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Perioperative Outcomes, Complications and Costs Associated with Lumbar Spinal Fusion in Older Patients with Spinal Stenosis and Spondylolisthesis: Analysis of the United States Medicare Claims Database
Proceedings of the NASS 27th Annual Meeting / The Spine Journal 12 (2012) 1S–21S
3S
health state utility for patients expressing satisfaction following their operation. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
improvements can be made in the effective delivery and cost of surgical care for patients with spinal stenosis and spondylolisthesis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
http://dx.doi.org/10.1016/j.spinee.2012.08.029
http://dx.doi.org/10.1016/j.spinee.2012.08.030
5. Perioperative Outcomes, Complications and Costs Associated with Lumbar Spinal Fusion in Older Patients with Spinal Stenosis and Spondylolisthesis: Analysis of the United States Medicare Claims Database Joshua D. Auerbach, MD1, Kevin L. Ong2, Edmund Lau2, Jordana Schmier3; 1Brooklyn, NY, US; 2Exponent Inc., Philadelphia, PA, US; 3Exponent Inc., Alexandria, VA, US
6. Cost-Utility and Comparative Effectiveness Analyses of Transforaminal Lumbar Interbody Fusion (TLIF) Versus Comprehensive Medical Management for Lumbar Spondylolisthesis Scott L. Parker, MD1, Saniya S. Godil, MD2, Scott L. Zuckerman1, Stephen K. Mendenhall1, David N. Shau, BS1, Clinton J. Devin, MD1, Matthew J. McGirt, MD3; 1Nashville, TN, US; 2Vanderbilt University, Nashville, TN, US; 3Vanderbilt University Medical Center, Nashville, TN, US
BACKGROUND CONTEXT: Among elderly patients with spinal stenosis and spondylolisthesis, lumbar spinal fusion is commonly performed to facilitate spinal decompression and stabilization. However, recent reports of excessive perioperative morbidity and soaring health care costs with fusion have led to the search for methods to improve the safety profile and to lower costs for this important surgical treatment. PURPOSE: The purpose of this study is to quantify the perioperative outcomes, complications, and costs associated with posterior spinal fusion among Medicare enrollees with spinal stenosis and spondylolisthesis using a national Medicare claims database. STUDY DESIGN/SETTING: Retrospective review of Medicare claims data (2005-2009). PATIENT SAMPLE: The 5% systematic sample of Medicare claims data (2005-2009) was used to identify and track the outcomes of patients who received any form of posterior spine fusion (PSF) for lumbar spinal stenosis (LSS) or spondylolisthesis. Surgical patients were identified by standard PSF procedural coding, while diagnoses of LSS and spondylolisthesis were identified using specific ICD-9 coding. OUTCOME MEASURES: Patients’ length of stay, discharge status, incidence and type of complications, and treatment costs following PSF were evaluated. METHODS: Enrollees further required a minimum of 2 years’ follow-up, and claim history of at least 12 months prior to surgery. RESULTS: A final cohort of 1,672 PSF patients was included. 50.7% had LSS only; 10.2% had spondylolisthesis only; and 39.1% had both LSS and spondylolisthesis. The average age was 71.4, and the average length of stay was 4.6 days. For the overall cohort, the average age was 71.4 þ/7.9, and the average length of stay was 4.6 þ/- 3.2 days. While 42.2% of the patients had routine discharges, a majority of the patients (54.6%) were discharged to an outside facility or required home health services (18.0%, 19.4%, and 17.2% were discharged to skilled nursing facilities, home health services, and rehabilitation facilities, respectively). At 3 months, 1 year and 2 years postoperative, the incidence of spine reoperation was 19.9%, 24.0%, and 28.0%, respectively, while readmission for complications was 34.5%, 41.4%, and 47.9%, respectively. 45.2% of patients had either a spine reoperation or post-op epidural injection due to continued pain at 2 years. The average payment was $36,230 þ/$17,020, $46,840 þ/- $31,350, and $61,610 þ/- $46,580 at 3 months, 1 year, and 2 years, respectively, and corresponded to an overall cost to Medicare of $60.6 million, $78.3 million, and $103.0 million for treating these patients. CONCLUSIONS: Over half of the PSF-treated patients in this study had LSS alone, and 32% of stenosis-only patients underwent fusion, suggesting that factors other than spondylolisthesis play a significant role in the decision to recommend spinal fusion in this elderly population. One in 4 elderly fusion patients being treated for LSS or spondylolisthesis was reoperated on the spine within 2 years, and nearly one in 2 readmitted for a surgery-related complication. This data highlights several areas where
BACKGROUND CONTEXT: The SPORT trial suggested that lumbar fusion was efficacious but NOT cost-effective for the treatment of lumbar spondylolisthesis. However, such randomized controlled trials inherently control and standardize medical resource utilization and cost. Furthermore, mid-trial crossover of medicine non-responders significantly inflates the utility of medical management, further biasing cost-utility analysis (CUA). PURPOSE: To perform a comparative effectiveness and CUA of trans-foraminal lumbar interbody fusion (TLIF) versus medical management for lumbar spondylolisthesis utilizing a prospective single-center multidisciplinary spine center registry in a real-world practice setting. STUDY DESIGN/SETTING: Prospective, longitudinal, observational cohort study. PATIENT SAMPLE: Eighty patients with degenerative lumbar spondylolisthesis managed at a single institution’s Multidisciplinary Spine Center. OUTCOME MEASURES: VAS, ODI, SF-12, Zung Depression scale, EQ-5D, Incremental cost-effectiveness ratio. METHODS: Eighty patients with degenerative lumbar spondylolisthesis managed at a single institution’s Multidisciplinary Spine Center were entered into a prospective registry. Surgical management consisted of TLIF, while comprehensive medical management included spinal steroid injections, physical therapy, oral medications, and various other therapies. Two-year patient-reported outcomes (PRO), back-related medical resource utilization, and work-day losses were prospectively assessed via phone interview and used to calculate Medicare fee-based direct cost and indirect cost from occupation loss. Difference in mean total two-year cost per QALY gained was assessed as incremental cost-effectiveness ratio (ICER). RESULTS: Baseline characteristics of the two cohorts were similar except EQ-5D score which was lower in TLIF cohort (p50.006). TLIF resulted in a significant (p!0.001) two-year improvement in all outcome measures, while comprehensive medical management failed to provide significant improvement. Two-year gain in QALY was significantly greater after TLIF (0.43 QALY gained) versus medical management (0.06 QALY gained). Total two-year cost was significantly greater for TLIF ($36,836) versus medical management ($8,762). The cost per QALY gained for surgery vs. medical management (ICER) was $75,876. CONCLUSIONS: In this prospective multidisciplinary registry, lumbar fusion versus medical management was shown to be cost-effective and provide greater two-year improvement in pain, disability, and quality of life. The findings from this real-world practice setting may more accurately reflect the true value and effectiveness of surgical versus medical care for degenerative spondylolisthesis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2012.08.031
All referenced figures and tables will be available at the Annual Meeting and will be included with the post-meeting online content.
3S
health state utility for patients expressing satisfaction following their operation. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
improvements can be made in the effective delivery and cost of surgical care for patients with spinal stenosis and spondylolisthesis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
http://dx.doi.org/10.1016/j.spinee.2012.08.029
http://dx.doi.org/10.1016/j.spinee.2012.08.030
5. Perioperative Outcomes, Complications and Costs Associated with Lumbar Spinal Fusion in Older Patients with Spinal Stenosis and Spondylolisthesis: Analysis of the United States Medicare Claims Database Joshua D. Auerbach, MD1, Kevin L. Ong2, Edmund Lau2, Jordana Schmier3; 1Brooklyn, NY, US; 2Exponent Inc., Philadelphia, PA, US; 3Exponent Inc., Alexandria, VA, US
6. Cost-Utility and Comparative Effectiveness Analyses of Transforaminal Lumbar Interbody Fusion (TLIF) Versus Comprehensive Medical Management for Lumbar Spondylolisthesis Scott L. Parker, MD1, Saniya S. Godil, MD2, Scott L. Zuckerman1, Stephen K. Mendenhall1, David N. Shau, BS1, Clinton J. Devin, MD1, Matthew J. McGirt, MD3; 1Nashville, TN, US; 2Vanderbilt University, Nashville, TN, US; 3Vanderbilt University Medical Center, Nashville, TN, US
BACKGROUND CONTEXT: Among elderly patients with spinal stenosis and spondylolisthesis, lumbar spinal fusion is commonly performed to facilitate spinal decompression and stabilization. However, recent reports of excessive perioperative morbidity and soaring health care costs with fusion have led to the search for methods to improve the safety profile and to lower costs for this important surgical treatment. PURPOSE: The purpose of this study is to quantify the perioperative outcomes, complications, and costs associated with posterior spinal fusion among Medicare enrollees with spinal stenosis and spondylolisthesis using a national Medicare claims database. STUDY DESIGN/SETTING: Retrospective review of Medicare claims data (2005-2009). PATIENT SAMPLE: The 5% systematic sample of Medicare claims data (2005-2009) was used to identify and track the outcomes of patients who received any form of posterior spine fusion (PSF) for lumbar spinal stenosis (LSS) or spondylolisthesis. Surgical patients were identified by standard PSF procedural coding, while diagnoses of LSS and spondylolisthesis were identified using specific ICD-9 coding. OUTCOME MEASURES: Patients’ length of stay, discharge status, incidence and type of complications, and treatment costs following PSF were evaluated. METHODS: Enrollees further required a minimum of 2 years’ follow-up, and claim history of at least 12 months prior to surgery. RESULTS: A final cohort of 1,672 PSF patients was included. 50.7% had LSS only; 10.2% had spondylolisthesis only; and 39.1% had both LSS and spondylolisthesis. The average age was 71.4, and the average length of stay was 4.6 days. For the overall cohort, the average age was 71.4 þ/7.9, and the average length of stay was 4.6 þ/- 3.2 days. While 42.2% of the patients had routine discharges, a majority of the patients (54.6%) were discharged to an outside facility or required home health services (18.0%, 19.4%, and 17.2% were discharged to skilled nursing facilities, home health services, and rehabilitation facilities, respectively). At 3 months, 1 year and 2 years postoperative, the incidence of spine reoperation was 19.9%, 24.0%, and 28.0%, respectively, while readmission for complications was 34.5%, 41.4%, and 47.9%, respectively. 45.2% of patients had either a spine reoperation or post-op epidural injection due to continued pain at 2 years. The average payment was $36,230 þ/$17,020, $46,840 þ/- $31,350, and $61,610 þ/- $46,580 at 3 months, 1 year, and 2 years, respectively, and corresponded to an overall cost to Medicare of $60.6 million, $78.3 million, and $103.0 million for treating these patients. CONCLUSIONS: Over half of the PSF-treated patients in this study had LSS alone, and 32% of stenosis-only patients underwent fusion, suggesting that factors other than spondylolisthesis play a significant role in the decision to recommend spinal fusion in this elderly population. One in 4 elderly fusion patients being treated for LSS or spondylolisthesis was reoperated on the spine within 2 years, and nearly one in 2 readmitted for a surgery-related complication. This data highlights several areas where
BACKGROUND CONTEXT: The SPORT trial suggested that lumbar fusion was efficacious but NOT cost-effective for the treatment of lumbar spondylolisthesis. However, such randomized controlled trials inherently control and standardize medical resource utilization and cost. Furthermore, mid-trial crossover of medicine non-responders significantly inflates the utility of medical management, further biasing cost-utility analysis (CUA). PURPOSE: To perform a comparative effectiveness and CUA of trans-foraminal lumbar interbody fusion (TLIF) versus medical management for lumbar spondylolisthesis utilizing a prospective single-center multidisciplinary spine center registry in a real-world practice setting. STUDY DESIGN/SETTING: Prospective, longitudinal, observational cohort study. PATIENT SAMPLE: Eighty patients with degenerative lumbar spondylolisthesis managed at a single institution’s Multidisciplinary Spine Center. OUTCOME MEASURES: VAS, ODI, SF-12, Zung Depression scale, EQ-5D, Incremental cost-effectiveness ratio. METHODS: Eighty patients with degenerative lumbar spondylolisthesis managed at a single institution’s Multidisciplinary Spine Center were entered into a prospective registry. Surgical management consisted of TLIF, while comprehensive medical management included spinal steroid injections, physical therapy, oral medications, and various other therapies. Two-year patient-reported outcomes (PRO), back-related medical resource utilization, and work-day losses were prospectively assessed via phone interview and used to calculate Medicare fee-based direct cost and indirect cost from occupation loss. Difference in mean total two-year cost per QALY gained was assessed as incremental cost-effectiveness ratio (ICER). RESULTS: Baseline characteristics of the two cohorts were similar except EQ-5D score which was lower in TLIF cohort (p50.006). TLIF resulted in a significant (p!0.001) two-year improvement in all outcome measures, while comprehensive medical management failed to provide significant improvement. Two-year gain in QALY was significantly greater after TLIF (0.43 QALY gained) versus medical management (0.06 QALY gained). Total two-year cost was significantly greater for TLIF ($36,836) versus medical management ($8,762). The cost per QALY gained for surgery vs. medical management (ICER) was $75,876. CONCLUSIONS: In this prospective multidisciplinary registry, lumbar fusion versus medical management was shown to be cost-effective and provide greater two-year improvement in pain, disability, and quality of life. The findings from this real-world practice setting may more accurately reflect the true value and effectiveness of surgical versus medical care for degenerative spondylolisthesis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2012.08.031
All referenced figures and tables will be available at the Annual Meeting and will be included with the post-meeting online content.