Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery (original) (raw)
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Variability in Hospital Costs of Adult Spinal Deformity Care
Spine, 2020
Study Design. Retrospective, single-center analysis. Objective. To calculate the total clinical hospital cost of the Adult Spinal Deformity (ASD) care trajectory, to explain cost variability by patient and surgery characteristics, and to identify areas of process improvement opportunities. Summary of Background Data. ASD is associated with a high financial and clinical burden on society. ASD care thus requires improved insights in costs and its drivers as a critical step toward the improvement of value, i.e., the ratio between delivered health outcome and associated costs. Methods. Patient characteristics and surgical variables were collected following ethical approval in a cohort of 139 ASD patients, treated between December, 2014 and January, 2018. Clinical hospital costs were calculated, including all care activities, from initial consultation to 1 year after initial surgery (excl. overhead) in a university hospital setting. Multiple linear regression analysis was performed to analyze the impact of patient and surgical characteristics on clinical costs. Results. 75.5% of the total clinical hospital cost (s27,865) was incurred during initial surgery with costs related to the operating theatre (80.3%), nursing units (11.9%), and intensive care (2.9%) being the largest contributors. 57.5% of the variation in total cost could be explained in order of importance by surgical invasiveness, age, coronary disease, single or multiple-staged surgery, and mobility status. Revision surgery, unplanned surgery due to complications, was found to increase average costs by 87.6% compared with elective surgeries (s 44,907 (AE s 23,429) vs. s 23,944 (AE s 7302)). Conclusion. This study identified opportunities for process improvement by calculating the total clinical hospital costs. In addition, it identified patient and treatment characteristics that predict 57.5% of cost variation, which could be taken into account when developing a payment system. Future research should include outcome data to assess variation in value.
Surgical treatment for adult spinal deformity: projected cost effectiveness at 5-year follow-up
The Ochsner journal, 2014
In the United States, expenditures related to spine care are estimated to account for 86billionannually.Policymakershavesetacost−effectivenessbenchmarkoflessthan86 billion annually. Policy makers have set a cost-effectiveness benchmark of less than 86billionannually.Policymakershavesetacost−effectivenessbenchmarkoflessthan100,000/quality adjusted life year (QALY), forcing surgeons to defend their choices economically. This study projects the cost/QALY for surgical treatment of adult spinal deformity at 5-year follow-up based on 2-year cost- and health-related quality-of-life (HRQOL) data. In a review of 541 patients with adult spinal deformity, the patients who underwent revision or were likely to undergo revision were identified and cost of surgery was doubled to account for the second procedure; all other patients maintained the cost of the initial surgery. Oswestry Disability Index (ODI) was modeled by revision status based on literature findings. Total surgical cost was based on Medicare reimbursement. Chi square and student t tests were utilized to compare cost-effective and non-cost-effective patients. The average cost/QA...
Predictors of inpatient morbidity and mortality in adult spinal deformity surgery.
PURPOSE: This nationwide study identifies ASD surgical risk factors for morbidity/mortality. METHODS: NIS discharges from 2001 to 2010 aged 25+ with scoliosis diagnoses, 4+ levels fused, and procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included. Demographics, comorbidities and procedure-related complications were determined for each subgroup (degenerative, congenital, idiopathic, other). Multivariate analysis reported as [OR (95 % CI)]. RESULTS: 11,982 discharges were identified. Morbidity, excluding device-related, and mortality rates were 50.81 and 0.28 %, respectively. Certain comorbidities were associated with increased morbidity/mortality: congestive heart failure (CHF) [1.62 (1.42-1.84)] [5.67 (3.30-9.73)], coagulopathy [3.52 (3.22-3.85)] [2.32 (1.44-3.76)], electrolyte imbalance [2.65 (2.52-2.79)] [4.63 (3.15-6.81)], pulmonary circulation disorders [9.45 (7.45-11.99)] [8.94 (4.43-18.03)], renal failure [1.29 (1.13-1.47)] [5.51 (2.57-11.82)], and pathologic weight loss [2.38 (2.01-2.81)] [7.28 (4.36-12.14)]. Chronic pulmonary disease was associated with higher morbidity [1.08 (1.02-1.14)]; liver disease was linked to increased mortality [36.09 (16.16-80.59)]. 9+ level fusions had increased morbidity vs 4-8 level fusions [1.69 (1.61-1.78)] and refusions [1.08 (1.02-1.14)]. Idiopathic scoliosis was associated with decreased morbidity vs all other subgroups [0.85 (0.80-0.91)]. Age >65 was associated with increased morbidity and mortality vs 25-64 group [1.09 (1.05-1.14)] [3.49 (2.31-5.29)]. Females had increased morbidity [1.18 (1.13-1.23)] and decreased mortality [0.30 (0.21-0.44)]. Mean comorbidity index (0.55) and age (64.38) for degenerative cohort were higher vs all other subgroups (P < 0.0001). CONCLUSIONS: Longer fusions were associated with increased morbidity. Age >65 was associated with increased morbidity/mortality, while females were associated with increased morbidity but decreased mortality. Idiopathic scoliosis had decreased morbidity. Degenerative ASD cases had higher comorbidity indices, potentially due to older age. This study is clinically useful for patient education, surgical decision-making, and optimizing patient outcomes.
Association of insurance status and spinal fusion usage in the United States during two decades
Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 2018
This study examined the distribution of spinal fusion usage among payer groups in the United States. Using the National Inpatient Sample (NIS) database, total discharges, length of stay, and mean hospital charges of patients who underwent spinal fusion from 1997 to 2014 in the United States were determined and analyzed. 5,715,625 total discharges with spinal fusion were reported. Among them, 2,875,188 (50.3%) were covered by private insurance, 1,710,182 by Medicare (29.9%), 342,638 (6.0%) by Medicaid, and 91,990 (1.6%) were uninsured. A statistically significant increase in spinal fusion usage occurred within each payer group over the study period (P < 0.001). For every year of the study period, private insurance patients had the most number and uninsured patients had the least number of total discharges with spinal fusion. Furthermore, annual growth in spinal fusion usage was greatest among private insurance patients, and smallest among uninsured patients. Total discharges with ...
Cost-effectiveness of adult spinal deformity surgery in a military healthcare system
Neurosurgical Focus
OBJECTIVEAdult spinal deformity surgery is an effective way of treating pain and disability, but little research has been done to evaluate the costs associated with changes in health outcome measures. This study determined the change in quality-adjusted life years (QALYs) and the cost per QALY in patients undergoing spinal deformity surgery in the unique environment of a military healthcare system (MHS).METHODSPatients were enrolled between 2011 and 2017. Patients were eligible to participate if they were undergoing a thoracolumbar spinal fusion spanning more than 6 levels to treat an underlying deformity. Patients completed the 36-Item Short Form Health Survey (SF-36) prior to surgery and 6 and 12 months after surgery. The authors used paired t-tests to compare SF-36 Physical Component Summary (PCS) scores between baseline and postsurgery. To estimate the cost per QALY of complex spine surgery in this population, the authors extended the change in health-related quality of life (HR...
Predictors for Non-Home Patient Discharge Following Elective Adult Spinal Deformity Surgery
Global Spine Journal, 2017
Study Design: Retrospective cohort study. Objectives: Adult spinal deformity (ASD) surgery encompasses a wide variety of spinal disorders and is associated with a morbidity rate between 20% and 80%. The utilization of spinal surgery has increased and this trend is expected to continue. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement and reduce length of stay. Methods: The 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Classification of Diseases, Ninth Revision diagnosis codes relevant to ASD. Patients were divided based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and hospital length of stay. Results: A total of 4552 patients met inclusion criteria, of which 1102 (24.2...
The 90-Day Reoperations and Readmissions in Complex Adult Spinal Deformity Surgery
Global Spine Journal
Study Design: Retrospective review. Objective: Identify surgical complex adult spine deformity patients who are at increased risk for an unplanned postoperative 90-day readmission and/or reoperation. Methods: A total of 227 consecutive records of complex adult (≥18 years old) spine deformity surgeries from 2015 to 2018 were reviewed. Demographics, comorbidities, operative details, and postoperative complication data was collected. Chi-square/Fisher’s exact test and t tests were used for bivariate analysis. To determine independent predictors for readmissions/reoperations, stepwise multivariate logistic regressions were employed. The C-statistic and Hosmer-Lemeshow (HL) value was used to measure concordance and goodness of fit. Results: Average age was 50.5 ± 17.8 years and 67.8% were female. Ninety-day readmission and reoperation rates were 7.0% and 5.3%, respectively. Median number of days after index discharge date resulting in readmission and reoperation were 16.5 and 28, respect...
Spine Deformity, 2019
Study Design: Retrospective review of a prospectively collected multicenter database. Objectives: To evaluate the evolution of surgical treatment strategies, complications, and patient-reported outcomes for adult spinal deformity (ASD) patients. Summary of Background Data: ASD surgery is associated with high complication rates. Evolving treatment strategies may reduce these risks. Methods: Adult patients undergoing ASD surgery from 2009 to 2016 were analyzed (n 5 905). Preoperative and surgical parameters were compared across years. Subgroup analysis of 436 patients with minimum two-year follow-up was also performed. Results: From 2009 to 2016, there was a significant increase in the mean preoperative age (52 to 63.1, p ! .001), body mass index (26.3 to 32.2, p 5 .003), Charlson Comorbidity index (1.4 to 2.2, p ! .001), rate of previous spine surgery (39.8% to 53.1%, p 5 .01), and baseline disability (visual analog scale [VAS] back and leg pain) scores (p ! .01), Oswestry Disability Index, and 22-item Scoliosis Research Society Questionnaire scores (p ! .001). Preoperative Schwab sagittal alignment modifiers and overall surgical invasiveness index were similar across time. Three-column osteotomy utilization decreased from 36% in 2011 to 16.7% in 2016. Lateral lumbar interbody fusion increased from 6.4% to 24.1% (p 5 .004), anterior lumbar interbody fusion decreased from 22.9% to 16.7% (p 5 .043), and transforaminal lumbar interbody fusion/posterior lumbar interbody fusion utilization remained similar (p 5 .448). Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in 2012 was 84.6%, declined to 58% in 2013, and rebounded to 76.3% in 2016 (p 5 .006). Tranexamic acid use increased rapidly from 2009 to 2016 (13.3% to 48.6%, p ! .001). Two-year follow-up sagittal vertical axis, pelvic tilt, pelvic incidenceelumbar lordosis, and maximum Cobb angles were similar across years. Intraoperative complications decreased from 33% in 2010 to 9.3% in 2016 (p ! .001). Perioperative (!30 days, !90 days) complications peaked in 2010 (42.7%, 46%) and decreased by 2016 (24.1%, p ! .001; 29.6%, p 5 .007). The overall complication rate decreased from 73.2% in 2008e2014 patients to 62.6% in 2015e2016 patients (p 5 .03). Two-year health-related quality of life outcomes did not significantly differ across the years (p O .05).
Factors Predicting Cost-effectiveness of Adult Spinal Deformity Surgery at 2 Years
Spine Deformity, 2014
Objective: To identify preoperative factors that lead to cost-effectiveness at 2 years' follow-up in the setting of surgical treatment for adult spinal deformity. Methods: Retrospective analysis of a prospective, consecutive, multicenter database including 514 patients who underwent surgery for adult spinal deformity. The change in quality-adjusted life-years (QALY) was calculated from the 2-year change in Oswestry Disability Index (ODI). Medicare coding was used to determine the direct costs based on diagnosis-related group and Relative Value Unit reimbursement. Analysis was performed to determine which factors were associated with a cost/QALY less than 100,000,makingtheprocedurecost−effective.Results:TheaverageQALYchangeforallpatientsinthisstudywas0.15andtheaveragecost/QALYwas100,000, making the procedure cost-effective. Results: The average QALY change for all patients in this study was 0.15 and the average cost/QALY was 100,000,makingtheprocedurecost−effective.Results:TheaverageQALYchangeforallpatientsinthisstudywas0.15andtheaveragecost/QALYwas243,761.97. A total of 56 patients (10.4%) had a cost/QALY of less than 100,000at2−yearfollow−up.Thosepatientsweremostlyfemale(89100,000 at 2-year follow-up. Those patients were mostly female (89%), with a mean age of 60 years and the following diagnoses: 18 (32.1%) adult idiopathic scoliosis, 12 (35.7%) adult de novo scoliosis, 87 (14.3%) sagittal imbalance, and 10 (17.9%) other scoliosis. The Health-Related Quality of Life ODI and Scoliosis Research Society (SRS) instruments were all associated with cost-effectiveness except SRSeMental. Factors associated with cost-effectiveness were age greater than 55 years, adult de novo scoliosis, prior surgery, higher preoperative sagittal vertical axis, lower maximum Cobb angles, 8 or fewer fusion levels, lower blood loss, worse global alignment classification, and global sagittal malalignment. Combined anterior-posterior surgeries were negatively associated with cost-effectiveness. Preoperative ODI scores between 60 and 70 and SRS Pain and Activity subscores more than 4 minimally clinically important difference points below the normative values had the highest percentage of cost-effective patients. Conclusions: The QALY change is 0.15 and the cost/QALY of adult deformity surgery is 100,000at2−yearfollow−up.Thosepatientsweremostlyfemale(89243,761.97 at 2 years. Patients with higher preoperative morbidity are more likely to be cost-effective with a cost/QALY less than $100,000.
Spine, 2019
Study Design. Retrospective review of prospectively-collected, multicenter adult spinal deformity (ASD) database. Objective. To evaluate the rate of patients who accrue catastrophic cost (CC) with ASD surgery utilizing direct, actual costs and determine the feasibility of predicting these outliers. Summary of Background Data. Cost outliers or surgeries resulting in CC are a major concern for ASD surgery as some question the sustainability of these surgical treatments. Methods. Generalized linear regression models were used to explain the determinants of direct costs. Regression tree and random forest models were used to predict which patients would have CC (>$100,000). Results. 210 ASD patients were included (mean age of 59.3 years, 83% women).