Cost-effectiveness of lumbar discectomy and single-level fusion for spondylolisthesis: experience with the NeuroPoint-SD registry

Lumbar Laminotomy: Variables Affecting 90-day Overall Reimbursement

INTRODUCTION

Lumbar laminotomy/diskectomy is a common procedure performed to address radiculopathy that persists despite conservative treatment. Understanding cost/reimbursement variability and its drivers has the potential to help optimize related healthcare delivery. The goal of this study was to assess variability and factors associated with reimbursement through 90 days after single-level lumbar laminotomy/diskectomy.

METHODS

Lumbar laminotomies/diskectomies were isolated from the 2010 to 2021 PearlDiver M151 data set. Exclusion criteria included patients younger than 18 years; other concomitant spinal procedures; and indications of trauma, oncologic, or infectious diagnoses. Patient, surgical, and perioperative data were abstracted. These variables were examined using a multivariable linear regression model with Bonferroni correction to determine factors independently correlated with reimbursement.

RESULTS

A total of 28,621 laminotomies/diskectomies were identified. The average ± standard deviation 90-day postoperative reimbursement was $9,453.83 ± 19,343.99 and, with a non-normal distribution, the median (inner quartile range) was $3,314 ($5,460). By multivariable linear regression, variables associated with greatest increase in 90-day postoperative reimbursement were associated with admission (with the index procedure [+$11,757.31] or readmission [+$31,248.80]), followed by insurance type (relative to Medicare, commercial +$4,183.79), postoperative adverse events (+$2,006.60), and postoperative emergency department visits (+$1,686.89) ( P < 0.0001 for each). Lesser associations were with Elixhauser Comorbidity Index (+$286.67 for each point increase) and age (-$24.65 with each year increase) ( P < 0.001 and P = 0.003, respectively).

DISCUSSION

This study assessed a large cohort of lumbar laminotomies/diskectomies and found substantial variations in reimbursement/cost to the healthcare system. The largest increase in reimbursement was associated with admission (with the index procedure or readmission), followed by insurance type, postoperative adverse events, and postoperative emergency department visits. These results highlight the need to balance inpatient versus outpatient surgeries while limiting postoperative readmissions to minimize the costs associated with healthcare delivery.

Methodology of economic evaluations in spine surgery: a systematic review and qualitative assessment

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.

Prediction of lumbar disc herniation resorption in symptomatic patients: a prospective, multi-imaging and clinical phenotype study

BACKGROUND CONTEXT

Symptomatic lumbar disc herniations (LDH) are very common. LDH resorption may occur by a "self-healing" process, however this phenomenon remains poorly understood. By most guidelines, if LDH remains symptomatic after 3 months and conservative management fails, surgical intervention may be an option.

PURPOSE

The following prospective study aimed to identify determinants that may predict early versus late LDH resorption.

STUDY DESIGN/SETTING

Prospective study with patients recruited at a single center.

PATIENT SAMPLE

Ninety-three consecutive patients diagnosed with acute symptomatic LDH were included in this study (n=23 early resorption and n=67 late resorption groups) with a mean age of 48.7±11.9 years.

OUTCOMES MEASURE

Baseline assessment of patient demographics (eg, smoking status, height, weight, etc.), herniation characteristics (eg, the initial level of herniation, the direction of herniation, prevalence of multiple herniations, etc.) and MRI phenotypes (eg, Modic changes, end plate abnormalities, disc degeneration, vertebral body dimensions, etc.) were collected for further analysis. Lumbar MRIs were performed approximately every 3 months for 1 year from time of enrollment to assess disc integrity.

METHODS

All patients were managed similarly. LDH resorption was classified as early (<3 months) or late (>3 months). A prediction model of pretreatment factors was constructed.

RESULTS

No significant differences were noted between groups at any time-point (p>.05). Patients in the early resorption group experienced greater percent reduction of disc herniation between MRI-0-MRI-1 (p=.043), reduction of herniation size for total study duration (p=.007), and percent resorption per day compared to the late resorption group (p<.001). Based on multivariate modeling, greater L4 posterior vertebral height (coeff:14.58), greater sacral slope (coeff:0.12), and greater herniated volume (coeff:0.013) at baseline were found to be most predictive of early resorption (p<.05).

CONCLUSIONS

This is the first comprehensive imaging and clinical phenotypic prospective study, to our knowledge, that has identified distinct determinants for early LDH resorption. Early resorption can occur in 24.7% of LDH patients. We developed a prediction model for early resorption which demonstrated great overall performance according to pretreatment measures of herniation size, L4 posterior body height, and sacral slope. A risk profile is proposed which may aid clinical decision-making and managing patient expectations.

Direct medical costs after surgical or nonsurgical treatment for degenerative lumbar spinal disease: A nationwide matched cohort study with a 10-year follow-up

Objective

The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease.

Methods

The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years.

Results

The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years.

Conclusion

Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

Prediction of Major Complications and Readmission After Lumbar Spinal Fusion: A Machine Learning-Driven Approach

BACKGROUND

Given the significant cost and morbidity of patients undergoing lumbar fusion, accurate preoperative risk-stratification would be of great utility. We aim to develop a machine learning model for prediction of major complications and readmission after lumbar fusion. We also aim to identify the factors most important to performance of each tested model.

METHODS

We identified 38,788 adult patients who underwent lumbar fusion at any California hospital between 2015 and 2017. The primary outcome was major perioperative complication or readmission within 30 days. We build logistic regression and advanced machine learning models: XGBoost, AdaBoost, Gradient Boosting, and Random Forest. Discrimination and calibration were assessed using area under the receiver operating characteristic curve and Brier score, respectively.

RESULTS

There were 4470 major complications (11.5%). The XGBoost algorithm demonstrates the highest discrimination of the machine learning models, outperforming regression. The variables most important to XGBoost performance include angina pectoris, metastatic cancer, teaching hospital status, history of concussion, comorbidity burden, and workers' compensation insurance. Teaching hospital status and concussion history were not found to be important for regression.

CONCLUSIONS

We report a machine learning algorithm for prediction of major complications and readmission after lumbar fusion that outperforms logistic regression. Notably, the predictors most important for XGBoost differed from those for regression. The superior performance of XGBoost may be due to the ability of advanced machine learning methods to capture relationships between variables that regression is unable to detect. This tool may identify and address potentially modifiable risk factors, helping risk-stratify patients and decrease complication rates.

The Association Between Early Postoperative Leg Pain Intensity and Disability at 1-Year and 2-Year Follow-Up After First-Time Lumbar Discectomy

STUDY DESIGN

Longitudinal cohort study.

OBJECTIVES

To investigate whether a cutoff point in leg pain intensity measured preoperatively or at early follow-up could identify patients at risk of poor outcomes in terms of disability at 1-year and 2-year follow-up after first-time lumbar discectomy, and to identify the characteristics associated with early postoperative leg pain intensity.

METHODS

From 2010 to 2013, 556 patients underwent lumbar discectomy. Leg pain intensity was measured preoperatively and at early postoperative follow-up and dichotomized according to an established cutoff point on a 0 to 100 visual analogue scale (mild <30, moderate/severe ≥30). The outcome measurement was Oswestry Disability Index (ODI). Generalized estimating equations modelling established the association between leg pain intensity and ODI. Characteristics associated with early postoperative leg pain intensity were identified using common hypothesis tests.

RESULTS

Moderate/severe leg pain intensity at early follow-up showed a statistically significant association with higher ODI at 1-year and 2-year follow-up compared to mild leg pain intensity (median [interquartile range]: 24 [26] and 26 [26] versus 12 [18] and 10 [20], respectively). Patients reporting moderate/severe leg pain intensity were more often smokers, were more prone to receive social benefits, and were more prone to have chronic back pain. The preoperative measurement of leg pain intensity showed inferior associations.

CONCLUSION

The proposed cutoff point in leg pain intensity at early follow-up can identify patients at risk of disability at both 1-year and 2-year follow-up after first-time discectomy. Future research should be undertaken to investigate whether patients with moderate/severe leg pain intensity at early postoperative follow-up could benefit from additional or more intensive postoperative interventions.

Patient journey following lumbar spinal fusion surgery (FuJourn): A multicentre exploration of the immediate post-operative period using qualitative patient diaries

The aim of this study was to capture and understand the immediate recovery journey of patients following lumbar spinal fusion surgery and explore the interacting constructs that shape their journey. A qualitative study using Interpretive Phenomenological Analysis (IPA) approach. A purposive sample of 43 adult patients (≥16 years) undergoing ≤4 level instrumented fusion for back and/or leg pain of degenerative cause, were recruited pre-surgery from 4 UK spinal surgery centres. Patients completed a weekly diary expressed in their own words for the first 4 weeks following surgery to capture their life as lived. Diary content was based on previous research findings and recorded progress, recovery, motivation, symptoms, medications, healthcare appointments, rehabilitation, positive/negative thoughts, and significant moments; comparing to the previous week. To maximise completion and data quality, diaries could be completed in paper form, word document, as online survey or as audio recording. Strategies to enhance diary adherence included a weekly prompt. A framework analysis for individual diaries and then across participants (deductive and inductive components) captured emergent themes. Trustworthiness was enhanced by strategies including reflexivity, attention to negative cases and use of critical co-investigators. Twenty-eight participants (15 female; n = 18 (64.3%) aged 45-64) contributed weekly diaries (12 withdrew post-surgery, 3 did not follow through with surgery). Adherence with diaries was 89.8%. Participants provided diverse and vivid descriptions of recovery experiences. Three distinct recovery trajectories were identified: meaningful recovery (engagement in physical and functional activities to return to functionality/mobility); progressive recovery (small but meaningful improvement in physical ability with increasing confidence); and disruptive recovery (limited purpose for meaningful recovery). Important interacting constructs shaped participants' recovery including their pain experience and self-efficacy. This is the first account of immediate recovery trajectories from patients' perspectives. Recognition of a patient's trajectory may inform patient-centred recovery, follow-up and rehabilitation to improve patient outcomes.

Is there bias in the treatment of degenerative spine disease? Analysis of anonymous voting via a multidisciplinary conference

Many institutions have developed shared decision-making conferences as a mechanism for reducing treatment costs and improving patient outcomes. Little is known about the process of shared decision-making that takes place in these conferences, and there is the possibility of bias among surgeons and nonsurgeons for treatment within their respective specialties. This study was conducted to determine who is contributing to the decision-making process in a multidisciplinary spine conference and to what extent treatment biases exist among the surgical and nonsurgical members of this conference. Voting data were collected during weekly multidisciplinary spine conferences. Descriptive statistics were calculated on the cases presented and the number and type of physicians voting for each case. The likelihood of a particular vote in the surgeon and nonsurgeon cohorts was evaluated using relative risk calculation and multinomial logistic regression. A total of 262 consecutive cases were analyzed. No significant differences in treatment recommendation were observed between surgery and nonsurgical management (relative risk, 1.1; 95% CI, 0.97-1.25) when comparing votes from the surgeon and nonsurgeon cohorts. Multinomial logistic regression showed the odds of nonsurgeons recommending nonsurgical management over surgery was 20% greater than receiving that recommendation from their surgeon colleagues. Individual surgeon and nonsurgeon voters were evenly distributed above and below the mean for treatment recommendation. Individual and group biases exist among surgeons and nonsurgeons treating degenerative spine diseases. Multidisciplinary conferences may or may not level these biases, depending on how they are conducted.

Machine learning-based preoperative predictive analytics for lumbar spinal stenosis

OBJECTIVEPatient-reported outcome measures (PROMs) following decompression surgery for lumbar spinal stenosis (LSS) demonstrate considerable heterogeneity. Individualized prediction tools can provide valuable insights for shared decision-making. The authors aim to evaluate the feasibility of predicting short- and long-term PROMs, reoperations, and perioperative parameters by machine learning (ML) methods.METHODSData were derived from a prospective registry. All patients had undergone single- or multilevel mini-open facet-sparing decompression for LSS. The prediction models were trained using various ML-based algorithms to predict the endpoints of interest. Models were selected by area under the receiver operating characteristic curve (AUC). The endpoints were dichotomized by minimum clinically important difference (MCID) and included 6-week and 12-month numeric rating scales for back pain (NRS-BP) and leg pain (NRS-LP) severity and the Oswestry Disability Index (ODI), as well as prolonged surgery (> 45 minutes), extended length of hospital stay (> 28 hours), and reoperations.RESULTSA total of 635 patients were included. The average age was 62 ± 10 years, and 333 patients (52%) were male. At 6 weeks, MCID was seen in 63%, 76%, and 61% of patients for ODI, NRS-LP, and NRS-BP, respectively. At internal validation, the models predicted MCID in these variables with accuracies of 69%, 76%, and 85%, and with AUCs of 0.75, 0.79, and 0.92. At 12 months, 66%, 63%, and 51% of patients reported MCID; the observed accuracies were 62%, 74%, and 66%, with AUCs of 0.68, 0.72, and 0.79. Reoperations occurred in 60 patients (9.5%), of which 27 (4.3%) occurred at the index level. Overall and index-level reoperations were predicted with 69% and 63% accuracy, respectively, and with AUCs of 0.66 and 0.61. In 15%, a length of surgery greater than 45 minutes was observed and predicted with 78% accuracy and AUC of 0.54. Only 15% of patients were admitted to the hospital for longer than 28 hours. The developed ML-based model enabled prediction of extended hospital stay with an accuracy of 77% and AUC of 0.58.CONCLUSIONSPreoperative prediction of a range of clinically relevant endpoints in decompression surgery for LSS using ML is feasible, and may enable enhanced informed patient consent and personalized shared decision-making. Access to individualized preoperative predictive analytics for outcome and treatment risks may represent a further step in the evolution of surgical care for patients with LSS.

Returning to Work Within Two Years After First-Time, Single-Level, Simple Lumbar Discectomy: A Multifactorial, Predictive Model

Purpose Continued inability to work has societal and individual consequences. Thus, the factors associated with sustained return to work after lumbar discectomy should be identified. Prior studies of the biopsychosocial factors associated with sustained RTW were primarily based on patient-reported outcome data and have shown conflicting results because of small study samples. In patients undergoing first-time, single-level, simple lumbar discectomy, we describe the time to sustained return to work within 2 years after surgery using outcome data from a national database and identify the pre- and peri-operative factors associated with sustained return to work within 2 years by developing and validating a predictive multivariable model. Methods The time to a sustained return to work within the study period was described using a Kaplan-Meier plot. A temporal validated Cox proportional hazards model examined associations between biopsychosocial factors and return to work. Results In the derivation cohort made up by 351 operated patients who were on sick-leave for more than 3 weeks around the time of surgery, 62% returned to work (median 15 weeks). The probability of sustained return to work was associated with a high education level, positive expectations towards future labor market attachment, pre-operative stable labor market attachment, pre-operative higher physical quality of life, and less disability. Conclusions Through the development and validation of a predictive model, this study identifies a number of patient-related factors associated with sustained return to work after lumbar discectomy, while revealing that most disease-related clinical findings were not associated with the outcome.

Cost-effectiveness Applications of Patient-reported Outcome Measures (PROMs) in Spine Surgery

Because of the rising health care costs in the United States, there has been a focus on value-based care and improving the cost-effectiveness of surgical procedures. Patient-reported outcome measures (PROMs) can not only give physicians and health care providers immediate feedback on the well-being of the patients but also be used to assess health and determine outcomes for surgical research purposes. Recently, PROMs have become a prominent tool to assess the cost-effectiveness of spine surgery by calculating the improvement in quality-adjusted life years (QALY). The cost of a procedure per QALY gained is an essential metric to determine cost-effectiveness in universal health care systems. Common patient-reported outcome questionnaires to calculate QALY include the EuroQol-5 dimensions, the SF-36, and the SF-12. On the basis of the health-related quality of life outcomes, the cost-effectiveness of various spine surgeries can be determined, such as cervical fusions, lumbar fusions, microdiscectomies. As the United States attempts to reduce costs and emphasize value-based care, PROMs may serve a critical role in spine surgery moving forward. In addition, PROM-driven QALYs may be used to analyze novel spine surgical techniques for value-based improvements.

Postoperative direct health care costs of lumbar discectomy are reduced with the use of a novel annular closure device in high-risk patients

BACKGROUND CONTEXT

Lumbar discectomy is largely successful surgical procedure; however, reherniation rates in patients with large annular defects are as high as 27%. The expense associated with a revision surgery places significant burden on the healthcare system.

PURPOSE

To compare the direct health care costs through 5 years follow-up of conventional discectomy (Control) with those of discectomy supplemented by an adjunctive annular closure device (ACD) in high-risk patients with large annular defects.

STUDY DESIGN

This was a cost-effectiveness study.

METHODS

All-cause index level reoperations were reviewed from a multicenter, randomized controlled superiority trial that allocated 554 high-risk discectomy patients with large annular defects to either control or ACD. Medicare and private insurer (Humana) direct costs were derived from a commercially available payer database to estimate costs in the US healthcare system, including those associated with facility, surgeon, imaging, follow-up visits, physical therapy, and injections. A 50:50 split between Medicare and commercial insurers was assumed for the base case analysis. The analysis was also performed on a 80:20 commercial:Medicare payer basis. For the base case scenario, a 2-year time horizon and outpatient cost setting was established for the index procedure. Repeat discectomy was assumed to be performed on a 60:40 outpatient-to-inpatient basis. Complications requiring surgery, revisions, and/or fusion were assumed to be managed in the inpatient setting. Total costs of reoperation and per-patient costs of reoperation were compared between groups for both forms of insurers. One author received consulting fees of <$50,000 for the completion of this study, and the other eight authors did not have any financial associations with the current work. Funding for this study was provided by Intrinsic Therapeutics, but all analyses, interpretation, and writing were performed independently by the authors.

RESULTS

At two years follow-up, use of the ACD reduced the rate of symptomatic reherniations in a large defect population to 13% compared with 25% in the control group (p<.001). This reduction in symptomatic reherniations in the ACD group translated to a savings of $2,802 per patient in direct health care costs compared with Control at 2 years and $5,315 per patient by 5 years based on 50% private and 50% public (Medicare) payer split. Under the scenario of 80:20 private:public insurance reimbursement, the estimated direct cost savings were $3,215 and $6,099 per patient at 2- and 5-years postoperatively, respectively, with the use of the ACD.

CONCLUSIONS

Symptomatic reherniation and reoperation rates were nearly double among control patients compared with ACD-treated patients, which translated to markedly greater per-patient healthcare costs in the control group, where the ACD was not used.

Quality of Life in Patients Undergoing Spine Surgery: Systematic Review and Meta-Analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVE

Despite the increasing importance of tracking clinical outcomes using valid patient-reported outcome measures, most providers do not routinely obtain baseline preoperative health-related quality of life (HRQoL) data in patients undergoing spine surgery, precluding objective outcomes analysis in individual practices. We conducted a meta-analysis of pre- and postoperative HRQoL data obtained from the most commonly published instruments to use as reference values.

METHODS

We searched PubMed, EMBASE, and an institutional registry for studies reporting EQ-5D, SF-6D, and Short Form-36 Physical Component Summary scores in patients undergoing surgery for degenerative cervical and lumbar spinal conditions published between 2000 and 2014. Observational data was pooled meta-analytically using an inverse variance-weighted, random-effects model, and statistical comparisons were performed.

RESULTS

Ninety-nine articles were included in the final analysis. Baseline HRQoL scores varied by diagnosis for each of the 3 instruments. On average, postoperative HRQoL scores significantly improved following surgical intervention for each diagnosis using each instrument. There were statistically significant differences in baseline utility values between the EQ-5D and SF-6D instruments for all lumbar diagnoses.

CONCLUSIONS

The pooled HRQoL values presented in this study may be used by practitioners who would otherwise be precluded from quantifying their surgical outcomes due to a lack of baseline data. The results highlight differences in HRQoL between different degenerative spinal diagnoses, as well as the discrepancy between 2 common utility-based instruments. These findings emphasize the need to be cognizant of the specific instruments used when comparing the results of outcome studies.

What are the Rates, Reasons, and Risk Factors of 90-day Hospital Readmission After Lumbar Discectomy?: An Institutional Experience

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

To report the rate, reasons, and risk factors for 90-day readmissions after lumbar discectomy at an academic medical center.

SUMMARY OF BACKGROUND DATA

Several studies have reported complications and readmissions after spine surgery; however, only one previous study has focused specifically on lumbar discectomy. As the patient profile and morbidity of various spine procedures is different, focus on procedure-specific complications and readmissions will be beneficial.

MATERIALS AND METHODS

Patients who underwent lumbar discectomy for unrelieved symptoms of prolapsed intervertebral disk and had at least 90 days of follow-up at an academic institution (2013-2014) were included. Retrospective review of electronic medical record was performed to record demographic and clinical profile of patients. Details of lumbar discectomy, index hospital stay, discharge disposition, hospital readmission within 90 days, reason for readmission and treatment given have been reported. Risk factors for hospital readmission were analyzed by multivariate logistic regression analysis.

RESULTS

A total of 356 patients with a mean age of 45.0±13.8 years were included. The 90-day readmission rate was 5.3% (19/360) of which two-third patients were admitted within 30 days giving a 30-day readmission rate of 3.7% (13/356). The top 2 primary reasons for readmission included back and/or leg pain, numbness, or tingling (42.9%), and persistent cerebrospinal fluid leak or seroma (25.0%). On adjusted analysis, risk factors associated with higher risk of readmission included incidental durotomy [odds ratio (OR), 26.2; 95% confidence interval (CI), 5.3-129.9] and discharge to skilled nursing facility/inpatient rehabilitation (OR, 25.2; 95% CI, 2.7-235.2). Increasing age was a negative predictor of readmission (OR, 0.95; 95% CI, 0.91-0.99).

CONCLUSIONS

Incidental durotomy, younger age, and discharge to nursing facility were associated with higher risk of 90-day hospital readmission after lumbar discectomy. As compared with extensive spine procedures, patient comorbidity burden may not be as significant in predicting readmission after this relatively less invasive procedure.

Budget impact analysis of demineralized bone matrix in combination with autograft in lumbar spinal fusion procedures for the treatment of lumbar degenerative disc disease in Spain

OBJECTIVE

To estimate the budget impact (BI) of introducing local autograft (LA) combined with demineralized bone matrix (LA + DBM) in lumbar spinal fusion (LSF) procedures to treat lumbar degenerative disc disease (LDDD) in Spain.

METHODS

A decision tree model was developed to evaluate the 4-year BI associated with introducing LA + DBM putty to replace currently available grafting methods, including iliac crest bone graft (ICBG), LA alone, and LA combined with beta-tricalcium phosphate (LA + ceramics), with 30%, 40%, and 30% market shares, respectively. The analysis was conducted for a hypothetical cohort of 100 patients with LDDD receiving LSF, assuming LA + DBM would replace 100% of the standard of care mix. The fusion rates extracted from the literature were validated by an expert panel. Costs (€2017) were obtained from different Spanish sources. Budget impact and incremental cost per successful fusion were calculated from the perspective of the Spanish National Health System (NHS).

RESULTS

Over 4 years, replacing currently available options with LA + DBM for 100 patients resulted in an additional cost of €12,330 (€123/patient), and an additional 14 successful fusions, implying a cost of €881 per additional successful fusion. When costs of productivity loss were included, the introduction of LA + DBM resulted in cost savings of €70,294 (€703/patient).

LIMITATIONS

The lack of high-quality, homogeneous, head-to-head research studying the efficacy of grafting procedures available to patients undergoing LSF, in addition to a lack of long-term follow-up in existing studies. Therefore, the number of fusions occurring within the model's time horizon may be underestimated.

CONCLUSIONS

Acquisition costs of DBM were partially offset by costs of failed fusions, adverse events and reoperation when switching 100 hypothetical LDDD patients undergoing LSF procedures from standard of care grafting methods to LA + DBM from the perspective of the Spanish NHS. DBM cost was entirely offset when costs of lost productivity were considered.

Cost-Effectiveness of Primary and Revision Surgery for Adult Spinal Deformity

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

The purpose of this study is to compare functional outcomes, hospital resource utilization, and spine-related costs during 2 years in patients who had undergone primary or revision surgery for adult spinal deformity (ASD).

SUMMARY OF BACKGROUND DATA

After surgery for ASD, patients may require revision for pseudarthrosis, implant complications, or deformity progression. Data evaluating cost-effectiveness of primary and, in particular, revision surgery, for ASD are sparse.

METHODS

We retrospectively reviewed records for 119 consecutive patients who had undergone primary or revision surgery for ASD. Two-year total spine-related medical costs were derived from hospital charge data. Functional outcome scores were extracted from prospectively collected patient data. Cost utility ratios (cost/quality-adjusted life-year [QALY]) at 2 years were calculated and assessed against a threshold of $154,458/QALY gained (three times the 2015 US per-capita gross domestic product).

RESULTS

The primary surgery cohort (n = 56) and revision cohort (n = 63) showed significant improvements in health-related quality-of-life scores at 2 years. Median surgical and spine-related 2-year follow-up costs were $137,990 (interquartile range [IQR], $84,186) for primary surgery and $115,509 (IQR, $63,753) for revision surgery and were not significantly different between the two groups (P = 0.12). We report 2-year QALY gains of 0.36 in the primary surgery cohort and 0.40 in the revision group (P = 0.71). Primary instrumented fusion was associated with a median 2-year cost per QALY of $197,809 (IQR, $187,350) versus $129,950 (IQR, $209,928) for revision surgery (P = 0.31).

CONCLUSION

Revision surgery had lower total 2-year costs and higher QALY gains than primary surgery for ASD, although the differences were not significant. Although revision surgery for ASD is known to be technically challenging and to have a higher rate of major complications than primary surgery, revision surgery was cost-effective at 2 years. The cost/QALY ratio for primary surgery for ASD exceeded the threshold for cost effectiveness at 2 years.

LEVEL OF EVIDENCE

3.

A 90-day Bundled Payment for Primary Single-level Lumbar Discectomy/Decompression: What Does "Big Data" Say?

Episode-based bundling may become the major form of reimbursement for many elective spine procedures. As the amount for a 90-day episode of care is not known for a lumbar discectomy, we analyzed the previous reimbursements from Commercial payers (2007-Q2 2015), Medicare Advantage (2007-Q2 2015), and Medicare (2005-2012) for a primary single-level lumbar discectomy/decompression. Distribution of payments among various service providers was studied and a 90-day bundle was simulated. Depending on the payer type, the average facility costs constituted 59.7% to 73.6% of total payments, followed by surgeon's fees, which accounted for 13.7% to 18.5%. Postacute services made up 8.8% to 15.8% of the total reimbursement. Surgeries performed in the inpatient setting were significantly more expensive as compared with surgeries performed in the outpatient setting (P<0.01). The average 90-day bundle amount was estimated at $11,091, $6571, and $6239 for Commercial payers, Medicare Advantage, and Medicare, respectively. Overall, service providers in the Southern region were reimbursed the lowest from Commercial payers and Medicare, compared with other regions. Postacute services are not as major cost drivers after discectomy as after total joint arthroplasty or hip fracture repair.

Multidimensional long-term outcome analysis after single-level lumbar microdiscectomy: a retrospective single-centre study

OBJECTIVE

To present multidimensional long-term results after mono-segmental microdiscectomy for lumbar disc herniation (LDH) in a large adult cohort treated at a tertiary care centre.

METHODS

Retrospective study design with Oswestry Disability Index (ODI) questionnaire employed at follow-up. All patients undergoing surgical treatment for single-level LDH between 2003 and 2009 were identified. Electronic patient records and imaging data were analysed.

RESULTS

A total of 939 patients underwent single-level lumbar MD at our institution. Three hundred and seven complete ODI forms (32.7%) were returned at a median follow-up of 48 months. Mean ODI score was 24.04, and mean age was 58 years. Females reported slightly higher ODI scores (25.52 vs. 22.68). Age and ODI score showed statistically significant correlation. Early surgery yielded lower ODI scores with patients faring significantly worse if symptoms persisted for a year or longer (one-way ANOVA, p < 0.001). ODI scores increased sharply even among those operated later than 1 week after symptom onset. Sequestered herniations were associated with significantly lower ODI scores than contained discs on MRI (21.96 vs. 39.89). Surgical complications occurred in 17 cases (5.6%), 82 patients (26.7%) required additional surgery, 58 (18.9%) of those for recurrent disc herniations.

CONCLUSION

Our findings suggest better outcomes with early surgical treatments. Time limits for conservative treatments should be set to avoid the chronification of pain and the worse overall outcomes that go along with belated surgery. Particularly in those with acute onset of pain, sequestered herniations and only mild degrees of immobilization good outcomes are common and surgical treatment appears best if indicated early.

An analysis from the Quality Outcomes Database, Part 2. Predictive model for return to work after elective surgery for lumbar degenerative disease

OBJECTIVE

Current costs associated with spine care are unsustainable. Productivity loss and time away from work for patients who were once gainfully employed contributes greatly to the financial burden experienced by individuals and, more broadly, society. Therefore, it is vital to identify the factors associated with return to work (RTW) after lumbar spine surgery. In this analysis, the authors used data from a national prospective outcomes registry to create a predictive model of patients’ ability to RTW after undergoing lumbar spine surgery for degenerative spine disease.

METHODS

Data from 4694 patients who underwent elective spine surgery for degenerative lumbar disease, who had been employed preoperatively, and who had completed a 3-month follow-up evaluation, were entered into a prospective, multicenter registry. Patient-reported outcomes—Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain (BP) and leg pain (LP), and EQ-5D scores—were recorded at baseline and at 3 months postoperatively. The time to RTW was defined as the period between operation and date of returning to work. A multivariable Cox proportional hazards regression model, including an array of preoperative factors, was fitted for RTW. The model performance was measured using the concordance index (c-index).

RESULTS

Eighty-two percent of patients (n = 3855) returned to work within 3 months postoperatively. The risk-adjusted predictors of a lower likelihood of RTW were being preoperatively employed but not working at the time of presentation, manual labor as an occupation, worker’s compensation, liability insurance for disability, higher preoperative ODI score, higher preoperative NRS-BP score, and demographic factors such as female sex, African American race, history of diabetes, and higher American Society of Anesthesiologists score. The likelihood of a RTW within 3 months was higher in patients with higher education level than in those with less than high school–level education. The c-index of the model’s performance was 0.71.

CONCLUSIONS

This study presents a novel predictive model for the probability of returning to work after lumbar spine surgery. Spine care providers can use this model to educate patients and encourage them in shared decision-making regarding the RTW outcome. This evidence-based decision support will result in better communication between patients and clinicians and improve postoperative recovery expectations, which will ultimately increase the likelihood of a positive RTW trajectory.

Need for Two-Year Patient-Reported Outcomes Score for Lumbar Spine Surgery Is Procedure-Specific: Analysis From a Prospective Longitudinal Spine Registry

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

The aim of this study was to determine whether 1-year patient-reported outcomes (PROs) can accurately assess effective care for patients undergoing surgery for degenerative lumbar spine disease.

SUMMARY OF BACKGROUND DATA

Prospective longitudinal PROs registries provide a means to accurately assess outcomes and determine the relative effectiveness of various spine treatments. Obtaining long-term PROs can be costly and challenging.

METHODS

Patients enrolled into a prospective registry who underwent lumbar spine surgery for degenerative disease were included. Baseline, 1-year, and 2-year Oswestry Disability Index (ODI) scores were captured. Previously published minimum clinically important difference (MCID) for ODI (14.9) was used. Multivariable linear regression model was created to derive model-estimated 2-year ODI scores. Absolute differences between 1-year and 2-year ODI were compared to absolute differences between 2-year and model-estimated 2-year ODI. Concordance rates in achieving MCID at 1-year and 2-year and predictive values were calculated.

RESULTS

A total of 868 patients were analyzed. One-year ODI scores differed from 2-year scores by an absolute difference of 9.7 ± 8.9 points and predictive model-estimated 2-year scores differed from actual 2-year scores by 8.8 ± 7.3 points. The model-estimated 2-year ODI was significantly different than actual 1-year ODI in assessing actual 2-year ODI for all procedures (P = 0.001) except for primary (P = 0.932) and revision microdiscectomy (P = 0.978) and primary laminectomy (P = 0.267). The discordance rates of achieving or not achieving MCID for ODI ranged from 8% to 27%. Concordance rate was about 90% for primary and revision microdiscectomy. The positive and negative predictive value of 1-year ODI to predict 2-year ODI was 83% and 67% for all procedures and 92% and 67% for primary and 100% and 86% for revision microdiscectomy respectively.

CONCLUSION

One-year disability outcomes can potentially estimate 2-year outcomes for patient populations, but cannot reliably predict 2-year outcomes for individual patients, except for patients undergoing primary and revision microdiscectomy.

LEVEL OF EVIDENCE

4.

Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study

STUDY DESIGN

Observational cohort pilot study.

OBJECTIVE

To determine the impact of a multidisciplinary conference on treatment decisions for lumbar degenerative spine disease.

SUMMARY OF BACKGROUND DATA

Multidisciplinary decision making improves outcomes in many disciplines. The lack of integrated systems for comprehensive care for spinal disorders has contributed to the inappropriate overutilization of spine surgery in the United States.

METHODS

We implemented a multidisciplinary conference involving physiatrists, anesthesiologists, pain specialists, neurosurgeons, orthopaedic spine surgeons, physical therapists, and nursing staff. Over 10 months, we presented patients being considered for spinal fusion or who had a complex history of prior spinal surgery. We compared the decision to proceed with surgery and the proposed surgical approach proposed by outside surgeons with the consensus of our multidisciplinary conference. We also assessed comprehensive demographics and comorbidities for the patients and examined outcomes for surgical patients.

RESULTS

A total of 137 consecutive patients were reviewed at our multidisciplinary conference during the 10-month period. Of these, 100 patients had been recommended for lumbar spine fusion by an outside surgeon. Consensus opinion of the multidisciplinary conference advocated for nonoperative management in 58 patients (58%) who had been previously recommended for spinal fusion at another institution (χ  = 26.6; P < 0.01). Furthermore, the surgical treatment plan was revised as a product of the conference in 28% (16 patients) of the patients who ultimately underwent surgery (χ  = 43.6; P < 0.01). We had zero 30-day complications in surgical patients.

CONCLUSION

Isolated surgical decision making may result in suboptimal treatment recommendations. Multidisciplinary conferences can reduce the utilization of lumbar spinal fusion, possibly resulting in more appropriate use of surgical interventions with better candidate selection while providing patients with more diverse nonoperative treatment options. Although long-term patient outcomes remain to be determined, such multidisciplinary care will likely be essential to improving the quality and value of spine care.

LEVEL OF EVIDENCE

3.

Is the use of minimally invasive fusion technologies associated with improved outcomes after elective interbody lumbar fusion? Analysis of a nationwide prospective patient-reported outcomes registry

BACKGROUND CONTEXT

Over the last decade, clinical investigators and biomedical industry groups have used significant resources to develop advanced technologies that enable less invasive spine fusions. These minimally invasive surgery (MIS) technologies often require increased expenditures by hospitals and payers. Although several small single center studies have suggested MIS technologies decrease surgical morbidity and reduce hospital stay, evidence documenting benefit from a patient perspective remains limited. Furthermore, MIS outcomes have yet to be evaluated from the perspective of multiple practice types representing the broad spectrum of US spine surgery.

PURPOSE

This study aimed to examine a population of patients who underwent one- or two-level interbody lumbar fusion diagnosed with lumbar stenosis or Grade 1 spondylolisthesis in an observational, prospective national registry for the purposes of determining how MIS and traditional open technologies affect postsurgical and patient-reported outcomes (PROs).

STUDY DESIGN/SETTING

This study used observational analysis of prospectively collected data.

PATIENT SAMPLE

The sample consisted of cases from the National Neurosurgery Quality and Outcomes Database (N²QOD).

OUTCOME MEASURES

Numeric rating scale for back and leg pain, Oswestry Disability Index, EuroQol-5D, return to work, and perioperative morbidity were the outcome measures.

METHODS

The N²QOD is a prospective PROs registry enrolling patients undergoing elective spine surgery from 60 hospitals in 27 US states via representative sampling. We analyzed the N²QOD aggregate dataset (2010-2014) to identify one- and two-level lumbar interbody fusion procedures performed for lumbar stenosis or Grade 1 spondylolisthesis with 12 months' follow-up where surgical instrumentation and implant types were clearly identified. Perioperative and 1-year outcomes were compared between cases performed with MIS enabling technologies versus traditional open technologies before and after propensity matching.

RESULTS

There were 467 (24%) patients who underwent elective interbody lumbar fusion using MIS enabling technologies whereas 1,480 (76%) underwent the procedure using traditional open technologies. The MIS patients were slightly healthier (American Society of Anesthesiologists grade), had private insurance more frequently, and underwent two-level fusion less frequently. Unmatched, the MIS cohort was associated with reduced blood loss, a 0.7-day reduction in mean length of hospital stay, and 5% reduced need for post-discharge inpatient rehabilitation, but equivalent 90-day safety measures. After propensity matching, the MIS cohort remained associated with reduced blood loss and a shorter length of stay for one-level fusion (p<.05) but had equivalent length of stay for two-level fusion. Outcomes in all other 90-day safety measures were similar. In both unadjusted and propensity-matched comparison, MIS versus open technologies were associated with equivalent return to work, patient-reported pain, physical disability, and quality of life at 3 and 12 months' follow-up.

CONCLUSIONS

In a representative sampling registry of elective interbody lumbar spine fusion procedures spanning 27 US states, nearly a quarter of procedures performed from 2010 to 2014 used minimally invasive enabling technologies. Regardless of approach, interbody lumbar fusion was associated with significant and sustained improvements in all measured health domains. When used in everyday care by a wide spectrum of spine surgeons in non-research settings, the use of MIS technologies was associated with reduced intraoperative blood loss but only a half-day reduction in mean length of hospital stay for one-level fusions. Minimally invasive surgery was not associated with any improved perioperative safety measures or 12-month outcomes. Although MIS enabling technologies may increase some in-hospital care efficiencies, MIS clinical outcomes are similar to open surgery for patients undergoing one- and two-level interbody lumbar fusions.

An analysis from the Quality Outcomes Database, Part 1. Disability, quality of life, and pain outcomes following lumbar spine surgery: predicting likely individual patient outcomes for shared decision-making

OBJECTIVE Quality and outcomes registry platforms lie at the center of many emerging evidence-driven reform models. Specifically, clinical registry data are progressively informing health care decision-making. In this analysis, the authors used data from a national prospective outcomes registry (the Quality Outcomes Database) to develop a predictive model for 12-month postoperative pain, disability, and quality of life (QOL) in patients undergoing elective lumbar spine surgery. METHODS Included in this analysis were 7618 patients who had completed 12 months of follow-up. The authors prospectively assessed baseline and 12-month patient-reported outcomes (PROs) via telephone interviews. The PROs assessed were those ascertained using the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for back pain (BP) and leg pain (LP). Variables analyzed for the predictive model included age, gender, body mass index, race, education level, history of prior surgery, smoking status, comorbid conditions, American Society of Anesthesiologists (ASA) score, symptom duration, indication for surgery, number of levels surgically treated, history of fusion surgery, surgical approach, receipt of workers' compensation, liability insurance, insurance status, and ambulatory ability. To create a predictive model, each 12-month PRO was treated as an ordinal dependent variable and a separate proportional-odds ordinal logistic regression model was fitted for each PRO. RESULTS There was a significant improvement in all PROs (p < 0.0001) at 12 months following lumbar spine surgery. The most important predictors of overall disability, QOL, and pain outcomes following lumbar spine surgery were employment status, baseline NRS-BP scores, psychological distress, baseline ODI scores, level of education, workers' compensation status, symptom duration, race, baseline NRS-LP scores, ASA score, age, predominant symptom, smoking status, and insurance status. The prediction discrimination of the 4 separate novel predictive models was good, with a c-index of 0.69 for ODI, 0.69 for EQ-5D, 0.67 for NRS-BP, and 0.64 for NRS-LP (i.e., good concordance between predicted outcomes and observed outcomes). CONCLUSIONS This study found that preoperative patient-specific factors derived from a prospective national outcomes registry significantly influence PRO measures of treatment effectiveness at 12 months after lumbar surgery. Novel predictive models constructed with these data hold the potential to improve surgical effectiveness and the overall value of spine surgery by optimizing patient selection and identifying important modifiable factors before a surgery even takes place. Furthermore, these models can advance patient-focused care when used as shared decision-making tools during preoperative patient counseling.

Pain and disability following first-time lumbar fusion surgery for degenerative disorders: a systematic review protocol

BACKGROUND

Lumbar spinal fusion for degenerative disorders of the lumbar spine is frequently used, despite current research presenting inconclusive evidence. This study aims to systematically review and meta-analyse the natural course of pain and disability in patients with degenerative disorders of the lumbar spine such as spinal stenosis, spondylolisthesis, disc herniation, or discogenic low back pain to improve lumbar spinal fusion management.

METHODS/DESIGN

An electronic database search will be conducted up to 30 September 2015 using MEDLINE, EMBASE, CINAHL, and ZETOC database. In addition, a search for articles in press and published ahead of print, British National Bibliography for Report Literature, and OpenGrey will be conducted. Prospective cohort studies using outcome measures of pain and disability will be eligible for inclusion. Two reviewers will screen titles, abstracts, and full-text independently using predetermined inclusion and exclusion criteria. The risk of bias of included studies will be assessed with the modified version of the Quality in Prognostic Studies tool. If meta-analysis of outcome data is deemed appropriate, variance-weighted pooled means will be calculated.

DISCUSSION

The results of this systematic review and meta-analysis may improve understanding of recovery after lumbar spinal fusion and improve lumbar spinal fusion management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015026922.

Comparing Utility Scores in Common Spinal Radiculopathies: Results of a Prospective Valuation Study

Study Design Prospective observational study. Objective To determine whether preference-based health utility scores for common spinal radiculopathies vary by specific spinal level. Methods We employed a standard gamble study using the general public to calculate individual preference-based quality of life for four common radiculopathies: C6, C7, L5, and S1. We compared utility scores obtained for each level of radiculopathy with analysis of variance and t test. Multivariable regression was used to test the effects of the covariates age, sex, and years of education. We also reviewed the literature for publications reporting EuroQol-5 Dimensions (EQ-5D) scores for patients with radiculopathy. Results Two hundred participants were included in the study. Average utility for the four spinal levels fell within a narrow range (0.748 to 0.796). There were no statistically significant differences between lumbar and cervical radiculopathies, nor were there significant differences among the different spinal levels (F = 0.0850, p = 0.086). Age and sex had no significant effect on utility scores. There was a significant correlation between years of education and utility values for S1 radiculopathy (p = 0.037). On review of the literature, no study separated utility values by specific spinal level. EQ-5D utilities for both cervical and lumbar radiculopathy were considerably lower than the results of our study. Conclusions Utility values associated with the most common levels of cervical and lumbar radiculopathy do not significantly differ from each other, validating the current practice of grouping utility by spinal segment rather than by specific root levels. The discrepancy in average utility values between our study and the EQ-5D highlights the need to be mindful of the underlying instruments used when assessing outcomes studies from different sources.

Lateral Lumbar Interbody Fusion in Ambulatory Surgery Centers: Patient Selection and Outcome Measures Compared With an Inhospital Cohort

STUDY DESIGN

Comparative analysis.

OBJECTIVE

To evaluate the safety and outcomes of moving lateral lumbar interbody fusion (LLIF) surgeries to an outpatient setting.

SUMMARY OF BACKGROUND DATA

LLIF has been popularized as a less invasive lumbar fusion surgery as an alternative approach to anterior lumbar interbody fusions, posterior lateral interbody fusion, and transforaminal lateral interbody fusion (TLIF). Lumbar fusions have been traditionally performed in a hospital setting because of the potential blood loss, length of surgery, and need for longer recovery. There is a movement to transition spine surgeries to outpatient settings with many benefits afforded by less invasive techniques and technologies.

METHODS

The medical records of 70 consecutive patients with prospectively collected data were retrospectively reviewed. Two cohort groups, inpatients (40 patients) and outpatients (30 patients), were created. Patient demographics, risk factors, and body mass index (BMI) were evaluated to determine inclusion criteria for study.

RESULT

A total of 34 males and 36 females, age range (31-71) average 59.3 ± 2.3 years. Average BMI was 29.6 ± 1.1 kg/m. The most common level operated on being L3-L4 in both groups (63%). Mean preoperative inpatient Oswestry Disability Index (ODI) increased from 48.5 ± 3.0 to 55.5 ± 3.2 compared with outpatient preoperative ODI means reduced from 45.2 ± 5.1 to 39.1 ± 4.6. There was no statistically significant change in VAS scores between groups. There was however significant improvement in outpatient preoperative VAS scores from 7.3 ± 0.5 to 4.1 ± 0.5, P = 0.045.

CONCLUSION

The outcomes of the present study have shown that patients who had LLIF performed in the outpatient setting had statistically significant improvement in ODI scores compared with the inpatient setting (P = 0.013). Fusion was achieved in all patients and there was no evidence of implant failure or subsidence. Complications were transient in both settings. We conclude that outpatient LLIF improves patients' outcomes with similar safety profile as the hospital setting.

LEVEL OF EVIDENCE

3.

Inadequacy of 3-month Oswestry Disability Index outcome for assessing individual longer-term patient experience after lumbar spine surgery

OBJECTIVE Prospective longitudinal outcomes registries are at the center of evidence-driven health care reform. Obtaining real-world outcomes data at 12 months can be costly and challenging. In the present study, the authors analyzed whether 3-month outcome measurements sufficiently represent 12-month outcomes for patients with degenerative lumbar disease undergoing surgery. METHODS Data from 3073 patients undergoing elective spine surgery for degenerative lumbar disease were entered into a prospective multicenter registry (N(2)QOD). Baseline, 3-month, and 12-month follow-up Oswestry Disability Index (ODI) scores were recorded. The absolute differences between actual 12- and 3-month ODI scores was evaluated. Additionally, the authors analyzed the absolute difference between actual 12-month ODI scores and a model-predicted 12-month ODI score (the model used patients' baseline characteristics and actual 3-month scores). The minimal clinically important difference (MCID) for ODI of 12.8 points and the substantial clinical benefit (SCB) for ODI of 18.8 points were used based on the previously published values. The concordance rate of achieving MCID and SCB for ODI at 3-and 12-months was computed. RESULTS The 3-month ODI scores differed from 12-month scores by an absolute difference of 11.9 ± 10.8, and predictive modeling estimations of 12-month ODI scores differed from actual 12-month scores by a mean (± SD) of 10.7 ± 9.0 points (p = 0.001). Sixty-four percent of patients (n = 1982) achieved an MCID for ODI at 3 months in comparison with 67% of patients (n = 2088) by 12 months; 51% (n = 1731) and 61% (n = 1860) of patients achieved SCB for ODI at 3 months and 12 months, respectively. Almost 20% of patients had ODI scores that varied at least 20 points (the point span of an ODI functional category) between actual 3- and 12-month values. In the aggregate analysis of achieving MCID, 77% of patients were concordant and 23% were discordant in achieving or not achieving MCID at 3 and 12 months. The discordance rates of achieving or not achieving MCID for ODI were in the range of 19% to 27% for all diagnoses and treatments (decompression with and without fusion). The positive and negative predictive value of 3-months ODI to predict 12-month ODI was 86% and 60% for MCID and 82% and 67% for SCB. CONCLUSIONS Based on their findings, the authors conclude the following: 1) Predictive methods for functional outcome based on early patient experience (i.e., baseline and/or 3-month data) should be used to help evaluate the effectiveness of procedures in patient populations, rather than serving as a proxy for long-term individual patient experience. 2) Prospective longitudinal registries need to span at least 12 months to determine the effectiveness of spine care at the individual patient and practitioner level.

Improvement in Health State Utility after Sacroiliac Joint Fusion: Comparison to Normal Populations

Study Design Prospective cohort study. Objective The sacroiliac joint (SIJ) is an important cause of lower back pain. The degree to which minimally invasive surgical fusion of the SIJ improves health state utility has not been previously documented. Methods Health state utility values were calculated using the EuroQOL-5D (EQ-5D) and Short Form-36 (SF-36) at baseline and 6 and 12 months after SIJ fusion surgery in subjects participating in a prospective, multicenter clinical trial (n = 172). Values were compared with individuals who participated in a nationally representative cross-sectional survey (National Health Measurement Study [NHMS], n = 3,844). Health utility values in the SIJ cohort were compared with those of the NMHS participants using both weighted linear regression and calculation of "health quantile" (i.e., percentile of health normalized to the NHMS cohort adjusted for age and gender). Results Baseline health state utility was significantly depressed in SIJ patients compared with normal subjects (SF-6D 0.509 versus 0.789, SF-36 physical component summary 31.7 versus 49.2, SF-36 mental component summary 8.5 versus 53.8, EQ-5D 0.433 versus 0.868; all p < 0.0001 after adjustment for age and gender). In the SIJ cohort, all the measures improved by 6 months postoperatively, and improvements were sustained at 12 months. Baseline health quantile was low (fifth percentile) in the SIJ cohort and improved significantly at follow-up. Conclusions Quality of life is markedly impaired in patients with SIJ pain compared with age- and gender-matched cohorts. SIJ fusion in this cohort resulted in a substantial improvement in health state utility, bringing the population back toward the expected levels of overall health. The quantile approach helps to explain the degree to which health is improved compared with age- and gender-matched cohorts.

Building an electronic health record integrated quality of life outcomes registry for spine surgery

OBJECT

Demonstrating the value of spine care requires adequate outcomes assessment. Long-term outcomes are best measured as overall improvement in quality of life (QOL) after surgical intervention. Present registries often require parallel data entry, introducing inefficiencies and limiting compliance. The authors detail the methodology of constructing an integrated electronic health record (EHR) system to collect QOL metrics and demonstrate the effect of data collection on routine clinical workflow. A streamlined approach to collecting QOL data can capture patient data without requiring dual data entry and without increasing clinic visit times.

METHODS

Through extensive literature review, a combination of QOL assessments was selected, consisting of the Patient Health Questionnaire-2 and -9, Oswestry Disability Index, Neck Disability Index, and visual analog scale for pain. These metrics were used to provide assessment of QOL following spine surgery and were incorporated into standard clinic workflow by a multidisciplinary team of surgeons, advanced practice providers, and health care information technology specialists. A clinical dashboard tracking more than 25 patient variables was developed. Clinic flow was assessed and opportunities for improvement reviewed. Duration of clinic visits before and after initiation of QOL measure capture was recorded, with assessment of mean clinic visit times for the 12 months before and the 12 months after implementation.

RESULTS

The integrated QOL capture was instituted for 3 spine surgeons in a tertiary care academic center. In the 12-month period prior to initiating collection of QOL data, 806 new patient visits were completed with an average visit time of 127.9 ± 51.5 minutes. In the 12 months after implementation, 1013 new patient visits were recorded, with 791 providing QOL measures with an average visit time of 117.0 ± 45.7 minutes. Initially the primary means of collecting patient outcome data was via paper form, with gradual transition to collection via entry into the electronic medical records system. To improve electronic data capture, paper forms were eliminated and an online portal used as part of the patient rooming process. This improved electronic capture to nearly 98% without decreasing the number of patients enrolled in the process.

CONCLUSIONS

A systematic approach to collecting spine-related QOL data within an EHR system is feasible and offers distinct advantages over registries that require dual data entry. The process of data collection does not impact patients’ clinical visit or providers’ clinical workflow. This approach is scalable, and may form the foundation for a decentralized outcomes registry network.

Trends for Spine Surgery for the Elderly: Implications for Access to Healthcare in North America

The proportion of the population over age 65 in the United States continues to increase over time, from 12% in 2000 to a projected 20% by 2030. There is an associated rise in the prevalence of degenerative spinal disorders with this aging population. This will lead to an increase in demand for both nonsurgical and surgical treatment for these disabling conditions, which will stress an already overburdened healthcare system. Utilization of spinal procedures and services has grown considerably. Comparing 1999 to 2009, lumbar epidural steroid injections have increased by nearly 900,000 procedures performed per year, while physical therapy evaluations have increased by nearly 1.4 million visits per year. We review the literature regarding the cost-effectiveness of spinal surgery compared to conservative treatment. Decompressive lumbar spinal surgery has been shown to be cost-effective in several studies, while adult spinal deformity surgery has higher total cost per quality-adjusted life year gained in the short term. With an aging population and unsustainable healthcare costs, we may be faced with a shortfall of beneficial spine care as demand for spinal surgery in our elderly population continues to rise.

ABBREVIATION

QALY, quality-adjusted life year.

Predictive value of 3-month lumbar discectomy outcomes in the NeuroPoint-SD Registry

OBJECT

The authors have established a multicenter registry to assess the efficacy and costs of common lumbar spinal procedures using prospectively collected outcomes. Collection of these data requires an extensive commitment of resources from each site. The aim of this study was to determine whether outcomes data from shorter-interval follow-up could be used to accurately estimate long-term outcome following lumbar discectomy.

METHODS

An observational prospective cohort study was completed at 13 academic and community sites. Patients undergoing single-level lumbar discectomy for treatment of disc herniation were included. SF-36 and Oswestry Disability Index (ODI) data were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively. Quality-adjusted life year (QALY) data were calculated using SF-6D utility scores. Correlations among outcomes at each follow-up time point were tested using the Spearman rank correlation test.

RESULTS

One hundred forty-eight patients were enrolled over 1 year. Their mean age was 46 years (49% female). Eleven patients (7.4%) required a reoperation by 1 year postoperatively. The overall 1-year follow-up rate was 80.4%. Lumbar discectomy was associated with significant improvements in ODI and SF-36 scores (p < 0.0001) and with a gain of 0.246 QALYs over the 1-year study period. The greatest gain occurred between baseline and 3-month follow-up and was significantly greater than improvements obtained between 3 and 6 months or 6 months and 1 year(p < 0.001). Correlations between 3-month, 6-month, and 1-year outcomes were similar, suggesting that 3-month data may be used to accurately estimate 1-year outcomes for patients who do not require a reoperation. Patients who underwent reoperation had worse outcomes scores and nonsignificant correlations at all time points.

CONCLUSIONS

This national spine registry demonstrated successful collection of high-quality outcomes data for spinal procedures in actual practice. Three-month outcome data may be used to accurately estimate outcome at future time points and may lower costs associated with registry data collection. This registry effort provides a practical foundation for the acquisition of outcome data following lumbar discectomy.