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Interspinous Process Devices versus Standard Conventional Surgical Decompression for Lumbar Spinal Stenosis: Cost Utility Analysis
Proceedings of the NASS 29th Annual Meeting / The Spine Journal 14 (2014) 1S–183S recommend for patients at risk for poor outcomes following lumbar spine surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2014.08.196
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value compared to the inpatient hospital setting. Given that 35,000 inpatient discectomies are covered by Medicare per year, CMS has the potential to save up to $98 million annually with future coverage of outpatient discectomy. Patient and provider incentives to encourage outpatient surgery for lumbar discectomy may be warranted. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2014.08.197
124. Lumbar Discectomy in the Ambulatory Care Setting: Defining Its Value across the Acute and Post-Acute Care Episode Scott L. Parker, MD1, Anthony Asher, MD, FACS2, E.H. Dyer, MD2, Tim E. Adamson, MD2, Clinton J. Devin, MD3, Matthew J. McGirt, MD2; 1 Vanderbilt University, Nashville, TN, US; 2Carolina Neurosurgery and Spine Associates, Charlotte, NC, US; 3Nashville, TN, US BACKGROUND CONTEXT: Current US health care costs are unsustainable. All stakeholders in health care reform have adopted value-based purchasing strategies to shift care toward higher benefit and lower cost treatment approaches. Low-back pathology is highly prevalent and its surgical intervention costly. PURPOSE: To quantify the potential cost savings and patient centered benefits associated with performing lumbar discectomy in an ambulatory surgery center versus inpatient hospital setting. STUDY DESIGN/SETTING: Prospective, comparison cohort study. PATIENT SAMPLE: Consecutive patients undergoing elective lumbar discectomy at inpatient vs outpatient setting over 15 months. OUTCOME MEASURES: 90-day morbidity, return to work, Numeric Rating Scale (NRS) for back (BP) and leg (LP) pain, Oswestry Disability Index (ODI), EuroQol-5D (EQ-5D), NASS satisfaction, and cost were prospectively assessed. METHODS: 251 consecutive cases of lumbar discectomy performed for single-level disc herniation at two centers were prospectively enrolled via a standardized web-based portal over a 15 month period. At center 1, all non-Medicare patients underwent lumbar discectomy in an outpatient ambulatory surgery center. At center 2, all non-Medicare patients underwent lumbar discectomy within the inpatient hospital setting. 90-day morbidity, return to work, and patient-reported outcomes were prospectively assessed. Direct costs were estimated from resource utilization via macro-costing with private pay estimated as 1.7 x Medicare fee schedule. Indirect costs were calculated from lost work productivity using standard human capital approach. RESULTS: 122 patients underwent outpatient discectomy and 129 inpatient discectomy with 3-month follow-up of 82%. Cohorts were similar at baseline. There was no perioperative surgical morbidity in either cohort. Ninety-day hospital re-admission (5.6% vs 3.0%, p50.50) and all-cause re-operation (2.8% vs 2.0%, p51.0) rates were both similar for inpatient and outpatient discectomy. Significant improvement in three-month pain, disability, quality of life, satisfaction, and return to work were also similar between outpatient and inpatient cohorts. The outpatient facility fee was 70% of inpatient facility fee during the study period. Mean total 3-month cost per patient was significantly reduced in the outpatient vs inpatient surgery cohort ($14,441 vs. $18,808; p!0.001) with similar QALYgained. CONCLUSIONS: During the acute care and post-acute care episode, the outpatient ambulatory care versus inpatient hospital setting was associated with significant cost savings without a compromise in safety or clinical effectiveness for the surgical treatment of lumbar disc herniation. From a patient, payer, purchaser and societal perspective, the ambulatory surgery center setting offers superior
125. Interspinous Process Devices versus Standard Conventional Surgical Decompression for Lumbar Spinal Stenosis: Cost Utility Analysis Wouter A. Moojen, MD, MSc1, Carmen Vleggeert-Lankamp, MD, PhD2, Wilco C. Peul, MD, PhD3; 1Leiden University Medical Center, Leiden, Netherlands; 2Netherlands; 3Leids Universitair Medisch Centrum, Leiden, Netherlands BACKGROUND CONTEXT: In the 1980s, a new implant was developed to treat patients with intermittent neurogenic claudication (INC) caused by lumbar spinal stenosis (LSS). This implant is now widely used. PURPOSE: To determine whether a favorable cost-effectiveness for interspinous process devices (IPD) compared with conventional bony decompression is attained. STUDY DESIGN/SETTING: Cost utility analysis was performed alongside a double-blind randomized controlled trial. PATIENT SAMPLE: The cost utility analysis was conducted among 159 patients with lumbar spinal stenosis comparing the implantation of IPD and bony decompression. OUTCOME MEASURES: Main outcome measures were qualityadjusted life-years and societal costs in one year, estimated from patient reported utilities (UK and Netherlands EuroQol 5D (EQ 5D) and EuroQol Visual Analog Scale [EQ VAS]) and diaries on costs (health care costs, patient costs and productivity costs). METHODS: All analyses followed the intention-to-treat principle. Group differences in QALYs and costs were statistically analyzed using standard unequal-variance t-tests. Sensitivity analyses were performed on the use of different utility measures (NL EQ-5D or VAS) and on the perspective (societal or health care perspective). Depending on the willingness to pay for obtained effectiveness, a strategy is cost-effective compared with an alternative strategy if it has a better average net benefit (willingness to pay* QALYs – costs). RESULTS: According to the EQ-5D, the valuation of quality of life after IPD and decompression was not different. Mean utilities during all four quarters were – not significantly – less favorable after IPD according to the EQ-5D with a decrease in QALYs according to the UK EQ 5D of 0.032 (95% confidence interval -0.047 to 0.111). From a health care perspective, the costs of IPD treatment were higher (difference V3,030 per patient, 95% interval V561 to V5,498). This significant difference is mainly due to additional cost of implants of V2,350 apiece. From a societal perspective, a nonsignificant difference of V2,762 (95% confidence interval -V1,572 to V7,095) in favor of conventional bony decompression was found. CONCLUSIONS: Implantation of IPD is highly unlikely to be cost effective compared with bony decompression for patients with intermittent neurogenic claudication caused by lumbar spinal stenosis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2014.08.198
Refer to onsite Annual Meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosures and FDA device/drug status at time of abstract submission.
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value compared to the inpatient hospital setting. Given that 35,000 inpatient discectomies are covered by Medicare per year, CMS has the potential to save up to $98 million annually with future coverage of outpatient discectomy. Patient and provider incentives to encourage outpatient surgery for lumbar discectomy may be warranted. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2014.08.197
124. Lumbar Discectomy in the Ambulatory Care Setting: Defining Its Value across the Acute and Post-Acute Care Episode Scott L. Parker, MD1, Anthony Asher, MD, FACS2, E.H. Dyer, MD2, Tim E. Adamson, MD2, Clinton J. Devin, MD3, Matthew J. McGirt, MD2; 1 Vanderbilt University, Nashville, TN, US; 2Carolina Neurosurgery and Spine Associates, Charlotte, NC, US; 3Nashville, TN, US BACKGROUND CONTEXT: Current US health care costs are unsustainable. All stakeholders in health care reform have adopted value-based purchasing strategies to shift care toward higher benefit and lower cost treatment approaches. Low-back pathology is highly prevalent and its surgical intervention costly. PURPOSE: To quantify the potential cost savings and patient centered benefits associated with performing lumbar discectomy in an ambulatory surgery center versus inpatient hospital setting. STUDY DESIGN/SETTING: Prospective, comparison cohort study. PATIENT SAMPLE: Consecutive patients undergoing elective lumbar discectomy at inpatient vs outpatient setting over 15 months. OUTCOME MEASURES: 90-day morbidity, return to work, Numeric Rating Scale (NRS) for back (BP) and leg (LP) pain, Oswestry Disability Index (ODI), EuroQol-5D (EQ-5D), NASS satisfaction, and cost were prospectively assessed. METHODS: 251 consecutive cases of lumbar discectomy performed for single-level disc herniation at two centers were prospectively enrolled via a standardized web-based portal over a 15 month period. At center 1, all non-Medicare patients underwent lumbar discectomy in an outpatient ambulatory surgery center. At center 2, all non-Medicare patients underwent lumbar discectomy within the inpatient hospital setting. 90-day morbidity, return to work, and patient-reported outcomes were prospectively assessed. Direct costs were estimated from resource utilization via macro-costing with private pay estimated as 1.7 x Medicare fee schedule. Indirect costs were calculated from lost work productivity using standard human capital approach. RESULTS: 122 patients underwent outpatient discectomy and 129 inpatient discectomy with 3-month follow-up of 82%. Cohorts were similar at baseline. There was no perioperative surgical morbidity in either cohort. Ninety-day hospital re-admission (5.6% vs 3.0%, p50.50) and all-cause re-operation (2.8% vs 2.0%, p51.0) rates were both similar for inpatient and outpatient discectomy. Significant improvement in three-month pain, disability, quality of life, satisfaction, and return to work were also similar between outpatient and inpatient cohorts. The outpatient facility fee was 70% of inpatient facility fee during the study period. Mean total 3-month cost per patient was significantly reduced in the outpatient vs inpatient surgery cohort ($14,441 vs. $18,808; p!0.001) with similar QALYgained. CONCLUSIONS: During the acute care and post-acute care episode, the outpatient ambulatory care versus inpatient hospital setting was associated with significant cost savings without a compromise in safety or clinical effectiveness for the surgical treatment of lumbar disc herniation. From a patient, payer, purchaser and societal perspective, the ambulatory surgery center setting offers superior
125. Interspinous Process Devices versus Standard Conventional Surgical Decompression for Lumbar Spinal Stenosis: Cost Utility Analysis Wouter A. Moojen, MD, MSc1, Carmen Vleggeert-Lankamp, MD, PhD2, Wilco C. Peul, MD, PhD3; 1Leiden University Medical Center, Leiden, Netherlands; 2Netherlands; 3Leids Universitair Medisch Centrum, Leiden, Netherlands BACKGROUND CONTEXT: In the 1980s, a new implant was developed to treat patients with intermittent neurogenic claudication (INC) caused by lumbar spinal stenosis (LSS). This implant is now widely used. PURPOSE: To determine whether a favorable cost-effectiveness for interspinous process devices (IPD) compared with conventional bony decompression is attained. STUDY DESIGN/SETTING: Cost utility analysis was performed alongside a double-blind randomized controlled trial. PATIENT SAMPLE: The cost utility analysis was conducted among 159 patients with lumbar spinal stenosis comparing the implantation of IPD and bony decompression. OUTCOME MEASURES: Main outcome measures were qualityadjusted life-years and societal costs in one year, estimated from patient reported utilities (UK and Netherlands EuroQol 5D (EQ 5D) and EuroQol Visual Analog Scale [EQ VAS]) and diaries on costs (health care costs, patient costs and productivity costs). METHODS: All analyses followed the intention-to-treat principle. Group differences in QALYs and costs were statistically analyzed using standard unequal-variance t-tests. Sensitivity analyses were performed on the use of different utility measures (NL EQ-5D or VAS) and on the perspective (societal or health care perspective). Depending on the willingness to pay for obtained effectiveness, a strategy is cost-effective compared with an alternative strategy if it has a better average net benefit (willingness to pay* QALYs – costs). RESULTS: According to the EQ-5D, the valuation of quality of life after IPD and decompression was not different. Mean utilities during all four quarters were – not significantly – less favorable after IPD according to the EQ-5D with a decrease in QALYs according to the UK EQ 5D of 0.032 (95% confidence interval -0.047 to 0.111). From a health care perspective, the costs of IPD treatment were higher (difference V3,030 per patient, 95% interval V561 to V5,498). This significant difference is mainly due to additional cost of implants of V2,350 apiece. From a societal perspective, a nonsignificant difference of V2,762 (95% confidence interval -V1,572 to V7,095) in favor of conventional bony decompression was found. CONCLUSIONS: Implantation of IPD is highly unlikely to be cost effective compared with bony decompression for patients with intermittent neurogenic claudication caused by lumbar spinal stenosis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2014.08.198
Refer to onsite Annual Meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosures and FDA device/drug status at time of abstract submission.