Cost-effectiveness analysis: comparing single-level cervical disc replacement and single-level anterior cervical discectomy and fusion

Clinical article

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Object

In recent years, there has been increased interest in the use of cervical disc replacement (CDR) as an alternative to anterior cervical discectomy and fusion (ACDF). While ACDF is a proven intervention for patients with myelopathy or radiculopathy, it does have inherent limitations. Cervical disc replacement was designed to preserve motion, avoid the limitations of fusion, and theoretically allow for a quicker return to activity. A number of recently published systematic reviews and randomized controlled trials have demonstrated positive clinical results for CDR, but no studies have revealed which of the 2 treatment strategies is more cost-effective. The purpose of this study was to evaluate the cost-effectiveness of CDR and ACDF by using the power of decision analysis. Additionally, the authors aimed to identify the most critical factors affecting procedural cost and effectiveness and to define thresholds for durability and function to focus and guide future research.

Methods

The authors created a surgical decision model for the treatment of single-level cervical disc disease with associated radiculopathy. The literature was reviewed to identify possible outcomes and their likelihood following CDR and ACDF. Health state utility factors were determined from the literature and assigned to each possible outcome, and procedural effectiveness was expressed in units of quality-adjusted life years (QALYs). Using ICD-9 procedure codes and data from the Nationwide Inpatient Sample, the authors calculated the median cost of hospitalization by multiplying hospital charges by the hospital-specific cost-to-charge ratio. Gross physician costs were determined from the mean Medicare reimbursement for each current procedural terminology (CPT) code. Uncertainty as regards both cost and effectiveness numbers was assessed using sensitivity analysis.

Results

In the reference case, the model assumed a 20-year duration for the CDR prosthesis. Cervical disc replacement led to higher average QALYs gained at a lower cost to society if both strategies survived for 20 years ($3042/QALY for CDR vs $8760/QALY for ACDF). Sensitivity analysis revealed that CDR needed to survive at least 9.75 years to be considered a more cost-effective strategy than ACDF. Cervical disc replacement becomes an acceptable societal strategy as the prosthesis survival time approaches 11 years and the $50,000/QALY gained willingness-to-pay threshold is crossed. Sensitivity analysis also indicated that CDR must provide a utility state of at least 0.796 to be cost-effective.

Conclusions

Both CDR and ACDF were shown to be cost-effective procedures in the reference case. Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF. Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR, future long-term studies are required to validate the present analysis.

Abbreviations used in this paper:ACDF = anterior cervical discectomy and fusion; CDR = cervical disc replacement; CEA = cost-effectiveness analysis; CER = cost-effectiveness ratio; CPT = current procedural terminology; DRG = diagnosis-related group; ICER = incremental CER; NDI = Neck Disability Index; NIS = Nationwide Inpatient Sample; QALY = quality-adjusted life year; SF-36 = 36-Item Short-Form Health Survey; WTP = willingness-to-pay.

Article Information

Address correspondence to: Sheeraz A. Qureshi, M.D., M.B.A., Mount Sinai Medical Center, Department of Orthopaedic Surgery, 5 E. 98th St., 9th Floor, Box 1188, New York, NY 10029. email: sheeraz.qureshi@mountsinai.org.

Please include this information when citing this paper: published online September 6, 2013; DOI: 10.3171/2013.8.SPINE12623.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Decision model for the treatment of single-level degenerative disc disease (DDD) in the reference case. M = male; y/o = year old.

  • View in gallery

    Variation in prosthesis survival time to determine threshold cost-effectiveness level. Incr. = incremental.

  • View in gallery

    Results of sensitivity analysis of the effect of the cost variance of CDR. Red line represents ACDF; blue line, CDR.

  • View in gallery

    Results of sensitivity analysis of the effect of utility factor variance on the ICER of CDR. Red line represents ACDF; blue line, CDR.

References

1

Anderson PASasso RCRiew KD: Comparison of adverse events between the Bryan artificial cervical disc and anterior cervical arthrodesis. Spine (Phila Pa 1976) 33:130513122008

2

Anderson PASasso RCRouleau JPCarlson CSGoffin J: The Bryan Cervical Disc: wear properties and early clinical results. Spine J 4:6 Suppl303S309S2004

3

Bhadra AKRaman ASCasey ATCrawford RJ: Single-level cervical radiculopathy: clinical outcome and cost-effectiveness of four techniques of anterior cervical discectomy and fusion and disc arthroplasty. Eur Spine J 18:2322372009

4

Bohlman HHEmery SEGoodfellow DBJones PK: Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am 75:129813071993

5

Burkus JKHaid RWTraynelis VCMummaneni PV: Long-term clinical and radiographic outcomes of cervical disc replacement with the Prestige disc: results from a prospective randomized controlled clinical trial. Clinical article. J Neurosurg Spine 13:3083182010

6

Chang RWPellisier JMHazen GB: A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA 275:8588651996

7

Coric DFinger FBoltes P: Prospective randomized controlled study of the Bryan Cervical Disc: early clinical results from a single investigational site. J Neurosurg Spine 4:31352006

8

Coric DNunley PDGuyer RDMusante DCarmody CNGordon CR: Prospective, randomized, multicenter study of cervical arthroplasty: 269 patients from the Kineflex|C artificial disc investigational device exemption study with a minimum 2-year follow-up. Clinical article. J Neurosurg Spine 15:3483582011

9

Emery SEBolesta MJBanks MAJones PK: Robinson anterior cervical fusion comparison of the standard and modified techniques. Spine (Phila Pa 1976) 19:6606631994

10

Epstein NE: Efficacy and outcomes of dynamic-plated single-level anterior diskectomy/fusion with additional analysis of comparative costs. Surg Neurol Int 2:92011

11

Fraser JFHartl R: Anterior approaches to fusion of the cervical spine: a meta-analysis of fusion rates. J Neurosurg Spine 6:2983032007

12

Fryback DGDasbach EJKlein RKlein BEDorn NPeterson K: The Beaver Dam Health Outcomes Study: initial catalog of health-state quality factors. Med Decis Making 13:891021993

13

Garrido BJTaha TASasso RC: Clinical outcomes of Bryan cervical disc arthroplasty a prospective, randomized, controlled, single site trial with 48-month follow-up. J Spinal Disord Tech 23:3673712010

14

Goffin JCasey AKehr PLiebig KLind BLogroscino C: Preliminary clinical experience with the Bryan Cervical Disc Prosthesis. Neurosurgery 51:8408472002

15

Goffin JVan Calenbergh Fvan Loon JCasey AKehr PLiebig K: Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: single-level and bi-level. Spine (Phila Pa 1976) 28:267326782003

16

Goffin Jvan Loon JVan Calenbergh FLipscomb B: A clinical analysis of 4- and 6-year follow-up results after cervical disc replacement surgery using the Bryan Cervical Disc Prosthesis. Clinical article. J Neurosurg Spine 12:2612692010

17

Gore DRSepic SB: Anterior cervical fusion for degenerated or protruded discs: a review of one hundred and forty-six patients. Spine (Phila Pa 1976) 9:6676711984

18

Heller JGSasso RCPapadopoulos SMAnderson PAFessler RGHacker RJ: Comparison of BRYAN cervical disc arthroplasty with anterior cervical decompression and fusion: clinical and radiographic results of a randomized, controlled, clinical trial. Spine (Phila Pa 1976) 34:1011072009

19

Hilibrand ASCarlson GDPalumbo MAJones PKBohlman HH: Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am 81:5195281999

20

Malter ADLarson EBUrban NDeyo RA: Cost-effectiveness of lumbar discectomy for the treatment of herniated intervertebral disc. Spine (Phila Pa 1976) 21:104810551996

21

McAfee PCReah CGilder KEisermann LCunningham B: A meta-analysis of comparative outcomes following cervical arthroplasty or anterior cervical fusion: results from 4 prospective multicenter randomized clinical trials and up to 1226 patients. Spine (Phila Pa 1976) 37:9439522012

22

Mummaneni PVBurkus JKHaid RWTraynelis VCZdeblick TA: Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial. J Neurosurg Spine 6:1982092007

23

Murrey DJanssen MDelamarter RGoldstein JZigler JTay B: Results of the prospective, randomized, controlled multicenter Food and Drug Administration investigational device exemption study of the ProDisc-C total disc replacement versus anterior discectomy and fusion for the treatment of 1-level symptomatic cervical disc disease. Spine J 9:2752862009

24

Naimark DKrahn MDNaglie GRedelmeier DADetsky AS: Primer on medical decision analysis: part 5—working with Markov processes. Med Decis Making 17:1521591997

25

Nesterenko SORiley LH IIISkolasky RL: Anterior cervical discectomy and fusion versus cervical disc arthroplasty: current state and trends in treatment for cervical disc pathology. Spine (Phila Pa 1976) 37:147014742012

26

Peng CWYue WMBasit AGuo CMTow BPChen JL: Intermediate results of the prestige LP cervical disc replacement: clinical and radiological analysis with minimum two-year follow-up. Spine (Phila Pa 1976) 36:E105E1112011

27

Riew KDBuchowski JMSasso RCZdeblick TMetcalf NHAnderson PA: Cervical disc arthroplasty compared with arthrodesis for the treatment of myelopathy. J Bone Joint Surg Am 90:235423642008

28

Robertson JTPapadopolous SMTraynelis VC: Assessment of adjacent-segment disease in patients treated with cervical arthroplasty: a prospective 2-year study. J Neurosurg Spine 3:4174232005

29

Russell LBGold MRSiegel JEDaniels NWeinstein MC: The role of cost-effectiveness analysis in health and medicine. JAMA 276:117211771996

30

Sasso RCSmucker JDHacker RJHeller JG: Artificial disc versus fusion: a prospective, randomized study with 2-year follow-up on 99 patients. Spine (Phila Pa 1976) 32:293329422007

31

Schulman KA: Medicare and cost-effectiveness analysis. N Engl J Med 354:2072092006. (Letter)

32

Siegel JEWeinstein MCRussell LBGold MR: Recommendations for reporting cost-effectiveness analyses. JAMA 276:133913411996

33

SooHoo NFKominski G: Cost-effectiveness analysis of total ankle arthroplasty. J Bone Joint Surg Am 86-A:244624552004

34

Tengs TOWallace A: One thousand health-related quality-of-life estimates. Med Care 38:5836372000

35

Tumeh JWMoore SGShapiro RFlowers CR: Practical approach for using Medicare data to estimate costs for cost-effectiveness analysis. Expert Rev Pharmacoecon Outcomes Res 5:1531622005

36

Upadhyaya CDWu JCTrost GHaid RWTraynelis VCTay B: Analysis of the three United States Food and Drug Administration investigational device exemption cervical arthroplasty trials. Clinical article. J Neurosurg Spine 16:2162282012

37

Weinstein MCSiegel JEGold MRKamlet MSRussell LB: Recommendations of the Panel on Cost-Effectiveness in Health and Medicine. JAMA 276:125312581996

38

Wohns R: Safety and cost-effectiveness of outpatient cervical disc arthroplasty. Surg Neurol Int 1:772010

39

Yue WMBrodner WHighland TR: Long-term results after anterior cervical discectomy and fusion with plating: a 5- to 11-year radiologic and clinical follow-up study. Spine (Phila Pa 1976) 30:213821442005

40

Zechmeister IWinkler RMad P: Artificial total disc replacement versus fusion for the cervical spine: a systematic review. Eur Spine J 20:1771842011

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