergency department presentations and readmissions would be a high-impact area for future quality improvement initiatives.
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Affiliation(s)
- Ellie Y Chen
- *Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI †Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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Pan Y, Chen S, Chen M, Zhang P, Long Q, Xiang L, Lucas H. Disparity in reimbursement for tuberculosis care among different health insurance schemes: evidence from three counties in central China. Infect Dis Poverty 2016; 5:7. [PMID: 26812914 PMCID: PMC4729161 DOI: 10.1186/s40249-016-0102-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/09/2015] [Indexed: 11/10/2022] Open
Abstract
Background Health inequity is an important issue all around the world. The Chinese basic medical security system comprises three major insurance schemes, namely the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Cooperative Medical Scheme (NCMS). Little research has been conducted to look into the disparity in payments among the health insurance schemes in China. In this study, we aimed to evaluate the disparity in reimbursements for tuberculosis (TB) care among the abovementioned health insurance schemes. Methods This study uses a World Health Organization (WHO) framework to analyze the disparities and equity relating to the three dimensions of health insurance: population coverage, the range of services covered, and the extent to which costs are covered. Each of the health insurance scheme’s policies were categorized and analyzed. An analysis of the claims database of all hospitalizations reimbursed from 2010 to 2012 in three counties of Yichang city (YC), which included 1506 discharges, was conducted to identify the differences in reimbursement rates and out-of-pocket (OOP) expenses among the health insurance schemes. Results Tuberculosis patients had various inpatient expenses depending on which scheme they were covered by (TB patients covered by the NCMS have less inpatient expenses than those who were covered by the URBMI, who have less inpatient expenses than those covered by the UEBMI). We found a significant horizontal inequity of healthcare utilization among the lower socioeconomic groups. In terms of financial inequity, TB patients who earned less paid more. The NCMS provides modest financial protection, based on income. Overall, TB patients from lower socioeconomic groups were the most vulnerable. Conclusion There are large disparities in reimbursement for TB care among the three health insurance schemes and this, in turn, hampers TB control. Reducing the gap in health outcomes between the three health insurance schemes in China should be a focus of TB care and control. Achieving equity through integrated policies that avoid discrimination is likely to be effective. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0102-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yao Pan
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China. .,The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Shanquan Chen
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.
| | - Manli Chen
- School of Management, Hubei University of Chinese Medicine, Wuhan, China.
| | - Pei Zhang
- Yichang Center for Disease Control and Prevention, Yichang, China.
| | - Qian Long
- Duke Global Health Institute, Duke University, Durham, NC, USA. .,Global Health Research Center, Duke Kunshan University, Kunshan, China.
| | - Li Xiang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China.
| | - Henry Lucas
- Institute of Development Studies, Sussex University, Brighton, UK.
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Hooten KG, Neal D, Lovaton Espadin RE, Gil JN, Azari H, Rahman M. Insurance Status Influences the Rates of Reportable Quality Metrics in Brain Tumor Patients. Neurosurgery 2015; 76:239-47; discussion 247-8. [DOI: 10.1227/neu.0000000000000594] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Huang KT, Martin J, Marky A, Chagoya G, Hatef J, Hazzard MA, Thomas SM, Lokhnygina Y, Lad SP. A national survey of spinal cord stimulation trial-to-permanent conversion rates. Neuromodulation 2014; 18:133-9; discussion 139-40. [PMID: 24930992 DOI: 10.1111/ner.12199] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/28/2014] [Accepted: 04/18/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Conversion rates from trial leads to permanent spinal cord stimulation (SCS) systems have recently come under scrutiny. Our goal was to examine the rate of conversion from trial lead to permanent system placement as well as identify factors associated with successful SCS conversion. MATERIALS AND METHODS We designed a large retrospective analysis using the Thomson Reuters MarketScan database. We included all patients who underwent a percutaneous trial of neurostimulatory electrodes from the years 2000 to 2009 who were aged 18 and older. Patients were then tracked to see if they went on to receive a permanent SCS system. Patients were also analyzed in univariate and multivariate models to identify factors associated with successful conversion. RESULTS A total of 21,672 unique instances of percutaneous trials were identified. Overall, 41.4% of those receiving trials went on to have a permanent SCS system installed within the subsequent three months. Factors associated with increased likelihood of successful conversion included having commercial insurance (43% vs. 37%, p < 0.0001), younger age (43% for those aged 35-44 vs. 39% for those aged 65 and older, p < 0.0001), and never having had a previous percutaneous trial attempt (44% for first-time trials vs. 27% for those on their second trial vs. 14% for those on their third or later trial, p < 0.0001). In multivariate analysis, we found significant variation in conversion rate by geographic area (patients in the North Central region vs. Northeast region: odds ratio 1.48, 95% confidence interval [1.31, 1.66]; p < 0.0001). CONCLUSIONS In this study of a national cohort of patients, we identified specific factors associated with higher conversion rates, along with significant geographical variation. In general, there is a need for better patient selection by physicians who practice neuromodulation.
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Affiliation(s)
- Kevin T Huang
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Deogaonkar M, Zibly Z, Slavin KV. Spinal Cord Stimulation for the Treatment of Vascular Pathology. Neurosurg Clin N Am 2014; 25:25-31. [DOI: 10.1016/j.nec.2013.08.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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