Total Health Care Expenditure in Patients With a Herniated Lumbar Disk That Ultimately Require Surgery: A 3- and 6-month Cost Comparison of Maximum Nonoperative Treatment. Issue 3 (April 2020)

• Record Type: Journal Article
• Authors: Davison, Mark A.; Lilly, Daniel T.; Moreno, Jessica; Bagley, Carlos; Adogwa, Owoicho
• Is Part Of: Clinical spine surgery. Volume 33:Issue 3(2020)
• Publication Date: 2020-04
• Subjects: nonoperative therapy -- herniated lumbar disk -- cost -- recourse utilization -- microdiscectomy -- opioids; Spinal cord -- Diseases -- Periodicals; Spinal cord -- Surgery -- Periodicals; 617.56059
• DOI: 10.1097/BSD.0000000000000829
• Languages: English
• ISSNs: 2380-0186

Abstract

Abstract : Study Design: A retrospective cohort study. Objective: To compare the cost of maximum nonoperative therapy (MNT) in patients diagnosed with a herniated lumbar disk undergoing primary (1–3 mo) versus prolonged (4–6 mo) conservative management before microdiscectomy. Summary of Background Data: Patients diagnosed with a herniated lumbar disk often attempt a 3-month trial of conservative management before microdiscectomy. A paucity of data exists characterizing the cost of a subsequent round of nonoperative therapies in patients who fail their initial trial, rather than undergo surgery. Methods: Clinical records from patients diagnosed with a herniated lumbar disk undergoing index microdiscectomy surgery from 2007 to 2017 were gathered from a large insurance database. Records were searchable by International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and generic drug codes. Two cohorts were established: patients undergoing primary (1–3 mo) versus prolonged (4–6 mo) courses of conservative management. Nonoperative therapy utilization was documented from initial herniation diagnosis to microdiscectomy surgery. "Utilization" encompassed cost billed to patients, prescriptions written, and quantity of units dispensed. Results: The 3-month MNT cohort included 4587 patients and the 6-month MNT cohort contained 1506 patients. A greater percentage of 6-month cohort patients utilized opioids ( P =0.0052), muscle relaxants ( P =0.0061), and lumbar steroid injections ( P <0.0001). When considering the average amount spent on conservative management, 6-month patients ($1824/patient) spent 1.55 times more than 3-month patients ($1178/patient). The 6-month:3-month average spending ratio was <2.0 for all of the nonoperative therapies except nonsteroidal anti-inflammatory drugs (2.66) and epidural steroid injections (2.25). When normalized by the number of opioid users, the number of opioid medications dispensed was proportionally less in 3-month patients compared with 6-month patients, with a 6-month:3-month ratio of 1.52. Conclusions: The costs associated with a subsequent course of nonoperative therapies for symptomatic lumbar disk herniation seem to be slightly less than that of the primary trial. Assuming a minimal clinical benefit after the initial trial of nonsurgical therapies, the incremental cost-effectiveness ratio of a subsequent trial versus surgery may be unfavorable. Future studies identifying patients likely to benefit from surgery earlier in the treatment course is required. Level of Evidence: Level III.