TY - JOUR
T1 - Total Health Care Expenditure in Patients With a Herniated Lumbar Disk That Ultimately Require Surgery
T2 - A 3- and 6-month Cost Comparison of Maximum Nonoperative Treatment
AU - Davison, Mark A.
AU - Lilly, Daniel T.
AU - Moreno, Jessica
AU - Bagley, Carlos
AU - Adogwa, Owoicho
N1 - Publisher Copyright:
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
PY - 2019/1/1
Y1 - 2019/1/1
N2 - Study Design: A retrospective cohort study. Objective: To compare the cost of maximum nonoperative therapy (MNT) in patients diagnosed with a herniated lumbar disk undergoing primary (1-3 mo) versus prolonged (4-6 mo) conservative management before microdiscectomy. Summary of Background Data: Patients diagnosed with a herniated lumbar disk often attempt a 3-month trial of conservative management before microdiscectomy. A paucity of data exists characterizing the cost of a subsequent round of nonoperative therapies in patients who fail their initial trial, rather than undergo surgery. Methods: Clinical records from patients diagnosed with a herniated lumbar disk undergoing index microdiscectomy surgery from 2007 to 2017 were gathered from a large insurance database. Records were searchable by International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and generic drug codes. Two cohorts were established: patients undergoing primary (1-3 mo) versus prolonged (4-6 mo) courses of conservative management. Nonoperative therapy utilization was documented from initial herniation diagnosis to microdiscectomy surgery. "Utilization" encompassed cost billed to patients, prescriptions written, and quantity of units dispensed. Results: The 3-month MNT cohort included 4587 patients and the 6-month MNT cohort contained 1506 patients. A greater percentage of 6-month cohort patients utilized opioids (P=0.0052), muscle relaxants (P=0.0061), and lumbar steroid injections (P<0.0001). When considering the average amount spent on conservative management, 6-month patients ($1824/patient) spent 1.55 times more than 3-month patients ($1178/patient). The 6-month:3-month average spending ratio was <2.0 for all of the nonoperative therapies except nonsteroidal anti-inflammatory drugs (2.66) and epidural steroid injections (2.25). When normalized by the number of opioid users, the number of opioid medications dispensed was proportionally less in 3-month patients compared with 6-month patients, with a 6-month:3-month ratio of 1.52. Conclusions: The costs associated with a subsequent course of nonoperative therapies for symptomatic lumbar disk herniation seem to be slightly less than that of the primary trial. Assuming a minimal clinical benefit after the initial trial of nonsurgical therapies, the incremental cost-effectiveness ratio of a subsequent trial versus surgery may be unfavorable. Future studies identifying patients likely to benefit from surgery earlier in the treatment course is required. Level of Evidence: Level III.
AB - Study Design: A retrospective cohort study. Objective: To compare the cost of maximum nonoperative therapy (MNT) in patients diagnosed with a herniated lumbar disk undergoing primary (1-3 mo) versus prolonged (4-6 mo) conservative management before microdiscectomy. Summary of Background Data: Patients diagnosed with a herniated lumbar disk often attempt a 3-month trial of conservative management before microdiscectomy. A paucity of data exists characterizing the cost of a subsequent round of nonoperative therapies in patients who fail their initial trial, rather than undergo surgery. Methods: Clinical records from patients diagnosed with a herniated lumbar disk undergoing index microdiscectomy surgery from 2007 to 2017 were gathered from a large insurance database. Records were searchable by International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and generic drug codes. Two cohorts were established: patients undergoing primary (1-3 mo) versus prolonged (4-6 mo) courses of conservative management. Nonoperative therapy utilization was documented from initial herniation diagnosis to microdiscectomy surgery. "Utilization" encompassed cost billed to patients, prescriptions written, and quantity of units dispensed. Results: The 3-month MNT cohort included 4587 patients and the 6-month MNT cohort contained 1506 patients. A greater percentage of 6-month cohort patients utilized opioids (P=0.0052), muscle relaxants (P=0.0061), and lumbar steroid injections (P<0.0001). When considering the average amount spent on conservative management, 6-month patients ($1824/patient) spent 1.55 times more than 3-month patients ($1178/patient). The 6-month:3-month average spending ratio was <2.0 for all of the nonoperative therapies except nonsteroidal anti-inflammatory drugs (2.66) and epidural steroid injections (2.25). When normalized by the number of opioid users, the number of opioid medications dispensed was proportionally less in 3-month patients compared with 6-month patients, with a 6-month:3-month ratio of 1.52. Conclusions: The costs associated with a subsequent course of nonoperative therapies for symptomatic lumbar disk herniation seem to be slightly less than that of the primary trial. Assuming a minimal clinical benefit after the initial trial of nonsurgical therapies, the incremental cost-effectiveness ratio of a subsequent trial versus surgery may be unfavorable. Future studies identifying patients likely to benefit from surgery earlier in the treatment course is required. Level of Evidence: Level III.
KW - cost
KW - herniated lumbar disk
KW - microdiscectomy
KW - nonoperative therapy
KW - opioids
KW - recourse utilization
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U2 - 10.1097/BSD.0000000000000829
DO - 10.1097/BSD.0000000000000829
M3 - Article
C2 - 31162185
AN - SCOPUS:85066797048
SN - 2380-0186
JO - Clinical Spine Surgery
JF - Clinical Spine Surgery
ER -