Elsevier

The Spine Journal

Volume 10, Issue 2, February 2010, Pages 108-116
The Spine Journal

Clinical Study
Economic impact of improving outcomes of lumbar discectomy

https://doi.org/10.1016/j.spinee.2009.08.453Get rights and content

Abstract

Background

Lumbar discectomy is usually a successful operation with a relatively low cost. Potential adjunctive procedures, such as repairing the anulus fibrosus or nucleus replacements, necessitate a cost-benefit analysis.

Purpose

This economic analysis was performed to understand the potential value of advanced implantable technologies designed to improve outcomes after discectomy.

Study design/setting

Using an insurance claims–based database, the economics of less-than-favorable outcomes after lumbar discectomy were studied. Estimates of improved clinical outcomes because of adjunctive surgical procedural items were modeled.

Patient sample

Using Current Procedural Terminology (CPT-4) codes and International Classification of Diseases, Clinical Modification procedure codes (ICD-9 CM), all lumbar discectomy patients were identified in a 6-month period from a large, 2002, commercially available claims-based data set representing 3.1 million insured lives.

Outcome measures

Not applicable.

Methods

Longitudinal data analysis from 3 years (2002–2004) of the database was performed for evidence of claims after the insured's discectomy (up to 18 months post) as a utilization estimate of surgical and medical treatment resultant of less-than-favorable outcomes. Incidence and cost of secondary operations, medical management, and complications were determined. Using these inputs, an economic model was generated to estimate the effect of improvement in discectomy outcomes.

Results

Of the 494 patients who had a discectomy within a 6-month period, 137 (28%) had subsequent claims that suggested the outcome was less than favorable within 18 months. Patients whose insurance claims included codes for a second operation (n=52 patients with 56 operations; 11%) and patients being medically/nonsurgically managed (n=85, 17%) were studied. Average reimbursed charges incurred (2006 dollars) of repeated discectomy (80% of cases) was $6,907 and for arthrodesis (20% of cases) was $24,375. Average additional medical treatment cost to diagnose or manage poor outcome requiring another surgery was $3,365. Procedure-related complications within 40 days of surgery were evident in 15% of the group; with additional average cost to manage of $3,939.

Conclusions

Substantial cost associated with poor discectomy outcomes is often overlooked or underappreciated. Surgical technologies that can improve outcomes of discectomy by 50% to 70% thus improving patient quality of life can be overall cost-neutral between $971 and $1,655 additionally per patient.

Introduction

Evidence & Methods

Some proportion of patients undergoing surgery for lumbar disc herniation have continued or recurrent symptoms. Some have suggested that annular repair, reconstruction or nuclear augmentation may reduce the risk of post-operative problems or re-operation. This study attempts to estimate how effective a hypothetical surgical technology would need to reduce post-operative problems (and costs) to be cost-neutral to an insurance payor.

With all the numerous assumptions inherent in this type of exercise, the authors calculated that a technology that improved outcomes in aggregate, by 50%, might be cost-neutral at approximately $1,000 (USD).

This study provides an interesting glimpse of the complex set of assumptions needed to estimate a future cost-benefit effect for given technology. Still, it is unclear from this analysis how much improvement is potentially gained by even a perfect technology, given the multi-dimensional nature of low back pain illnesses.

The Editors

Routine lumbar discectomy or microdiscectomy is generally perceived to be a successful operation [1] to relieve symptoms from a herniated intervertebral disc at a cost relatively lower than other spine surgeries such as cervical [2], [3], [4] or lumbar fusions [5], [6], [7], [8]. Spine fusion procedures often require instrumentation or bone grafting alternatives such as bone morphogenetic proteins that can increase overall cost substantially [9]. More recently, artificial disc replacement has been suggested for some surgical cases that would have otherwise received a fusion; the cost-effectiveness of these devices is currently being challenged in spite of favorable analyses, reporting that the overall economic impact over a 2-year time horizon is likely to be significantly less than standard-of-care lumbar fusions [10].

The literature suggests that discectomy procedures are not always successful [11], [12], [13], [14], [15], [16] when considering patient satisfaction or surgical outcomes despite advancements in operative techniques such as minimally invasive approaches or the use of adjunctive technologies, for example, anular repair products or nucleus replacements. In addition, these advancements tended to increase the base cost of the procedure. The cost-benefit ratio of proposed techniques such as chemonucleolysis [17], automated percutaneous discectomy [18], intradiscal electrothermal therapy [19], other perioperative items [20], [21], or ancillary services [22], [23], [24], [25], [26] that may impact the overall cost of a discectomy have been studied in various ways with various historical outcomes. Many of these techniques were introduced with high expectations because many were perceived as less invasive and were purported to improve discectomy outcomes by changing clinical path decisions, decreasing morbidity, or reducing reoperation rates. Some eventually produced favorable clinical trial evidence, yet most of these have not become the standard of care that routine lumbar microdiscectomy surgery is today [27], [28]. However, the impact of implantable materials and devices that could potentially be used during or after discectomy for herniated discs without significant degenerative collapse (ie, not requiring arthrodesis or total prosthetic replacement), such as anular repair devices [29], [30], [31], [32], [33], [34], [35], [36], [37] or nucleoplasty implant [38], [39], has not yet been examined from an economic vantage point.

The purpose of this analysis was to understand the economic value to the US health care system of advanced implantable technologies designed to improve outcomes of lumbar discectomy. This study was based on an economic analysis of reimbursed charges from large claims-based data sets. Data from these large medical claims databases were analyzed with comparison to literature-based clinical outcome data after discectomy.

Section snippets

Methods

As a starting point, the overall annual volume of discectomy procedures in the United States was estimated from three sources: 1) a 2002 research database (Reden & Anders Ltd, Minneapolis, MN, USA) that included over 3.1 million insured covered lives from a large national managed care plan; 2) the Nationwide Inpatient Sample distributed through the Healthcare Cost and Utilization Project (Agency for Healthcare Research and Quality), which is the largest all-payer inpatient care database in the

Results

The total estimate of commercially insured inpatient discectomy procedures (Healthcare Cost and Utilization Project discharge data) in 2002 was 131,398 and outpatient discectomy procedures totaled 120,276. The total number of discectomies covered by Medicare was 35,448, and these procedures were heavily skewed toward inpatient procedures (86%) versus outpatient procedures (14%) [44]. Therefore, the total number of discectomies performed in 2002 was 287,122. Furthermore, CPT coding modifiers for

Discussion

Costs associated with new technology introduced within a surgery that has already been deemed overall cost-effective is often a matter of heated debate from many different perspectives. Hospital administration is concerned about rising costs that make it difficult to continue or add to the variety of services it is accustomed to offering because of reductions in reimbursements from third-party insurance companies and the US Federal government's Medicare system. Yet physicians and surgeons are

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      Citation Excerpt :

      However, when conservative treatments fail, surgical options (discectomy for disc herniation and fusion or arthroplasty for disc disease) can be proposed [3–5]. Despite the low rate of required surgery, the prevalence of disc surgery is relatively high (0.1% in the United States [6]) and the frequency of lumbar fusion surgery has increased considerably in recent years (e.g., >150% in the United States in the last 3 decades [7]). Surgery has a high success rate in the short-term but decreases with time after surgery [8].

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    FDA device/drug status: none.

    Author disclosures: JS (stock ownership, consulting fees, speaking arrangements, board of directors, scientific advisory board, Anulex Technologies, Inc); JC (stock ownership, scientific advisory board, Anulex Technologies, Inc); DS (stock ownership, other office in the company, Anulex Technologies, Inc); MB (stock ownership, board of directors, other office in the company, Anulex Technologies, Inc); NLR (other sponsorship, Anulex Technologies, Inc); SLG (stock ownership, other office in the company, Anulex Technologies, Inc).

    This study was supported by funding from Anulex Technologies, Inc., to Strategic Health Resources, Inc.

    This study was presented at the 2007 AANS/CNS Joint Section Meeting, Phoenix, AZ (March 8, 2007); and the 2007 Spinal Arthroplasty Society Meeting, Berlin, Germany (May 1, 2007).

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