Introduction: The efficacy and cost-effectiveness of spinal cord stimulation (SCS) in treating chronic pain is well-documented, despite initial healthcare acquisition costs. Nevertheless, a subset of patients ultimately require explantation. This study examines if SCS explantation negatively impacts patient outcomes and identifies differences in healthcare resource utilization following explant.
Methods: We designed a large, retrospective analysis using the Thomson Reuters MarketScan database. We analyzed all adult patients who underwent percutaneous or paddle SCS implantation from 2000-2012, classifying patients based on SCS explantation =1 year post-procedure. Explanted and explant-free patients were propensity score matched, and healthcare resource utilization was analyzed using logistic regression models with prior pain diagnosis and provider implant volume as an independent factor.
Results: Of the 12,079 patients who underwent permanent SCS implantation, 925 (0.08%) subsequently underwent explantation. Explanted patients were on average younger compared to explant-free patients (51.5 ± 12.9 vs. 52.6 ± 13.3; p = 0.004), and had a higher total cost of treatment (median $47,411.7 vs. $31,896.5; p < 0.0001). Explanted patients had higher total cost of treatment compared to explant-free patients (median $207,712.0 vs. $138,564.4; p < 0.0001) and higher total cost of pain encounters (median $159,279.9 vs. $100,455.1; p < 0.0001) at 1-year post-procedure. Age and prior history of back pain were independent predictors of explant rates at all follow-up times. Gender, medical insurance type, employment status, and geographic region were not associated with rate of explantation.
Conclusions: In this national cohort study of patients, we demonstrate that explantation is associated with higher healthcare resource utilization both prior to and post-explantation, irrespective of pain diagnosis at 1-year. These costs are driven largely by increased number and cost of pain encounters, inpatient admissions, and number of pain prescriptions. Our results identify practice variations that inform provider selection, and emphasize careful selection of patients to optimize SCS implantation and follow-up rates.
Patient Care: The significant costs associated with SCS necessitate judicious patient selection and full consideration of alternative therapies. An increased awareness of the independent patient factors that impact treatment success will help to prevent excessive healthcare expenditures, as well as potentially avoidable morbid procedures, as it relates to surgical success in pain management.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Identify variations in healthcare resource utilization in patients with SCS explantation, 2) Understand the effect of prior pain diagnosis and provider volume status in explantation, and 3) Evaluate independent predictors of explant rates.