Cost Benefit of Preoperative Mental Health Optimization for Adult Spinal 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

View E-Poster

Co-Author(s)

PD

Pooja R. Dave

Miami, 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
OO

Oluwatobi Onafowokan

United Kingdom

Submitter(s)

PP

Peter G. Passias, M.D.

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

View E-Poster

Disclosure(s):

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

Background: The complexity of adult spinal deformity (ASD) corrective surgery can carry a significant cost burden. Psychological distress can be associated with worsening surgical outcomes and postoperative course. Given that these outcomes influence cost, associations between pre-surgical psychological state, intervention, and cost is warranted.

Purpose: To investigate if preoperative optimization of psychiatric conditions using Cognitive Behavioral Therapy improves surgical cost utility

Methods: CD Patients >18yrs with NDI>20%. Patients administered 4 validated self-report instruments: Distress and Risk Assessment Method (DRAM), Fear-Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), Outcome Expectation question (OEQ). Patients randomized using matched pairs: Sham (placebo educational group receiving six sham treatments then surgery); CBT (treatment by licensed professional prior to surgery). Surveys administered at enrollment. Thresholds were set >17 DRAM, >49/66 FABQ, >30/52 PCS. Subjects who did not meet cutoff were assigned into control group. Those who are above any thresholds placed into either the Sham or CBT group based on a 1:1 randomization. Any who exceeded psychological distress criteria were assigned to DRAM observation only group. Basic demographics and baseline measures HRQLs (NDI, EQ5D, PCS, FABQ) were assessed via descriptive analyses. Cost data valued by CMS.gov DRG. QALYS was calculated using NDI converted to EQ5D using published conversion, with 3% discount to account for life expectancy (78.7 years). Total utility gained calculated by change in utility multiplied by life expectancy. ANOVA and multivariate logistic regression determined predictive factors between cost and cohort groups.

Results: 47 included (53.6years, 49% female, 29.4 kg/m2). At baseline, average PCS 27.4, FABQ 40, average EQ5D of 9.3, NDI of 25.6. 57.1% had a severe FABQ score, 40.8% severe PCS, 27.7% severe NDI. 17 were CBT, 11 Sham, 10 Control, 9 DRAM. 33 (68.8%) completed 2Y follow-up. Average initial surgical costs were: CBT: $4,722; Sham: $4,720; Control: $4,267; DRAM: $6,052 (p=0.685). Total utility gained was found to be the greatest in DRAM patients (.467), as compared to Sham (0.3712), CBT (0.3510), and Control (0.2349; p=0.029). Control patients with no intervention had lower cost effectiveness ($11,274) compared to the other groups (CBT: $7,043; Sham: $7,224; DRAM: $6,024). CBT trended toward a higher rate of improvement in PCS (56% vs. other groups: 41%, p=0.338), FABQ (50% vs. 28%, p=0.133), NDI (69% vs. 45%, p=0.124), EQ5D (50% vs. 31%, p=0.209), VAS (63% vs. 38%, p=0.114), NRS Neck (56% vs. 38%, p=0.236), and NRS Back (63% vs. 38%, p=0.114). Multivariate analysis found greater odds of increasing cost with higher baseline NDI (OR: 1.22, [1.02, 1.86], p=0.027).

Conclusions: Preoperative patient optimization can overall improve postoperative outcomes and patient satisfaction. This study found that increasing rates of mental health related disability are associated with diminished outcomes and cost effectiveness for cervical deformity surgery. Overall, lowest cost effectiveness was found in those receiving no treatment. With increasing baseline disability predicting greater surgical cost, optimizing patient’s mental wellbeing in preoperative period can improve overall outcomes and healthcare burden.