Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois.
Department of Neurosurgery, University of Texas South Western Medical Center, Dallas, Texas.
Spine (Phila Pa 1976). 2019 Mar 15;44(6):424-430. doi: 10.1097/BRS.0000000000002849.
Retrospective cohort study.
The purpose of this study is to characterize the utilization and costs of MNTs prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis.
The costs and utilization of long-term maximal nonoperative therapy (MNT) can be substantial, and in the current era of bundled payments, the duration of conservative therapy trials should be reassessed.
A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. Only patients with lumbar stenosis or spondylolisthesis and those continuously active within the insurance system for at least 5 years prior to the index operation were eligible.
A total of 4133 out of 497,822 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion. 20.8% of patients were smokers, 44.5% had type II DM, and 38.2% were obese (body mass index [BMI] >30 kg/m). Patient MNT utilization was as follows: 66.7% used nonsteroidal anti-inflammatory drugs (NSAIDs), 84.4% used opioids, 58.6% used muscle relaxants, 65.5% received lumbar epidural steroid injections (LESI), 66.6% attended 21.1% presented to the emergency department (ED), and 24.9% received chiropractor treatments. The total direct cost associated with all MNT prior to index spinal fusion was $9,000,968; LESI comprised the largest portion of the total cost of MNT ($4,094,646, 45.5%), followed by NSAIDS ($1,624,217, 18.0%) and opioid costs ($1,279,219, 14.2%). At the patient level, when normalized per patient utilizing therapy, an average $4010 was spent on nonoperative treatments prior to index lumbar surgery.
Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost-effectiveness ratio (ICER) for MNTs could be highly unfavorable.
回顾性队列研究。
本研究的目的是描述在接受症状性腰椎管狭窄症或脊椎滑脱症脊柱融合手术的患者中，术前使用运动疗法（MNT）的利用情况和费用。
长期最大非手术治疗（MNT）的成本和利用率可能相当高，并且在当前捆绑支付的时代，应重新评估保守治疗试验的持续时间。
对 2007 年至 2016 年间接受腰椎减压和融合术的症状性腰椎管狭窄症或脊椎滑脱症患者进行了一项大型保险数据库查询。该数据库包含 2090 万被保险人，包括私人/商业保险和医疗保险优势受益人的患者。仅符合条件的患者为腰椎狭窄症或脊椎滑脱症患者，并且在索引手术前至少在保险系统内连续活跃 5 年。
4133 名符合条件的患者（0.8%）接受了 1、2 或 3 个节段的后路腰椎器械融合术。20.8%的患者为吸烟者，44.5%的患者患有 2 型糖尿病，38.2%的患者肥胖（BMI＞30kg/m）。患者 MNT 利用情况如下：66.7%使用非甾体抗炎药（NSAIDs），84.4%使用阿片类药物，58.6%使用肌肉松弛剂，65.5%接受腰椎硬膜外类固醇注射（LESI），66.6%就诊，21.1%就诊于急诊室（ED），24.9%接受脊椎指压治疗。与所有术前脊柱融合前的 MNT 相关的直接总成本为 9000968 美元；LESI 构成了 MNT 总成本的最大部分（4094646 美元，占 45.5%），其次是 NSAIDs（1624217 美元，占 18.0%）和阿片类药物费用（1279219 美元，占 14.2%）。在患者层面，当按接受治疗的患者进行归一化时，在接受腰椎手术前，每位患者平均花费 4010 美元用于非手术治疗。
假设在最大非手术治疗后疼痛和功能障碍有最小改善，MNT 的增量成本效益比（ICER）可能非常不利。
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