Crawford Eric J, Ravinsky Robert A, Coyte Peter C, Rampersaud Y Raja
From the Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Crawford, Rampersaud); the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (Crawford, Coyte); the Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Ariz. (Ravinksy); the Division of Orthopaedic Surgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); the Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud); and the Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ont. (Rampersaud).
Can J Surg. 2021 Jul 23;64(4):E391-E402. doi: 10.1503/cjs.015719.
The objective of this study was to compare the cost-effectiveness of minimally invasive surgery (MIS) for patients with degenerative lumbar spondylolisthesis (DLS) relative to failed medical management with the cost-effectiveness of hip and knee arthroplasty for matched cohorts of patients with osteoarthritis.
A cohort of patients with DLS undergoing MIS procedures with decompression alone or decompression and instrumented fusion between 2008 and 2014 was matched to cohorts of patients with hip osteoarthritis (OA) and knee OA undergoing total joint replacement. Incremental cost-utility ratios (ICURs) were calculated from the perspective of the Ontario Ministry of Health, using prospectively collected Short Form-6 Dimension utility data. Costs and quality-adjusted life years (QALYs) were discounted at 3% and sensitivity analyses were performed.
Sixty-six patients met the inclusion criteria for the DLS cohort (n = 35 for decompression alone), with a minimum follow-up time of 1 year (mean 1.7 yr). The mean age of patients in the DLS cohort was 64.76 years, and 45 patients (68.2%) were female. For each cohort, utility scores improved from baseline to follow-up and the magnitude of the gain did not differ by group. Lifetime ICURs comparing surgical with nonsurgical care were Can$7946/QALY, Can$7104/QALY and Can$5098/QALY for the DLS, knee OA and hip OA cohorts, respectively. Subgroup analysis yielded an increased ICUR for the patients with DLS who underwent decompression and fusion (Can$9870/QALY) compared with that for the patients with DLS who underwent decompression alone (Can$5045/QALY). The rank order of the ICURs by group did not change with deterministic or probabilistic sensitivity analyses.
Lifetime ICURs for MIS procedures for DLS are similar to those for total joint replacement. Future research should adopt a societal perspective and potentially capture further economic benefits of MIS procedures.
本研究的目的是比较退行性腰椎滑脱症（DLS）患者微创手术（MIS）相对于药物治疗失败的成本效益，以及匹配的骨关节炎患者队列进行髋关节和膝关节置换术的成本效益。
将2008年至2014年间接受单纯减压或减压加器械融合的MIS手术的DLS患者队列与接受全关节置换的髋关节骨关节炎（OA）和膝关节OA患者队列进行匹配。从安大略省卫生部的角度计算增量成本-效用比（ICUR），使用前瞻性收集的简式6维效用数据。成本和质量调整生命年（QALY）按3%进行贴现，并进行敏感性分析。
66例患者符合DLS队列的纳入标准（单纯减压35例），最短随访时间为1年（平均1.7年）。DLS队列患者的平均年龄为64.76岁，45例患者（68.2%）为女性。对于每个队列，效用评分从基线到随访均有所改善，且改善幅度在组间无差异。比较手术治疗与非手术治疗的终身ICUR分别为：DLS队列7946加元/QALY，膝关节OA队列7104加元/QALY，髋关节OA队列5098加元/QALY。亚组分析显示，接受减压融合的DLS患者的ICUR（9870加元/QALY）高于单纯减压的DLS患者（5�45加元/QALY）。通过确定性或概率敏感性分析，各组ICUR的排序未发生变化。
DLS的MIS手术终身ICUR与全关节置换术相似。未来的研究应从社会角度进行，并可能捕捉到MIS手术的更多经济效益。
