Cost-Utility and Comparative Effectiveness Analyses of Laminectomy Versus Comprehensive Medical Management for Lumbar StenosisScott Parker, MD1, Scott Zuckerman1, David Shau1, Stephen Mendenhall1, Joseph S. Cheng, MD1, Clinton Devin1, Matthew McGirt, MD11Nashville, TN United States Keywords: cost effectiveness, lumbar spine, laminectomy, spinal stenosis, medicationInteractive ManuscriptAsk Questions of this Manuscript: What is the background behind your study?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). What is the purpose of your study?We performed comparative effectiveness and CUA of laminectomy versus medical management for lumbar stenosis utilizing a prospective registry in real-world practice setting. Describe your patient group.Ninety-four patients with lumbar stenosis managed at a Multidisciplinary Spine Center were entered into a prospective registry. Describe what you did.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). Describe your main findings.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. Describe the main limitation of this study.This is a retrospective study. Describe your main conclusion.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. Describe the importance of your findings and how they can be used by others.The findings from this real-world practice setting may more accurately reflect true value and effectiveness of surgical versus medical care for lumbar stenosis. 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. Project Roles:
S. Parker (), S. Zuckerman (), D. Shau (), S. Mendenhall (), J. Cheng (), C. Devin (), M. McGirt ()
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