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Ament JD, Petros J, Zabehi T, Yee R, Johnson JP, Vokshoor A. A prospective study of lumbar facet arthroplasty in the treatment of degenerative spondylolisthesis and stenosis: cost-effective assessment from the Total Posterior Spine system (TOPS TM) IDE Study: 2-year model revision and sensitivity analyses based on 305 subjects. Spine J 2024; 24:1001-1014. [PMID: 38253290 DOI: 10.1016/j.spinee.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND CONTEXT A previous cost-effectiveness analysis published in 2022 found that the Total Posterior Spine (TOPSTM) system was dominant over transforaminal lumbar interbody fusion (TLIF). This analysis required updating to reflect a more complete dataset and pricing considerations. PURPOSE To evaluate the cost-effectiveness of TOPSTM system as compared with TLIF based on an updated and complete FDA investigational device exemption (IDE) data set. STUDY DESIGN/SETTING Cost-utility analysis of the TOPSTM system compared to TLIF. PATIENT SAMPLE A multicenter, FDA IDE, randomized control trial (RCT) investigated the efficacy of TOPSTM compared to TLIF with a current population of n=305 enrolled and n=168 with complete 2-year follow-up. OUTCOME MEASURES Cost and quality adjusted life years (QALYs) were calculated to determine our primary outcome measure, the incremental cost-effectiveness ratio. Secondary outcome measures included: net monetary benefit as well at willingness-to-pay (WTP) thresholds. METHODS The primary outcome of cost-effectiveness is determined by incremental cost-effectiveness ratio. A Markov model was used to simulate the health outcomes and costs of patients undergoing TOPSTM or TLIF over a 2-year period. alternative scenario sensitivity analysis, one-way sensitivity analysis, and probabilistic sensitivity analysis were conducted to assess the robustness of the model results. RESULTS The updated base case result demonstrated that TOPSTM was immediately and longitudinally dominant compared with the control with an incremental cost-effectiveness ratio of -9,637.37 $/QALY. The net monetary benefit was correspondingly $2,237, both from the health system's perspective and at a WTP threshold of 50,000 $/QALY at the 2-year time point. This remained true in all scenarios tested. The Alternative Scenario Sensitivity Analysis suggested cost-effectiveness irrespective of payer type and surgical setting. To remain cost-effective, the cost difference between TOPSTM and TLIF should be no greater than $1,875 and $3,750 at WTP thresholds of $50,000 and 100,000 $/QALY, respectively. CONCLUSIONS This updated analysis confirms that the TOPSTM device is a cost-effective and economically dominant surgical treatment option for patients with lumbar stenosis and degenerative spondylolisthesis compared to TLIF in all scenarios examined.
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Affiliation(s)
- Jared D Ament
- Cedars Sinai Medical Center, Los Angeles, CA, USA; Neuronomics LLC, Los Angeles, CA, USA; Neurosurgery & Spine Group, Los Angeles, CA, USA; Institute of Neuro Innovation, Santa Monica, CA, USA.
| | - Jack Petros
- Institute of Neuro Innovation, Santa Monica, CA, USA
| | - Tina Zabehi
- Institute of Neuro Innovation, Santa Monica, CA, USA
| | - Randy Yee
- Neuronomics LLC, Los Angeles, CA, USA
| | | | - Amir Vokshoor
- Neuronomics LLC, Los Angeles, CA, USA; Neurosurgery & Spine Group, Los Angeles, CA, USA; Institute of Neuro Innovation, Santa Monica, CA, USA
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Abstract
Surgery for degenerative lumbar spondylolisthesis is significantly more cost-effective than nonsurgical management in patients who have failed to improve with a 6-week trial of nonsurgical management. Decompression plus fusion becomes more cost-effective compared with decompression alone at 2 years following surgery. Further study is needed to evaluate the most cost-effective fusion approach and augmentation strategy.
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Affiliation(s)
- Kristen E Jones
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA.
| | - David W Polly
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA; Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue Southeast, Suite R200, Minneapolis, MN 55454, USA
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Anderson DB, Ferreira ML, Harris IA, Davis GA, Stanford R, Beard D, Li Q, Jan S, Mobbs RJ, Maher CG, Yong R, Zammit T, Latimer J, Buchbinder R. SUcceSS, SUrgery for Spinal Stenosis: protocol of a randomised, placebo-controlled trial. BMJ Open 2019; 9:e024944. [PMID: 30765407 PMCID: PMC6398750 DOI: 10.1136/bmjopen-2018-024944] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/12/2018] [Accepted: 12/12/2018] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Central lumbar spinal stenosis (LSS) is a common cause of pain, reduced function and quality of life in older adults. Current management of LSS includes surgery to decompress the spinal canal and alleviate symptoms. However, evidence supporting surgical decompression derives from unblinded randomised trials with high cross-over rates or cohort studies showing modest benefits. This protocol describes the design of the SUrgery for Spinal Stenosis (SUcceSS) trial -the first randomised placebo-controlled trial of decompressive surgery for symptomatic LSS. METHODS AND ANALYSIS SUcceSS will be a prospectively registered, randomised placebo-controlled trial of decompressive spinal surgery. 160 eligible participants (80 participants/group) with symptomatic LSS will be randomised to either surgical spinal decompression or placebo surgical intervention. The placebo surgical intervention is identical to surgical decompression in all other ways with the exception of the removal of any bone or ligament. All participants and assessors will be blinded to treatment allocation. Outcomes will be assessed at baseline and at 3, 6, 12 and 24 months. The coprimary outcomes will be function measured with the Oswestry Disability Index and the proportion of participants who have meaningfully improved their walking capacity at 3 months postrandomisation. Secondary outcomes include back pain intensity, lower limb pain intensity, disability, quality of life, anxiety and depression, neurogenic claudication score, perceived recovery, treatment satisfaction, adverse events, reoperation rate and rehospitalisation rate. Those who decline to be randomised will be invited to participate in a parallel observational cohort. Data analysis will be blinded and by intention to treat. A trial-based cost-effectiveness analysis will determine the potential incremental cost per quality-adjusted life year gained. ETHICS AND DISSEMINATION Ethics approval has been granted by the NSW Health (reference:17/247/POWH/601) and the Monash University (reference: 12371) Human Research Ethics Committees. Dissemination of results will be via journal articles and presentations at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12617000884303; Pre-results.
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Affiliation(s)
- David B Anderson
- Insitute of Bone and Joint Research, The Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Insitute of Bone and Joint Research, The Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, University of New South Wales, St Leonards, New South Wales, Australia
| | - Gavin A Davis
- Department of Neurosurgery, Austin Health, Heidelberg, New South Wales, Australia
- Department of Neurosurgery, Cabrini Hospital, Malvern, Victoria, Australia
| | - Ralph Stanford
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, New South Wales, Australia
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, NIHR Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Qiang Li
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ralph J Mobbs
- Department of Orthopaedic Surgery, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Department of Neurosurgery, Prince of Wales Private Hospital, Randwick, New South Wales, Australia
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Christopher G Maher
- School of Public Health, The University of Sydney, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Renata Yong
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Tara Zammit
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane Latimer
- School of Public Health, The University of Sydney, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Fujimori T, Miwa T, Iwasaki M, Oda T. Cost-effectiveness of lumbar fenestration surgery in the Japanese universal health insurance system. J Orthop Sci 2018; 23:889-894. [PMID: 30075994 DOI: 10.1016/j.jos.2018.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 05/12/2018] [Accepted: 06/26/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Healthcare costs are a global concern, and cost-effectiveness analyses of interventions have become important. However, data regarding cost-effectiveness are limited to a few medical fields. The purpose of our study was to examine the Japanese universal health insurance system cost per quality-adjusted life year (QALY) for lumbar fenestration surgery. METHODS Forty-eight patients who underwent fenestration for lumbar degenerative spinal canal stenosis between July 2013 and September 2015 were included. Effectiveness was evaluated by measuring the EuroQOL 5-dimension (EQ-5D), Short-Form 8 physical component summary (PCS), and visual analog scale (VAS). Cost was analyzed from the perspective of the public healthcare payer. Effectiveness and cost were measured 1 year after surgery. QALYs were calculated by multiplying the utility value (EQ-5D) and life years. Only direct costs based on actual reimbursements were included. Cost per QALY with a 5-year time horizon with a 2% discount rate was estimated. Sensitivity analysis was performed by varying the time horizon (2 years or 10 years). RESULTS Mean total cost 1 year after fenestration surgery was 1,254,300 yen (standard deviation [SD], 430,000 yen; median, 1,172,300 yen). Operative cost was 406,800 yen (SD, 251,500 yen; median, 363,000 yen). Mean gained score was 0.21 for EQ-5D (SD, 0.18; median, 0.24), 11 for PCS (SD, 10; median, 12), and -43 for VAS (SD, 34; median, -38). Cost per QALY was 1,268,600 yen. Sensitivity analysis demonstrated that cost per QALY with a 10-year time horizon was 679,300 yen and that with a 2-year time horizon was 3,004,600 yen. CONCLUSIONS Cost per QALY of lumbar fenestration with a 5-year time horizon was 1,268,600 yen (11,532 US dollar), which was below the widely accepted benchmark (cost per QALY <5,000,000-6,500,000 yen (50,000 US dollars)). Fenestration is a cost-effective intervention.
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Affiliation(s)
- Takahito Fujimori
- Departments of Orthopedic Surgery, Sumitomo Hospital, Osaka, Japan; Department of Orthopedic Surgery, Japan Community Health Care Organization, Osaka Hospital, Osaka, Japan.
| | - Toshitada Miwa
- Departments of Orthopedic Surgery, Sumitomo Hospital, Osaka, Japan
| | - Motoki Iwasaki
- Department of Orthopedic Surgery, Osaka Rosai Hospital, Osaka, Japan
| | - Takenori Oda
- Departments of Orthopedic Surgery, Sumitomo Hospital, Osaka, Japan; Department of Orthopedic Surgery, Osaka Minami Medical Center, Osaka, Japan
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Kim CH, Chung CK, Kim MJ, Choi Y, Kim MJ, Shin S, Jung JM, Hwang SH, Yang SH, Park SB, Lee JH. 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. World Neurosurg 2018; 119:e313-e322. [PMID: 30053562 DOI: 10.1016/j.wneu.2018.07.139] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Brain and Cognitive Sciences, Seoul National University, Gwanak-gu, Seoul, South Korea.
| | - Myo Jeong Kim
- Health Insurance Review and Assessment Research Institute, Health Insurance Review and Assessment Service, Wonju, South Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Min-Jung Kim
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Sukyoun Shin
- Department of Customer Supporting Team, Samsung Life Insurance, Seocho-gu, Seoul, South Korea
| | - Jong-Myung Jung
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Sung Hwan Hwang
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea; Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, South Korea; Clinical Research Institute, Seoul National University Hospital, Jongno-gu, Seoul, South Korea
| | - Sung Bae Park
- Department of Neurosurgery, Seoul National University Hospital, Jongno-gu, Seoul, South Korea; Department of Neurosurgery, Seoul National University Boramae Hospital, Borame Medical Center Dongjak-gu, Seoul, South Korea
| | - Jun Ho Lee
- Department of Neurosurgery, Kyung Hee University Medical Center, Kyung Hee University School of Medicine, Dongdaemun-gu, Seoul, Republic of Korea
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O'Lynnger TM, Zuckerman SL, Morone PJ, Dewan MC, Vasquez-Castellanos RA, Cheng JS. Trends for Spine Surgery for the Elderly: Implications for Access to Healthcare in North America. Neurosurgery 2015; 77 Suppl 4:S136-41. [PMID: 26378351 DOI: 10.1227/neu.0000000000000945] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The proportion of the population over age 65 in the United States continues to increase over time, from 12% in 2000 to a projected 20% by 2030. There is an associated rise in the prevalence of degenerative spinal disorders with this aging population. This will lead to an increase in demand for both nonsurgical and surgical treatment for these disabling conditions, which will stress an already overburdened healthcare system. Utilization of spinal procedures and services has grown considerably. Comparing 1999 to 2009, lumbar epidural steroid injections have increased by nearly 900,000 procedures performed per year, while physical therapy evaluations have increased by nearly 1.4 million visits per year. We review the literature regarding the cost-effectiveness of spinal surgery compared to conservative treatment. Decompressive lumbar spinal surgery has been shown to be cost-effective in several studies, while adult spinal deformity surgery has higher total cost per quality-adjusted life year gained in the short term. With an aging population and unsustainable healthcare costs, we may be faced with a shortfall of beneficial spine care as demand for spinal surgery in our elderly population continues to rise. ABBREVIATION QALY, quality-adjusted life year.
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Affiliation(s)
- Thomas M O'Lynnger
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Manchikanti L, Falco FJE, Pampati V, Cash KA, Benyamin RM, Hirsch JA. Cost utility analysis of caudal epidural injections in the treatment of lumbar disc herniation, axial or discogenic low back pain, central spinal stenosis, and post lumbar surgery syndrome. Pain Physician 2013; 16:E129-E143. [PMID: 23703415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND In this era of escalating health care costs and the questionable effectiveness of multiple interventions, cost effectiveness or cost utility analysis has become the cornerstone of evidence-based medicine, and has an influence coverage decisions. Even though multiple cost effectiveness analysis studies have been performed over the years, extensive literature is lacking for interventional techniques. Cost utility analysis studies of epidural injections for managing chronic low back pain demonstrated highly variable results including a lack of cost utility in randomized trials and contrasting results in observational studies. There has not been any cost utility analysis studies of epidural injections in large randomized trials performed in interventional pain management settings. OBJECTIVES To assess the cost utility of caudal epidural injections in managing chronic low back pain secondary to lumbar disc herniation, axial or discogenic low back pain, lumbar central spinal stenosis, and lumbar post surgery syndrome. STUDY DESIGN This analysis is based on 4 previously published randomized trials. SETTING A private, specialty referral interventional pain management center in the United States. METHODS Four randomized trials were conducted assessing the clinical effectiveness of caudal epidural injections with or without steroids for lumbar disc herniation, lumbar discogenic or axial low back pain, lumbar central spinal stenosis, and post surgery syndrome. A cost utility analysis was performed with direct payment data for a total of 480 patients over a period of 2 years from these 4 trials. Outcome included various measures with significant improvement defined as at least a 50% improvement in pain reduction and disability status. RESULTS The results of 4 randomized controlled trials of low back pain with 480 patients with a 2 year follow-up with the actual reimbursement data showed cost utility for one year of quality-adjusted life year (QALY) of $2,206 for disc herniation, $2,136 for axial or discogenic pain without disc herniation, $2,155 for central spinal stenosis, and $2,191 for post surgery syndrome. All patients showed significant improvement clinically and showed positive results in the cost utility analysis with an average cost per one year QALY of $2,172.50 for all patients and $1,966.03 for patients judged to be successful. The results of this assessment show a better cost utility or lower cost of managing chronic, intractable low back pain with caudal epidural injections at a QALY that is similar or lower in price than medical therapy only, physical therapy, manipulation, and surgery in most cases. LIMITATIONS The limitations of this cost utility analysis include that it is a single center evaluation, even though 480 patients were included in the analysis. Further, only the costs of interventional procedures and physician visits were included. The benefits of returning to work were not assessed. CONCLUSION This cost utility analysis of caudal epidural injections in the treatment of disc herniation, axial or discogenic low back pain, central spinal stenosis, and post surgery syndrome in the lumbar spine shows the clinical effectiveness and cost utility of these injections at less than $2,200 per one year of QALY.
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Overdevest GM, Luijsterburg PAJ, Brand R, Koes BW, Bierma-Zeinstra SMA, Eekhof JAH, Vleggeert-Lankamp CLAM, Peul WC. Design of the Verbiest trial: cost-effectiveness of surgery versus prolonged conservative treatment in patients with lumbar stenosis. BMC Musculoskelet Disord 2011; 12:57. [PMID: 21371314 PMCID: PMC3058072 DOI: 10.1186/1471-2474-12-57] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Accepted: 03/03/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Degenerative changes of lumbar spine anatomy resulting in the encroachment of neural structures are often regarded progressive, ultimately necessitating decompressive surgery. However the natural course is not necessarily progressive and the efficacy of a variety of nonsurgical interventions has also been described. At present there is insufficient data to compare surgical and nonsurgical interventions in terms of their relative benefit and safety. Previous attempts failed to provide clear clinical recommendations or to distinguish subgroups that substantially benefit from a certain treatment strategy. We present the design of a randomized controlled trial on (cost-) effectiveness of surgical decompression versus prolonged conservative treatment in patients with neurogenic intermittent claudication caused by lumbar stenosis. METHODS/DESIGN The aim of the Verbiest trial is to evaluate the effectiveness of prolonged conservative treatment compared to decompressive surgery. The study is a multi-center randomized controlled trial with two parallel groups design. Patients (age over 50) presenting to the neurologist or neurosurgeon with at least 3 months complaints of neurogenic intermittent claudication and considering surgical treatment are eligible for inclusion. Participants are randomly allocated to either prolonged conservative treatment, receiving further treatment from their general practitioner and physical therapist, or allocated to surgery and operated within 4 weeks. Primary outcome measure is the functional assessment of the patient as measured by the Zurich Claudication Questionnaire at 24 months of follow-up. Data is analyzed according to the intention to treat principle. DISCUSSION With a cost-effectiveness analysis the trade off between the costs of prolonged conservative treatment and delayed surgery in a smaller number of patients are compared with the current policy of surgical management. As surgery is expected to be inevitable in certain subgroups of patients, the distinction of and classification by predictive patient characteristics is most relevant to clinical practice. TRIAL REGISTRATION Netherlands Trial Register (NTR): NTR2216.
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Affiliation(s)
- Gijsbert M Overdevest
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, Lijnbaan 32, 2512 VA The Hague, The Netherlands
| | - Pim AJ Luijsterburg
- Department of General Practice, Erasmus MC, University Medical Center, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Ronald Brand
- Department of Medical Statistics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Bart W Koes
- Department of General Practice, Erasmus MC, University Medical Center, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Sita MA Bierma-Zeinstra
- Department of General Practice, Erasmus MC, University Medical Center, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
- Department of Orthopaedic Surgery, Erasmus MC, University Medical Center, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Just AH Eekhof
- Department of General Practice, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | | | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, Lijnbaan 32, 2512 VA The Hague, The Netherlands
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Hansson T, Hansson E, Karlsson J. [Four years on a waiting lists for surgery--an expensive option. Millions in lost production while waiting for an orthopedic intervention]. Lakartidningen 2003; 100:1428-30, 1433-4. [PMID: 12756710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
This study was performed in order to determine the cost to society (in terms of loss of production) of having patients on paid sick-leave while on a waiting list for elective orthopedic surgery. All patients on surgical waiting lists receiving sick-leave benefits for the same diagnosis as for the planned procedure, specifically for lumbar disc herniation, lumbar spinal stenosis, and certain knee and shoulder diagnoses (not including arthritis), were identified at two large Swedish orthopedic clinics. These diagnoses were chosen since there is evidence that surgery can reduce pain and disability and also improve work ability. The number of days on sick-leave was determined individually as was each subject's reimbursement from universal health insurance. These benefits were treated as equal to the production losses caused by their inability to work according to the so-called Human Capital Method. 159 patients on the waiting lists were on sick-leave. The average waiting time varied between one and two years for the diagnoses included. Forty-four of the patients were granted temporary or permanent disability pensions while awaiting surgery. The costs for paid sick-leave together with future costs for those granted permanent disability pensions were almost 90 million SEK (almost 90 million USD). This amount corresponded to the cost of more than 2000 disc operations or more than 1000 total hip replacements. Instead of being spent on sick-leave this money ought to be used to shorten the waiting time for surgery.
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Affiliation(s)
- Tommy Hansson
- Ortopedkliniken, Sahlgrenska Universitetssjukhuset, Göteborg.
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Kuntz KM, Snider RK, Weinstein JN, Pope MH, Katz JN. Cost-effectiveness of fusion with and without instrumentation for patients with degenerative spondylolisthesis and spinal stenosis. Spine (Phila Pa 1976) 2000; 25:1132-9. [PMID: 10788859 DOI: 10.1097/00007632-200005010-00015] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cost-effectiveness study was performed from the societal perspective. OBJECTIVE To evaluate the costs and benefits of laminectomy alone and laminectomy with concomitant lumbar fusion for patients with degenerative lumbar spondylolisthesis and spinal stenosis. SUMMARY OF BACKGROUND DATA Costs, probabilities, and utilities were estimated from the literature. Short-term risks considered were perioperative complications, the probability of the fusion healing, and the probability that surgery will relieve symptoms. Long-term risks considered were recurrence of symptoms and reoperation. METHODS The 10-year costs, quality-adjusted life years, and incremental cost-effectiveness ratios (reported as dollars per quality-adjusted year of life gained) were calculated using a Markov model. Sensitivity analysis was performed on all variables using clinically plausible ranges. RESULTS Laminectomy with noninstrumented fusion costs $56,500 per quality-adjusted year of life versuslaminectomy without fusion. The cost-effectiveness of laminectomy with noninstrumented fusion was most sensitive to the increase in quality-of-life associated with relief of severe stenosis symptoms. The cost-effectiveness ratio of instrumented fusion compared with noninstrumented fusion was $3,112,800 per quality-adjusted year of life. However, if the proportion of patients experiencing symptom relief after instrumented fusion was 90% as compared with 80% for patients with noninstrumented fusion, then the cost-effectiveness ratio of instrumented fusion compared with noninstrumented fusion would be $82,400 per quality-adjusted year of life. CONCLUSIONS The cost-effectiveness of laminectomy with noninstrumented fusion compares favorably with other surgical interventions, although it depends greatly on the true effectiveness of these surgeries to alleviatesymptoms and on how patients value the quality-of-life effect of relieving severe stenosis symptoms. Instrumented fusion was very expensive compared with the incremental gain in health outcome. Better data on the effectiveness of these alternative procedures are needed.
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Affiliation(s)
- K M Kuntz
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115-5924, USA.
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Katz JN, Lipson SJ, Lew RA, Grobler LJ, Weinstein JN, Brick GW, Fossel AH, Liang MH. Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes. Spine (Phila Pa 1976) 1997; 22:1123-31. [PMID: 9160471 DOI: 10.1097/00007632-199705150-00012] [Citation(s) in RCA: 234] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
DESIGN A prospective, multicenter observational study. OBJECTIVES 1) Identify correlates of the decision to perform arthrodesis in patients undergoing laminectomy for lumbar spinal stenosis. 2) Compare symptoms, walking capacity, and satisfaction 6 and 24 months after laminectomy alone and laminectomy with noninstrumented and with instrumented arthrodesis. BACKGROUND DATA Few prospective studies have compared outcomes of laminectomy alone or laminectomy with noninstrumented or with instrumented arthrodesis in patients with degenerative lumbar spinal stenosis. There is uncertainty regarding the optimal use of arthrodesis and instrumentation. METHODS Two hundred seventy--two patients undergoing--surgery for degenerative lumbar stenosis by eight surgeons at four centers were included in the study cohort. Of these, 37 had noninstrumented and 41 had instrumented arthrodesis. Logistic regression identified factors associated with arthrodesis. The principal outcomes-health status, walking capacity, back and leg pain, and satisfaction with surgery-were assessed 6 and 24 months postoperatively with univariate and multivariate techniques. Outcomes also were assessed in a restricted cohort of patients with at least 5 mm spondylolisthesis and/or 15 degrees scoliosis. Hospital costs were obtained from a computerized hospital cost accounting system. RESULTS The major predictor of the decision to perform arthrodesis was the individual surgeon (P = 0.0001). Noninstrumented arthrodesis was associated with superior relief of low back pain at 6 months (P = 0.004) and 24 months (P = 0.01). This difference persisted in multivariate analyses, with borderline statistical significance. There were no significant differences in the other outcomes across treatment groups. Mean hospital costs of laminectomy alone and noninstrumented and instrumented arthrodesis were $12,615, $18,495, and $25,914, respectively (P = 0.0001). CONCLUSION Findings were limited by the small number of participating surgeons, modest sample size that produced P values of borderline significance, and nonrandomized design. With these caveats in mind, the authors conclude: (1) The individual surgeon was a more important correlate of the decision to perform arthrodesis than clinical variables such as spondylolisthesis. (2) Noninstrumented arthrodesis resulted in superior relief of back pain after 6 and 24 months. (3) Instrumented arthrodesis was the most costly option. These results highlight the need for randomized controlled trials and cost effectiveness analyses of lumbar arthrodesis and instrumentation in patients with degenerative lumbar spinal stenosis.
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Affiliation(s)
- J N Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Deyo RA, Cherkin DC, Loeser JD, Bigos SJ, Ciol MA. Morbidity and mortality in association with operations on the lumbar spine. The influence of age, diagnosis, and procedure. J Bone Joint Surg Am 1992; 74:536-43. [PMID: 1583048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We examined the rates of postoperative complications and mortality, as recorded in a hospital discharge registry for the State of Washington for the years 1986 through 1988, for patients who had had an operation on the lumbar spine. When patients who had had a malignant lesion, infection, or fracture are excluded, there were 18,122 hospitalizations for procedures on the lumbar spine, 84 per cent of which involved a herniated disc or spinal stenosis. The rates of morbidity and mortality during hospitalization, as well as the hospital charges, increased with the ages of the patients. The rate of complications was 18 per cent for patients who were seventy-five years or older. Nearly 7 per cent of patients who were seventy-five years old or more were discharged to nursing homes. Complications were most frequent among patients who had spinal stenosis, but multivariate analysis suggested that the complications associated with procedures for this condition were primarily related to the patient's age and the type of procedure. Complications, length of hospitalization, and charges were higher for patients who had had a spinal arthrodesis than for those who had not. Over-all, operations for conditions other than a herniated disc were associated with more complications and greater use of resources, particularly when arthrodesis was performed, than were operations for removal of a herniated disc. No data on symptoms or functional results were available.
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Affiliation(s)
- R A Deyo
- Department of Medicine, University of Washington, Seattle 98195
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