Cost-Effectiveness of Lumbar Discectomy for the Treatment of Herniated Intervertebral Disc

Malter, Alex D.; Larson, Eric B.; Urban, Nicole; Deyo, Richard A.

doi:10.1097/00007632-199605010-00011

Cited by 128 publications

(91 citation statements)

References 24 publications

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“…Whilst five full economic evaluations were identified in the systematic review [20,21,22,23,24], the majority of evaluations were undertaken in conjunction with clinical trials with a lack of published decisions models. A full narrative review of the economic evidence has been published elsewhere [11].…”

Section: Resultsmentioning

confidence: 99%

Cost-effectiveness of different strategies to manage patients with sciatica

Fitzsimmons

Phillips

Bennett

et al. 2014

Pain

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SummaryA model-based economic evaluation demonstrates that stepped approaches based on initial treatment with non-opioids are most likely to represent the most cost-effective regimens for sciatica. 2 AbstractThe aim of this paper is to estimate the relative cost-effectiveness of treatment regimens for managing patients with sciatica. A deterministic model structure was constructed, based on information from the findings from a systematic review of clinical and cost-effectiveness, published sources of unit costs and expert opinion. The assumption was patients presenting with sciatica would be managed through one of three pathways (primary care, stepped approach, immediate referral to surgery).. Results were expressed as incremental cost per patient with symptoms successfully resolved. Analysis also included incremental cost per utility gained over a 12 month period. One-way sensitivity analyses were used to address uncertainty. The model demonstrated that none of the strategies resulted in 100% success. For initial treatments, the most successful regime in the first pathway was non-opioids, with a probability of success of 0.613. In the second pathway, the most successful strategy was non-opioids, followed by biological agents, followed by epidural/nerve block and disc surgery, with a probability of success of 0.996. Pathway 3 (immediate surgery) was not cost-effective. Sensitivity analyses identified that the use of the highest cost estimates results in a similar overall picture. While the estimates of cost per QALY are higher, the economic model demonstrated that stepped approaches based on initial treatment with non-opioids are likely to represent the most cost-effective regimens for the treatment of sciatica. However, development of alternative economic modelling approaches is required.3

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Section: Resultsmentioning

confidence: 99%

Cost-effectiveness of different strategies to manage patients with sciatica

Fitzsimmons

Phillips

Bennett

et al. 2014

Pain

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“…In another study, Parker et al 17 found that the mean cost per patient for primary discectomy surgery was similar to that for revision discectomy, $42,554. In a randomized study, Malter et al 13 analyzed insurance data from 372 patients who had undergone discectomy and found that the mean cost for these patients was $13,390.…”

Section: Discussionmentioning

confidence: 99%

Quality of life outcomes after revision lumbar discectomy

Lubelski

Şenol

Silverstein

et al. 2015

SPI

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OBJECT The authors investigated quality of life (QOL) outcomes after primary versus revision discectomy. METHODS A retrospective review was performed for all patients who had undergone a primary or revision discectomy at the Cleveland Clinic Center for Spine Health from January 2008 through December 2011. Among patients in the revision cohort, they identified those who needed a second revision discectomy. Patient QOL measures were recorded before and after surgery. These measures included responses to the EQ-5D health questionnaire, Patient Health Questionnaire–9, Pain and Disability Questionnaire, and quality-adjusted life years (QALYs). Cohorts were compared by using independent-sample t-tests and Fisher exact tests for continuous and categorical variables, respectively. Multivariable logistic regression was performed to adjust for confounding. RESULTS A total of 196 patients were identified (116 who underwent primary discectomy and 80 who underwent revision discectomy); average follow-up time was 150 days. There were no preoperative QOL differences between groups. Postoperatively, both groups improved significantly in all QOL measures. For QALYs, the primary cohort improved by 0.25 points (p < 0.001) and the revision cohort improved by 0.18 points (p < 0.001). QALYs improved for significantly more patients in the primary than in the revision cohort (76% vs 59%, respectively; p = 0.02), and improvement exceeded the minimum clinically important difference for more patients in the primary cohort (62% vs 45%, respectively; p = 0.03). Of the 80 patients who underwent revision discectomy, yet another recurrent herniation (third herniation) occurred in 14 (17.5%). Of these, 4 patients (28.6%) chose to undergo a second revision discectomy and the other 10 (71.4%) underwent conservative management. For those who underwent a second revision discectomy, QOL worsened according to all questionnaire scores. CONCLUSIONS QOL, pain and disability, and psychosocial outcomes improved after primary and revision discectomy, but the improvement diminished after revision discectomy.

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“…Additionally, a higher utility was assigned to CDR than ACDF, reflecting a better overall neurological status, overall success, and improved range of motion in the CDR group. 20,35 Sensitivity analysis was conducted to evaluate the effect of altering the assumed utilities on the ICER of CDR.…”

Section: Utility Of Cdrmentioning

confidence: 99%

“…A review of the literature demonstrated a hardware failure rate of 0%-2% at 1 year after hardware placement. [1][2][3][4][5][6][7][13][14][15][18][19][20][21][22][24][25][26][27][28]30,31,35,36,40 Following hardware failure, a patient could undergo either a revision arthroplasty or a revision ACDF.…”

mentioning

confidence: 99%

“…In the 1990s, total hip replacement demonstrated a CER of $4600 per QALY; medical treatment of hypertension, a CER of $24,900 per QALY; and lumbar discectomy, a CER of $29,200 per QALY. 6,20 More recently, total ankle arthroplasty was shown to have an ICER of $18,419 per QALY gained, as compared with ankle fusion. 33 The ICER is a comparative calculation and represents the difference in cost divided by the difference in the effectiveness of 2 procedures.…”

mentioning

confidence: 99%

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Cost-effectiveness analysis: comparing single-level cervical disc replacement and single-level anterior cervical discectomy and fusion

Qureshi¹,

McAnany²,

Goz³

et al. 2013

SPI

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Object In recent years, there has been increased interest in the use of cervical disc replacement (CDR) as an alternative to anterior cervical discectomy and fusion (ACDF). While ACDF is a proven intervention for patients with myelopathy or radiculopathy, it does have inherent limitations. Cervical disc replacement was designed to preserve motion, avoid the limitations of fusion, and theoretically allow for a quicker return to activity. A number of recently published systematic reviews and randomized controlled trials have demonstrated positive clinical results for CDR, but no studies have revealed which of the 2 treatment strategies is more cost-effective. The purpose of this study was to evaluate the cost-effectiveness of CDR and ACDF by using the power of decision analysis. Additionally, the authors aimed to identify the most critical factors affecting procedural cost and effectiveness and to define thresholds for durability and function to focus and guide future research. Methods The authors created a surgical decision model for the treatment of single-level cervical disc disease with associated radiculopathy. The literature was reviewed to identify possible outcomes and their likelihood following CDR and ACDF. Health state utility factors were determined from the literature and assigned to each possible outcome, and procedural effectiveness was expressed in units of quality-adjusted life years (QALYs). Using ICD-9 procedure codes and data from the Nationwide Inpatient Sample, the authors calculated the median cost of hospitalization by multiplying hospital charges by the hospital-specific cost-to-charge ratio. Gross physician costs were determined from the mean Medicare reimbursement for each current procedural terminology (CPT) code. Uncertainty as regards both cost and effectiveness numbers was assessed using sensitivity analysis. Results In the reference case, the model assumed a 20-year duration for the CDR prosthesis. Cervical disc replacement led to higher average QALYs gained at a lower cost to society if both strategies survived for 20 years ($3042/QALY for CDR vs $8760/QALY for ACDF). Sensitivity analysis revealed that CDR needed to survive at least 9.75 years to be considered a more cost-effective strategy than ACDF. Cervical disc replacement becomes an acceptable societal strategy as the prosthesis survival time approaches 11 years and the $50,000/QALY gained willingness-to-pay threshold is crossed. Sensitivity analysis also indicated that CDR must provide a utility state of at least 0.796 to be cost-effective. Conclusions Both CDR and ACDF were shown to be cost-effective procedures in the reference case. Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF. Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR, future long-term studies are required to validate the present analysis.

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Cost-Effectiveness of Lumbar Discectomy for the Treatment of Herniated Intervertebral Disc

Abstract: For carefully selected patients with herniated discs, surgical discectomy is a cost-effective treatment. Discectomy's favorable cost-effectiveness results from its substantial effect on quality of life and moderate costs.

Cited by 128 publications

References 24 publications

Cost-effectiveness of different strategies to manage patients with sciatica

Cost-effectiveness of different strategies to manage patients with sciatica

Quality of life outcomes after revision lumbar discectomy

Cost-effectiveness analysis: comparing single-level cervical disc replacement and single-level anterior cervical discectomy and fusion

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