Journal ClubMarch 12, 2014

Azam Basheer MDHenry Ford Neurosurgery

Objective—To assess the short-term cost-effectiveness of spine surgery relative to nonoperative care for stenosis alone and for stenosis with spondylolisthesis.

Design—Prospective cohort study.

Data Sources—Resource utilization, productivity, and EuroQol EQ-5D score measured at 6 weeks and at 3, 6, 12, and 24 months after treatment among SPORT participants.

Target Population—Patients with image-confirmed spinal stenosis, with and without degenerative spondylolisthesis.

Time Horizon—2 years.

Intervention—Nonoperative care or surgery (primarily decompressive laminectomy for stenosis and decompressive laminectomy with fusion for stenosis associated with degenerative Spondylolisthesis).

Outcome Measures—Cost per quality-adjusted life-year (QALY) gained.

Objective—To assess the short-term cost-effectiveness of spine surgery relative to nonoperative care for stenosis alone and for stenosis with spondylolisthesis.

Target Population—Patients with image-confirmed spinal stenosis, with and without degenerative spondylolisthesis.

Intervention—Nonoperative care or surgery (primarily decompressive laminectomy for stenosis and decompressive laminectomy with fusion for stenosis associated with degenerative Spondylolisthesis).

The Spine Patient Outcomes Research Trial compared surgical and non-surgical treatments for intervertebral disc herniation (IDH), spinal stenosis (SpS) and degenerative spondylolisthesis (DS). Approximately 2500 patients took part in the study, which was conducted at 13 sites across the country. Reported favorable surgery outcomes over 2 years

The results of SPORT were released in three phases:

1. Intervertebral disc herniation, published in JAMA, November, 2006

2. Degenerative Spondylolisthesis, published in The New England Journal of Medicine, May, 2007

3. Spinal Stenosis, published in The New England Journal of Medicine, February 21, 2008

intervertebral disc herniation (IDH), spinal stenosis (SpS) and degenerative spondylolisthesis (DS)

To measure health outcomes, QALYs were used to account for both quality and length of life. QALYs were assessed at baseline; 6 weeks; and 3, 6, 12, and 24 months with EuroQol EQ-5D

Health care diaries helped participants track resource use and work or activities.

- Direct Medical CostsIncluded any emergency department or outpatient visit, imaging, injections, etc

- Indirect CostsThe effect of spine-related problems on productivity, missed work days, missed

housekeeping days

QALY = Quality Adjusted Life Year

1. Relied on Medicare payment schedules to estimate medical costs.

2. Estimated costs by using the standard human capital approach of multiplying the change in hours worked by the gross of tax wage rate, on the basis of self-reported wages at study entry

“We estimated mean total costs and QALYs from baseline to 2 yearsfor each diagnosis and treatment group by using a 3% annualized discount rate for both end points”

“Sensitivity analyses of analytic assumptions included restricting analyses to the randomized or observational cohort, limiting cost type, increasing surgery costs to 70% of the amount billed to Medicare, using the Short Form-6D (SF-6D) to estimate effectiveness, and accounting for observed mortality”

4 Year f/u Study

"Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation." Spine 2011;36:2061-8. Results. Surgery was performed initially or during the 4-year follow-up among 414 of 634 (65.3%) SPS, 391 of 601 (65.1%) DS, and 789 of 1192 (66.2%) IDH patients. Surgery improved health, with persistent QALY differences observed through 4 years (SPS QALY gain 0.22; 95% confidence interval, CI: 0.15, 0.34; DS QALY gain 0.34, 95% CI: 0.30, 0.47; and IDH QALY gain 0.34, 95% CI: 0.31, 0.38). Costs per QALY gained decreased for SPS from $77,600 at 2 years to $59,400 (95% CI: $37,059, $125,162) at 4 years, for DS from $115,600 to $64,300 per QALY (95% CI: $32,864, $83,117), and for IDH from $34,355 to $20,600 per QALY (95% CI: $4,539, $33,088).

"Surgical versus Non-Operative Treatment for Lumbar Disk Herniation: Eight-year Results for the Spine Patient Outcomes Research Trial (SPORT)" Spine 39(1):3-16, 2014.