Economic burden of nonoperative treatment of adult spinal deformity

Peter G. Passias Departments of Orthopaedic and Neurologic Surgery, Division of Spine, NYU Langone Medical Center; New York Spine Institute, New York, New York;

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Waleed Ahmad Departments of Orthopaedic and Neurologic Surgery, Division of Spine, NYU Langone Medical Center; New York Spine Institute, New York, New York;

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Pooja Dave Departments of Orthopaedic and Neurologic Surgery, Division of Spine, NYU Langone Medical Center; New York Spine Institute, New York, New York;

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Renaud Lafage Department of Orthopedics, Hospital for Special Surgery, New York, New York;

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Virginie Lafage Department of Orthopedics, Hospital for Special Surgery, New York, New York;

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Jamshaid Mir Departments of Orthopaedic and Neurologic Surgery, Division of Spine, NYU Langone Medical Center; New York Spine Institute, New York, New York;

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Eric O. Klineberg Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York;

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Khaled M. Kabeish Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland;

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Jeffrey L. Gum Norton Leatherman Spine Center, Louisville, Kentucky;

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Breton G. Line Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado;

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Robert Hart Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington;

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Douglas Burton Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;

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Justin S. Smith Department of Neurosurgery, University of Virginia, Charlottesville, Virginia;

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Christopher P. Ames Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;

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Christopher I. Shaffrey Department of Neurological Surgery, University of California, San Francisco, California;

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Frank Schwab Department of Orthopedics, Hospital for Special Surgery, New York, New York;

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Richard Hostin Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas; and

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Thomas Buell Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

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D. Kojo Hamilton Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

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Shay Bess Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado;

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 MD , on behalf of International Spine Study Group
Publication Date:
15 Sep 2023
Page Range:
1–6
Volume/Issue:
Publish Before Print
DOI link:
https://doi.org/10.3171/2023.7.SPINE23195
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OBJECTIVE

The purpose of this study was to investigate the cost utility of nonoperative treatment for adult spinal deformity (ASD).

METHODS

Nonoperatively and operatively treated patients who met database criteria for ASD and in whom complete radiographic and health-related quality of life data at baseline and at 2 years were available were included. A cost analysis was completed on the PearlDiver database assessing the average cost of nonoperative treatment prior to surgical intervention based on previously published treatments (NSAIDs, narcotics, muscle relaxants, epidural steroid injections, physical therapy, and chiropractor). Utility data were calculated using the Oswestry Disability Index (ODI) converted to SF-6D with published conversion methods. Quality-adjusted life years (QALYs) used a 3% discount rate to account for residual decline in life expectancy (78.7 years). Minor and major comorbidities and complications were assessed according to the CMS.gov manual’s definitions. Successful nonoperative treatment was defined as a gain in the minimum clinically importance difference (MCID) in both ODI and Scoliosis Research Society (SRS)–pain scores, and failure was defined as a loss in MCID or conversion to operative treatment. Patients with baseline ODI ≤ 20 and continued ODI of ≤ 20 at 2 years were considered nonoperative successful maintenance. The average utilization of nonoperative treatment and cost were applied to the ASD cohort.

RESULTS

A total of 824 patients were included (mean age 58.24 years, 81% female, mean body mass index 27.2 kg/m2). Overall, 75.5% of patients were in the operative and 24.5% were in the nonoperative cohort. At baseline patients in the operative cohort were significantly older, had a greater body mass index, increased pelvic tilt, and increased pelvic incidence–lumbar lordosis mismatch (all p < 0.05). With respect to deformity, patients in the operative group had higher rates of severe (i.e., ++) sagittal deformity according to SRS–Schwab modifiers for pelvic tilt, sagittal vertical axis, and pelvic incidence–lumbar lordosis mismatch (p < 0.05). At 2 years, patients in the operative cohort showed significantly increased rates of a gain in MCID for physical component summary of SF-36, ODI, and SRS-activity, SRS-pain, SRS-appearance, and SRS-mental scores. Cost analysis showed the average cost of nonoperative treatment 2 years prior to surgical intervention to be $2041. Overall, at 2 years patients in the nonoperative cohort had again in ODI of 0.36, did not show a gain in QALYs, and nonoperative treatment was determined to be cost-ineffective. However, a subset of patients in this cohort underwent successful maintenance treatment and had a decrease in ODI of 1.1 and a gain in utility of 0.006 at 2 years. If utility gained for this cohort was sustained to full life expectancy, patients’ cost per QALY was $18,934 compared to a cost per QALY gained of $70,690.79 for posterior-only and $48,273.49 for combined approach in patients in the operative cohort.

CONCLUSIONS

Patients with ASD undergoing operative treatment at baseline had greater sagittal deformity and greater improvement in health-related quality of life postoperatively compared to patients treated nonoperatively. Additionally, patients in the nonoperative cohort overall had an increase in ODI and did not show improvement in utility gained. Patients in the nonoperative cohort who had low disability and sagittal deformity underwent successful maintenance and cost-effective treatment.

ABBREVIATIONS

ASD = adult spinal deformity; BMI = body mass index; HRQOL = health-related quality of life; LOS = length of stay; MCID = minimum clinically importance difference; ODI = Oswestry Disability Index; PI-LL = pelvic incidence–lumbar lordosis mismatch; PT = pelvic tilt; QALY = quality-adjusted life year; SRS = Scoliosis Research Society; SVA = sagittal vertical axis.
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Contributor Notes

Correspondence Peter G. Passias: New York Spine Institute, NYU Langone Medical Center, Orthopedic Hospital–NYU School of Medicine, New York, NY. peter.passias@nyumc.org.

INCLUDE WHEN CITING Published online September 15, 2023; DOI: 10.3171/2023.7.SPINE23195.

Disclosures Dr. Passias reported other financial or material support from Cerapedics and from Spinevision; paid presenter or speaker from Globus Medical; paid consultant from Medtronic, Royal Biologics, SpineWave, and Terumo; editorial or governing board at Spine; and research support from Cervical Scoliosis Research Society outside the submitted work. Mr. R. Lafage reported personal fees from Carlsmed outside the submitted work. Dr. V. Lafage reported consulting fees from Alphatec and from Globus Medical; royalties from NuVasive; personal fees from Johnson and Johnson and from Stryker for lectures; nonfinancial support from ISSG as an editorial committee member; and nonfinancial support from SRS as a committee member outside the submitted work. Dr. Klineberg reported consulting fees from DePuy Synthes Spine, Stryker, Medtronic, SI Bone, and Agnovos; stock ownership from MMI and Relatable; fellowship grant, chair elect, and fellowship chair from AO Spine; and chair elect from IMAST outside the submitted work. Dr. Kebaish reported royalties from DePuy Synthes, Stryker, Orthofix, and SpineCraft outside the submitted work. Dr. Gum reported personal fees from Acuity, DePuy, Medtronic, NuVasive, Stryker, FYR Medical, Expanding Innovations, Norton Healthcare, Inc., National Spine Health Foundation, Kyana, Pacira Pharmaceuticals, Baxter, Broadwater, North American Spine Society, and MiMedx; nonfinancial support from Fischer Owen travel fund; stock ownership in Cingulate Therapeutics and FYR Medical; grants for research funding from Alan L. & Jacqueline B. Stuart Spine Center, Biom’Up, Cerapedics, Inc., Empirical Spine, Inc., Medtronic, National Spine Health Foundation, Pfizer, SRS, Stryker, and Texas Scottish Rites Hospital; and journal reviews for The Spine Journal, Spine Deformity, and Global Spine Journal outside the submitted work. In addition, Dr. Gum had a patent issued for a device with Medtronic. Dr. Line reported personal fees from ISSG outside the submitted work. Dr. Hart reported personal fees from Globus and from SeaSpine; and stock ownership from Mirus and Amplify outside the submitted work. Dr. Burton reported personal fees from Globus, DePuy Spine, and Blue Ocean Spine; stock options from Progenerative Medical; and nonfinancial support from the ISSG and SRS boards of directors outside the submitted work. Dr. Smith reported grants from DePuy Synthes/ISSG Foundation (ISSGF) during the conduct of the study; personal fees from Cerapedics, Carlsmed, and NuVasive; grants from NuVasive; personal fees from ZimVie and DePuy Synthes; grants from DePuy Synthes/ISSGF and AOSpine; and personal fees from Thieme and SeaSpine outside the submitted work. Dr. Ames reported royalties from Stryker, Biomet Zimmer Spine, DePuy Synthes, NuVasive, Next Orthosurgical, K2M, and Medicrea; consulting fees from DePuy Synthes, Medtronic, Medicrea, K2M, Agada Medical, and Carlsmed; personal fees for research from Titan Spine, DePuy Synthes, and ISSG; nonfinancial support from Operative Neurosurgery; membership on the Neurospine editorial board; grants from SRS; nonfinancial support from ISSG as an executive committee member; nonfinancial support from Global Spinal Analytics as a director; and nonfinancial support from SRS as chair of the Safety and Value Committee outside the submitted work. Dr. Shaffrey reported grants from ISSGF to Duke University during the conduct of the study; and personal fees from NuVasive, Medtronic, SI Bone, and Proprio outside the submitted work. Dr. Schwab reported consulting fees and royalties from Zimmer Biomet and MSD; consulting fees from Mainstay Medical; personal fees from ISSG as an executive committee member; and shareholder status in VFT Solutions and SeaSpine outside the submitted work. Dr. Bess reported grants from DePuy Synthes, NuVasive, K2M, and ISSGF during the conduct of the study; and grants from DePuy Synthes, Medtronic, Globus, Stryker, SeaSpine, Carlsmed, and ISSGF outside the submitted work.

  • 1

    Scheer JK, Hostin R, Robinson C, et al. Operative management of adult spinal deformity results in significant increases in QALYs gained compared to nonoperative management: analysis of 479 patients with minimum 2-year follow-up. Spine (Phila Pa 1976). 2018;43(5):339–347.

    • Search Google Scholar
    • Export Citation
  • 2

    Carter OD, Haynes SG. Prevalence rates for scoliosis in US adults: results from the first National Health and Nutrition Examination Survey. Int J Epidemiol. 1987;16(4):537–544.

    • Search Google Scholar
    • Export Citation
  • 3

    Francis RS. Scoliosis screening of 3,000 college-aged women. The Utah Study—phase 2. Phys Ther. 1988;68(10):1513–1516.

  • 4

    Choi SH, Son SM, Goh TS, Park W, Lee JS. Outcomes of operative and nonoperative treatment in patients with adult spinal deformity with a minimum 2-year follow-up: a meta-analysis. World Neurosurg. 2018;120:e870–e876.

    • Search Google Scholar
    • Export Citation
  • 5

    Champain S, Benchikh K, Nogier A, Mazel C, Guise JD, Skalli W. Validation of new clinical quantitative analysis software applicable in spine orthopaedic studies. Eur Spine J. 2006;15(6):982–991.

    • Search Google Scholar
    • Export Citation
  • 6

    O’Brien MF, Kuklo TR, Blanke KM, Lenke LG, eds. Spinal Deformity Study Group Radiographic Measurement Manual. Medtronic Sofamor Danek; 2005.

    • Search Google Scholar
    • Export Citation
  • 7

    Rillardon L, Levassor N, Guigui P, et al. Validation of a tool to measure pelvic and spinal parameters of sagittal balance. Article in French. Rev Chir Orthop Repar Appar Mot. 2003;89(3):218–227.

    • Search Google Scholar
    • Export Citation
  • 8

    Brown AE, Alas H, Pierce KE, et al. Obesity negatively affects cost efficiency and outcomes following adult spinal deformity surgery. Spine J. 2020;20(4):512–518.

    • Search Google Scholar
    • Export Citation
  • 9

    Poorman GW, Passias PG, Qureshi R, et al. Cost-utility analysis of cervical deformity surgeries using 1-year outcome. Spine J. 2018;18(9):1552–1557.

    • Search Google Scholar
    • Export Citation
  • 10

    Horn SR, Passias PG, Hockley A, et al. Cost-utility of revisions for cervical deformity correction warrants minimization of reoperations. J Spine Surg. 2018;4(4):702–711.

    • Search Google Scholar
    • Export Citation
  • 11

    Passias PG, Poorman GW, Bortz CA, et al. Predictors of adverse discharge disposition in adult spinal deformity and associated costs. Spine J. 2018;18(10):1845–1852.

    • Search Google Scholar
    • Export Citation
  • 12

    Qureshi R, Puvanesarajah V, Jain A, Shimer AL, Shen FH, Hassanzadeh H. A comparison of anterior and posterior lumbar interbody fusions: complications, readmissions, discharge dispositions, and costs. Spine (Phila Pa 1976). 2017;42(24):1865–1870.

    • Search Google Scholar
    • Export Citation
  • 13

    Version 28.0 ICD-10 MS-DRGs Update. CMS.gov. Accessed July 31, 2023. https://www.cms.gov/Medicare/Coding/ICD10/downloads/v28msdrgupdate.pdf

    • Search Google Scholar
    • Export Citation
  • 14

    Carreon LY, Glassman SD, McDonough CM, Rampersaud R, Berven S, Shainline M. Predicting SF-6D utility scores from the Oswestry disability index and numeric rating scales for back and leg pain. Spine (Phila Pa 1976). 2009;34(19):2085–2089.

    • Search Google Scholar
    • Export Citation
  • 15

    Carreon LY, Bratcher KR, Das N, Nienhuis JB, Glassman SD. Estimating EQ-5D values from the Oswestry Disability Index and numeric rating scales for back and leg pain. Spine (Phila Pa 1976). 2014;39(8):678–682.

    • Search Google Scholar
    • Export Citation
  • 16

    Sassi F. Calculating QALYs, comparing QALY and DALY calculations. Health Policy Plan. 2006;21(5):402–408.

  • 17

    Murray CJ. Quantifying the burden of disease: the technical basis for disability-adjusted life years. Bull World Health Organ. 1994;72(3):429–445.

    • Search Google Scholar
    • Export Citation
  • 18

    Tan-Torres T, Baltussen R, Adam T, et al., eds. Making Choices in Health: WHO Guide to Cost-Effectiveness Analysis. World Health Organization; 2003:71.

    • Search Google Scholar
    • Export Citation
  • 19

    Smith JS, Shaffrey CI, Ames CP, Lenke LG. Treatment of adult thoracolumbar spinal deformity: past, present, and future. J Neurosurg Spine. 2019;30(5):551–567.

    • Search Google Scholar
    • Export Citation
  • 20

    Passias PG, Jalai CM, Line BG, et al. Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from nonoperative to surgical treatment: initial steps to reduce ineffective ASD management. Spine J. 2018;18(2):234–244.

    • Search Google Scholar
    • Export Citation
  • 21

    Fu KM, Smith JS, Sansur CA, Shaffrey CI. Standardized measures of health status and disability and the decision to pursue operative treatment in elderly patients with degenerative scoliosis. Neurosurgery. 2010;66(1):42–47.

    • Search Google Scholar
    • Export Citation
  • 22

    Bess S, Line B, Fu KM, et al. The health impact of symptomatic adult spinal deformity: comparison of deformity types to United States population norms and chronic diseases. Spine (Phila Pa 1976). 2016;41(3):224–233.

    • Search Google Scholar
    • Export Citation
  • 23

    Gum JL, Hostin R, Robinson C, et al. Impact of cost valuation on cost-effectiveness in adult spine deformity surgery. Spine J. 2017;17(1):96–101.

    • Search Google Scholar
    • Export Citation

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