Cost Benefit Analysis of Preoperative Optimization of Modifiable Health Conditions Prior to Adult Cervical Deformity Surgery

Thursday, June 1, 2023

8:30 AM – 6:15 PM

Presenting Author (Person doing the Podium Present(s)

PP

Peter G. Passias, M.D.

Spine Surgeon
NYU Langone Orthopedic Hospital
New York, New York, United States

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Co-Author(s)

PD

Pooja R. Dave

Miami, Florida, United States
KM

Kim Mcfarland

Florida, United States
PT

Peter S. Tretiakov, BS

United States
JM

Jamshaid M. Mir, MD

Research Fellow
NYU Langone Health | NY Spine Institute, United States
AS

Andrew J. Schoenfeld, MD, MSc

Associate Professor
Brigham and Women's Hospital, Department of Orthopaedic Surgery
Boston, Massachusetts, United States

Submitter(s)

PP

Peter G. Passias, M.D.

Spine Surgeon
NYU Langone Orthopedic Hospital
New York, New York, United States

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Disclosure(s):

Peter G. Passias, MD: No relevant disclosure to display

Background: Recent literature has emphasized the importance of frailty in surgical outcomes for adult cervical deformity patients and modifiable health conditions are a known contributor to frailty and overall comorbidity status. Benefits and cost differences to optimizing comorbidities prior to surgical adult cervical deformity correction merits further study.

Purpose: determine the effects of pre-operatively optimizing modifiable health conditions on cost in operative cervical deformity patients.

Methods: ACD patients with available up to 2-year data were included. Preoperative optimization for osteoporosis was assessed by treatment with an FDA approved drug prior to surgery. Patients were divided into 2 groups: those who had preoperative rehabilitation [Prehab] and those who did not [no Prehab]. Prehab consisted of cognitive behavioral therapy and physical therapy with core, paraspinal and leg strengthening. Nutritional status assessed by ranking patients into quartiles (Q1-Q4) by baseline BMI. Q1 (low BMI) and Q4 (high BMI) were considered not optimized. Patients stratified by optimization in all three groups (Opt) or non-optimized. Cost analysis was based on average Medicare reimbursement while accounting for surgical approach and revision status. Reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for services within a 30 day window. All costs were inflation adjusted to 2022. For QALY analysis, utility was calculated using EQ-5D as previously published. ANCOVA and logistic regression analyses assessed outcomes while accounting for surgical and demographic differences between groups.

Results: 347 ACD patients (average 57.9±12.1 years, 48% female, 29.0±6.82 kg/m2) were included. Multivariate analysis confirmed Prehab patients more likely to improve in ODI (OR .055 [CI .006-.476], p=.008) at 2Y. However, Prehab and no Prehab patients exhibited similar ODI IHS recovery rates from BL to 2Y, P<.05. Total cost for Prehab patients was $59,272 compared to $72,878 for not Prehab, P<.05. Cost effectiveness was determined via cost per QALY: Prehab = $14,463 and not Prehab = $45,515, P<.05. For osteoporosis (85.4% Opt), Opt patients had lower odds of 2Y complications (OR: 0.207 [.086, .498],p <.001) and lower cost ($28,053 vs. $33,171,p=.002) compared to non-optimized patients. Optimized patients were significantly less female (43% vs. 52%, p=.038) and had fewer levels fused (4.14±3.50 vs. 5.21±4.15, p=.002), shorter length of stay (3.96±3.94 vs. 5.12±8.18 days, p=.044), less operative time (261.9±166.6 vs. 315.8±189.7 mins, p=.002), and lower EBL (502.8±950.6 vs. 679.0±965.5 mL, p=.039). Optimized patients had lower cost at 2 years ($33,898.40 vs. $36,861.86, p=.009). Linear regression modeling was significant for optimized BMI predicting lower cost at 2 years with average change of $2963.45 (OR:.45 [1.02,2.89], p=.009).

Conclusions: While preoperative optimization of modifiable health conditions may present greater upfront costs, the longer-term cost savings associated with optimized adult cervical deformity patients may outweigh the initial cost.