Total posterior spine system is a cost-effective option for spondylolisthesis, stenosis
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Compared with transforaminal lumbar interbody fusion, the Total Posterior Spine System by Premia Spine is a more cost-effective option for treatment of degenerative lumbar spondylolisthesis and stenosis, according to results.
In a prospective, multicenter, randomized controlled trial, Jared D. Ament, MD, and colleagues analyzed 121 patients (mean age of 64 years) with grade 1 degenerative spondylolisthesis and lumbar stenosis who were randomly assigned to receive either the novel Total Posterior Spine System, also known as TOPS, or standard transforaminal lumbar interbody fusion (TLIF) with a minimum 1-year follow-up. Researchers noted a 2:1 randomization that favored the TOPS cohort.
Outcome measures included incremental cost-effectiveness ratio (ICER), as well as quality-adjusted life-years (QALYs) and cost, which were discounted at a yearly rate of 3% to reflect their present value, according to the study. Additionally, the primary time horizon to estimate cost and health utility was 2 years after index surgery, and researchers assumed a 50/50 split between Medicare and private payers.
At 2 years, the novel system incurred a $300 greater cost than TLIF while gaining 0.0489 additional QALYs. The 2-year ICER for the novel system vs. TLIF was $6,158 per QALY, “significantly lower than the most conservative U.S. willingness-to-pay (WTP) threshold of $50,000 per QALY,” the researchers noted. “At 6 years and beyond, TOPS becomes the dominant economic strategy, irrespective of payer mix or surgical setting,” Ament and colleagues wrote in the study. Despite a $4,000 upcharge vs. TLIF, 63% of all 5,000 input parameter simulations favored the novel system at WTP thresholds of $100,000 per QALY.
“This is the first instance of a lumbar facet arthroplasty device demonstrating cost-effectiveness over fusion. Since the TOPS system yields greater quality of life at a lower total cost over time, it deserves serious attention,” the researchers added. “In the emerging, rapidly expanding field of value-based medicine, there will be an increased demand for these analyses, ensuring surgeons are empowered to make the best, most sustainable solutions for their patients and society,” they wrote.
Perspective
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This study represents an elegant and sophisticated cost-effectiveness estimation of the Total Posterior Spine System by Premia Spine vs. transforaminal lumbar interbody fusion for a degenerative spondylolisthesis cohort from an IDE study. Cost-effectiveness studies are challenging when dealing with the actual hard data as Tosteson and colleagues did with the SPORT data in 2008. This paper essentially showed that surgery for degenerative spondylolisthesis was not cost-effective at 2 years when compared with the nonsurgical cohort. Subsequent study and longer follow-up demonstrated, due to the durability of the excellent results with surgery, that the intervention (surgery) became cost-effective at 4 years.
Those conclusions were based, however, on data rather than estimation. It would be excellent if, with careful and complete follow-up, the results of the present study and their conclusions are born out.
We certainly know that decompression and fusion results in excellent and durable outcomes for our patients with stenosis and degenerative spondylolisthesis. Improvements and more cost-effective interventions would be great for both surgeons and patients. More work is certainly warranted to see if this aspiration can be attained.
References:
Tosteson ANA, et al. Ann Intern Med. 2008;doi:10.7326/0003-4819-149-12-200812160-00003.
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