Cost-Utility and Comparative Effectiveness Analyses of Laminectomy Versus Comprehensive Medical Management for Lumbar Stenosis

Keywords: cost effectiveness, lumbar spine, laminectomy, spinal stenosis, medication

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     SPORT suggested lumbar laminectomy was efficacious but only moderately cost-effective for treatment of lumbar stenosis. Such randomized trials inherently control and standardize medical resource utilization and cost. Furthermore, mid-trial crossover of medicine non-responders significantly inflates utility of medical management, further biasing cost-utility analysis(CUA).
     We performed comparative effectiveness and CUA of laminectomy versus medical management for lumbar stenosis utilizing a prospective registry in real-world practice setting.
     Ninety-four patients with lumbar stenosis managed at a Multidisciplinary Spine Center were entered into a prospective registry.
     Surgical management consisted of laminectomy. Comprehensive medical management included spinal steroid injections, physical therapy, oral medications, and other therapies. Two-year patient-reported outcomes(PRO), back-related medical resource utilization, and work-day losses were prospectively assessed and used to calculate Medicare fee-based direct costs and indirect costs from occupation loss. Difference in mean cost per QALY gained assessed as incremental cost-effectiveness ratio(ICER).
     Laminectomy resulted in significant (p<0.01) two-year improvement in all outcome measures, while comprehensive medical management failed to provide significant effectiveness. Two-year gain in QALY was significantly greater after laminectomy(0.36 QALY gained) versus medical management(0.10 QALY gained). Total two-year cost was significantly greater for laminectomy ($24,264) versus medical management($9,550). Cost per QALY gained for surgery vs. medical management(ICER) was $56,592.
     This is a retrospective study.
     In this prospective multi-disciplinary registry, lumbar laminectomy versus medical management was shown to be cost-effective and provide greater two-year improvement in pain, disability, and quality of life.
     The findings from this real-world practice setting may more accurately reflect true value and effectiveness of surgical versus medical care for lumbar stenosis.


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