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Background Back pain attributable to lumbar disc herniation is a substantial cause of reduced workplace productivity. Disc herniation surgery is effective in reducing pain and improving function. However, few studies have examined the effects of surgery on worker productivity. Questions/purposes We wished to determine the effect of disc herniation surgery on workers’ earnings and missed workdays and how accounting for this effect influences the cost-effectiveness of surgery? Methods Regression models were estimated using data from the National Health Interview Survey to assess the effects of lower back pain caused by disc herniation on earnings and missed workdays. The results were incorporated into Markov models to compare societal costs associated with surgical and nonsurgical treatments for privately insured, working patients. Clinical outcomes and utilities were based on results from the Spine Patient Outcomes Research Trial and additional clinical literature. Results We estimate average annual earnings of $47,619 with surgery and $45,694 with nonsurgical treatment. The increased earnings for patients receiving surgery as compared with nonsurgical treatment is equal to $1925 (95% CI, $1121–$2728). After surgery, we also estimate that workers receiving surgery miss, on average, 3 fewer days per year than if workers had received nonsurgical treatment (95% CI, 2.4–3.7 days). However, these fewer missed work days only partially offset the assumed 20 workdays missed to recover from surgery. More fully accounting for the effects of disc herniation surgery on productivity reduced the cost of surgery per quality-adjusted life year (QALY) from $52,416 to $35,146 using a 4-year time horizon and from $27,359 to $4186 using an 8-year time horizon. According to a sensitivity analysis, the 4-year cost per QALY varies between $27,921 and $49,787 depending on model assumptions. Conclusions Increased worker earnings resulting from disc herniation surgery may offset the increased direct medical costs associated with surgery. After accounting for the effects on productivity, disc herniation surgery was found to be a highly cost-effective surgery and may yield net societal savings if the benefits of outpatient and inpatient surgery persist beyond 6 and 12 years, respectively. Level of Evidence Level II, economic and decision analysis. See the Instructions for Authors for a complete description of levels of evidence.

Josh D Saavoss,1 Lane Koenig,1 Daniel J Cher2 1KNG Health Consulting, LLC, Rockville, MD, 2SI-BONE, Inc., San Jose, CA, USA Introduction: Sacroiliac joint (SIJ) dysfunction is associated with a marked decrease in quality of life. Increasing evidence supports minimally invasive SIJ fusion as a safe and effective procedure for the treatment of chronic SIJ dysfunction. The impact of SIJ fusion on worker productivity is not known. Methods: Regression modeling using data from the National Health Interview Survey was applied to determine the relationship between responses to selected interview questions related to function and economic outcomes. Regression coefficients were then applied to prospectively collected, individual patient data in a randomized trial of SIJ fusion (INSITE, NCT01681004) to estimate expected differences in economic outcomes across treatments. Results: Patients who receive SIJ fusion using iFuse Implant System® have an expected increase in the probability of working of 16% (95% confidence interval [CI] 11%–21%) relative to nonsurgical patients. The expected change in earnings across groups was US $3,128 (not statistically significant). Combining the two metrics, the annual increase in worker productivity given surgical vs nonsurgical care was $6,924 (95% CI $1,890–$11,945). Conclusion: For employees with chronic, severe SIJ dysfunction, minimally invasive SIJ fusion may improve worker productivity compared to nonsurgical treatment. Keywords: sacroiliac joint fusion, low back pain, sacroiliac joint pain, clinical trial, health care costs, indirect costs

Supplemental Digital Content is available in the text., Background: Little evidence exists on the effects of receiving care in a long-term acute care hospital (LTCH). Objective: To examine LTCH effects on mortality and Medicare payments overall and among high-acuity patients. Research Design: A retrospective cohort study of Medicare beneficiaries using probit and generalized linear models. An instrumental variable technique was used to adjust for selection bias. Subjects: Medicare beneficiaries within 5 major diagnostic categories and not on prolonged mechanical ventilation. Measures: Mortality (365 d) and Medicare payments (180 d) during an episode of care. Results: LTCH care is associated with increases in Medicare payments ranging from $3146 to $17,589 (P

Background Among policy alternatives considered to reduce health care costs and improve outcomes, value-based insurance design (VBID) has emerged as a promising option. Most applications of VBID, however, have not used higher cost sharing to discourage specific services. In April 2011, the state of Oregon introduced a policy for public employees that required additional cost sharing for high-cost procedures such as total knee arthroplasty (TKA). Objectives Our objectives were to estimate the societal impact of higher co-pays for TKA using Oregon as a case study and building on recent work demonstrating the effects of knee osteoarthritis and surgical treatment on employment and disability outcomes. Methods We used a Markov model to estimate the societal impact in terms of quality of life, direct costs, and indirect costs of higher co-pays for TKA using Oregon as a case study. Results We found that TKA for a working population can generate societal benefits that offset the direct medical costs of the procedure. Delay in receiving surgical care, because of higher co-payment or other reasons, reduced the societal savings from TKA. Conclusions We conclude that payers moving toward value-based cost sharing should consider consequences beyond direct medical expenses.