Spine surgery is an expensive procedure, but for patients who would benefit from surgical correction the long-term economic benefits can far outweigh the initial cost of care. Especially with new minimally invasive and outpatient spine procedures, the cost of spine surgery has dramatically decreased over the past few years.
For example, a November 2013 study published in The Spine Journal showed the direct hospital costs were $19,512 for patients who underwent minimally invasive transforaminal lumbar interbody fusion, compared with $23,550 for the open procedure.
A further article published in 2012 in Spine examined the cost and quality-adjusted life year for single-level instrumented posterolateral lumbar fusion for patients with degenerative lumbar spine conditions. The researchers found:
• Cost per QALY gained at the five-year postoperative interval was $33,018.
• The analogous average direct cost based on Medicare reimbursement for five years was $20,669, with a resultant cost per QALY gained of $30,053.
• The average total work productivity cost for five years was $14,377 with a resultant total cost per QALY gained from $53,949 to $53,914.
"Compared to other fields of medicine, there continues to be a relative paucity of high-level evidence available to direct the care of patients with spinal conditions," says Peter Whang, MD, FACS, an Associate Professor in the Department of Orthopaedics and Rehabilitation at the Yale University School of Medicine in New Haven, Conn. "However, we have been trying to make up for lost time and this is reflected in the quality of research that ahs recently been published. One obvious example is the considerable amount of data derived from the Spine Patient Outcomes Research Trial."
When surgery is indicated, there are several factors that increase the cost of care for spine surgery patients. Implants and fusion material are a huge expense, along with resource management costs like operative time and length of stay. When patients have poor pain control or experience complications, costs exceed several thousands of dollars for each additional day in the hospital.
"Despite our best efforts, complications will inevitably occur and they certainly have he potential to prolong hospital stay, increase costs and ultimately compromise patient outcomes," says Dr. Whang. "Obviously the best treatment for any complication is prevention which requires constant vigilance on our part before, during and after the operation. This involves adhering to proper patient selection, identifying significant risk factors and implementing preemptive measures."
Improved pain control can have several economic benefits:
• Quicker discharge from the hospital
• Reduced readmissions for acute pain
• Reduced costs for chronic pain treatment
• Improved patient satisfaction scores
• Reduced legal liability
Physicians are beginning to learn the risk factors for complications and anticipating adverse events to aggressively treat patients earlier. "We certainly cannot eliminate complications in spine surgery, but we can hopefully decrease their incidence and mitigate their consequences," says Dr. Whang. "For the most part, surgeons have recognized the importance of clinical outcomes and strived to incorporate them into their practice."
Electronic medical records make collecting data easier and clinicians can pinpoint the source of negative trends or outliers in their data. One of the biggest opportunities to reduce complications and associated costs is through postoperative pain management.
"I think the importance of establishing an effective postsurgical pain management regimen cannot be overstated. While no surgeon wants their patients to be uncomfortable after surgery, it has become increasingly clear that poorly-controlled pain is associated with a wide range of perioperative complications—immobility, falls and mental status changes," says Dr. Whang. "Another challenge we face is that many analgesics we commonly use may also give rise to any number of adverse events."
For complications such as respiratory depression, recovery adds 3.3 days in the hospital on average. Patients who experience nausea and/or vomiting due to poor postoperative pain control spend another 2.5 days in the hospital on average. Ileus and/or constipation causes 3.4 extra days, and delayed ambulation can mean patients are staying in the hospital for three extra days.
"In the end, inadequate treatment of this pain may even lead to worsening clinical outcomes, both in the immediate postoperative period and possibly even over the long term as well," says Dr. Whang. "The issue is certainly an area of active research and in the future it is likely that we will need to utilize a multimodal strategy including longer-acting local anesthetics and novel analgesics in an attempt to address postsurgical pain."
For general and colorectal surgery, the average cost per day of additional hospital stays and inpatient care is $2,095. There are additional costs associated with nursing hours and supplies to care for patients with complications. Reparatory depression costs nurses an average of four hours of time per day and $200 in drugs and supplies per day. Nausea and vomiting adds three hours of nursing time and $167 in drug and supply cost. Delayed ambulation requires three hours of nursing time per day and incurs $166 in drug and supply costs per day.
Reducing narcotics-related side-effects and complications could mean substantial savings. However, some of the non-narcotic alternatives still have high costs; a survey shows the average cost for pain pumps, supplies and drugs is $450 on average. An additional $196 is necessary for the pharmacy to fill the pump, bringing the total cost to $646 for drug administration. Nurse time to monitor the patient is 3.3 hours on average, valued at $165 per case.
Administering the long-acting EXPAREL could save an average of $410 per patient because the drug is administered once during surgery and can relieve pain for up to 72 hours.
More Articles on Spine Surgery:
5 Big Findings on BMP Complications in Spine Surgery
Spine Reimbursements, Regulations & Research: 5 Surgeons on the Top Challenges in Spine
Spinal Cord Injury: Promising Research to Restore Hand Function at UCLA