Costs and readmission rates for the resection of primary and metastatic spinal tumors: a comparative analysis of 181 patients

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OBJECTIVE

Because the surgical strategies for primary and metastatic spinal tumors are different, the respective associated costs and morbidities associated with those treatments likely vary. This study compares the direct costs and 90-day readmission rates between the resection of extradural metastatic and primary spinal tumors. The factors associated with cost and readmission are identified.

METHODS

Adults (age 18 years or older) who underwent the resection of spinal tumors between 2008 and 2013 were included in the study. Patients with intradural tumors were excluded. The direct costs of index hospitalization and 90-day readmission hospitalization were evaluated. The direct costs were compared between patients who were treated surgically for primary and metastatic spinal tumors. The independent factors associated with costs and readmissions were identified using multivariate analysis.

RESULTS

A total of 181 patients with spinal tumors were included (63 primary and 118 metastatic tumors). Overall, the mean index hospital admission cost for the surgical management of spinal tumors was $52,083. There was no significant difference in the cost of hospitalization between primary ($55,801) and metastatic ($50,098) tumors (p = 0.426). The independent factors associated with higher cost were male sex (p = 0.032), preoperative inability to ambulate (p = 0.002), having more than 3 comorbidities (p = 0.037), undergoing corpectomy (p = 0.021), instrumentation greater than 7 levels (p < 0.001), combined anterior-posterior approach (p < 0.001), presence of a perioperative complication (p < 0.001), and longer hospital stay (p < 0.001). The perioperative complication rate was 21.0%. Of this cohort, 11.6% of patients were readmitted within 90 days, and the mean hospitalization cost of that readmission was $20,078. Readmission rates after surgical treatment for primary and metastatic tumors were similar (11.1% vs 11.9%, respectively) (p = 0.880). Prior hospital stay greater than 15 days (OR 6.62, p = 0.016) and diagnosis of lung metastasis (OR 52.99, p = 0.007) were independent predictors of readmission.

CONCLUSIONS

Primary and metastatic spinal tumors are comparable with regard to the direct costs of the index surgical hospitalization and readmission rate within 90 days. The factors independently associated with costs are related to preoperative health status, type and complexity of surgery, and postoperative course.

OBJECTIVE

Because the surgical strategies for primary and metastatic spinal tumors are different, the respective associated costs and morbidities associated with those treatments likely vary. This study compares the direct costs and 90-day readmission rates between the resection of extradural metastatic and primary spinal tumors. The factors associated with cost and readmission are identified.

METHODS

Adults (age 18 years or older) who underwent the resection of spinal tumors between 2008 and 2013 were included in the study. Patients with intradural tumors were excluded. The direct costs of index hospitalization and 90-day readmission hospitalization were evaluated. The direct costs were compared between patients who were treated surgically for primary and metastatic spinal tumors. The independent factors associated with costs and readmissions were identified using multivariate analysis.

RESULTS

A total of 181 patients with spinal tumors were included (63 primary and 118 metastatic tumors). Overall, the mean index hospital admission cost for the surgical management of spinal tumors was $52,083. There was no significant difference in the cost of hospitalization between primary ($55,801) and metastatic ($50,098) tumors (p = 0.426). The independent factors associated with higher cost were male sex (p = 0.032), preoperative inability to ambulate (p = 0.002), having more than 3 comorbidities (p = 0.037), undergoing corpectomy (p = 0.021), instrumentation greater than 7 levels (p < 0.001), combined anterior-posterior approach (p < 0.001), presence of a perioperative complication (p < 0.001), and longer hospital stay (p < 0.001). The perioperative complication rate was 21.0%. Of this cohort, 11.6% of patients were readmitted within 90 days, and the mean hospitalization cost of that readmission was $20,078. Readmission rates after surgical treatment for primary and metastatic tumors were similar (11.1% vs 11.9%, respectively) (p = 0.880). Prior hospital stay greater than 15 days (OR 6.62, p = 0.016) and diagnosis of lung metastasis (OR 52.99, p = 0.007) were independent predictors of readmission.

CONCLUSIONS

Primary and metastatic spinal tumors are comparable with regard to the direct costs of the index surgical hospitalization and readmission rate within 90 days. The factors independently associated with costs are related to preoperative health status, type and complexity of surgery, and postoperative course.

The spine is a common location for the development of primary and metastatic tumors. Metastatic spinal tumors (secondary malignancies) make up the majority of all spinal tumors. In fact, 31% of autopsies of patients who die of a malignant neoplasm harbor sites of spinal metastases.29 Most often, metastatic spinal tumors affect the bony vertebral column and are infrequently found in the intradural space. Conversely, primary spinal tumors may be benign or malignant, are relatively rare, and have a more heterogeneous origin as they may arise from the osseous spinal column, intradural extramedullary compartments, or spinal cord. Both primary and metastatic spinal lesions can demonstrate a range of benign and locally aggressive behaviors.

The surgical indications, management, and goals of treating primary and metastatic tumors are different. Cure is the aim for primary tumors, while palliation to alleviate pain, restore or preserve neurological function, and stabilize the spine are the goals of metastatic tumor treatment. Therefore, surgical strategies are diverse and include simple decompression, local tumor debridement, complete tumor resection (via piecemeal or en bloc removal), and/or spinal reconstruction, which may be accomplished via anterior and posterior approaches.19 Although the surgical treatment of metastatic and primary tumors of the spine may be associated with significant morbidity, surgery for metastatic tumors has been proven to offer significant improvements in Karnofsky Performance Scale scores and overall survival.23 Similarly, the outcomes of resection for primary spinal tumors are favorable.28

Improvement of functional outcomes is ideally accompanied by cost-effective care. Cost analyses of numerous spinal surgical techniques for treating various pathologies permeate the spine literature, ranging from the management of degenerative disc disease to scoliosis deformity.1–3,7,10,11,16,21,24–27,30,31,38,39,43 Elucidating the elements that affect the cost of spinal surgery can have significant implications for providing safe care in a cost-effective manner. There is a paucity of studies that directly evaluate the cost of surgery for spinal tumors.9,12,34,41,44 Many of the past studies have focused on the health care costs associated with managing (medically and/or surgically) heterogeneous cohorts of patients with bony metastasis8,13,14,17 or evaluated the cost effectiveness of adjuvant radiotherapy for spinal metastasis.15 In addition, among those studies there is a lack of details regarding the type of procedure performed or a dedicated analysis of the factors that affect cost. To the best of our knowledge, there are no studies comparing the costs between primary and metastatic spinal tumors. Therefore, in this study, we performed a detailed retrospective assessment of the index hospital costs associated with the surgical management of extradural primary and metastatic spinal tumors at a single institution. We compare the direct costs of primary and metastatic spinal tumors and identify the independent factors associated with cost. The independent risk factors for 90-day readmission are also examined.

Methods

Patients

The study cohort represents a consecutive series of adult patients (18 years or older) who underwent surgery for a spinal tumor between 2008 and 2013 at a single institution. The diagnosis of a spinal tumor was confirmed by histopathological analysis. Patients were excluded from the final analysis if they had an intradural tumor, underwent biopsy only, underwent kyphoplasty/vertebroplasty only, and/or did not have cost data available for analysis. The indications for surgery in the patients with either primary or metastatic spinal tumors were the presence of spinal cord or nerve compression with impending injury, presence of a neurological deficit, spinal instability due to bony destruction, growing radioresistant tumors, and/or intractable pain unresponsive to nonsurgical management. In addition, for patients with metastatic tumors, patients were evaluated by the oncology team for advice regarding prognosis. Surgery was offered to patients with greater than 3 months of life expectancy.

Data

The primary outcome of interest was the direct cost associated with the index hospitalization. Cost data were obtained through the hospital's administrative records and represent the direct cost to the hospital for the patient's admission. These were based on 4 categories: surgical supplies (implants and other surgical supplies), services (including inpatient services such as physical/occupational therapy and intraoperative services such as operating room staffing fees, neuromonitoring, and fluoroscopy), room and care, and pharmacy services. Indirect costs (i.e., hospital administrative and facilities overhead, health information management, accounting and billing, and housekeeping) were excluded. Surgeon fees, the costs for a skilled nursing facility, and acute rehabilitation were not included in the direct cost data. Anesthesia fees were considered as a component of the operating room costs. The secondary outcomes of interest were the 90-day readmission rate and cost associated with hospitalization. The 90-day readmission rate concentrates only on the complications related to spinal tumor surgery.

The demographic data and clinical variables, including tumor type and perioperative outcomes, were retrospectively collected through detailed review of the medical records. The collected demographic and clinical variables included age (stratified as younger than 45 years, 45–65 years, and older than 65 years), sex, presence of preoperative neurological deficit, preoperative ability to ambulate, and presence of various comorbidities (psychiatric disease, thyroid disease, pulmonary disease, vascular disease, hyperlipidemia, diabetes mellitus, liver disease, kidney disease, stroke, and heart disease). The ability to ambulate was defined as upright walking with or without a walking aid, but without help from an individual. The use of preoperative, perioperative, and/or postoperative radiation therapy was recorded. The postoperative radiotherapies of interest were treatments administered within the 90-day readmission period. The tumor characteristics of interest included tumor type (primary or metastasis) and spinal region (cervical, thoracic, lumbar, or sacral). Data regarding extraspinal tumor burden and metastasis were recorded and categorized by the number of metastasis sites: 0, 1, 2, and 3 or more. Perioperative parameters included type of procedure (corpectomy), number of levels instrumented, presence of perioperative complications, and length of hospitalization (in days). A perioperative complication was defined as any unforeseen event requiring additional medical or surgical care within the perioperative period.

Statistical Analysis

Descriptive statistical methods were used to define the mean direct cost and 90-day readmission rate. Bivariate analyses were used to test the associations of the covariates with the direct costs and readmission rates. Analysis of variance was used for continuous outcome variables (direct cost), and chi-square analysis was used for categorical outcomes (readmission rate). To identify independent factors associated with the outcomes of interest, multivariate analytical methods were employed. Multivariate analysis of covariance was used for continuous outcomes (direct cost), and logistic regression analysis was used for categorical outcomes (readmission rate). Covariates with a p value < 0.20 were included in the final multivariate models. The threshold for statistical significance for this study was a p value less than 0.05. All statistical analyses were performed using SAS (version 9.3 SAS Institute).

Results

Of the 222 patients initially identified, 181 patients met the a priori inclusion criteria and had sufficient data for the final analysis. The mean age was 55.0 years, and 52.5% of patients were male. Of the 181 patients, 63 patients (34.8%) had primary spinal tumors and 118 patients (65.2%) had metastatic spinal tumors. The types of primary tumors encountered in this cohort were chordomas, chondrosarcomas, giant cell tumors, nerve sheath tumors, schwannomas, neurofibromas, and hemangiomas. In patients with metastatic tumors, the tumor types encountered were testicular cancer, lung cancer, endometrial cancer, prostate cancer, breast cancer, renal cell carcinoma, cervical cancer, colon cancer, squamous cell carcinoma from the skin, melanoma, transitional cell bladder cancer, multiple myeloma, lymphoma, leiomyosarcoma, cholangiocarcinoma, and pancreatic adenocarcinoma. The tumors were most commonly located in the thoracic spine (47.0% of cases), and 35.9% of patients had extraspinal sites of metastasis. With regard to function, preoperative neurological deficits were present in 56.9% of patients, and 81.2% were able to ambulate. Of 181 patients, 67.4% underwent corpectomy and 70.1% underwent instrumented fusion. The perioperative complication rate was 21.0%.

The overall mean index hospital cost for the surgical management of spinal tumors was $52,083 (Table 1). There were no significant differences in the costs between patients who underwent surgery for a primary or metastatic spinal tumor ($55,801 vs $50,098, respectively; p = 0.426). Of the 181 patients, 40 (22.1%) patients underwent radiation therapy: 32 preoperatively, 5 intraoperatively, and 3 postoperatively. The hospital costs were similar between patients who underwent radiotherapy and patients without radiation exposure ($52,200 vs $51,671; p = 0.949). There were no significant differences in the direct hospital costs among patients, regardless of the presence or number of extraspinal metastasis. As shown in Table 1, the factors significantly associated with higher costs in the univariate analysis were the inability to ambulate (p = 0.027), presence of vascular disease (p = 0.037), procedures requiring corpectomy (p < 0.001), more extensive instrumentation (p < 0.001), combined anterior-posterior approach (p < 0.001), presence of perioperative complication (p < 0.001), and longer length of stay (p < 0.001).

TABLE 1.

Covariates associated with the direct hospital cost of patients who underwent surgery for spinal tumors

VariableNo. of Patients (%)Mean Direct Cost (SD)p Value
Total181$52,083 ($45,585)NA
Tumor type0.426
  Primary tumor63 (34.8)$55,801 ($65,961)
  Met118 (65.2)$50,098 ($29,961)
Diagnosis0.908
  Chordoma23 (12.7)$65,413 ($56,633)
  Chondrosarcoma10 (5.5)$59,113 ($31,581)
  Meningioma/nerve sheath tumor31 (17.1)$48,775 ($79,115)
  Prostate met13 (7.2)$48,503 ($40,196)
  Breast met20 (11.1)$48,371 ($33,384)
  Lung met21 (11.6)$45,023 ($22,896)
  Renal cell met14 (7.7)$56,777 ($32,534)
  Gastrointestinal met15 (8.3)$50,425 ($19,106)
  Testicular met5 (2.8)$65,401 ($53,159)
  Leiomyosarcoma met5 (2.8)$63,614 ($30,842)
  Multiple myeloma/leukemia met6 (3.3)$47,353 ($23,838)
  Melanoma met5 (2.8)$18,802 ($5,206)
  Uterine/cervical met5 (2.8)$44,658 ($8,532)
  Other8 (4.4)$59,776 ($28,798)
Age, yrs0.419
  <4539 (21.5)$54,132 ($72,107)
  45–65104 (57.5)$54,499 ($38,520)
  >6538 (21.0)$43,368 ($24,411)
Sex0.152
  Male95 (52.5)$56,717 ($53,095)
  Female86 (47.5)$46,965 ($35,451)
Neurological deficit0.409
  Yes103 (56.9)$54,535 ($51,322)
  No78 (43.1)$48,846 ($37,105)
Ambulatory0.027
  Yes147 (81.2)$48,483 ($36,448)
  No34 (18.8)$67,651 ($72,197)
Radiation therapy0.949
  Yes40 (22.1)$52,200 ($49,094)
  No141 (77.9)$51,671 ($31,491)
Extraspinal met0.724
  0116 (64.1)$54,679 ($53,229)
  131 (17.1)$49,433 ($27,419)
  218 (9.9)$48,794 ($30,542)
  ≥316 (8.8)$42,099 ($24,599)
Comorbidities
  Psychiatric0.554
    Yes26 (14.4)$47,152 ($30,467)
    No155 (85.6)$52,911 ($47,821)
  Thyroid disease0.517
    Yes14 (7.7)$59,712 ($33,518)
    No167 (92.3)$51,444 ($46,610)
  Pulmonary0.301
    Yes21 (11.6)$42,360 ($21,718)
    No160 (88.4)$53,359 ($47,875)
  Vascular0.037
    Yes18 (9.9)$73,334 ($97,516)
    No163 (90.1)$49,737 ($35,610)
  Hyperlipidemia0.562
    Yes22 (12.2)$50,612 ($33,922)
    No159 (87.8)$52,287 ($47,193)
  Diabetes mellitus0.326
    Yes17 (9.4)$41,696 ($29,628)
    No164 (90.6)$53,160 ($46,999)
  Liver disease0.914
    Yes10 (5.5)$53,603 ($39,764)
    No171 (94.5)$51,994 ($46,137)
  Kidney disease0.259
    Yes10 (5.5)$67,982 ($41,292)
    No171 (94.5)$51,154 ($45,896)
  Stroke0.743
    Yes2 (1.1)$41,484 ($41,484)
    No179 (98.9)$52,202 ($45,892)
  Hypertension0.843
    Yes54 (29.8)$53,123 ($32,948)
    No127 (70.2)$51,641 ($50,277)
  Heart disease0.985
    Yes19 (10.5)$51,893 ($35,649)
    No162 (89.5)$52,106 ($46,840)
Total comorbidities0.058
  None71 (39.2)$50,670 ($42,541)
  1–398 (54.1)$51,152 ($49,254)
  >312 (6.6)$68,051 ($31,378)
Spinal region0.353
  Cervical34 (18.8)$58,781 ($48,595)
  Thoracic85 (47.0)$47,925 ($27,104)
  Lumbar43 (23.8)$49,044 ($37,724)
  Sacral19 (10.5)$65,581 ($97,141)
Corpectomy<0.001
  Yes122 (67.4)$63,484 ($50,086)
  No59 (32.6)$28,509 ($20,311)
Fusion<0.001
  None54 (29.8)$22,753 ($13,277)
  1–7100 (55.2)$59,893 ($47,497)
  >727 (14.9)$81,819 ($50,767)
Anterior-posterior approach<0.001
    Yes49 (27.1)$82,214 ($64,887)
    No132 (72.9)$40,898 ($29,372)
Complication<0.001
  Yes38 (21.0)$86,609 ($76,143)
  No143 (79.0)$42,909 ($27,097)
Length of stay<0.001
  <536 (19.9)$21,904 ($12,474)
  5–1075 (41.4)$38,340 ($19,675)
  11–1540 (22.1)$62,478 ($23,151)
  >1530 (16.6)$108,798 ($77,315)

Met = metastasis; NA = not applicable.

Table 2 shows the result of the multivariate analysis of the factors associated with the cost of surgical management for spinal tumors. Tumor type was not an independent factor associated with hospital cost (p = 0.268). Rather, several other clinical and perioperative variables were independently associated with hospital cost. The preoperative factors independently associated with direct cost can be seen in Table 2 and Fig. 1. Male sex was independently associated with higher cost compared with female sex ($56,717 vs $46,965, respectively; p = 0.032) (Fig. 1A). The ability to ambulate preoperatively was an independent factor associated with cost (p = 0.002); ambulatory patients had a significantly lower cost ($48,483) than nonambulatory patients ($67,651) (Fig. 1B). With regard to comorbidities, having more than 3 medical comorbidities was independently associated with higher cost (p = 0.037): no comorbidities, $50,670; 1 to 3 comorbidities, $51,152; and more than 3 comorbidities, $68,051 (Fig. 1C).

TABLE 2.

Results of the multivariate analysis of the factors that may influence the direct hospital cost in patients who undergo surgery for spinal tumors

FactorMean Direct Cost (SD)p Value
Tumor type
  Primary tumor$55,801 ($65,961)Ref
  Met$50,098 ($29,961)0.268
Sex
  Male$56,717 ($53,095)0.032
  Female$46,965 ($35,451)Ref
Ambulatory
  Yes$48,483 ($36,448)Ref
  No$67,651 ($72,197)0.002
Vascular disease
  Yes$73,334 ($97,516)0.194
  No$49,737 ($35,610)Ref
Total comorbidities
  None$50,670 ($42,541)Ref
  1–3$51,152 ($49,254)0.205
  >3$68,051 ($31,378)0.037
Corpectomy
  Yes$63,484 ($50,086)0.021
  No$28,509 ($20,311)Ref
Fusion
  None$22,753 ($13,277)Ref
  1–7$59,893 ($47,497)0.024
  >7$81,819 ($50,767)<0.001
Anterior-posterior approach
  Yes$82,214 ($64,887)<0.001
  No$40,898 ($29,372)Ref
Complication
  Yes$86,609 ($76,143)<0.001
  No$42,909 ($27,097)Ref
Length of stay, days
  <5$21,904 ($12,474)Ref
  5–10$38,340 ($19,675)0.011
  11–15$62,478 ($23,151)0.064
  >15$108,798 ($77,315)<0.001

Ref = reference.

FIG. 1.
FIG. 1.

Preoperative factors significantly associated with hospital cost in patients undergoing surgery for spinal tumors. Male sex (p = 0.032) (A), inability to ambulate (p = 0.002) (B), and having more than 3 comorbidities (p = 0.037) (C) were all independently associated with higher cost.

The surgical factors that were independently associated with cost can be seen in Table 2 and Fig. 2. Performing a corpectomy (p < 0.001), undergoing instrumentation involving more than 7 levels (relative to no fusion) (p < 0.001), and approaching the spine through a combined anterior-posterior approach (p < 0.001) were all independently associated with higher cost. Patients who underwent corpectomy had a mean cost of $63,483 compared with $28,509 in patients who did not undergo corpectomy (Fig. 2A). Instrumentation of more than 7 levels had a mean cost of $81,818; this was significantly higher than both instrumentation of 1 to 7 levels ($59,893) and no instrumentation ($22,753) (Fig. 2B). A combined anterior-posterior approach was associated with a cost of $82,214; this is approximately double the cost of a single approach ($40,898) (Fig. 2C).

FIG. 2.
FIG. 2.

Surgery-related factors significantly associated with hospital cost in patients undergoing surgery for spinal tumors. Undergoing corpectomy (p = 0.021) (A), greater than 7 levels of instrumentation (p < 0.001) (B), and a combined anterior-posterior approach (p < 0.001) (C) were independently associated with higher cost.

The postoperative factors independently associated with hospital cost are shown in Table 2 and Fig. 3. Patients who experienced a complication had approximately double the cost of patients without complications ($86,609 vs $42,909, respectively; p < 0.001) (Fig. 3 left). A length of stay greater than 5 days was independently associated with higher cost compared with 5 to 10 days (p = 0.011), 11 to 15 days (p = 0.064), and longer than 15 days (p < 0.001). The costs of each categorized length of stay were as follows: less than 5 days ($21,904), 5 to 10 days ($38,340), 11 to 15 days ($62,478), and greater than 15 days ($108,798) (Fig. 3 right).

FIG. 3.
FIG. 3.

Postoperative factors significantly associated with hospital cost in patients undergoing surgery for spinal tumors. Complication (p < 0.001) (left) and length of overall hospital stay greater than 15 days (p < 0.001) (right) were independently associated with higher cost.

Overall, the 90-day readmission rate for the cohort was 11.6% (Table 3). The mean hospital cost for the 90-day readmission was $20,078. There was no significant difference in the readmission rates between patients who had primary tumors (11.1%) compared with patients who had metastatic tumors (11.9%) (p = 0.880). Radiation therapy also was not significantly associated with the 90-day readmission rate: 15.0% of patients who underwent radiation treatment were readmitted, and 10.6% of readmitted patients did not undergo radiation therapy (p = 0.447). The presence or number of extraspinal metastases was not significantly associated with the 90-day readmission rate. The only variable that was significantly associated with a higher readmission rate in the univariate analysis was the presence of vascular disease (p = 0.024).

TABLE 3.

Analysis of the factors associated with the readmission rate of patients who underwent surgery for spinal tumors

VariableNo. of Patients (%)No. Readmitted (%)p Value
Total18121 (11.6)NA
Tumor type0.880
  Primary tumor63 (34.8)7 (11.1)
  Met118 (65.2)14 (11.9)
Diagnosis0.100
  Chordoma23 (12.7)3 (13.0)
  Chondrosarcoma10 (5.5)2 (20.0)
  Meningioma/nerve sheath tumor31 (17.1)2 (6.5)
  Prostate met13 (7.2)0 (0.0)
  Breast met20 (11.1)1 (5.0)
  Lung met21 (11.6)5 (23.8)
  Renal cell met14 (7.7)3 (21.4)
  Gastrointestinal met15 (8.3)1 (6.7)
  Testicular met5 (2.8)2 (40.0)
  Leiomyosarcoma met5 (2.8)2 (40.0)
  Multiple myeloma/leukemia met6 (3.3)0 (0.0)
  Melanoma met5 (2.8)0 (0.0)
  Uterine/cervical met5 (2.8)0 (0.0)
  Other8 (4.4)0 (0.0)
Age, yrs0.936
  <4539 (21.5)4 (10.3)
  45–65104 (57.5)12 (11.5)
  >6538 (21.0)5 (13.2)
Sex0.635
  Male86 (47.5)10 (11.6)
  Female95 (52.5)11 (11.6)
Neurological deficit0.623
  Yes103 (56.9)13 (12.6)
  No78 (43.1)8 (10.3)
Ambulatory0.531
  Yes147 (81.2)16 (10.9)
  No34 (18.8)5 (14.7)
Radiation0.447
  Yes40 (22.1)6 (15.0)
  No141 (77.9)15 (10.6)
Extraspinal met0.422
  0116 (64.1)13 (11.2)
  131 (17.1)2 (6.5)
  218 (9.9)4 (22.2)
  ≥316 (8.8)2 (12.5)
Comorbidities
  Psychiatric0.525
    Yes26 (14.4)4 (15.4)
    No155 (85.6)17 (11.0)
  Thyroid disease0.744
    Yes14 (7.7)2 (14.3)
    No167 (92.3)19 (11.4)
  Pulmonary0.077
    Yes21 (11.6)0 (0.0)
    No160 (88.4)21 (13.1)
  Vascular0.024
    Yes18 (9.9)5 (27.8)
    No163 (90.1)16 (9.8)
  Hyperlipidemia0.695
    Yes22 (12.2)2 (9.1)
    No159 (87.8)19 (11.9)
  Diabetes mellitus0.983
    Yes17 (9.4)2 (11.8)
    No164 (90.6)19 (11.6)
  Liver disease0.239
    Yes10 (5.5)0 (0.0)
    No171 (94.5)21 (12.3)
  Kidney disease0.871
    Yes10 (5.5)1 (10.0)
    No171 (94.5)20 (11.7)
  Stroke0.088
    Yes2 (1.1)1 (50.0)
    No179 (98.9)20 (11.2)
  Hypertension0.521
    Yes54 (29.8)5 (9.3)
    No127 (70.2)16 (12.6)
  Heart disease0.547
    Yes19 (10.5)3 (15.8)
    No162 (89.5)18 (11.1)
Total comorbidities0.472
  None71 (39.2)6 (8.5)
  1–398 (54.1)14 (14.3)
  >312 (6.6)1 (8.3)
Spinal region0.083
  Cervical34 (18.8)0 (0.0)
  Thoracic85 (47.0)11 (12.9)
  Lumbar43 (23.8)8 (18.6)
  Sacral19 (10.5)2 (10.5)
Corpectomy0.057
  Yes122 (67.4)18 (14.8)
  No59 (32.6)3 (5.1)
Fusion0.086
  None54 (29.8)3 (5.6)
  1–7100 (55.2)12 (12.0)
  >727 (14.9)6 (22.2)
Anterior-posterior approach0.227
  Yes49 (27.1)8 (16.3)
  No132 (72.9)13 (9.8)
Complication0.816
  Yes38 (21.0)4 (10.5)
  No143 (79.0)17 (11.9)
Length of stay, days0.184
  <536 (19.9)1 (2.8)
  5–1075 (41.4)9 (12.0)
  11–1540 (22.1)5 (12.5)
  >1530 (16.6)6 (20.0)

Table 4 shows the results of the multivariate analysis of the independent risk factors associated with 90-day readmission. Two factors were independently associated with readmission: diagnosis of lung metastasis (Table 4 and Fig. 4 upper) and index hospitalization length of stay (Table 4 and Fig. 4 lower). A diagnosis of lung metastasis was associated with an increase in the odds of 90-day readmission relative to a diagnosis of breast cancer (odds ratio 52.99; 95% confidence interval 2.96–948.39; p = 0.007). Relative to a length of stay shorter than 5 days, patients who stayed in the hospital for longer than 15 days during the initial admission had 6.62 higher odds of being readmitted within 90 days (95% confidence interval 1.30–33.74; p = 0.016). The readmission rates stratified by prior length of stay are as follows: shorter than 5 days (2.8%), 5 to 10 days (12.0%), 11 to 15 days (12.5%), and longer than 15 days (20.0%). The reasons for readmissions are included in Table 5.

TABLE 4.

Results of the multivariate analysis of the factors that may influence the readmission rate of patients who undergo surgery for spinal tumors

VariableReadmission
ORCIp Value
Tumor type
  Primary tumorRefRefRef
  Met1.09<0.01 to >999.990.999
Comorbidities
  Pulmonary
    Yes<0.01<0.01 to >999.990.769
    NoRefRefRef
  Vascular
    Yes4.270.53–34.480.173
    NoRefRefRef
  Stroke
    Yes>999.99<0.01 to >999.990.881
    NoRefRefRef
  Diagnosis
    Chordoma26.03<0.01 to >999.990.985
    Chondrosarcoma4.14<0.01 to >999.990.993
    Meningioma/nerve sheath tumor4.94<0.01 to >999.990.992
    Prostate met<0.01<0.01 to >999.990.892
    Breast metRefRefRef
    Lung met52.992.96–948.390.007
    Renal cell met4.040.21–79.070.358
    Gastrointestinal met3.860.09–175.160.488
    Testicular met9.780.39–244.530.165
    Leiomyosarcoma met8.950.31–259.800.202
    Multiple myeloma/leukemia met<0.01<0.01 to >999.990.892
    Melanoma met0.02<0.01 to >999.990.936
    Uterine/cervical met<0.01<0.01 to >999.990.916
    Other<0.01<0.01 to >999.990.897
Spinal region
  Cervical<0.01<0.01 to >999.990.564
  Thoracic0.320.06 to 1.610.166
  LumbarRefRefRef
  Sacral0.070.01 to 1.510.090
Corpectomy
  Yes5.200.60–45.240.135
  NoRefRefRef
Fusion
  NoneRefRefRef
  1–70.440.05–3.900.457
  >71.601.17–15.480.687
Length of stay, days
  <5RefRefRef
  5–105.430.67–43.810.112
  11–152.340.28–19.420.432
  >1510.101.36–74.970.024

CI = confidence interval; OR = odds ratio.

FIG. 4.
FIG. 4.

Independent predictors of hospital readmission within 90 days of surgery for the resection of spinal tumor. Only the length of hospital stay greater than 15 days on index admission (lower) was independently associated with a higher odds of readmission (OR 6.62, CI 1.30–33.74; p = 0.016). Met = metastasis.

TABLE 5.

Surgery-related causes for 90-day readmission following spinal tumor surgery

ReasonNo. of Patients
Primary tumors
  Wound infection requiring surgical washout5
  Wound infection not requiring reoperation2
  Recurrent tumor requiring decompression1
  Postoperative pain control1
  Proximal junctional kyphosis requiring revision surgery1
Metastatic tumors
  Wound infection not requiring washout4
  Wound infection requiring washout1
  Dyspnea due to pleural effusion2
  Severe ileus1
  Tumor progression w/myelopathy requiring reoperation1
  Deep vein thrombosis requiring anticoagulation1
  Screw pullout & cage subsidence requiring revision surgery1

Discussion

This study utilizes a single institutional cohort to review the direct cost of hospitalization for spinal tumor surgery. Overall, the mean cost of admission for surgery was $52,083, and there were no differences in costs when operating on primary or metastatic spinal tumors. Rather, the findings of this study suggest that there are various preoperative, surgical, and postoperative factors that have the potential to influence and alter hospital cost. The 90-day readmission rate in this cohort was 11.6%, and there was no difference in this rate following the treatment of primary or metastatic spinal tumors. With further understanding of the factors associated with cost of surgery and readmission for spinal tumor surgery, improvements can be made to enhance future cost effectiveness.

There are only a few studies in the literature that have concentrated on the cost associated with the surgical management of spinal tumors. Among those articles, hospitalization costs range widely secondary to the variability in the procedures performed, pathologies treated, and geographic location (such as different countries).9,12,34,41,44 None of the available studies evaluate and compare the cost of both primary and metastatic spinal tumors. There are several articles that have examined the health care utilization and cost associated with the management of general bony metastasis and its associated “skeletal events,” with some providing a subanalysis of spinal column metastasis.8,13,14,17 These studies contain a heterogeneous cohort of patients, but offer a valuable sense of the expense associated with the management of bony metastasis. The average cost of treating a skeletal event secondary to metastasis is reported to range from $10,000 to $12,000.14,22 This seems to be a relatively low cost; however, the reported means include both medical and surgical management modalities (with surgery making up a very small proportion of cases). Therefore, the extrapolation of the actual cost of surgery among these studies is difficult and limited. The cost is as high as $90,000 in studies that stratify the cost of inpatient surgery for pathological bony fractures,17 and the cost of inpatient surgical treatment of spinal cord compression from spinal metastasis ranges from $43,691 to $59,854.8 This is similar to the present study, for which the treatment of spinal metastasis was $50,098.

In more homogeneous cohorts of patients who were surgically treated for spinal metastasis, the associated direct cost can be better evaluated. Chew et al. performed a prospective analysis of the cost associated with percutaneous vertebroplasty for the treatment of spinal metastasis in 11 patients.12 The overall cost (including consumables, capital equipment, hotel, clinic, and staffing costs) per patient was £2213. With a US dollar conversion rate of 1.5 times, this cost would be equivalent to $3319. Relative to the cost of surgical management, vertebroplasty is extremely low cost and seemingly sustainable. However, the indications for vertebroplasty differ from those for the surgical management of spinal tumors, and thus the costs are not comparable. In a European prospective study by Turner et al., 74 patients with symptomatic spinal metastasis were enrolled in a study to evaluate the hospital cost of surgery.41 Among those patients, the average cost was £16,885 (equivalent to $25,327); this is half the cost of what was observed in our cohort. Still, it remains difficult to compare the present study with the study by Turner et al. because of the intrinsic differences in the health care expenditure and reimbursement policies between the US and Europe. However, understanding and identifying differences between each health care system may aid in the identification of the key factors that influence spinal tumor surgery cost effectiveness.

In this study, the mean cost of surgery for primary spinal tumors was $52,083. The cost reported in our study is lower than that reported by prior studies, with costs ranging from $61,157 to $250,160.9,34 Sharma et al. performed a retrospective review of hospitalization cost on 15,545 admissions for spinal cord tumor surgery included in the US Nationwide Inpatient Sample database.34 Overall, between 2003 and 2007, the average cost of surgery was $61,157. Interestingly, the cost in 2003 ($45,452) was significantly lower than in 2007 ($76,698). These costs differ from those of extradural primary bony spinal tumor (chordoma and osteosarcoma) surgery. Brown et al. reported a mean total hospital cost ranging from $161,028 to $250,160 for 25 patients with sacral tumors who underwent sacrectomy.9 The cost of operating on sacral tumors in our study was much lower at $65,581, though only a few patients underwent sacrectomy. There is an ongoing need for studies to evaluate the hospital cost associated with primary tumors of the cervical, thoracic, and lumbar spine.

It is clear that the costs of surgery for spinal tumors range widely and depend on a variety of factors. Identifying the factors that are modifiable is critical for decreasing the cost of spinal tumor surgery. Preoperative baseline clinical variables and tumor characteristics are factors that are typically not amendable to modification. In this study, male sex was independently associated with higher cost (an additional $9752 or 1.2 times). A similar finding was also seen in a separate study on the surgical management of spinal metastasis.41 It is unclear why male sex is associated with a higher hospital cost, but it has been suggested that sex-specific cancers command different costs. Other identified factors independently associated with higher cost were the inability to ambulate (an additional $19,168 or 1.4 times) and greater than 3 comorbidities (an additional $16,899–$17,381 or 1.3 times). It is evident that functional status and overall healthiness are variables that influence hospital-related costs. However, there are conflicting data about the relationship between patient comorbidity and hospital cost. Similar to our study, Sharma et al. demonstrated that patients with more comorbidities tend to accumulate higher hospital charges when undergoing surgery for spinal metastasis.34 The rationale is that patients with more medical issues tend to require additional medical care, procedures, and specialty consultations. On the other hand, Turner et al. showed that the EQ-5D and American Society of Anesthesia scores were inversely associated with cost for patients who underwent surgery for spinal cord tumors (i.e., sicker patients had lower hospital cost).41 In addition, their study showed that the Frankel grade was inversely associated with cost as well. Their explanation of their findings was that healthier and more functional patients underwent more aggressive and complex surgeries. However, information on the specific surgical procedures performed is not available from a large national reimbursement-driven database, and their hypothesis cannot be confirmed.

The operative variables independently associated with higher hospital costs included surgeries that involved corpectomy (an additional $34,975 or 2.2 times), instrumentation greater than 7 levels (an additional $21,926–$59,066 or 2.6–3.6 times), and utilizing a combined anterior-posterior approach ($41,316 or 2.0 times). These individual variables are likely surrogates and indicators for more complex cases that require a longer operative time, greater blood loss (thereby requiring blood transfusions), and longer hospital recovery, which are also factors that contribute to cost. With combined anterior-posterior approaches to the thoracic and lumbar spine, thoracic surgery and general surgery are often consulted for exposure, leading to additional costs. These findings demonstrate that the surgical management of spinal tumors that require large tumor resections and complex spinal reconstructions are associated with higher costs. Technically, these operative factors are modifiable, but the specific surgical procedure is dictated by the patient's clinical presentation, disease process, and goals. Understanding how to perform these complex cases in a safe and cost-efficient manner is key to lowering the overall associated hospital cost. For example, Brown et al. demonstrated that by staging complex tumor resections, specifically during sacrectomy, the cost decreased by a mean of $89,132 per patient.9 In their study, the decreased costs were associated with decreases in length of stay in the intensive care unit, length of ventilator use, number of transfusions, and utilization of advanced pharmacy services.

The complications and length of stay have been robustly shown to be associated with an increase in hospitalization cost across many subspecialties of medicine35,36,42 and in the surgical management of spinal tumors.34,41 Our study further supports these findings. Preventing complications and promoting faster postoperative recovery is paramount to decreasing the cost of hospitalization.

Another important consideration in evaluating the longer term cost effectiveness of surgery for spinal tumors is to understand the events that occur after discharge, particularly unforeseen readmission to the hospital. Hospital readmission is emerging as a quality indicator, and perhaps more importantly has a significant negative impact on patient satisfaction.40 The reported 90-day readmission rate following various types of spine surgery (degenerative cervical spine to scoliosis deformity correction) ranges from 1.0% to 12.3%.4,5,32 The 90-day readmission rate in our study falls into the higher range of the reported rates (11.6%), with average hospital readmission costs totaling $20,078. This cost is significant, especially when taking into account the number of patients who undergo spine tumor surgery. If approximately 1 in 10 patients are readmitted with an average admission cost of approximately $20,000, every 100 patients treated will result in an additional cost of $200,000 from readmission. Therefore, understanding the risk factors for readmission is vital to preventing future readmission-associated costs. The most common reason for readmission was wound infection (57.1% of the 21 readmissions), and of these infections 75.0% required surgical washout. Other authors have also reported that surgical site infections and wound complications were the most common reasons for readmission, making up to 46% to 72% of all readmissions during the 90-day discharge period.5,32 In our study, the diagnosis of lung cancer and hospital stay longer than 15 days during the index hospitalization were independently associated with 90-day readmission, which is consistent with prior studies as well.6 Other previously identified risk factors for readmission following spine surgery include malignancy, longer operative time, longer constructs, higher patient severity of illness, and surgical complications.6,32 Over the 1-year postoperative period, the most common cause for readmission after spinal tumor surgery is tumor recurrence (33% of readmissions).33 Specifically, aggressive metastatic spinal tumors (lung, osteosarcoma, stomach, bladder, esophagus, and pancreas) and the presence of medical comorbidities increased the risk for readmission.33

Attention to the negative findings from a study are also valuable in understanding the factors associated with direct cost. There are often various clinical and patient factors that would be expected to have an impact on direct hospital cost, but this really needs verification. Based on this study, it is surprising that pathological diagnosis, age, history of radiation therapy, and presence of extraspinal metastasis did not have significant associations with direct hospital cost. In addition, none of these factors, except pathological diagnosis, influenced the 90-day readmission rate. These findings may indicate that such outcomes are not dictated strictly on the presence of certain preoperative clinical demographics, but rather how these factors are managed medically and surgically.

Traditionally, it is understood that patients with metastatic cancers would be at greater risk of complications, higher cost, and more frequent readmissions. However, this study suggests the opposite: similar costs and readmission outcomes were observed between patients with metastatic and primary spinal tumors. These findings may be explained by careful patient selection among those with metastatic tumors. All patients with metastasis underwent comprehensive evaluation by an oncology team prior to surgery to determine disease burden and prognosis. Only patients with favorable life expectancy (greater than 3 months) were offered surgery. These patients most likely also had favorable Karnofsky Performance Scale scores and, thus, were able to tolerate resection well. On the contrary, if all patients with metastatic spinal tumors (regardless of cancer burden and health status) were offered surgery, worse outcome and higher associated cost may be observed.

Radiation has been understood to be a major risk factor for wound breakdown, dehiscence, and poor healing. However, we did not observe significant differences in the hospital costs and 90-day readmission rates between patients who underwent radiation therapy and patients without radiation treatment. This may be explained by the evolution of how radiation is delivered to spinal tumors. Over the past several years, there has been a transition to the use of stereotactic radiosurgery via high-dose, hypofractionated, image-guided radiation therapy, rather than conventional fractional radiotherapy.20 A recent published study by Harel et al. concluded that modern-day adjuvant stereotactic radiosurgery (single fraction) to the spine following surgery for metastasis allows high local control rates, but at the same time delivers less radiation to the wound.18 Additional contemporary studies are needed to further evaluate this topic.

There are several limitations to the present study related to its single-center and retrospective design. Hospital cost is associated with a multitude of variables, many of which are not reliably accounted for with a retrospective study. This generates undetected confounders that were not adjusted for in the multivariate analysis. A prospective study that is designed to record all hospitalization costs and activities may aid in elucidating additional factors associated with surgical cost. As a single-center study, this investigation may lack generalizability of the present findings because costs typically vary by location, institution, and geography, which are composed of different local health care microclimates. Despite these limitations, the data provided in this study offer new insights into the cost associated with surgery for spinal tumors. Additional studies are needed to examine the long-term functional outcomes and assess the cost effectiveness of surgery for spinal tumors, such as that undertaken by Tipsmark et al., who analyzed the total health care cost of 629 patients who underwent spinal metastasis treatment from the initiation of treatment (i.e., index hospitalization) until death.37

Conclusions

The overall mean hospital cost associated with the surgical management of spinal tumors was $52,083, and there is no difference in the mean cost between treating primary and metastatic spinal tumors. The factors affecting cost can be stratified based on nonmodifiable and modifiable factors. The identified independent risk factors for high cost include male sex, nonambulatory status, more than 3 comorbidities, corpectomy, more than 7 levels of instrumentation, combined anterior-posterior approach, presence of perioperative complications, and longer lengths of stay. Many of these factors are surrogates for worse disease that warrant more complex surgical interventions. The overall readmission rate was 11.6%, which is similar to the readmission rates following complex spine surgery. Additional studies that look at long-term outcome and cost effectiveness should be undertaken, as they may add to the understanding of the costs associated with the surgical management of spinal tumors.

References

  • 1

    Adogwa OOwens RKarikari IAgarwal VGottfried ONBagley CA: Revision lumbar surgery in elderly patients with symptomatic pseudarthrosis, adjacent-segment disease, or same-level recurrent stenosis. Part 2 A cost-effectiveness analysis Clinical article. J Neurosurg Spine 18:1471532013

  • 2

    Adogwa OParker SLDavis BJAaronson ODevin CCheng JS: Cost-effectiveness of transforaminal lumbar interbody fusion for Grade I degenerative spondylolisthesis. J Neurosurg Spine 15:1381432011

  • 3

    Adogwa OParker SLShau DNMendenhall SKDevin CJCheng JS: Cost per quality-adjusted life year gained of laminectomy and extension of instrumented fusion for adjacent-segment disease: defining the value of surgical intervention. J Neurosurg Spine 16:1411462012

  • 4

    Akamnonu CCheriyan TGoldstein JAErrico TJBendo JA: Ninety-day readmissions after degenerative cervical spine surgery: A single-center administrative database study. Int J Spine Surg 9:192015

  • 5

    Akamnonu CCheriyan TGoldstein JALafage VErrico TJBendo JA: Unplanned hospital readmission after surgical treatment of common lumbar pathologies: rates and causes. Spine (Phila Pa 1976) 40:4234282015

  • 6

    Akins PTHarris JAlvarez JLChen YPaxton EWBernbeck J: Risk factors associated with 30-day readmissions after instrumented spine surgery in 14,939 patients: 30-day readmissions after instrumented spine surgery. Spine (Phila Pa 1976) 40:102210322015

  • 7

    Angevine PDZivin JGMcCormick PC: Cost-effectiveness of single-level anterior cervical discectomy and fusion for cervical spondylosis. Spine (Phila Pa 1976) 30:198919972005

  • 8

    Barlev ASong XIvanov BSetty VChung K: Payer costs for inpatient treatment of pathologic fracture, surgery to bone, and spinal cord compression among patients with multiple myeloma or bone metastasis secondary to prostate or breast cancer. J Manag Care Pharm 16:6937022010

  • 9

    Brown MJKor DJCurry TBWarner MARodrigues ESRose SH: Sacral tumor resection: the effect of surgical staging on patient outcomes, resource management, and hospital cost. Spine (Phila Pa 1976) 36:157015782011

  • 10

    Carreon LYAnderson PATraynelis VCMummaneni PVGlassman SD: Cost-effectiveness of single-level anterior cervical discectomy and fusion five years after surgery. Spine (Phila Pa 1976) 38:4714752013

  • 11

    Carreon LYGlassman SDDjurasovic MCampbell MJPuno RMJohnson JR: RhBMP-2 versus iliac crest bone graft for lumbar spine fusion in patients over 60 years of age: a cost-utility study. Spine (Phila Pa 1976) 34:2382432009

  • 12

    Chew CO'Dwyer PJEdwards R: Health service cost associated with percutaneous vertebroplasty in patients with spinal metastases. Clin Radiol 68:7767792013

  • 13

    Decroisette CMonnet IBerard HQuere GLe Caer HBota S: Epidemiology and treatment costs of bone metastases from lung cancer: a French prospective, observational, multicenter study (GFPC 0601). J Thorac Oncol 6:5765822011

  • 14

    Delea TLanger CMcKiernan JLiss MEdelsberg JBrandman J: The cost of treatment of skeletal-related events in patients with bone metastases from lung cancer. Oncology 67:3903962004

  • 15

    Fehlings MGNater AHolmer H: Cost-effectiveness of surgery in the management of metastatic epidural spinal cord compression: a systematic review. Spine (Phila Pa 1976) 39:22 Suppl 1S99S1052014

  • 16

    Glassman SDPolly DWDimar JRCarreon LY: The cost effectiveness of single-level instrumented posterolateral lumbar fusion at 5 years after surgery. Spine (Phila Pa 1976) 37:7697742012

  • 17

    Hagiwara MDelea TESaville MWChung K: Healthcare utilization and costs associated with skeletal-related events in prostate cancer patients with bone metastases. Prostate Cancer Prostatic Dis 16:23272013

  • 18

    Harel REmch TChao SElson PKrishnaney ADjemil T: Quantitative evaluation of local control and wound healing following surgery and stereotactic spine radiosurgery (SRS) for spine tumors. World Neurosurg [epub ahead of print]2015

  • 19

    Kaloostian PEZadnik PLEtame ABVrionis FDGokaslan ZLSciubba DM: Surgical management of primary and metastatic spinal tumors. Cancer Contr 21:1331392014

  • 20

    Keam JBilsky MHLaufer IShi WZhang ZTam M: No association between excessive wound complications and preoperative high-dose, hypofractionated, image-guided radiation therapy for spine metastasis. J Neurosurg Spine 20:4114202014

  • 21

    Kuntz KMSnider RKWeinstein JNPope MHKatz JN: Cost-effectiveness of fusion with and without instrumentation for patients with degenerative spondylolisthesis and spinal stenosis. Spine (Phila Pa 1976) 25:113211392000

  • 22

    Lage MJBarber BLHarrison DJJun S: The cost of treating skeletal-related events in patients with prostate cancer. Am J Manag Care 14:3173222008

  • 23

    Lau DLeach MRLa Marca FPark P: Independent predictors of survival and the impact of repeat surgery in patients undergoing surgical treatment of spinal metastasis. J Neurosurg Spine 17:5655762012

  • 24

    McCarthy IHostin RO'Brien MSaigal RAmes CP: Health economic analysis of adult deformity surgery. Neurosurg Clin N Am 24:2933042013

  • 25

    McCarthy IO'Brien MAmes CRobinson CErrico TPolly DW Jr: Incremental cost-effectiveness of adult spinal deformity surgery: observed quality-adjusted life years with surgery compared with predicted quality-adjusted life years without surgery. Neurosurg Focus 36:5E32014

  • 26

    McCarthy IMHostin RAAmes CPKim HJSmith JSBoachie-Adjei O: Total hospital costs of surgical treatment for adult spinal deformity: an extended follow-up study. Spine J 14:232623332014

  • 27

    Meyer SAMummaneni PV: Cost-effectiveness of transforaminal lumbar interbody fusion. J Neurosurg Spine 15:1361372011

  • 28

    Munoz-Bendix CSlotty PJAhmadi SABostelmann RSteiger HJCornelius JF: Primary bone tumors of the spine revisited: A 10-year single-center experience of the management and outcome in a neurosurgical department. J Craniovertebr Junction Spine 6:21292015

  • 29

    Ortiz Gómez JA: The incidence of vertebral body metastases. Int Orthop 19:3093111995

  • 30

    Parker SLAdogwa OBydon ACheng JMcGirt MJ: Cost-effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis associated low-back and leg pain over two years. World Neurosurg 78:1781842012

  • 31

    Parker SLFulchiero ECDavis BJAdogwa OAaronson OSCheng JS: Cost-effectiveness of multilevel hemilaminectomy for lumbar stenosis-associated radiculopathy. Spine J 11:7057112011

  • 32

    Schairer WWCarrer ADeviren VHu SSTakemoto SMummaneni P: Hospital readmission after spine fusion for adult spinal deformity. Spine (Phila Pa 1976) 38:168116892013

  • 33

    Schairer WWCarrer ASing DCChou DMummaneni PVHu SS: Hospital readmission rates after surgical treatment of primary and metastatic tumors of the spine. Spine (Phila Pa 1976) 39:180118082014

  • 34

    Sharma MSonig AAmbekar SNanda A: Discharge dispositions, complications, and costs of hospitalization in spinal cord tumor surgery: analysis of data from the United States Nationwide Inpatient Sample, 2003–2010. J Neurosurg Spine 20:1251412014

  • 35

    Starks HWang SFarber SOwens DACurtis JR: Cost savings vary by length of stay for inpatients receiving palliative care consultation services. J Palliat Med 16:121512202013

  • 36

    Stephen AEBerger DL: Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery 133:2772822003

  • 37

    Tipsmark LSBünger CEWang MMorgen SSDahl BSøgaard R: Healthcare costs attributable to the treatment of patients with spinal metastases: a cohort study with up to 8 years follow-up. BMC Cancer 15:3542015

  • 38

    Tosteson ANLurie JDTosteson TDSkinner JSHerkowitz HAlbert T: Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Intern Med 149:8458532008

  • 39

    Tosteson ANSkinner JSTosteson TDLurie JDAndersson GBBerven S: The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 33:210821152008

  • 40

    Tsai TCJoynt KEOrav EJGawande AAJha AK: Variation in surgical-readmission rates and quality of hospital care. N Engl J Med 369:113411422013

  • 41

    Turner IMinhas ZKennedy JMorris SCrockard AChoi D: Cost of surgery for symptomatic spinal metastases in the UK. World Neurosurg 84:123512432015

  • 42

    Vonlanthen RSlankamenac KBreitenstein SPuhan MAMuller MKHahnloser D: The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients. Ann Surg 254:9079132011

  • 43

    Whitmore RGSchwartz JSSimmons SStein SCGhogawala Z: Performing a cost analysis in spine outcomes research: comparing ventral and dorsal approaches for cervical spondylotic myelopathy. Neurosurgery 70:8608672012

  • 44

    Zong SZeng GXiong CWei B: Treatment results in the differential surgery of intradural extramedullary schwannoma of 110 cases. PLoS One 8:e638672013

Disclosures

The authors report the following. Dr. Ames is an employee of UCSF, is a consultant for DePuy, Stryker, and Medtronic, owns stock in Doctors Research Group, holds patents with Fish & Richardson, P.C., and receives royalties from Stryker and Biomet Spine. Dr. Berven owns stock in Simpirica and Providence Medical and is a consultant for Medtronic, Globus, Stryker, and RTI. Dr. Burch is a consultant for Medtronic, receives clinical or research support for the study described from Lily, Inc., and Integra Life Sciences, and receives spine fellowship support from AOSpine, Globus, and NuVasive. Dr. Chou is a consultant for Globus, Medtronic, and Orthofix. Dr. Deviren is a consultant for NuVasive, Guidepoint, and Stryker and receives spine fellowship support from NuVasive, Globus, and AOSpine. Dr. Mummaneni is a consultant for Stryker, owns stock in Spinicity/ISD, owns royalties with DePuy Spine, Taylor and Francis Publishing, Springer Publishing, and Thieme Publishing, receives honoraria from Globus, and receives non–study-related clinical or research support from AOSpine and NREF.

Author Contributions

Conception and design: Ames, Lau. Acquisition of data: Lau, Chan. Analysis and interpretation of data: Lau. Drafting the article: Ames, Lau, Chan. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Ames. Statistical analysis: Lau. Study supervision: Ames.

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Article Information

INCLUDE WHEN CITING Published online April 29, 2016; DOI: 10.3171/2016.2.SPINE15954.

Correspondence Christopher P. Ames, Department of Neurological Surgery, University of California, San Francisco, 400 Parnassus Ave., A850, San Francisco, CA 94143. email: amesc@neurosurg.ucsf.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Preoperative factors significantly associated with hospital cost in patients undergoing surgery for spinal tumors. Male sex (p = 0.032) (A), inability to ambulate (p = 0.002) (B), and having more than 3 comorbidities (p = 0.037) (C) were all independently associated with higher cost.

  • View in gallery

    Surgery-related factors significantly associated with hospital cost in patients undergoing surgery for spinal tumors. Undergoing corpectomy (p = 0.021) (A), greater than 7 levels of instrumentation (p < 0.001) (B), and a combined anterior-posterior approach (p < 0.001) (C) were independently associated with higher cost.

  • View in gallery

    Postoperative factors significantly associated with hospital cost in patients undergoing surgery for spinal tumors. Complication (p < 0.001) (left) and length of overall hospital stay greater than 15 days (p < 0.001) (right) were independently associated with higher cost.

  • View in gallery

    Independent predictors of hospital readmission within 90 days of surgery for the resection of spinal tumor. Only the length of hospital stay greater than 15 days on index admission (lower) was independently associated with a higher odds of readmission (OR 6.62, CI 1.30–33.74; p = 0.016). Met = metastasis.

References

  • 1

    Adogwa OOwens RKarikari IAgarwal VGottfried ONBagley CA: Revision lumbar surgery in elderly patients with symptomatic pseudarthrosis, adjacent-segment disease, or same-level recurrent stenosis. Part 2 A cost-effectiveness analysis Clinical article. J Neurosurg Spine 18:1471532013

  • 2

    Adogwa OParker SLDavis BJAaronson ODevin CCheng JS: Cost-effectiveness of transforaminal lumbar interbody fusion for Grade I degenerative spondylolisthesis. J Neurosurg Spine 15:1381432011

  • 3

    Adogwa OParker SLShau DNMendenhall SKDevin CJCheng JS: Cost per quality-adjusted life year gained of laminectomy and extension of instrumented fusion for adjacent-segment disease: defining the value of surgical intervention. J Neurosurg Spine 16:1411462012

  • 4

    Akamnonu CCheriyan TGoldstein JAErrico TJBendo JA: Ninety-day readmissions after degenerative cervical spine surgery: A single-center administrative database study. Int J Spine Surg 9:192015

  • 5

    Akamnonu CCheriyan TGoldstein JALafage VErrico TJBendo JA: Unplanned hospital readmission after surgical treatment of common lumbar pathologies: rates and causes. Spine (Phila Pa 1976) 40:4234282015

  • 6

    Akins PTHarris JAlvarez JLChen YPaxton EWBernbeck J: Risk factors associated with 30-day readmissions after instrumented spine surgery in 14,939 patients: 30-day readmissions after instrumented spine surgery. Spine (Phila Pa 1976) 40:102210322015

  • 7

    Angevine PDZivin JGMcCormick PC: Cost-effectiveness of single-level anterior cervical discectomy and fusion for cervical spondylosis. Spine (Phila Pa 1976) 30:198919972005

  • 8

    Barlev ASong XIvanov BSetty VChung K: Payer costs for inpatient treatment of pathologic fracture, surgery to bone, and spinal cord compression among patients with multiple myeloma or bone metastasis secondary to prostate or breast cancer. J Manag Care Pharm 16:6937022010

  • 9

    Brown MJKor DJCurry TBWarner MARodrigues ESRose SH: Sacral tumor resection: the effect of surgical staging on patient outcomes, resource management, and hospital cost. Spine (Phila Pa 1976) 36:157015782011

  • 10

    Carreon LYAnderson PATraynelis VCMummaneni PVGlassman SD: Cost-effectiveness of single-level anterior cervical discectomy and fusion five years after surgery. Spine (Phila Pa 1976) 38:4714752013

  • 11

    Carreon LYGlassman SDDjurasovic MCampbell MJPuno RMJohnson JR: RhBMP-2 versus iliac crest bone graft for lumbar spine fusion in patients over 60 years of age: a cost-utility study. Spine (Phila Pa 1976) 34:2382432009

  • 12

    Chew CO'Dwyer PJEdwards R: Health service cost associated with percutaneous vertebroplasty in patients with spinal metastases. Clin Radiol 68:7767792013

  • 13

    Decroisette CMonnet IBerard HQuere GLe Caer HBota S: Epidemiology and treatment costs of bone metastases from lung cancer: a French prospective, observational, multicenter study (GFPC 0601). J Thorac Oncol 6:5765822011

  • 14

    Delea TLanger CMcKiernan JLiss MEdelsberg JBrandman J: The cost of treatment of skeletal-related events in patients with bone metastases from lung cancer. Oncology 67:3903962004

  • 15

    Fehlings MGNater AHolmer H: Cost-effectiveness of surgery in the management of metastatic epidural spinal cord compression: a systematic review. Spine (Phila Pa 1976) 39:22 Suppl 1S99S1052014

  • 16

    Glassman SDPolly DWDimar JRCarreon LY: The cost effectiveness of single-level instrumented posterolateral lumbar fusion at 5 years after surgery. Spine (Phila Pa 1976) 37:7697742012

  • 17

    Hagiwara MDelea TESaville MWChung K: Healthcare utilization and costs associated with skeletal-related events in prostate cancer patients with bone metastases. Prostate Cancer Prostatic Dis 16:23272013

  • 18

    Harel REmch TChao SElson PKrishnaney ADjemil T: Quantitative evaluation of local control and wound healing following surgery and stereotactic spine radiosurgery (SRS) for spine tumors. World Neurosurg [epub ahead of print]2015

  • 19

    Kaloostian PEZadnik PLEtame ABVrionis FDGokaslan ZLSciubba DM: Surgical management of primary and metastatic spinal tumors. Cancer Contr 21:1331392014

  • 20

    Keam JBilsky MHLaufer IShi WZhang ZTam M: No association between excessive wound complications and preoperative high-dose, hypofractionated, image-guided radiation therapy for spine metastasis. J Neurosurg Spine 20:4114202014

  • 21

    Kuntz KMSnider RKWeinstein JNPope MHKatz JN: Cost-effectiveness of fusion with and without instrumentation for patients with degenerative spondylolisthesis and spinal stenosis. Spine (Phila Pa 1976) 25:113211392000

  • 22

    Lage MJBarber BLHarrison DJJun S: The cost of treating skeletal-related events in patients with prostate cancer. Am J Manag Care 14:3173222008

  • 23

    Lau DLeach MRLa Marca FPark P: Independent predictors of survival and the impact of repeat surgery in patients undergoing surgical treatment of spinal metastasis. J Neurosurg Spine 17:5655762012

  • 24

    McCarthy IHostin RO'Brien MSaigal RAmes CP: Health economic analysis of adult deformity surgery. Neurosurg Clin N Am 24:2933042013

  • 25

    McCarthy IO'Brien MAmes CRobinson CErrico TPolly DW Jr: Incremental cost-effectiveness of adult spinal deformity surgery: observed quality-adjusted life years with surgery compared with predicted quality-adjusted life years without surgery. Neurosurg Focus 36:5E32014

  • 26

    McCarthy IMHostin RAAmes CPKim HJSmith JSBoachie-Adjei O: Total hospital costs of surgical treatment for adult spinal deformity: an extended follow-up study. Spine J 14:232623332014

  • 27

    Meyer SAMummaneni PV: Cost-effectiveness of transforaminal lumbar interbody fusion. J Neurosurg Spine 15:1361372011

  • 28

    Munoz-Bendix CSlotty PJAhmadi SABostelmann RSteiger HJCornelius JF: Primary bone tumors of the spine revisited: A 10-year single-center experience of the management and outcome in a neurosurgical department. J Craniovertebr Junction Spine 6:21292015

  • 29

    Ortiz Gómez JA: The incidence of vertebral body metastases. Int Orthop 19:3093111995

  • 30

    Parker SLAdogwa OBydon ACheng JMcGirt MJ: Cost-effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis associated low-back and leg pain over two years. World Neurosurg 78:1781842012

  • 31

    Parker SLFulchiero ECDavis BJAdogwa OAaronson OSCheng JS: Cost-effectiveness of multilevel hemilaminectomy for lumbar stenosis-associated radiculopathy. Spine J 11:7057112011

  • 32

    Schairer WWCarrer ADeviren VHu SSTakemoto SMummaneni P: Hospital readmission after spine fusion for adult spinal deformity. Spine (Phila Pa 1976) 38:168116892013

  • 33

    Schairer WWCarrer ASing DCChou DMummaneni PVHu SS: Hospital readmission rates after surgical treatment of primary and metastatic tumors of the spine. Spine (Phila Pa 1976) 39:180118082014

  • 34

    Sharma MSonig AAmbekar SNanda A: Discharge dispositions, complications, and costs of hospitalization in spinal cord tumor surgery: analysis of data from the United States Nationwide Inpatient Sample, 2003–2010. J Neurosurg Spine 20:1251412014

  • 35

    Starks HWang SFarber SOwens DACurtis JR: Cost savings vary by length of stay for inpatients receiving palliative care consultation services. J Palliat Med 16:121512202013

  • 36

    Stephen AEBerger DL: Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery 133:2772822003

  • 37

    Tipsmark LSBünger CEWang MMorgen SSDahl BSøgaard R: Healthcare costs attributable to the treatment of patients with spinal metastases: a cohort study with up to 8 years follow-up. BMC Cancer 15:3542015

  • 38

    Tosteson ANLurie JDTosteson TDSkinner JSHerkowitz HAlbert T: Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Intern Med 149:8458532008

  • 39

    Tosteson ANSkinner JSTosteson TDLurie JDAndersson GBBerven S: The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 33:210821152008

  • 40

    Tsai TCJoynt KEOrav EJGawande AAJha AK: Variation in surgical-readmission rates and quality of hospital care. N Engl J Med 369:113411422013

  • 41

    Turner IMinhas ZKennedy JMorris SCrockard AChoi D: Cost of surgery for symptomatic spinal metastases in the UK. World Neurosurg 84:123512432015

  • 42

    Vonlanthen RSlankamenac KBreitenstein SPuhan MAMuller MKHahnloser D: The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients. Ann Surg 254:9079132011

  • 43

    Whitmore RGSchwartz JSSimmons SStein SCGhogawala Z: Performing a cost analysis in spine outcomes research: comparing ventral and dorsal approaches for cervical spondylotic myelopathy. Neurosurgery 70:8608672012

  • 44

    Zong SZeng GXiong CWei B: Treatment results in the differential surgery of intradural extramedullary schwannoma of 110 cases. PLoS One 8:e638672013

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