Schoenfeld Andrew J, Bensen Gordon P, Blucher Justin A, Ferrone Marco L, Balboni Tracy A, Schwab Joseph H, Harris Mitchel B, Katz Jeffrey N, Losina Elena
Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
J Bone Joint Surg Am. 2021 Dec 1;103(23):2221-2228. doi: 10.2106/JBJS.21.00023. Epub 2021 Jul 21.
Operative and nonoperative treatments for spinal metastases are expensive interventions with a high rate of complications. We sought to determine the cost-effectiveness of a surgical procedure compared with nonoperative management as treatment for spinal metastases.
We constructed a Markov state-transition model with health states defined by ambulatory status and estimated the quality-adjusted life-years (QALYs) and costs for operative and nonoperative management of spine metastases. We considered 2 populations: 1 in which patients presented with independent ambulatory status and 1 in which patients presented with nonambulatory status due to acute (e.g., <48 hours) metastatic epidural compression. We defined the efficacy of each treatment as a likelihood of maintaining, or returning to, independent ambulation. Transition probabilities for the model, including the risks of mortality and becoming dependent or nonambulatory, were obtained from secondary data analysis and published literature. Costs were determined from Medicare reimbursement schedules. We conducted analyses over patients' remaining life expectancy from a health system perspective and discounted outcomes at 3% per year. We conducted sensitivity analyses to account for uncertainty in data inputs.
Among patients presenting as independently ambulatory, QALYs were 0.823 for operative treatment and 0.800 for nonoperative treatment. The incremental cost-effectiveness ratio (ICER) for a surgical procedure was $899,700 per QALY. Among patients presenting with nonambulatory status, those undergoing surgical intervention accumulated 0.813 lifetime QALY, and those treated nonoperatively accumulated 0.089 lifetime QALY. The incremental cost-effectiveness ratio for a surgical procedure was $48,600 per QALY. The cost-effectiveness of a surgical procedure was most sensitive to the variability of its efficacy.
Our data suggest that the value to society of a surgical procedure for spinal metastases varies according to the features of the patient population. In patients presenting as nonambulatory due to acute neurologic compromise, surgical intervention provides good value (ICER, $48,600 per QALY). There is a low value for a surgical procedure performed for patients who are ambulatory at presentation (ICER, $899,700 per QALY).
Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.
脊柱转移瘤的手术和非手术治疗是昂贵的干预措施，且并发症发生率高。我们试图确定与非手术治疗相比，手术治疗脊柱转移瘤的成本效益。
我们构建了一个马尔可夫状态转换模型，其健康状态由活动状态定义，并估计了脊柱转移瘤手术和非手术治疗的质量调整生命年（QALY）及成本。我们考虑了2组人群：一组患者就诊时具有独立活动能力，另一组患者因急性（如<48小时）转移性硬膜外压迫而无活动能力。我们将每种治疗的疗效定义为维持或恢复独立行走的可能性。模型的转移概率，包括死亡率以及变得依赖或失去活动能力的风险，来自二次数据分析和已发表的文献。成本根据医疗保险报销时间表确定。我们从卫生系统的角度对患者的剩余预期寿命进行了分析，并以每年3%的贴现率对结果进行贴现。我们进行了敏感性分析以考虑数据输入的不确定性。
在就诊时具有独立活动能力的患者中，手术治疗的QALY为0.823，非手术治疗为0.800。手术的增量成本效益比（ICER）为每QALY 899,700美元。在无活动能力的患者中，接受手术干预的患者累积终身QALY为0.813，非手术治疗的患者累积终身QALY为0.089。手术的增量成本效益比为每QALY 48,600美元。手术的成本效益对其疗效的变异性最为敏感。
我们的数据表明，脊柱转移瘤手术对社会的价值因患者群体的特征而异。对于因急性神经功能损害而无活动能力的患者，手术干预具有良好的价值（ICER，每QALY 48,600美元）。对于就诊时具有活动能力的患者进行手术的价值较低（ICER，每QALY 899,700美元）。
经济和决策分析III级。有关证据水平的完整描述，请参阅作者指南。
