Introduction: Current healthcare reform calls for reduction of procedures/treatments that are less effective, more costly, and of little “value”. We assessed the two-year cost and effectiveness of comprehensive medical management for lumbar spondylolisthesis and stenosis utilizing a prospective single-center multidisciplinary spine center registry in a real-world practice setting.
Methods: Patients with lumbar spondylolisthesis (n=50) and lumbar stenosis (n=50) non-operatively managed were entered into a prospective registry. Comprehensive medical management included spinal steroid injections, physical therapy, bracing, and various narcotic and non-narcotic oral agents. Baseline and two-year patient-reported outcomes were assessed. Back-related medical resource utilization and work-day losses were prospectively collected and used to calculate Medicare fee-based direct and indirect costs. Costs were assessed from the payer and societal perspectives.
Results: Baseline characteristics are presented in Table 1. Two year leg pain, disability, quality of life, depression, and general health state were not significantly improved with medical management, Figure 1. Only LP-VAS (p=0.012) had improved by two years, Table 2. Twenty-seven (54%) patients with spondylolisthesis and 22 (44%) with stenosis eventually required surgical management due to lack of improvement. Mean ± SD total (direct and indirect) two-year cost of comprehensive medical management was $8,411 ± 4,408 for the spondylolisthesis cohort and $10,486 ± 7,902 for the stenosis cohort. Cost-components are specified in, Table 3. Overall, comprehensive medical management was associated with a mean two-year cost $9,446 without a significant gain in QALYs.
Conclusions: In this prospective registry, comprehensive medical management was shown to provide no durable improvement for patients with degenerative lumbar spondylolisthesis or lumbar stenosis. From both the societal and payer perspective, medical management of lumbar stenosis and spondylolisthesis is of minimal value given its lack of utility despite its cost. The findings from this real-world practice setting may more accurately reflect the true value and effectiveness of non-operative care in this patient population.
Patient Care: Our research shows that medical management of lumbar stenosis and spondylolisthesis is of minimal value given its lack of utility despite its cost.
Learning Objectives: At the end of the session, participants should be able to: 1) Discuss the level of improvement achieved by medical management in patients with lumbar stenosis and spondylolisthesis, and 2) Understand the value of medical management of lumbar stenosis and spondylolisthesis.