Cost-Effective Spine Surgery: 8 Things to KnowWritten by Laura Miller | November 11, 2011
Here are eight things to know about decreasing the cost of spine care.
1. Surgery can be cost-effective and improves QALY for spinal stenosis, other procedures. Surgical treatment for patients with spinal stenosis, degenerative spondylolisthesis and intervertebral disc herniation show good value for spine care when compared with nonoperative treatment over a four-year period, according to a study published in Spine.
The cost-effectiveness study was conducted as part of the Spine Patient Outcomes Research Trial. The study included 634 patients, 414 of whom underwent surgery either initially or during the four-year follow-up period.
Surgery was shown to improve health with persistent quality-adjusted life year differences throughout the follow-up period. The costs per QALY gained decreased for each group during the follow up period:
• Spinal stenosis: $77,600 at two years to $59,400 at four years
• Degenerative spondylolisthesis: $115,600 at two years to $64,300 at four years
• Intervertebral disc herniation: $34,355 at two years to $20,600 at four years
2. Refined indications can avoid failed surgery. A lot more money stands to be made on performing spinal discectomies instead of decompressions, and some surgeons may perform unnecessary surgeries for financial gain. However, even well-meaning spine surgeons may be driving up the cost of spinal healthcare by performing fusions on patients who are at a high risk for needing revision surgeries, such as young patients or patients with adjacent level disease.
"If someone has a fusion at one level, does all conservative therapy and the operation is a success, there's still a chance the patient will come back with an adjacent level disease," says Michael Finn, MD, a neurosurgeon in the department of neurosurgery at the University of Colorado. "If the patient has arthritis at one level, they are predisposed for adjacent level disease because of their medical history and because the degeneration is quickened by stress from the previous fusion."
Other times, surgeons perform fusions on patients who would benefit from conservative treatment. When a patient comes in for the initial visit, some surgeons assume they have exhausted all non-operative methods already. However, this isn't always the case. "You want to get to know the patients before surgery and make sure they have done the whole gamut of conservative management and really have a motivation to get better," says Sumeer Sathi, MD, a neurosurgeon with Long Island Neurosciences in East Patchogue, N.Y.
3. Artificial disc replacements may be more cost-effective than spinal fusion. Richard Delamarter, MD, co-director of the Cedars-Sinai Spine Center, reported a study earlier this year in which he found that artificial disc replacement for patients with degenerative disc disease had a more positive economic impact than spinal fusions. The study examined 209 patients with damaged cervical spine discs who underwent either cervical disc replacement or spinal fusion. Four years after the surgery, the fusion patients were four times more likely to need additional surgery and half of those operations were necessary because of new disc complications occurring at levels adjacent to the fusion.
Another study focused on patients suffering from three-level lower back disc disease, comparing the cost of care between disc replacement and fusion. The total hospital costs for the disc replacement patients were, on average, 49 percent lower than fusion patients.
4. Spending more upfront on surgical procedures can decrease the risk of failed back surgery. While the cost of one surgery might be cheaper than another, surgeons might choose the more expensive surgery to decrease the risk of complications or failed back surgery. Patients who return to surgeons for adjacent level fusions or revision surgeries drive up the cost of care, so spending more on the initial surgery could curtail the costs associated with future surgeries. "You don't want to do a cheaper surgery if it is going to fail," says Sheeraz Qureshi, MD, MBA, a spine surgeon at Mount Sinai Medical Center in New York City. "On the other hand, you have to see how much more effective a treatment will be if it is more expensive."
In many cases, surgeons don't see much of a compensation increase by performing more complex surgeries. For example, complex fusions don't reimburse much higher than simple fusions.
The cost of complex fusions is higher because the surgeon is inserting a cage in addition to the traditional rods and screws for increased support. "Studies show that increasing support has better results and a higher success rate, which is why surgeons might choose to use them," says Dr. Qureshi. "The surgeon isn't compensated much more for performing the complex as opposed to the simple fusions."
5. Waste-cutting programs can decrease the cost of care. In a recent study presented at the NASS annual meeting in Chicago, Beth Deaconess Medical Center implemented an intraoperative waste awareness program to cut unnecessary costs to surgical expenses. Researchers prospectively examined the number of spine procedures and incidence of intraoperative waste during a 15-month observational period and a subsequent 10-month awareness program.
Analysis showed that the most common reasons for waste and the main driver of the cost burden was "surgeon changed mind." Surgical implants were associated with higher cost-per-item wasted and the awareness program was successful in decreasing the costs associated with intraoperative waste by 66 percent. After waste was identified and all parties were notified of its classification, the medical center established guidelines on what could and couldn't be used.
6. Transforaminal lumbar interbody fusions can have a positive economic cost. A study presented at the American Association of Neurological Surgeons annual meeting in April discussed the economic benefits for patients with leg and back pain associated with grade 1 degenerative spondylolisthesis to receive TLIF. Researchers followed patients for two years to see where the postoperative economic impact lay:
• Patients reported less disability and improved quality of life according to questionnaires they were given.
• The mean two-year direct medical cost was $25,251.
• The mean surgical cost was $21,311±2,086, and the mean outpatient resource cost was $3,940±2,720.
• The average total two-year cost of TLIF was $36,835±11,800.
• The average reported annual income prior to surgery was $50,000. Patients missed an average of 60 work days, representing a two-year societal cost of $11,584.
• At two years after surgery, the total cost per Quality Adjusted Life Years gained of TLIF was $42,854, well below the accepted $50,000 cost-effective threshold.
7. Many instrumented lumbar fusions don't require postoperative radiographs. Most patients undergoing a single or multilevel lumbar instrumented fusion don't require routine postoperative radiographs, according to a study published in Spine. Researchers followed 63 patients who underwent single or multilevel instrumented fusions, and all received plain radiographs at 269 subsequent visits. During only approximately 6.3 percent of the visits specialists detected abnormal findings using the radiographs.
When patients presented with new symptoms or deterioration, abnormal findings were reported 22 percent of the time. Only 2.7 percent of asymptomatic patients reported abnormal findings, leading the authors to suggest radiographs be used as indicated clinically instead of routinely.
8. Consider workers' compensation patients individually. It's important to indicate the appropriate patients for surgery to achieve the best possible outcomes. However, appropriately indicating patients for surgery goes beyond examining their physical characteristics. Surgeons must also assess the patient's psychological health and motivation to recover. In many cases, workers' compensation patients can be problematic because they often have psychological instabilities and little motivation to return to work, says Dr. Sathi. "We try to minimize exposure to workers' compensation patients unless there is a motivation from the patient to get better," he says. These patients have also often been on pain medication for an extended period of time, which can cause further complications.
Related Articles on Spine Surgery:
Neuropathy or Radiculopathy: 4 Points on Differentiating the Diagnosis
Endoscopic Spine Surgery: 6 Things to Know About the Present and Future
Where Infuse Stands: 6 Points on the Controversial Spinal Fusion Product
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