Bernstein, David N., Hammoor, Bradley, Ukogu, Chierika, Tobert, Daniel G., Cha, Thomas, Hershman, Stuart, Bono, Christopher, Schwab, Joseph, and Fogel, Harold
There is a growing focus on reigning in costs while simultaneously optimizing patient outcomes via a value-based health care (VBHC) transformation. To date, the true cost of care has not been well delineated and many proxies for cost (eg, negotiated reimbursement rates) have been used but are inaccurate and not comprehensive. More robust cost analysis can be done using time-driven activity-based costing (TDABC), a well-documented approach out of Harvard Business School to accurately measure costs. 1) To determine the variation of total cost in 1- or 2- level lumbosacral decompression and fusion surgery and the breakdown of total cost by pre-, intra-, and postoperative care; 2) To determine differences in characteristics between high-cost (top decile) and non-high cost lumbosacral decompression surgeries; 3) To determine the primary cost drivers of 1- or 2-level lumbosacral decompression surgery. Multicenter (one quaternary referral academic medical center and one community hospital) economic analysis. A total of 405 patients who underwent primary 1- or 2-level lumbosacral decompression surgery between November 2, 2021 and December 2, 2022. Variation in total cost, differences between high- and non-high cost patients, and main drivers of total cost (broken down into pre-, intra-, and postoperative cost), as calculated using TDABC. Patients undergoing primary 1- or 2-level lumbosacral decompression and fusion surgery were identified from our institutional database. TDABC methodology was used to calculate total cost. The episode of care was defined as three phases: pre-, intra-, and postoperative. Patient and surgery-related characteristics were identified. To abide by institutional requirements, total cost was normalized to a mean of 1. The variation of total cost was assessed by looking at the most and least expensive total cost. Consistent with prior literature, high cost patients were defined as being in the top decile and a comparison of all factors were made between them and non-high cost patients. Multivariable linear regression was used to identify factors associated with total cost. The highest total cost for a 1- or 2-level lumbosacral decompression and fusion surgery was 9.5x the lowest total cost. On average, intraoperative cost accounted for 87% of the total cost of care. Overall, the hardware itself accounted for 30% of the total cost of care; however, this ranged from 6% to 44% of the total cost of care. High cost patients more often had commercial insurance (n=25 [63%] versus n=190 [52%], p=0.007). When accounting for all other factors, length of stay was associated with increased cost (Regression Coefficient [RC]: 0.02 (95% CI: 0.003 to 0.04), p=0.02). Outpatient surgery (RC: -0.10 (95% CI: -0.18 to -0.01), p=0.027) and multiple surgeons (Surgeons 2, 3, 5, 6, 7, 9, 11, 13, 14, and 15; all p<0.05) were associated with decreased total cost. A wide variation (9.5x difference) in total cost for primary 1- or 2-level lumbosacral decompression and fusion exists. In addition, this study confirms that just under 90% of the total cost is driven by the intraoperative cost, with the large majority being the hardware and technology. Thus, for the same indications, this wide variation in total cost appears to be driven by surgeon preference and idiosyncrasy. Spine surgeons should appreciate these findings and help lead discussions around initiatives and innovations to reduce cost, while also optimizing patient outcomes as part of the VBHC transformation This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]