P104. A 2-year cost analysis of maximum nonoperative treatments in patients with symptomatic lumbar stenosis or spondylolisthesis that ultimately required surgery

Abstract

BACKGROUND CONTEXT A variety of nonoperative therapies are attempted for pain management in patients with symptomatic lumbar stenosis or spondylolisthesis prior to surgery. The costs and utilization of maximal nonoperative therapy (MNT) remains unknown. PURPOSE The purpose of this study is to characterize the utilization and costs of MNTs within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1, 2, or 3-level lumbar decompression and fusion procedures between 2007 and 2016 within a large insurance database were included. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. OUTCOME MEASURES The primary outcome was the utilization of MNTs within 2 years prior to index surgery. METHODS Research records were searchable by International Classification of Diseases (ICD) diagnosis and procedure codes, Current Procedural Terminology (CPT) codes, and generic drug codes specific to Humana. “Utilization” of MNTs was characterized by cost billed to the patient, prescriptions written and number of units billed. RESULTS A total of 27,877 out of 3,423,114 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion; 17.6% of patients were smokers, 35.1% of patients had type II DM, and 24.8% were obese (BMI > 30 kg/m2). Patient maximal nonoperative therapy (MNT) utilization was as follows: 11,383 (40.8%) used NSAIDs, 19,770 (70.9%) used opioids, 12,414(44.5%) used muscle relaxants, 14,422 (51.7%) received LESI, 11,156 (40.0%) attended PT/OT, 4,005 (14.4%) presented to the ED, and 4,042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28,241,320. LESI comprised the largest portion of the total cost of MNT ($15,296,941, 54.2%), followed by opioids ($3,702,463, 13.1%) and NSAIDs ($3,058,335, 10.8%). At the patient level, on average $1,013.07 was spent on nonoperative treatments prior to index lumbar surgery. CONCLUSIONS Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio (ICER) for MNT could be highly unfavorable. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. A variety of nonoperative therapies are attempted for pain management in patients with symptomatic lumbar stenosis or spondylolisthesis prior to surgery. The costs and utilization of maximal nonoperative therapy (MNT) remains unknown. The purpose of this study is to characterize the utilization and costs of MNTs within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. Retrospective cohort study. Patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1, 2, or 3-level lumbar decompression and fusion procedures between 2007 and 2016 within a large insurance database were included. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. The primary outcome was the utilization of MNTs within 2 years prior to index surgery. Research records were searchable by International Classification of Diseases (ICD) diagnosis and procedure codes, Current Procedural Terminology (CPT) codes, and generic drug codes specific to Humana. “Utilization” of MNTs was characterized by cost billed to the patient, prescriptions written and number of units billed. A total of 27,877 out of 3,423,114 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion; 17.6% of patients were smokers, 35.1% of patients had type II DM, and 24.8% were obese (BMI > 30 kg/m2). Patient maximal nonoperative therapy (MNT) utilization was as follows: 11,383 (40.8%) used NSAIDs, 19,770 (70.9%) used opioids, 12,414(44.5%) used muscle relaxants, 14,422 (51.7%) received LESI, 11,156 (40.0%) attended PT/OT, 4,005 (14.4%) presented to the ED, and 4,042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28,241,320. LESI comprised the largest portion of the total cost of MNT ($15,296,941, 54.2%), followed by opioids ($3,702,463, 13.1%) and NSAIDs ($3,058,335, 10.8%). At the patient level, on average $1,013.07 was spent on nonoperative treatments prior to index lumbar surgery. Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio (ICER) for MNT could be highly unfavorable.