Effects of a Commercial Insurance Policy Restriction on Lumbar Fusion in North Carolina and the Implications for National Adoption

Hospital-level variation in hospitalization costs for spinal fusion in the United States

BACKGROUND

With a growing emphasis on value of care, understanding factors associated with rising healthcare costs is increasingly important. In this national study, we evaluated the degree of center-level variation in the cost of spinal fusion.

METHODS

All adults undergoing elective spinal fusion were identified in the 2016 to 2020 National Inpatient Sample. Multilevel mixed-effect models were used to rank hospitals based on risk-adjusted costs. The interclass coefficient (ICC) was utilized to tabulate the amount of variation attributable to hospital-level characteristics. The association of high cost-hospital (HCH) status with in-hospital mortality, perioperative complications, and overall resource utilization was analyzed. Predictors of increased costs were secondarily explored.

RESULTS

An estimated 1,541,740 patients underwent spinal fusion, and HCH performed an average of 9.5% of annual cases. HCH were more likely to be small (36.8 vs 30.5%, p<0.001), rural (10.1 vs 8.8%, p<0.001), and located in the Western geographic region (49.9 vs 16.7%, p<0.001). The ICC demonstrated 32% of variation in cost was attributable to the hospital, independent of patient-level characteristics. Patients who received a spinal fusion at a HCH faced similar odds of mortality (0.74 [0.48-1.15], p = 0.18) and perioperative complications (1.04 [0.93-1.16], p = 0.52), but increased odds of non-home discharge (1.30 [1.17-1.45], p<0.001) and prolonged length of stay (β 0.34 [0.26-0.42] days, p = 0.18). Patient factors such as gender, race, and income quartile significantly impacted costs.

CONCLUSION

The present analysis identified 32% of the observed variation to be attributable to hospital-level characteristics. HCH status was not associated with increased mortality or perioperative complications.

Application of Wearable Sensors Technology for Lumbar Spine Kinematic Measurements during Daily Activities following Microdiscectomy Due to Severe Sciatica

Simple Summary

The recurrence rate after lumbar spine disc surgeries is estimated to be 5–15%. Lumbar spine flexion of more than 10° is mentioned in the literature as the most harmful load to the operated disc level that could lead to recurrence during the first six postoperative weeks. The purpose of this study is to quantify flexions during daily living following such surgeries, for six weeks postoperatively, using wearable sensors technology. These data determine the patients’ kinematic pattern, reflecting a high-risk factor for pathology recurrence. The operated patients were measured to have 30% normal lumbar motion after the first postoperative week, while they were restored to almost 75% at the end of the sixth, respectively. Further in vitro studies should be carried out using these data to identify if such kinematic patterns could lead to pathology recurrence.

Abstract

Background: The recurrence rate of lumbar spine microdiscectomies (rLSMs) is estimated to be 5–15%. Lumbar spine flexion (LSF) of more than 10° is mentioned as the most harmful load to the intervertebral disc that could lead to recurrence during the first six postoperative weeks. The purpose of this study is to quantify LSFs, following LSM, at the period of six weeks postoperatively. Methods: LSFs were recorded during the daily activities of 69 subjects for 24 h twice per week, using Inertial Measurement Units (IMU). Results: The mean number of more than 10 degrees of LSFs per hour were: 41.3/h during the 1st postoperative week (P.W.) (29.9% healthy subjects-H.S.), 2nd P.W. 60.1/h (43.5% H.S.), 3rd P.W. 74.2/h (53.7% H.S.), 4th P.W. 82.9/h (60% H.S.), 5th P.W. 97.3/h (70.4% H.S.) and 6th P.W. 105.5/h (76.4% H.S.). Conclusions: LSFs constitute important risk factors for rLDH. Our study records the lumbar spine kinematic pattern of such patients for the first time during their daily activities. Patients’ data report less sagittal plane movements than healthy subjects. In vitro studies should be carried out, replicating our results to identify if such a kinematic pattern could cause rLDH. Furthermore, IMU biofeedback capabilities could protect patients from such harmful movements.

Trends in Lumbar Fusion Procedure Rates and Associated Hospital Costs for Degenerative Spinal Diseases in the United States, 2004 to 2015

STUDY DESIGN

Analysis of National Inpatient Sample (NIS), 2004 to 2015.

OBJECTIVE

Describe recent trends in US rates of lumbar fusion procedures and associated costs, by surgical indication.

SUMMARY OF BACKGROUND DATA

Spinal fusion is appropriate for spinal deformity and instability, but evidence of effectiveness is limited for primary disc herniation and spinal stenosis without instability. It remains controversial for treatment of axial pain secondary to degenerative disc disease. There are potential non-instability, non-deformity indications for fusion surgery, including but not limited to severe foraminal stenosis and third-time disc herniation.

METHODS

Elective lumber fusion trends were reported using Poisson regression, grouped by indication as degenerative scoliosis, degenerative spondylolisthesis, spinal stenosis, disc herniation, and disc degeneration. Generalize linear regression was used to estimate trends in hospital costs, adjusted for age, sex, indication, comorbidity, and inflation.

RESULTS

Volume of elective lumbar fusion increased 62.3% (or 32.1% per 100,000 US adults), from 122,679 cases (60.4 per 100,000) in 2004 to 199,140 (79.8 per 100,000) in 2015. Increases were greatest among age 65 or older, increasing 138.7% by volume (73.2% by rate), from 98.3 per 100,000 (95% confidence interval [CI] 97.2, 99.3) in 2004 to 170.3 (95% CI 169.2, 171.5) in 2015. Although the largest increases were for spondylolisthesis (+47,390 operations, 111%) and scoliosis (+16,129 operations, 186.6%), disc degeneration, herniation, and stenosis combined to accounted for 42.3% of total elective lumbar fusions in 2015. Aggregate hospital costs increased 177% during these 12 years, exceeding $10 billion in 2015, and averaging more than $50,000 per admission.

CONCLUSION

While the prevalence of spinal pathologies is not known, the rate of elective lumbar fusion surgery in the United States increased most for spondylolisthesis and scoliosis, indications with relatively good evidence of effectiveness. The proportion of fusions coded for indications with less evidence of effectiveness has slightly decreased in the most recent years.

LEVEL OF EVIDENCE

3.

Increased Volume of Surgery for Lumbar Spinal Stenosis and Changes in Surgical Methods and Outcomes: A Nationwide Cohort Study with a 5-Year Follow-Up

OBJECTIVE

Examining spine surgery patterns over time is crucial to provide insights into variations and changes in clinical decision making. Changes in the number of surgeries, surgical methods, reoperation rates, and cost-effectiveness were analyzed for all patients who underwent surgery for lumbar spinal stenosis without spondylolisthesis in 2003 (2003 cohort) and 2008 (2008 cohort).

METHODS

The national health insurance database was used to create the 2003 cohort (n = 10,990) and 2008 cohort (n = 27,942). The surgical methods were classified into decompression and fusion surgery. The cumulative reoperation probability between those surgeries was calculated using the Kaplan-Meier method in the 2003 cohort and 2008 cohort. Comparison of the incremental cost-effectiveness ratios showed the additional direct cost of a 1% change in the reoperation probability.

RESULTS

The surgical volume increased 2.54-fold in the 2008 cohort. The age-adjusted number of surgeries per 1 million people increased 2.6-fold (from 154 in the 2003 cohort to 399 in the 2008 cohort) in aged patients and 1.9-fold (from 154 in the 2003 cohort to 291 in the 2008 cohort) in patients 20-59 years old in the 2008 cohort. The proportion of fusion surgeries increased from 20.3% in the 2003 cohort to 37.0% in the 2008 cohort. In total, the 5-year reoperation probabilities increased from 8.1% in the 2003 cohort to 11.2% in the 2008 cohort. Fusion decreased the reoperation probability by 1% at the cost of 1,711 U.S. dollars.

CONCLUSIONS

The increased numbers of spinal surgeries, fusion surgeries, and surgeries in older patients in a recent cohort were noteworthy. However, the increased surgical volume and fusion surgeries did not reduce the reoperation rate.

Ninety-Day Reimbursements for Primary Single-Level Posterior Lumbar Interbody Fusion From Commercial and Medicare Data

STUDY DESIGN

Retrospective, economic analysis.

OBJECTIVE

To analyze the distribution of 90-day payments for a primary single-level posterior lumbar interbody fusion from Commercial payers and Medicare.

SUMMARY OF BACKGROUND DATA

Episode-based bundled payments aim to align incentives of all health care providers toward the common goal of high quality and economic health care. Understanding the evolving reimbursement models for spine surgery will require knowledge on existing payments, distribution, and variation. Also, it will help identify areas for cost reduction. This is currently not known for a primary single-level posterior lumbar interbody fusion.

METHODS

Administrative claims data were used to study reimbursements from Commercial payers (2007-Q3 2015), Medicare Advantage (2007-Q3 2015), and Medicare (2005-2012) for a primary single-level posterior lumbar interbody fusion. Distribution of payments among various service providers was studied. In addition to descriptive analysis, variation between regions and payers was studied by a one-way analysis of variance and post hoc Tukey test.

RESULTS

Average hospital costs comprise 74.2% to 77% of the total payments, followed by surgeon's fees which accounted for 12.8% to 13.7%. Overall burden of readmissions/revisions was 2.1% to 2.7%, but for the readmitted patient it constitutes 25% to 54% of the 90-day payment. Inpatient surgery had significantly higher facility costs than outpatient surgery (P = 0.02). The average 90-day payment amount was $51,465, $26,234, and $25,501 for Commercial payers, Medicare Advantage, and Medicare, respectively. There was some regional variation, however not consistent among different payers.

CONCLUSION

Hospital costs constitute the majority share of 90-day payments, which can be reduced by performing surgery in the outpatient setting. Reducing hospital costs and readmissions can lower the financial burden associated with this common spine procedure.

LEVEL OF EVIDENCE

3.

Impact of the Economic Downturn on Elective Lumbar Spine Surgery in the United States: A National Trend Analysis, 2003 to 2013

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

The impact of the 2008-2009 economic downtown on elective lumbar spine surgery is unknown. Our objective was to investigate the effect of the economic downturn on the overall trends of elective lumbar spine surgery in the United States.

METHODS

The Nationwide Inpatient Sample (NIS) was used in conjunction with US Census and macroeconomic data to determine historical trends. The economic downturn was defined as 2008 to 2009. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), were used in order to identify appropriate procedures. Confidence intervals were determined using subgroup analysis techniques.

RESULTS

From 2003 to 2012, there was a 19.8% and 26.1% decrease in the number of lumbar discectomies and laminectomies, respectively. Over the same time period, there was a 56.4% increase in the number of lumbar spinal fusions. The trend of elective lumbar spine surgeries per 100 000 persons in the US population remained consistent from 2008 to 2009. The number of procedures decreased by 4.5% from 2010 to 2011, 7.6% from 2011 to 2012, and 3.1% from 2012 to 2013. The R2 value between the number of surgeries and the S&P 500 Index was statistically significant (P ≤ .05).

CONCLUSIONS

The economic downturn did not affect elective lumbar fusions, which increased in total from 2003 to 2013. The relationship between the S&P 500 Index and surgical trends suggests that during recessions, individuals may utilize other means, such as insurance, to cover procedural costs and reduce out-of-pocket expenditures, accounting for no impact of the economic downturn on surgical trends. These findings can assist multiple stakeholders in better understanding the interconnectedness of macroeconomics, policy, and elective lumbar spine surgery trends.