Elsevier

The Spine Journal

Volume 13, Issue 6, June 2013, Pages 651-656
The Spine Journal

Clinical Study
Cost analysis of anterior-posterior circumferential fusion and transforaminal lumbar interbody fusion

https://doi.org/10.1016/j.spinee.2012.11.055Get rights and content

Abstract

Background context

Although lumbar interbody fusion has long been a common procedure in the practice of spine surgery, focus on the technological development has produced the relatively new procedure of transforaminal lumbar interbody fusion (TLIF). This procedure is often available to surgeons as an alternative to anterior-posterior circumferential fusion (AP fusion), and both procedures have been demonstrated to be clinically equivalent at up to 5 years after surgery. In the context of clinical equipoise, it is unknown which procedure is more economically advantageous.

Purpose

To compare the hospital costs, charges, and payments received for surgical treatment with either AP fusion or TLIF. Future directions for health economic research with respect to spine surgery are also considered and discussed.

Study design

This is an institutional review board–approved, single-institution retrospective chart review and cost analysis.

Patient sample

Our study included patients undergoing either single-level AP fusion or single-level TLIF between 2006 and 2008. All patients were older than 18 years at the time of surgery; the decision of which procedure was performed was entirely at the discretion of the attending surgeon.

Outcome measures

Hospital costs, charges, and payments received for the treatment of each patient.

Methods

We performed a retrospective review of the medical and financial records of patients undergoing either AP fusion (n=179) or TLIF (n=90) on one operative level between 2006 and 2008. Medical records were evaluated for a history of spine surgery, operative time, estimated blood loss, and length of stay, whereas financial records were reviewed for the hospital costs, charges, and payments received as recorded by the hospital accounting data. Operative materials and service charges were also isolated and compared separately. This study was departmentally sponsored; there were no interest-associated biases for any of the authors involved.

Results

AP fusion patients had a longer operative time than TLIF patients, with a mean time of 246.5 versus 202.7 minutes (p<.01). Conversely, TLIF patients had a higher estimated blood loss during surgery (469.8 cm3) than AP fusion patients (311.2 cm3) (p<.01). The mean hospital cost for AP fusion was $25,165, whereas for TLIF was $23,390 (p=.04). The mean hospital charges and payments received for AP fusion were 1.07 (p=.05) and 1.35 (p<.01) times those received for TLIF, respectively. Therefore, mean hospital charges and payments received for TLIF were 0.93 and 0.76 times those received for AP fusion, respectively.

Conclusions

Our study demonstrates that a single-level AP fusion results in longer operative time, lower blood loss during surgery, higher hospital costs, higher hospital charges, and greater payments received than a single-level TLIF. Although the decision on how best to treat a patient lies solely at the judgment of the attending surgeon, this comparative cost information may be pertinent in cases of clinical equivalence. This study also calls attention to various shortcomings that are found in present spine surgery cost-effectiveness research, as there is an ongoing need for increased standards of quality in the area of health economics research.

Introduction

Evidence & Methods

Cost analyses are being increasingly performed given the costs of health care. In this article, the authors compare costs of anterior-posterior (AP) fusion versus transforaminal lumbar interbody fusion (TLIF).

The mean hospital costs were slightly higher for AP fusion versus TLIF, but the payment received by the hospital was greater for AP fusions.

This study has significant limitations that may limit generalization including retrospective design, unmatched controls, failure to assess costs outside of the hospital perspective, assumed contribution margin, single institution, presumed equivalent clinical outcomes (eg, infection rates, readmission rates, DVT rates), and so on. That said, the hospital perspective is an interesting one given that bundled payments to hospitals appear to be integral to the federal government's shift from a “volume” to “quality” reimbursement model. The article should serve as a nidus to prospective-controlled studies.

—The Editors

An increasing number of lumbar interbody fusions have been performed over the last 10 years for a variety of pathological conditions in the spine. Both anterior-posterior (AP) and transforaminal lumbar interbody (TLIF) fusions can be used to achieve a circumferential interbody fusion. Several studies have examined both clinical and radiographic outcomes associated with AP and TLIF fusions [1], [2], [3], [4]; the two procedures have been demonstrated to be clinically equivalent at up to 5 years after surgery, including results of both single- and multilevel procedures for the treatment of spondylolisthesis or degenerative disc disease [5]. There certainly remain clinical contexts in which the technical nuance and spine surgeon expertise may lead to preferential choice of one technique over the other. Therefore, a cost difference might be a consideration in a clinical scenario in which either procedure would appear to be effective and certainly when TLIF looks to be the best option.

To our knowledge, only one previous publication has directly addressed a cost comparison of these two procedures. In 2001, Whitecloud et al. [6] presented a comparison of hospital charges with patients of AP fusion and TLIF; these authors reported that TLIF patients were charged an average of about $15,000 less for treatment than AP fusion patients. However, these findings included hospital charges only and were, therefore, limited in their ability to provide a realistic image of the costs associated with these procedures. With growing pressure to reduce costs while continuing to deliver high-quality care, cost research in spinal surgery is becoming an increasingly important subject of discussion.

The objective of this study was to report a hospital cost, charge, and reimbursement analysis comparing AP with TLIF in single-level lumbar fusion.

Section snippets

Methods

Institutional review board approval was obtained before the collection of data. The medical and financial records of patients undergoing either anterior-posterior circumferential fusion (AP fusion) via anterior lumbar interbody fusion with supplemental posterolateral fusion or TLIF on one level from 2006 to 2008 were retrospectively obtained from the hospital's medical and financial records departments and reviewed.

Demographic data collected included sex, age, race, body mass index, and

Results

A total of 269 patients, who underwent surgery at our institution from 2006 to 2008 were included in this analysis (AP, n=179; TLIF, n=90) (Table 1). The mean age for the groups was significantly different; AP patients averaged 44.5±11.4 years, whereas TLIF patients had a mean age of 51.4±13 years (p<.01). The AP group had 90 men (50.3%) and 89 women (49.7%), whereas the TLIF group had 47 men (52.2%) and 43 women (47.8%); this gender distribution was not statistically significant (p=.76). With

Discussion

Cost research has developed to encompass a wide variety of ways to quantify the idea of the “value” gained from a surgical intervention; it may be calculated using various quantifications of expenses to patients, caregivers, insurers, and society, as well as various measurements of patient satisfaction and quality of life [7], [8]. Despite this, researchers are confident that surgical intervention is a worthwhile pursuit for many patients [9].

A relatively unexplored area of cost research is

Conclusion

The present findings of cost with respect to AP fusion and TLIF are able to show a comprehensive comparison of monetary flow for these procedures and may provide an insightful illustration of the roles that they play in the grander setting of modern health-care expenditure and profit. Our results suggest that TLIF is more advantageous to AP fusion with regard to the direct hospital costs and charges, but they also raise the question of which costs must be included when attempting to apply a

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    Although Fischer et al.'s study evaluated the cost-effectiveness of AP fusion versus posterior-only fusion with or without interbody fusion, the study lacked a matched control group and was based on Medicare data that have been found to be inaccurate and lacking granularity [9]. Andres et al. looked at costs between AP and TLIF procedures but did not evaluate clinical utility to determine true cost-effectiveness [10]. Because of the high expense associated with these procedures, it is essential for the cost-effectiveness of these procedures to be explored.

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Author disclosures: TMA: Nothing to disclose. JJP: Nothing to disclose. PARH: Nothing to disclose. BJM: Nothing to disclose. DTW: Nothing to disclose. TJE: Royalties: K2M (F); Consulting: K2M (D); Research Support: Paradigm (F, paid directly to institution); Fellowship Support: AO (E, paid directly to institution), OREF (E, paid directly to institution).

The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

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