Which is more cost-effective for spinal arthrodesis: biological substitutes or extenders?
A group of researchers analyzed the literature and sought to find the answer and publihsed their findings in Spine. The researchers examined articles in PubMed/MEDLINE, the Cochrane Collaboration Library, EMBASE, the Centre for Reviews and Dissemination database and Tuft's CEA registry. They included articles published through December 2013 that included a full formal economic analysis comparing biological grafts with iliac crest bone for spinal fusion.
There were 88 citations and six full economic analyses articles that meat the criteria.
A second article published in the same edition of Spine examined whether rhBMP makes a difference in spinal fusion rate. The researchers examined 5,456 cases where BMP was used and compared results with 3,969 cases where BMP was not used.
Here are five conclusions from two articles in Spine:
1. Using recombinant bone morphogenetic protein is not cost-effective when compared with iliac crest bone graft for lumbar spinal fusion from the payer perspective because rhBMP-2 has higher upfront costs.
2. rhBMP-2 may be cost-effective from a societal perspective because there is decreased lost productivity for lumbar spinal fusion patients.
3. Anterior cervical discectomy and fusion with allograft is similarly cost-effective to ACDF with autograft from a societal perspective.
4. The reoperation rate for non-BMP patients was higher after one year — 2.2 percent for the non-BMP group compared with 1.9 percent for the BMP group. But there was no significant difference at two years follow-up.
5. The operative nonunion rates did not reach statistical significance for the different spine regions and different patient characteristics, operative times and levels fused. The risk of reoperation rate for the BMP group versus the non-BMP group was 0.67.
A 2007 article published in Health Technology Assessment examined rhBMP articles spinal fusion. At the time, literature suggested rhBMP-2 was more effective than autogenous bone graft for radiographic fusion in patients with single-level degenerative disc disease. The BMP use was associated with:
• Reduced operative time
• Improved clinical outcomes
• Shorter hospital stays
The study included data from the United Kingdom, which examined cost effectiveness there. Estimated cost per quality-adjusted life year gained with BMP was 120,390 pounds, and the probability that BMP is cost-effective was only 6.4 percent.
"According to the results of economic evaluation, the use of BMP for spinal fusion is unlikely to be cost-effective," the study authors concluded. A cost utility study featured by the North American Spine Society on patients 60 years and older found the average two-year cost for care was $34,235 per patient for the non-BMP group and $36,530 for the BMP group. The bigger concern was complications; patients tacked-on $10,888 per complication and revision surgery for nonunion was $46,852 on average. Additional treatment for a spine-related event was $5,892 per patient on average.
The study authors found two fewer BMP patients had complications and half as many had additional interventions when compared with patients who received iliac crest bone graft. Five patients who received the iliac crest bone graft required revision surgery for nonunion, whereas only one BMP patients underwent the revision procedure.