Reduction of direct costs in high-risk lumbar discectomy patients during the 90-day post-operative period through annular closure

Abstract

Purpose

Despite being an extremely successful procedure, recurrent disc herniation is one of the most common post-discectomy complications in the lumbar spine and contributes significant health care and socioeconomic costs. Patients with large annular defects are at a high risk for reherniation, but an annular closure device (ACD) has been designed to reduce reherniation risk in this population and may, in turn, help control direct health care costs after discectomy.

Patients and methods

This analysis examined the 90-day post-discectomy cost estimates among ACD-treated (n=272) and control (discectomy alone; n=278) patients in a randomized controlled trial (RCT). Direct medical costs were estimated based on 2017 Humana and Medicare claims. Index discectomies were assumed to occur in an outpatient (OP) setting, whereas repeat discectomies were assumed to be 60% in OP and 40% in inpatient (IP). A sensitivity analysis was performed on this assumption. The device cost was not included in the analysis in order to focus on costs in the 90-day post-operative period.

Results

Within 90 days of follow-up, post-operative complications occurred in 3.3% of the ACD patients and 8.6% of the control patients (P=0.01). The average 90-day cost to treat an ACD patient was $10,257 compared to $11,299 per control patient for a 80:20 distribution of Commercial:Medicare coverage ($1,042 difference). This difference varied from $687 with 100% Medicare to $1,132 with 100% Commercial coverage. Varying the IP vs OP distribution resulted in a cost difference range of $968 to $1,156 with the ACD.

Conclusion

Augmenting discectomy with an ACD in high-risk patients with a large annular defect reduced reherniation and reoperation rates, which translated to a reduction of direct health care costs between $687 and $1,156 per patient during the 90-day post-operative period. Large annular defect patients are an easily identifiable high-risk population. Operative strategies that reduce complication risks in these patients, such as the ACD, could be advantageous from both patient care and economic perspectives.

Keywords:

• annular closure device
• value-based care
• 90-day bundle
• lumbar discectomy
• large annular defect
• recurrent herniation

Supplementary materials

Local ethics committees that gave approval for the randomized controlled trial

• Ethikkommission: Medizinische Universität Graz

• Ethikkommission der Medizinischen Universität Innsbruck

• ZiekenhuisNetwerk Antwerpen (ZNA/OCMW Antwerpen)

• O.L.Vrouwziekenhuis Aalst Ethisch Comite

• ZNA/OCMW Antwerpen

• Commissie voor Medische Ethiek, A.Z. Nikolaas

• Comité de Protection des Personnes (CPP)

• MHH (Hannover Medical School)

• BLÄK (Ethics Committee of the Bavarian Regional Medical Association)

• Charité Ethikkommission

• Medizinische Fakultät Der Christian-Albrechts-Universität Zu Kiel

• Med. Ethik-Kommission II

• Heinrich Heine Universität Düsseldorf Ethikkommission der Medizinischen Fakultät

• Ethik-Kommission Der Ärztekammer Hamburg

• Ethikkommission an der Medizinischen Fakultät der Universität Rostock

• Ethik-Kommission der Medizinischen Fakultät der RUB

• St. Lucas Andreas Ziekenhuis

• Isala Klinieken

• METC Zuidwest Holland

• Kanton Aargau,Kantonale Ethikkommission

Acknowledgments

The authors would like to acknowledge Telos Partners, LLC for their technical editing contributions.

Disclosure

JDA received consulting fees from Intrinsic Therapeutics related to the cost calculations for this study. CT, JDA, and MJM have received educational consulting fees unrelated to this work from Intrinsic Therapeutics. CT’s institution received study support for conducting the RCT from Intrinsic Therapeutics. All other authors are free from any potential conflicts of interest related to this work.