Estimating a price point for cost-benefit of bone morphogenetic protein in pseudarthrosis prevention for adult spinal deformity surgery

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OBJECTIVE

Bone morphogenetic protein (BMP) is associated with reduced rates of pseudarthrosis and has the potential to decrease the need for revision surgery. There are limited data evaluating the cost-benefit of BMP for pseudarthrosis-related prevention surgery in adult spinal deformity.

METHODS

The authors performed a single-center retrospective review of 200 consecutive patients with adult spinal deformity. Demographic data and costs of BMP, primary surgery, and revision surgery for pseudarthrosis were collected. Patients with less than 12 months of follow-up or with infection, tumor, or neuromuscular disease were excluded.

RESULTS

One hundred fifty-one patients (107 [71%] women) with a mean age of 65 years met the inclusion criteria. The mean number of levels fused was 10; BMP was used in 98 cases (65%), and the mean follow-up was 23 months. Fifteen patients (10%) underwent surgical revision for pseudarthrosis; BMP use was associated with an 11% absolute risk reduction in the rate of reoperation (17% vs 6%, p = 0.033), with a number needed to treat of 9.2. There were no significant differences in age, sex, upper instrumented vertebra, or number of levels fused in patients who received BMP. In a multivariate model including age, sex, number of levels fused, and the upper instrumented vertebra, only BMP (OR 0.250, 95% CI 0.078–0.797; p = 0.019) was associated with revision surgery for pseudarthrosis. The mean direct cost of primary surgery was $87,653 ± $19,879, and the mean direct cost of BMP was $10,444 ± $4607. The mean direct cost of revision surgery was $52,153 ± $26,985. The authors independently varied the efficacy of BMP, cost of BMP, and cost of reoperation by ± 50%; only reductions in the cost of BMP resulted in a cost savings per 100 patients. Using these data, the authors estimated a price point of $5663 in order for BMP to be cost-neutral.

CONCLUSIONS

Use of BMP was associated with a significant reduction in the rates of revision surgery for pseudarthrosis. At its current price, the direct in-hospital costs for BMP exceed the costs associated with revision surgery; however, this likely underestimates the true value of BMP when considering the savings associated with reductions in rehabilitation, therapy, medication, and additional outpatient costs.

ABBREVIATIONS ASD = adult spinal deformity; BMP-2 = bone morphogenetic protein–2; CCI = Charlson Comorbidity Index; HRQOL = health-related quality of life; NNT = number of patients needed to treat; QALY = quality-adjusted life-year; SRS = Scoliosis Research Society; SVA = sagittal vertical axis; UIV = upper instrumented vertebra.

Article Information

Correspondence Christopher Ames: University of California, San Francisco, CA. christopher.ames@ucsf.edu.

INCLUDE WHEN CITING Published online March 8, 2019; DOI: 10.3171/2018.12.SPINE18613.

M.M.S. and C.L.D.O. contributed equally to this work.

Disclosures Dr. Deviren: consultant for NuVasive, Seaspine, Pfizer, Medicrea, Guidepoint, and Biomet; and institutional fellowship grant support: NuVasive, AOSpine, and Globus. Dr. Ames: employee of UCSF; consultant for Medtronic, Biomet Zimmer, DePuy Synthes, K2M, and Medicrea; support of non–study-related clinical or research effort from Titan Spine, DePuy Synthes, and ISSG; editorial board of Operative Neurosurgery; grant funding from the Scoliosis Research Society; executive committee of ISSG; director of Global Spine Analytics; and royalties from Biomet Zimmer, Stryker, DePuy Synthes, K2M, Next Spine, and Medicrea.

© AANS, except where prohibited by US copyright law.

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Figures

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    Cost-benefit of BMP for prevention of pseudarthrosis-related revision surgery. Variations in the price of BMP were plotted against the cost savings by reoperations prevented to identify the price point at which BMP became cost-neutral.

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