The Additional Economic Burden of Frailty in Adult Cervical Deformity Patients Undergoing Surgical Intervention

Abstract

Summary of Background Data. The influence of frailty on economic burden following corrective surgery for the adult cervical deformity (CD) is understudied and may provide valuable insights for preoperative planning. Objective. To assess the influence of baseline frailty status on the economic burden of CD surgery Study Design. Retrospective cohort. Materials and Methods. CD patients with frailty scores and baseline and two-year Neck Disability Index data were included. Frailty score was categorized patients by modified CD frailty index into not frail (NF) and frail (F). Analysis of covariance was used to estimate marginal means adjusting for age, sex, surgical approach, and baseline sacral slope, T1 slope minus cervical lordosis, C2–C7 angle, C2–C7 sagittal vertical axis. Costs were derived from PearlDiver registry data. Reimbursement consisted of a standardized estimate using regression analysis of Medicare payscales for services within a 30-day window including length of stay and death. This data is representative of the national average Medicare cost differentiated by complication/comorbidity outcome, surgical approach, and revision status. Cost per quality-adjusted life-year (QALY) at two years was calculated for NF and F patients. Results. There were 126 patients included. There were 68 NF patients and 58 classified as F. Frailty groups did not differ by overall complications, instance of distal junctional kyphosis, or reoperations (all P>0.05). These groups had similar rates of radiographic and clinical improvement by two years. NF and F had similar overall cost ($36,731.03 vs. $37,356.75, P=0.793), resulting in equivocal costs per QALYs for both patients at two years ($90,113.79 vs. $80,866.66, P=0.097). Conclusion. F and NF patients experienced similar complication rates and upfront costs, with equivocal utility gained, leading to comparative cost-effectiveness with NF patients based on cost per QALYs at two years. Surgical correction for CD is an economical healthcare investment for F patients when accounting for anticipated utility gained and cost-effectiveness following the procedure. Level of Evidence. III.

Methodology of economic evaluations in spine surgery: a systematic review and qualitative assessment

“…They will be used in a separate study to develop evidence-based recommendations for economic evaluations in spine surgery. Finally, a total of 130 clinical cost-effectiveness studies were included 24–153…”

A Hierarchical Approach to Realignment Strategies in Adult Cervical Deformity Surgery

“…However, the benefits of deformity correction should always be weighed against the risks associated with such procedures. The cervical deformity population has been shown to have greater frailty, with higher numbers of comorbidities, increasing susceptibility to perioperative medical adverse events 1,28,29. In addition, complications like DJF, mechanical failure, and subsequent reoperation adversely impact the benefit of deformity correction 28.…”

“…1,28,29 In addition, complications like DJF, mechanical failure, and subsequent reoperation adversely impact the benefit of deformity correction. 28 There are relatively few studies that merge the prospect of clinical success with the development of complications in a composite measure specific to a cervical deformity cohort. With similar rates and ranges of complications to previous underwent reoperation by two years), our results provide insight into multiple considerations during preoperative planning, even when encountering a frail patient.…”

Contextualizing Frailty in Contemporary Spine Practice

“…At the same time, as shown by nearly all of the papers collated here, frailty does not necessarily impair the capacity to benefit from surgical interventions, particularly in deformity and elective lumbar settings. According to the work of the International Spine Study Group , we can infer that in properly selected and indicated frail patients, even the cost of the episode of care is not dramatically different from more physiologically robust individuals 6. As such, while a flag for nuanced preoperative discussion, more comprehensive assessment and preoperative planning, it would appear that frailty in-and-of itself should not serve as a viable reason to decide against surgical intervention in a patient who is otherwise anticipated to benefit from such a procedure.…”

“…In the first work, the International Spine Study Group presents results from a multicenter cohort of patients undergoing surgery for adult cervical spine deformity. 6 In this investigation, patient frailty was characterized at baseline using the modified cervical deformity frailty index originally described by Passias et al 7 With the goal of developing an econometric assessment, the International Spine Study Group then calculated utilities from two-year Neck Disability Index Scores and generated cost determinations using an elegant approach that leveraged Medicare data available through the Pearldiver platform. Overall costs were similar, irrespective of baseline frailty, as was the utility gained by two years.…”