Cost Utility Analysis of Postoperative Discharge Pathways Following Posterior Spinal Fusion for Scoliosis in Non-Ambulatory Cerebral Palsy Patients

K. Aaron Shaw DOVahe Heboyan PhDNicholas Fletcher MDJoshua S. Murphy MD

Dwight D. Eisenhower Army Medical CenterChildren’s Healthcare of Atlanta

Children’s Healthcare of Atlanta

Introduction

• Scoliosis is common in children with non-ambulatory cerebral palsy (CP)– Affects upwards of 100% of patients(Saito

et al. Lancet. 1998)

• Traditionally, there has been controversary as to the preferred treatment approach to in non-ambulatory CP

• A recent critical review analysis identified improved patient outcomes and caregiver satisfaction with operative intervention – Shaw et al. JBJS Reviews. 2019

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Accelerated Discharge Pathway

• Accelerated discharge (AD) pathways are multidisciplinary approaches targeted to improve perioperative care and safely expedite patient discharge to home

• AD have been shown to decrease hospital length of stay in adolescent idiopathic scoliosis without increasing postoperative complications compared with more traditional (TD) approaches (Fletcher et al. J Pediatri Orthop 2015)

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Accelerated Discharge Pathway

• Bellaire et al. demonstrated significantly shorter hospital length of stay, with a trend toward lower complication rates with AD for non-ambulatory CP patients undergoing PSF– Spine Deform. 2019;7(5):804-11.

• Although this evidence supports the utility of AD pathways over a TD pathways for some patients, the impact of these pathways on the cost-utility of treatment has not been investigated.

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Methods

• Decision-analysis model was constructed using TreeAge Pro

• Hypothetical Patient: 15-year-old male with non-ambulatory CP and 65-degree thoracolumbar scoliosis with associated pelvic obliquity

• Treatment: Posterior spinal fusion from T2-pelvis with pedicle screw fixation.

1 Serhan et al. J Spinal Disord Tech. 2013.

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Data Variable

• Literature review was performed to identify associated complication profiles for TD and AD pathways in the setting of non-ambulatory CP scoliosis and to estimate probability, health utility, and quality-adjusted life years (QALYs)

• Complication Profiles Idenitified:– Death– Neurologic injury– Pulmonary complication– Infection– Revision Surgery

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Data Variables

Event Net Probability (%) Net Cost ($) Net QALY

Traditional PathwayUncomplicated 41 50,952 16 .5

Death 5 50,952 0Pulmonary

Complication20 28,915 15.9

Revision Surgery 19 130,000 16.3Neurologic Injury 5 45,000 12.9

Infection 10 104,000 16.3Accelerated Pathway

Uncomplicated 51 42,992 16.5Death 5 42,992 0

Pulmonary Complication

15 28,915 15.9

Revision Surgery 14 130,000 16.3Neurologic Injury 5 45,000 12.9

Infection 10 104,000 16.3 7

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Final Decision Analysis Model

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Analysis

• Health utility and QALYs were constructed using age-matched values for US population average, applying a corrective value for diagnosis of CP. Craig et al. Matern Child Life. 2016;20(4)

• A sensitivity analysis was performed using Mixed first-order and second-order Monte Carlo simulations. Incremental cost utility ratio (ICUR) and incremental net monetary benefit (NMB) were calculated.

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Results

• Operative treatment, combining AD and TD, resulted in a NMB of $629,783 with cost utility ratio of $4426.70/life years.

• AD pathway resulted in a net cost of $57,353 compared to a net cost of $65,001 for the TD pathway.

• AD resulted in a 29% greater NMB with a cost utility ratio of $3,734.58/life year compared with the TD cost utility ratio of $5,292.81/life year. Both figures falling below the societal willingness-to-pay threshold of $50,000/life year.

Protocol Cost ($)Effectiveness (Life Years)

Net Monetary Benefit ($)

C/E ratio ($/Life Year)

Operative Treatment

61,177 13.82 629,783 4,426.70

Accelerated (AD) 57,353 15.36 710,516 3,734.58Traditional (TD) 65,001 12.28 549,052 5,292.81

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Conclusion

• An AD pathway following PSF for non-ambulatory cerebral palsy may provide a 29% greater NMB with a favored cost utility ratio when compared with a TD pathway

• Future studies should aim to identify pre-operative and post-operative variables that increase safety and decrease cost of treating these patients.

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Thank You