Drivers of Cost in Primary Single-Level Lumbar Fusion Surgery

Abstract

Study Design: Retrospective cohort. Objectives: Allocating cost is challenging with traditional hospital accounting. Time-driven activity-based costing (TDABC) is an efficient method to accurately assign cost. We sought to characterize the variation in direct total hospital cost (THC) among both lumbar fusion approaches and surgeons. Methods: Patients were treated with single-level anterior interbody (ALIF), lateral interbody (LLIF), transforaminal interbody (TLIF), instrumented posterolateral (PLF) or in-situ fusion (ISF) for degenerative disease. Process maps were developed for preoperative, intraoperative and postoperative care. THC was composed of implant, medication, other supply, and personnel costs. Linear regression and descriptive statistics were used to analyze THC variation. Results: A total of 696 patients underwent surgery by 8 surgeons. Approximately 50% of THC variation was associated with procedure choice while patient characteristics explained 10%. Implants (including biologics) accounted for 45% of cost. With reference to PLF, THC ranged from 0.6x (ISF) to 1.7x (LLIF). Implant cost ranged from 2.5x reference (LLIF) to 0.1x (ISF). There was a 1.7x difference between the highest THC surgeon and the lowest. The fusion type with the highest THC variation was TLIF. The surgeon with the highest TLIF THC was 1.5x more expensive than the surgeon with the lowest. Conclusions: Surgeon-based choices have the greatest effect on THC variation and represent the largest opportunities for cost savings. Primary single-level lumbar fusion THC is driven primarily by fusion type. Implants, including biologics, account for nearly half this cost. Future work should incorporate outcomes data to characterize the differential value conferred by higher THC fusions.

The Markup on Orthopaedic Services: An Analysis of 2014-2019 Medicare Data and the Potential for Surprise Billing

“…The ability of large medical device manufacturers to set variable prices for their implants, as well as the limited transparency regarding purchasing agreements between these manufacturers and health-care organizations 35,36 , may additionally result in substantially different prices for these devices across systems. This has been previously demonstrated in the implant-heavy field of orthopaedic surgery, with Carducci et al and Hwang et al finding that variable implant prices were the largest contributor to total costs of care for total joint arthroplasty (TJA) and spine procedures, respectively 37,38 . However, while implant cost variation may help explain the demonstrated variation in CCRs, it also may serve as an avenue to reduce health-care costs and avoid markedly low CCRs.…”

SPINE: High heterogeneity and no significant differences in clinical outcomes of endoscopic foraminotomy vs fusion for lumbar foraminal stenosis: a meta-analysis

“…It is important to note that fusion has specific long-term risks, including pseudarthrosis, adjacent segment disease, hardware-related complications, and metallic wear related complications, while patients treated with endoscopic foraminotomy may require fusion surgery in the long-term ( 64 , 65 ). Furthermore, the cost of fusion surgery has increased over recent years, with 50% of the global cost being due to implants ( 66 ). Moreover, in many countries, endoscopic foraminotomy is an outpatient surgery, which can lead to a substantial reduction in cost ( 4 , 67 ).…”

Validation of Impaction Grafting for Single-Level Transforaminal Lumbar Interbody Fusion-Technical Pearls and MicroCT Analysis

“…Though these substrates come at a substantial cost compared with the readily available local autografts, the superiority of the former has not been clearly demonstrated for TLIF 14,15. In fact, implants and biologics account for nearly half of the direct total hospital cost for lumbar fusions 16. Morselized autogenous bone overcomes the challenges of cost and physical constraints of cages and biologics.…”