COST ANALYSIS
Bending the Cost Curve—Establishing Value in
Spine Surgery
Scott L. Parker, MD∗
Silky Chotai, MD∗
Clinton J. Devin, MD∗
Lindsay Tetreault, PhD‡
Thomas E. Mroz, MD§
Darrel S. Brodke, MD¶
Michael G. Fehlings, MD, PhD||
Matthew J. McGirt, MD#
∗
Department of Orthopedics Surgery
and Neurological surgery, Vanderbilt
University Medical Center, Nashville,
Tennessee; ‡ Spinal Cord Injury Clinical
Research Unit, Krembil Neuroscience
Centre, University Health Network,
Toronto, Canada; § Center for Spine
Health, Department of Neurosurgery
and Orthopaedic Surgery, Cleveland
Clinic, Cleveland, Ohio; ¶ Department
of Orthopedics, University of Utah
School of Medicine, Salt Lake City, Utah;
||
Division of Neurosurgery, University of
Toronto, Toronto, Canada; # Department
of Neurological Surgery, Carolina
Neurosurgery and Spine Associates,
Charlotte, North Carolina
Correspondence:
Mathew J. McGirt, MD,
Department of Neurological Surgery,
Carolina Neurosurgery and
Spine Associates,
Charlotte, NC.
E-mail: [email protected]
Received, August 16, 2016.
Accepted, October 31, 2016.
C 2016 by the
Copyright Congress of Neurological Surgeons
BACKGROUND: As publically promoted by all stakeholders in health care reform,
prospective outcomes registry platforms lie at the center of all current evidence-driven
value-based models.
OBJECTIVE: To demonstrate the variability in outcomes and cost at population level and
individual patient level for patients undergoing spine surgery for degenerative diseases.
METHODS: Retrospective analysis of prospective longitudinal spine registry data was
conducted. Baseline and postoperative 1-year patient-reported outcomes were recorded.
Previously published minimal clinically important difference for Oswestry Disability Index
(14.9) was used. Back-related resource utilization and quality-adjusted life years (QALYs)
were assessed. Variations in outcomes and cost were analyzed at population level and at
the individual patient level.
RESULTS: A total of 1454 patients were analyzed. There was significant improvement in
patient-reported outcomes at postoperative 1 year (P < .0001). For patients demonstrating
health benefit at population level, 12.5%, n = 182 of patients experienced no gain from
surgery and 38%, n = 554 failed to achieve minimal clinically important difference. Mean
1-year QALY-gained was 0.29; 18% of patients failed to report gain in QALY. For patients with
2-year follow-up, surgery resulted in 0.62 QALY-gained at average direct cost of $28 953. A
wide variation in both QALY-gained and cost was observed.
CONCLUSION: Spine treatments that on average are cost-effective may have wide
variability in value at the individual patient level. The variability demonstrated here
represents an opportunity, through registries, to identify specific care that may be less
effective, and refine patient-specific care delivery and indications to drive overall grouplevel treatment value. Understanding value of spine care at an individualized as well as
population level will allow clinicians, and eventually payers, to better target resources for
improving care for nonresponders, ultimately driving up the average health for the whole
population.
KEY WORDS: Value, Spine, Surgery, Cost, Cost-effectiveness, QOD, Spine registry, Patient-reported outcomes
Neurosurgery 80:S61–S69, 2017
DOI:10.1093/neuros/nyw081
T
he health care expenditure in the United
States (US) is on an upward trajectory
and clearly unsustainable.1-3 According
to the Centers for Medicare and Medicaid
Services, the health spending is projected to
grow 1.3 parentage points faster than gross
ABBREVIATIONS: GDP, gross domestic product;
EQ-5D, EuroQol-5D; HCRU, healthcare resource
utilization; MCID, minimum clinically important
difference; ODI, oswestry disability index; PROs,
patient-reported outcomes; QALYs, qualityadjusted life years; QOD, quality outcome database
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www.neurosurgery-online.com
domestic product (GDP) per year, resulting in
projected health share of GDP as high as 20%
by 2025. 1,4 Spine degenerative pathologies and
associated disability is highly prevalent and an
economic burden.5-9 The estimated direct costs
for treating these patients range from $80 to
100 billion.6,10-13
In an effort to curb escalating costs, the
Patient Protection and Affordable Care Act and
Centers for Medicare and Medicaid Services
have adopted a pay-for-performance value-based
purchasing.14 Health care value is measured by
comparing quality delivered against cost incurred
(benefit/cost) and is optimally examined in the
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PARKER ET AL
context of various consensus-based health care outcomes.15-17
The numerator “benefit” is defined by the efficacy of the
treatment in terms of outcomes following intervention. The
denominator of the question cost is defined as dollar spent for
the intervention from the patient, provider, and societal perspectives.17 Therefore, in order to ultimately bend the cost curve and
improve the value of spine surgery, the effectiveness of a surgical
procedure as it pertains to patient outcomes and quality of life
measures must be closely defined in the real-world setting.
Prospective registries have demonstrated their value to
efficiently capture patient-reported outcomes (PROs) data across
multiple centers, achieving necessary statistical power to assess
true value of spine care at both the population level and at
the individual patient level.18-20 Prospective registries measure
safety, quality, and effectiveness of procedures in real-world health
care delivery settings that are not limited, and biased by the
simulated research setting and structure criteria of a clinical
trial. It is for these reasons that registries represent the “next
disruptive technology” in clinical research.21 Furthermore, the
real-world registry data have the enormous potential to identify
the value of spine care at the population level and at the individual
patient level. Accurately identifying contributors of high- and
low-value spine care and incentivizing providers accordingly have
the potential to yield tremendous economic and health benefit
at the population level. The keys to identifying and optimizing
the value of any treatment or disease management strategy
ultimately lies at the individualized patient level, where heterogeneous patients demonstrate large variation in treatment response
and cost. Understanding variation in individual-level treatment
response allows a decision maker to apply an effective treatment
to the ideal patient to optimize value. In this analysis, utilizing
a single-center prospective longitudinal registry data, we demonstrate the variability in outcomes and cost at population level and
individual patient level for patients undergoing spine surgery for
degenerative diseases.
METHODS
Retrospective analysis of prospective longitudinal spine registry based
data was conducted. The inclusion criteria of the registry were: (1)
patient’s age > 18 years; (2) presenting with leg and/or back pain; (3)
correlative imaging findings for the degenerative lumbar spine diagnosis
including disk herniation, stenosis, spondylolisthesis, adjacent segment
disease, and recurrent disk herniation; and (4) failed multimodal nonoperative care (including bracing, pharmacological therapies, or injection
therapy) over 3 months or patients with progressive neurological deficit.
The exclusion criteria were: (1) diagnosis of spinal tumor, trauma, or
infection; (2) any extraspinal cause of back or leg pain; (3) patients who
were unwilling or unable to participate in the follow-up questionnaires.
Patient demographics including age at the time of surgery, body mass
index, duration of preoperative narcotic use (days), smoking status of the
patient, symptom duration, history of prior surgery, employment status,
comorbidities including diabetes, hypertension, coronary artery disease,
myocardial infarction, preoperative anticoagulation, congestive heart
failure, chronic obstructive pulmonary disease, and osteoporosis, clinical
presentation, operative variables, including intraoperative estimated
S62 | VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement
blood loss, length of surgery, length of hospital stay, and postoperative
morbidity including 90-day complications, and discharge destination
(home vs facility) are reviewed through electronic medical records.
Patient-reported Outcomes
Validated PROs were recorded at baseline and 12 months after
surgery: (1) back-related disability: Oswestry Disability Index (ODI)22 ;
(2) numeric rating scale pain scores for back pain and leg pain23 ; (3)
quality of life: EuroQol-5D (EQ-5D)24 .
For this analysis, the concept of minimum clinically important
difference (MCID) was used to define the clinically significant
improvement in disability (ODI). The MCID is a critical threshold
that compares the change in score for a PRO following the intervention
to another externally validated measure of outcomes such as perceived
improvement or satisfaction following the procedure in question.25,26
Previously published MCID values for the ODI (14.9) were used for
analysis.27
Cost Data
Incremental cost including both direct health care expenditures and
indirect economic consequences from societal perspective are captured.
Total costs were defined as sum of direct and indirect cost. The direct
cost included costs associated with inpatient hospital stay (hospital cost),
surgeons’ professional fee, readmission cost, and postdischarge health
care resource utilization including, based on the patient self-reported
frequency of health care provider visits, medication use and diagnostic
imaging utilization. Indirect costs included patient or family member
workday losses and cost of a caregiver, if this was needed.28-32
Quality-adjusted Life Years Calculation
Quality-adjusted life years (QALYs) were calculated from the EQ-5D
with US valuation using time-weighted area under the curve approach.33
Mean total 1-year cost per QALY-gained after surgery was assessed. For
patients with 2-year follow-up, mean total 2-year cost per QALY-gained
after surgery was assessed.
RESULTS
Patient Demographics
A total of 1454 patients undergoing elective lumbar surgery
for disk herniation, revision disk herniation, stenosis, spondylolisthesis, and adjacent segment disease were analyzed. Mean age
± standard deviation of the cohort was 58.9 ± 13.7 years with
718 (49.3%) males. Table 1 summarizes the characteristics of
the patients enrolled in the registry for lumbar spine diagnosis.
Principal diagnoses in descending order of frequency were lumbar
stenosis (38.3%), lumbar spondylolisthesis (25.1%), lumbar disk
herniation (20.5%), adjacent segment disease 146 (10%), and
recurrent disk herniation (6%). Fifty-three percent of patients
(n = 767) underwent lumbar fusion surgery.
Outcomes
There was significant improvement in disability (ODI), pain
(back and leg), and quality of life scores (EQ-5D) at 1 year
after surgery (P < .0001). Figure 1 illustrates the group mean
of a cohort’s PROs, improvements in pain, disability, and quality
of life. However, at the individual patient level, tremendous
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ESTABLISHING VALUE IN SPINE SURGERY
TABLE 1. Patient Demographic and Diagnosis Characteristics
Total n = 1454 n (%)
Age (at time of surgery; mean ± SD)
BMI (mean ± SD)
Smoker
Gender: male
Zung depression scale score (mean ± SD)
MSPQ anxiety score (mean ± SD)
ASA grades (>3)
History of diabetes
History of myocardial infarction
History of hypertension
Duration of symptoms > 12 months
Neurogenic claudication
Motor deficit
Revision surgery
Diagnosis
Stenosis
Spondylolisthesis
disk herniation
Adjacent segment disease
Recurrent disc herniation
Fusion
Number of levels involved (mean ± SD)
Length of surgery in minutes (mean ± SD)
Length of hospital stay in days (mean ± SD)
58.9 ± 13.7 years
30.9 ± 7.1
236 (16.2%)
718 (49.3%)
34.8 ± 9.2
5.9 ± 4.5
938 (64.4%)
334 (22.9%)
77 (5.3%)
875 (60.1%)
799 (54.9%)
288 (19.7%)
449 (30.8%)
408 (28.1%)
557 (38.3%)
366 (25.2%)
298 (20.5%)
146 (10%)
87 (6%)
767 (52.7%)
1.8 ± 0.8
187.7 ± 93.3
3.2 ± 4.5
variability in outcome was observed despite having the same
diagnosis and undergoing the same surgical treatment. For
surgeries demonstrating health benefit and value via traditional
metrics (group average change), 12.5% (n = 182) of patients
experienced no gain from surgery and 38% (n = 554) failed
to achieve clinically meaningful benefit by MCID threshold
(Figure 2). This was true for each of 5 common surgical diagnoses.
Surgery was of little to no value for these subsets of patients.
The quality outcome database (QOD) registry is national
multicenter prospective longitudinal registry, designed to
establish risk-adjusted expected morbidity rates and outcomes
for the most common surgical procedures performed by spine
surgeons.34,35 The QOD registry enrolls spine surgery patients
from 76 participating centers across 28 US states via representative sampling and collects measures of surgical safety and
PROs.36 Pain, disability, quality of life, and return to work are
measured using valid instruments. A tremendous variability in
PROs outcome was observed despite having the same diagnosis
and undergoing the same surgical treatment, at the individual
patient level (Figure 3). These variations observed at 76 centers
from different geographical location validate the variability
observed at the single-center Vanderbilt Spine Registry.
Cost
The mean direct cost at 1 year was $25 459 ± $9896, and the
mean total cost was $28 340 ± $12 204. Table 2 summarizes
the cost breakdown for all the patients. The mean 1-year QALYgained was 0.29 for all diagnosis, and 18% of patients failed to
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report gain in QALY at 1 year postoperatively. For the patients
followed up to 2 year postoperatively, the mean total 2-year cost
was $31 834 ± $15 220 (direct cost: $28 953 ± $12 781) and the
mean 2-year QALY-gained was 0.62 for all diagnosis, and 14% of
patients failed to report gain in QALY at 2 year postoperatively.
Figure 4 demonstrates that a significant variation was observed
in both benefit (QALY-gained on X axis) and 2-year cost of care
(Y axis). While on average, surgery resulted in a 2-year gain of
0.62 QALYs at an average direct cost of $28 953, resulting in cost
per QALY-gained of $51 762. As demonstrated in Figure 4, the
patients fell in all 4 quadrants of value: QALY gain with low cost
(greatest value), QALY gain with high cost, QALY loss with low
cost, and QALY loss with high cost (lowest value). For the patients
undergoing laminectomy and fusion surgery for the diagnosis of
spondylolisthesis, the mean total direct cost at 2 year was $59
700/QALY, but varied from $10 728/QALY to $302 937/QALY
at the individual patient level. Such variations were observed for
all diagnoses.
DISCUSSION
Value in spine care is a measure of the outcome of all health
care services delivered to maximize a person’s function and participation in society while minimizing impairments, pain, and other
symptoms.16,37 High-value care is not merely a broad application of a treatment found to be cost-effective in a research
study, but rather personalized application of the best available
treatment for a given patient at the correct time, with the best
adjuvant care throughout the health care episode. Low-value care
can be realized 1 of 2 ways: (1) failing to experience any health
benefit or loss of health status (decreasing the numerator of the
value equation), or (2) experiencing minimal to modest health
gains that require expenditures well outside the group average
(increasing the denominator of the value equation).15 Therefore,
the value of intervention needs to be evaluated at the population
level and at the individual patient level. In our study, at population
level, there was a significant improvement in disability outcome
and quality of life 1 year after lumbar spine surgery. However,
there was wide variability in effectiveness, representing a lack
of treatment optimization as well as lack of generalizability of
spinal surgical procedures. At individual patient level, about oneeighth of the patients did not experience any gain from surgery
and about one-third did not achieve meaningful improvement.
The in-depth assessment of what identifiable factors are common
for these patients is vital to refine current treatment indications
and decision-making. The patients that are less likely to gain
improvement from spine surgery might gain benefit from other
treatment strategies, or intervention focusing on some of the
individual modifiable factors might increase the likelihood of
gaining benefit from surgery. This is the essence of individualized
or personalized health care.
Value from the patient’s perspective is heavily dependent on
desirable and accurately measured patient-centered outcomes
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FIGURE 1. Mean ODI and EQ-5D (quality of life) at baseline, 3 months, and 12 months after surgery for patients undergoing surgery for the diagnosis of disk
herniation, recurrent disk herniation, spondylolisthesis, stenosis, and adjacent segment disease. On average, surgery resulted in a significant improvement in ODI and
EQ-5D at 1 year following surgery.
against the risk and cost of care over the patient’s entire life span.
Traditional health economic studies report and draw conclusions based on the aggregate average incremental cost of care
and average incremental benefit of care at the group-mean
level. In reality, singular treatments for standardized diagnosis
types still result in a wide variation of observed costs. Tosteson
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et al31 reported a direct cost of $21 756 for lumbar fusion for
spinal stenosis at 2 years postoperatively. For the same procedure,
same indication, and same follow-up, Tso et al38 reported a
direct cost of $13 892. The main differences in the studies were
that the former study31 used Medicare national reimbursement
adjustment for cost and included 2 year follow-up costs, whereas
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ESTABLISHING VALUE IN SPINE SURGERY
FIGURE 2. Scattergram of patient-level response. Each dot represents a single patient. Dots above the diagonal line reported worsened ODI 1 year
after surgery, while those below the dotted line reported improved ODI. The farther the distance from the diagonal line, the greater the change in
disability. Blue dots represent patients who did not achieve an MCID improvement 1 year after surgery and green dots represent patients who achieved
MCID at 1 year after surgery.
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FIGURE 3. Variation in improvement in quality of life (EQ-5D) for the 5 common lumbar diagnoses. Distance from the
diagonal line represents patient-level response. Each dot represents a single patient. Dots above the diagonal line represent
improved health state 1 year after surgery, while those below the dotted line reported declined health state. While surgery
for each diagnosis yielded between a 0.2 and 0.29 QALY gain on average by 1 year after surgery, 18% of patients failed to
report a QALY gain. The wide variation in reported QALY-gained across the 76-center QOD network is consistent with
the variation observed at the Vanderbilt Spine Registry reported above.
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ESTABLISHING VALUE IN SPINE SURGERY
TABLE 2. Mean 1-year Costs
Hospital cost
$19 582 ± $8089
Surgeons’ professional fee
Postdischarge HCRU 1 year
Indirect cost 1 yeara
Direct cost 1 year
Total cost 1 year
$2824
$3067
$2880
$25 459
$28 340
±
±
±
±
±
$1188
$590
$6713
$9896
$12 204
a
The indirect cost was as high as $9299 for patients who were employed preoperatively
and/or whose either a family member took a day off, and/or a caregiver was hired to
care for the patient. HCRU, healthcare resource utilization.
Tso et al38 utilized a case-costing database and did not include the
follow-up costs.
Cost represents not only the expenditures for the surgery, but
expenditures associated with complications, all-cause perioperative readmissions, or any disease-related care utilization within
the episode of care. Costs from hospital perspective include
direct costs, costs of staff, supplies, and utilities. Costs from
payers’ and providers’ perspective include payment to hospital
and physicians. From the societal perspective, cost includes lost
work productivity, loss of contribution to society, as well as all
downstream-associated costs for caregivers and indirect consequences of care.39-45 An acceptable “bang-for-buck” or QALYgained from surgery is relative to the perspective of the payer,
purchaser, or society.
An intervention is considered cost-effective if the cost per
QALY-gained is within the predetermined society’s willingness
to pay threshold.28,46-49 Various willingness to pay thresholds
are reported in the literature, each of which is derived based
on different context (improving QALYs vs life saving or life
extending) and perspectives (individual vs societal).50,51,52 What
is thought to be cost-effective is in the eyes of the payer, and
currently assigned thresholds may vary depending upon the
socioeconomic status of the patient.49,53-55 Therefore, there is
FIGURE 4. Scatterplot of 2-year direct health care cost per QALY-gained after single-level surgery for lumbar spine diagnoses
in an uncontrolled real-world setting. Each dot represents a single patient. Tremendous variation was observed in both benefit
(QALY-gained on X axis) and 2-year cost of care (Y axis). While on average, surgery resulted in a 2-year gain of 0.615 QALYs
at an average cost of $28 953, patients fell in all 4 quadrants of value: QALY gain with low cost (greatest value), QALY gain
with high cost, QALY loss with low cost, and QALY loss with high cost (lowest value). Diagonal line represents $50 000 cost
per QALY-gained.
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no single generally accepted threshold that can be used as a
cut-off for deciding if an intervention is cost-effective. The
commonly used willingness to pay threshold is $20 000 to $30
000 in the UK56,57 and $50 000 to $100 000 in the US58,59 ,
whereas WHO has recommended that any intervention that is
1 to 3 times the country’s GDP is considered cost-effective.50,60
Numerous studies have analyzed the cost-effectiveness of various
spine procedures.47,61,62 The mean 1-year cost per QALY-gained,
in our analysis, was $97 388/QALY-gained. For patients with 2year follow-up, the mean 2-year cost per QALY-gained was $51
762/QALY-gained. Distinguishing individual patient level cost
per benefit from a verage group-level cost per benefit allows a
much more granular way to optimize the value of treatments and
care paradigms through refinement of procedure indications and
delivery. As demonstrated in this analysis, there was a considerable
variation in the cost per benefit at the individual patient level. At
population level, a treatment may be considered high value when
evaluated as the mean of the group. In the subsets of patients
failing to benefit or experiencing morbid or costly complications,
however, a given treatment loses its value. As we understand the
variability in the cost and benefit at the individual patient level,
we can now focus on identifying the modifiable factors associated
with outliers of high- and low-value spine care. Designing interventions to manipulate those factors should help contain costs and
improve surgical outcomes, thereby increasing the overall value of
spine care.
Prospective registries have proven potential to assess the safety,
quality, and value of spine care at both individual patient level
and at the population level.36,63-65 The registries provide reliable
and expeditious access to outcomes data such as complications, readmission, pain, disability, quality of life, patient satisfaction, and cost-effectiveness.63 Moving forward, individual
providers and hospital systems can utilize the real-world registry
outcomes and cost data to perform an in-depth assessment of
individual patient level factors that can be modified to increase
the benefit and lower the cost of spine care. Furthermore, this
will allow the clinicians to better target interventions to improve
outcomes in nonresponders. As the value equation takes on
further dimensions, the decision makers can prevent ineffective or
wasteful care at the population level as well as individual patient
level, to increase the overall value of spine care.
CONCLUSION
Value in spine care is a measure of the outcome of all health
care services delivered to maximize a person’s function and participation in society while minimizing impairments, pain, and other
symptoms. High-value care is not merely broad application of
a treatment found to be cost-effective on average in a research
setting, but rather personalized application of the best available
treatment for a given patient at the correct time, with the best
adjuvant care throughout the health care episode. Spine treatments that, on average, are cost-effective may have wide variability
S68 | VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement
in value at the individual patient level. The wide variability
in effectiveness and cost of care at the individual patient level
demonstrated here represents an opportunity through registries to
identify specific care that may be less effective, and refine patientspecific care delivery and indications to drive overall grouplevel treatment value. Understanding value of spine care at an
individualized as well as population level will allow clinicians, and
eventually payers, to better target resources for improving care for
nonresponders, ultimately driving up the average health for the
whole population.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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