Introduction: Cervical radiculopathy due to cervical spondylosis is commonly treated by either posterior cervical foraminotomy (PCF) or anterior cervical discectomy and fusion with plating (ACDFP). The present study analyzes the cost effectiveness of ACDFP versus PCF for patients with single-level cervical radiculopathy.

Methods: 45 patients who underwent ACDFP and 25 patients who underwent PCF were analyzed. All patients had single-level cervical radiculopathy. 1-year postoperative health outcomes were assessed based on Visual Analogue Scale (VAS), Pain Disability Questionnaire (PDQ), Patient Health Questionnaire (PHQ-9), and EuroQol-5 Dimensions (EQ-5D) questionnaires. Direct medical costs were estimated using Medicare national payment amounts, health resource utilization was recorded from patient electronic medical records, and indirect costs were based on patient missed work days and patient income. Postoperative 1-year cost/utility ratios and the incremental cost effectiveness ratio (ICER) were calculated to assess for cost effectiveness using a threshold of $100,000/QALY gained.

Results: Compared with preoperative health states, the ACDFP cohort showed postoperative improvement in VAS, PDQ, and EQ-5D scores at 1 year postoperatively (p<0.01). Compared with preoperative health states, the PCF cohort showed postoperative improvement in EQ-5D scores at 1 year postoperatively. The 1-year cost-utility ratio (Total Cost/QALY gained) for the PCF cohort was significantly lower ($79,856/QALY gained) than that for the ACDFP cohort ($131,951/QALY gained) (p<0.01). In calculating the 1-year ICER, ACDFP was found to be dominated by PCF (i.e., negative ICER - not reported).

Conclusions: Statistically and clinically significant (i.e., > minimum clinically important differences) improvements in quality of life measures were seen 1 year postoperatively for both cohorts. While both cohorts showed improved health outcomes, ACDFP is not cost effective relative to the threshold of $100,000/QALY gained at 1 year postoperatively while PCF was.

Patient Care: As healthcare costs continue to rise, it is imperative that healthcare outcomes remain in line with the costs spent in the healthcare system. In 2009, the United States spent 16% of its gross domestic product (GDP) on healthcare services – a cost high enough to achieve a rank of 2nd by the World Health Organization (WHO) among all countries in annual healthcare spending. Yet, the WHO ranks the U.S. 37th out of 191 countries relative to the quality of its healthcare system. An increasing focus on healthcare costs has spurred interest in analyzing long term economic analysis of surgical procedures through comparative effectiveness research. This has been true of many fields, including spine surgery. Cost-effectiveness analysis (CEA) is a component of comparative effectiveness research (CER) that estimates the value of a healthcare intervention by not only comparing treatments based on quality of life gained, but also on the financial burden of the different treatments to the patient. A cost-utility analysis (CUA) is a specific type of CEA whereby the benefit of the intervention is expressed as a utility measure numerically chosen by the patient. A CUA also provides data that can be used to compare one intervention in one specific field of medicine (e.g., spine surgery) to other disciplines of medicine (e.g., cardiology). Rising costs associated with spinal fusion procedures, as well an increasing number of patients undergoing fusion and varying results of effectiveness, warrant intensive cost-utility analyses in the spine field. Cost-utility and incremental cost effectiveness ratios derived from CUAs can be used to better allocate healthcare resources and reduce the economic burden to both the patient and the healthcare institution in the future. Our research seeks to focus on calculating these ratios for common surgical procedures in the spine field in order to aid the spine surgeon or neurosurgeon in determining the most cost effective option for his or her patient population.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Understand the importance of cost effectiveness research to cervical spine surgical procedures and 2) Discuss how to apply cost-utility ratios and incremental cost effectiveness ratios to practice.

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