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We appreciate all forms of engagement from our readers and listeners, and welcome your support. Thank you! Differences in service costs were statistically significant between all approaches with the exception of the lateral approach compared with ALIF or PSF. The average length of stay ranged from 2.
Only 13 patients required ICU admission, but ICU cost was a major contributor to the total cost of care for these patients. Pharmacy costs contributed the least of all categories, accounting for 4. The statistical analysis was performed both with exclusion and inclusion of the extreme outliers with negligible impact on the results.
The results of our study are useful in identifying the composition of cost drivers for single-level lumbar fusions and the variance within these components.
Important cost drivers included surgical approach, implants, operating room time, and length of hospital stay. There were statistically significant differences in the mean direct costs between combined circumferential fusions and single approach fusions and between cageless fusion constructs and those using interbody cages lateral, TLIF, ALIF, and circumferential. Surgical implants, especially the use of an interbody cage, contribute the highest portion of the direct cost for instrumented fusions Figure 1 and Table 4.
There were no differences in cost by diagnosis, including trauma. Furthermore, diagnoses were spread across all approach categories. One of the most important observations of this study was the prevalence of such high variance in costs among a relatively homogenous cohort of patients.
Such a wide gap is indicative of several factors, which extend far beyond how many implants are used. The cost of implants and osteobiologics vary depending on contracted rates. With the low standard of evidence required for most orthopedic devices—which come to market through k clearances—there is a paucity of data available to establish any correlation between the cost of an implant and outcomes achieved.
Without standardization in cost across centers, such analysis is infeasible. While this article does not consider clinical outcomes, it wishes to shine a light on the issues that lack of cost transparency presents in advancing evidence-based approaches to care. We report median costs in our results because of the presence of significant variance including several extreme outliers that disproportionately affect the mean cost.
Highly variable costs have been reported in the literature for other types of spinal surgery. Being able to predict cost accurately is essential to successfully driving the transition toward bundled payment initiatives. There are indications for which more expensive procedures can be cost-effective by improving the durability of outcomes achieved—spending more upfront to prevent continuous inefficient spending in order to bend the cost curve. A wide range of costs also suggests high variance in the management of patients that undergo similar procedures.
The literature has demonstrated variation between surgeons for various types of spine surgery with regard to recommendations for surgical management, surgical approach, instrumentation, and intraoperative services used. Several intraoperative services demonstrated high variance between practitioners. Cell saver was used in only Cost-effectiveness studies of cell saver in adult lumbar spine surgery have reported mixed results. Although only a minor contributor to the total cost of care, the use of cell saver is an example of a service that may not be indicated in elective single-level lumbar fusions and is a potential area where cost savings can be achieved by limiting its use.
In our facility, a vascular surgeon is used for the approach in the ALIF procedure. As such, the operating room time in anterior procedures can be influenced by the experience of the surgeon performing the approach. There appears to be a relationship in the duration of operating room time and length of hospital stay.
Working closely with experienced approach surgeons can help achieve cost savings both in the reduction of operative time and length of stay. The length of stay was the shortest for lateral fusions and thus room and care costs were the smallest in this group.
By not using neuromonitoring, which often requires total intravenous anesthesia TIVA , the opportunity to use gas anesthesia offers a potential for cost savings as well. Room and care costs are highly dependent on length of stay and level of care ie, ICU admission. At our institution, patients undergoing spine surgery are routinely admitted to an orthopedic specialty unit postoperatively, which provides more specialized nursing care at a lower cost than other hospital units.
The cost structure and efficiency of care in different hospitals cannot be assumed to be the same. The advantages of specialized orthopedic units—including shorter lengths of stay, lower rates of transfer to the ICU, and lower costs — have been reported in the literature at various institutions.
Furthermore, the utilization of risk assessment and prediction tools can further facilitate preoperative planning of postoperative care. In our analysis, implants represented the largest proportion of spending for all surgical approaches except cageless posterior fusions. In a study of 45 academic medical centers, Pahlavan and Bederman 27 found that the price of individual spinal implants varied over 4-fold for pedicle screws and cervical plates to nearly 8-fold for TLIF cages.
Furthermore, they found a significant relationship between higher volume of use and lower unit cost of these implants. Multiple factors contribute to the variable costs in spinal implants, including differences in surgeon choices for instrumentation 11 , 12 and variation in the prices paid by hospitals for the same implant. Similar implants have widely variable costs, as demonstrated by differences in cost between standard pedicle screws and specialty pedicle screws, including cannulated and coated screws.
A study by Streit et al 28 found that orthopedic surgeons have poor knowledge of implant costs and frequently underestimate costs. Awareness of implant costs and uniformity of costs for similar implants can significantly reduce cost variance for implants.
Reducing variance is an important goal for consistency of cost and for hospital budgeting for spine surgery. Clarifying cost-effective and clinical indications for use of interbody cages, BMP, neuromonitoring, and cell saver might help reduce variance without negatively affecting clinical outcomes.
An important limitation of this report is that we do not consider the clinical outcome of care. The purpose of this article is to promote cost transparency, characterize the determinants of direct costs, and report variance for single-level lumbar fusions. However, the value of interventions encompasses more than simply short-term cost. Porter and Lee 30 suggest that the medical community must shift to track outcomes by condition over the entire cycle of care rather than by individual interventions.
In this regard, if a more expensive spine surgery can improve health status and reduce revision surgery rates, postoperative medication utilization, and physical therapy visits more effectively and for a more prolonged period of time than a less expensive surgery, it may actually be cost saving to both the patient and health care system in terms of money, time, and resource utilization. Specifically, there is evidence that circumferential fusion may be cost saving and value enhancing over time, despite having significantly higher direct costs than other surgical approaches in the present study.
A cost-utility analysis by Soegaard et al 31 demonstrated that circumferential fusions resulted in improved clinical outcomes and lower long-term costs due to a reduction in the need for additional treatments and revision surgeries compared to posterolateral fusions.
In light of this, we have identified a subset of patients from this cohort who have a minimum of 2 years of clinical follow-up and we plan to follow-up this study with an analysis between the costs and surgical outcomes for these patients in a subsequent project. With the help of the HSS Hospital Cost Estimator, you can make sure you're asking the critical questions to find the hospital that's right for you.
Understanding the data points below will help you avoid unnecessary setbacks and avoidable costs. Learn why we chose these factors. Surgical procedure in which bones of the spine are joined, removed, or otherwise altered. Types of spinal surgery include laminectomy, microdiscectomy, and traditional lumbar fusion. Ranges from one day to several days, depending on the complexity of the procedure and your overall health. Other professional services, such as those provided by your surgeon or anesthesiologist, are billed for separately.
My doctor was the first person to believe that I could have a life that would not be defined by my chronic pain. Because of this surgery, I am able to better care for both myself and the patients I see as a nurse practitioner.
Spine Fusion. Success Rate. Of HSS patients reported improvement within 12 months after their treatment. Looking for an alternative to fusion? Find out about the innovative new procedure to relieve back and leg pain, restore range of motion, and help you continue doing the things you love. Will your insurer pay for back surgery? The Hidden Costs Of Back Surgery While the surgical bill is rightly the most important financial concern for most people, there are other costs associated with back surgery that extend beyond this operation—both for you as an individual and for society.
Individual Costs Less than a third of the money spent on fusions is for the procedure itself. Back surgery patients also pay significantly for: The activities before and after surgery—Primary care visits, anti-inflammatories and muscle relaxants, chiropractors, epidural injections, medication, and physical therapy are all costly endeavors that lead up to, and in some cases follow, surgery.
Studies have also shown that fusion is associated with a significant increase in prolonged work loss. Cost To Society Society as a whole also has costs to bear in relation to the epidemic of back pain and treatment: Opioid dependence is prolonged for fusion patients—Recent studies have shown that the use of opioids after lumbar fusion surgery is largely due to the failure of fusion to relieve pain.
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