Increased risk factors may reduce cost-effectiveness of adult spinal deformity surgery
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Results showed a higher number of risk factors prior to and during adult spinal deformity surgery may reduce cost-effectiveness by increasing total cost and reducing quality-adjusted life years.
Peter G. Passias, MD, and colleagues collected demographic variables and surgical and complication data, and assessed health-related quality of life using the Oswestry Disability Index (ODI) and SF-36 among 727 patients enrolled in the International Spine Study Group Adult Spinal Deformity database.
“In terms of risk stratification criteria, we modified the original work that was done by [Ferran Pellisé, MD, PhD and colleagues] to more appropriately fit our population,” Passias said in his presentation at the North American Spine Society Annual Meeting, which received a 2021 Value Award.
He noted these criteria included lowest instrumental vertebrae at pelvis, frailty, sagittal deformity, lordosis gap, T1 sagittal tilt, blood loss and surgical time.
“Patients in the highest tertials of these frailty, sagittal deformity measures, estimated blood loss and surgical times were defined as possessing the risk factor of interest for the purpose of our analysis,” Passias said.
Researchers made cost calculations using the PearlDiver database and used standardized estimate by regression analysis of Medicare pay-scales to ensure generalizability. They included all services within a 30-day window in cost calculations and assessed complications and comorbidities according to CMS definitions.
Passias noted patients had corresponding increases in major complication rates and reoperation rates as the number of risk factors increased.
“Patients who met three of the four risk factors had significantly higher major complication rates, reoperations, surgical ICU admissions, proximal kyphosis, pseudoarthrosis by 2 years, surgical implant failure and rod and screw breakage,” Passias said.
Cost evaluation showed an increase per risk factor when analyzing risk factor quantity against initial surgical cost, according to Passias. Trend-line analysis for risk factors against national average cost showed a more robust difference. Passias noted risk factors had a positive correlation with 2-year ODI and cost per quality-adjusted life year (QALY) increased by approximately $46,000 per risk factor.
“Generally, across the board, as risk factors increased, total 2-year cost increased, QALYs gained at 2 years and life expectancy decreased, and cost per QALY at life expectancy increased, indicating decreased cost-effectiveness,” Passias said.
Perspective
Back to TopRoger Härtl, MD, and Ibrahim Hussain, MD
In our current economic climate, hospitals and insurance companies are increasingly scrutinizing not only the costs of performing complex surgeries, but their long-term effectiveness in restoring patients’ health and function to soften further burden to the health care system. Understanding which patients are at increased risk for complications can influence decision-making and risk mitigation strategies, which impact costs 2 years down the road, as the authors of the current study demonstrate.
Their findings echo previously published reports examining patients with high frailty indices, abnormal age-adjusted radiographic parameters, and those who endure higher blood loss and longer procedural times. What’s astounding about their study is the inclusion of 727 patients with 2-year follow-up. This is a herculean task that can only accomplished by organized, multicenter study groups. Patients falling into three of these risk factor categories had significantly higher complications and reoperations. Moreover, the authors found that quality-adjusted life year costs increased a staggering $46,000 per risk factor.
Peter G. Passias, MD, and colleagues should be commended for this work. It strongly underscores the importance of thorough patient and surgical approach selection beyond standard clinicoradiographic findings. While we can quantitatively estimate the costs of these adverse outcomes, the ultimate cost to the patient is immeasurable.
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Passias PG, et al. Paper 207. Presented at: North American Spine Society Annual Meeting. Sept. 29 - Oct. 2, 2021; Boston (hybrid meeting).
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