David W. Polly, MD, gave a presentation on determining the cost-effectiveness of spine care and how to translate those findings into the language decision-makers understand at the North American Spine Society Annual Meeting earlier this year.
At the national level, policy-makers use league tables to gather information on the cost-effectiveness of different treatments by quality adjusted life years. That information is then translated into quadrants comparing the cost of a treatment with the increase in QALYs.
"If something results in better care and it costs less, we all want to do that. That's what we call strong positive dominance. If it costs more and gives us worst results, we certainly don't want to do that. That's strong negative dominance," he said. "Where most of the game is played is its a little bit better and it costs more. So then the question becomes how much better and how much more. Also conversely, in a limited resource environment, what we are going to start facing is [something] isn't quite as good but it costs less. That may be part of the next decade of debate."
What number do physicians have to reach in order to have their intervention be cost effective? Dr. Polly argues it's around $50,000 to $100,000/QALY in the United States, which is different from other countries.
The best methodology is a randomized controlled trial of no treatment versus treatment, or placebo treatment versus treatment of interest will most likely give the best data, he said. However, this data still has challenges and limitations.
"If you want to make surgery look bad, look at one year data. If you want to make pills look good, look at three month data. The problem with pills is the longer you have to take them, if you have to take them for life that expense continues on forever. If we do a good surgery that becomes durable, we have upfront costs, but then it may last 10, 20, 30, 40 years," said Dr. Polly.
The most common cost data used today is administrative or billing data, but the actual cost tracking of each item of resource utilization is hard and sometimes done through patient diaries. "The big hope and potentially disruptive transformation is when we can get registry data that we compare with payer expense data at which point we may get some more meaningful information," he said.
Spine surgeons and researchers are making an effort to conduct comparative effectiveness studies with the data available today. For example, in a clinical study conducted at the Mount Sinai Hospital, Mount Sinai School of Medicine in the department of orthopedic surgery, researchers examined the cost-effectiveness of single-level cervical disc replacement and anterior cervical discectomy and fusion.
They measured cost per QALY data and found the cervical disc replacement needs to last eight or night years for it to be cost-effective. Their findings were sensitive to the cost of the implant and individual surgeon skill.
When conducting cost-effectives studies where less data currently exists, researchers must compare the cost of interventions and cost of potential complications and then compare it to the cost of non-operative care over the treatment period. For example, Dr. Polly cited a study out of the University of Minnesota examining the cost-effectiveness of sacroiliac joint treatment.
"When you go through and mine the [Medicare data] looking at the codes, you find out we actually spend a fair amount of money on nonoperative care, and that for five years the cost of nonoperative management is about $20,000 for an SI joint patient problem based on the best information we can pull out," he said. "Then you take the intervention costs and come up with those for a variety of methodologies; going back to the data set, saying what does it cost to do and then you put it all together as a model. Then you say how many patients, what intervention — and you have to presume durability, etc. — and in this case, in this model, it suggests that [the SI joint surgery] falls in that quadrant of costs less and potentially better, so it would be strong positive dominance."
However, it also becomes very sensitive to the treatment success rate. At about 78 percent, surgical intervention appears in the strong positive dominance category. However, some may not achieve that success rate. A sensitivity analysis can show what factors affect the cost-effectiveness of a procedure, and those factors that have big impact need more precise estimates for surgeons to have a valuable model.
"Decision-makes have got to make decisions. They will use the best information they have and it's almost never perfect," said Dr. Polly. They are using cost per QALY to make their decisions. "If you are going to rational, intelligent, thoughtful health allocation, what you want to do is get the biggest benefit for the dollar spent. This is the only way we know how to do this at this point in time. We need to present our evidence for our interventions for our patients in this language or it doesn't help because the decision-makers still have to make their decisions. The good news for the spine stuff is that we have a pretty compelling story to tell."
For spine surgeons to take a seat at the table during process and policy decisions, whether at the local or national level, they need to show value in terms that the decision-makers understand.
"If we want our patients to have an access to our care, we need to speak this language," he said.
More Articles on Spine Surgery:
Spinal Fusion for Adult Scoliosis: What Are Survival Rates?
20 Spine & Orthopedic Practices that Grew in 2013
Spine Surgeon Relationships With Device Companies: Where They Could Go Wrong