Cost-Utility Analysis of Anterior Vertebral Body Tethering versus Spinal Fusion in Idiopathic Scoliosis from a US Integrated Healthcare Delivery System Perspective

David W Polly,1 A Noelle Larson,2 Amer F Samdani,3 William Rawlinson,4 Hannah Brechka,4 Alex Porteous,4 William Marsh,4 Richard Ditto5 1Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA; 2Mayo Clinic, Rochester, MN, USA; 3Temple University, Philadelphia, PA, USA; 4Costello Medical Consulting Ltd, Cambridge, UK; 5Zimmer Biomet, Warsaw, IN, USACorrespondence: David W Polly Tel +1 612-273-7951Fax +1 612-273-7959Email pollydw@umn.eduPurpose: Anterior vertebral body tethering (VBT) is a non-fusion, minimally invasive, growth-modulating procedure with some early positive clinical outcomes reported in pediatric patients with idiopathic scoliosis (IS). VBT offers potential health-related quality of life (HRQoL) benefits over spinal fusion in allowing patients to retain a greater range of motion after surgery. We conducted an early cost-utility analysis (CUA) to compare VBT with fusion as a first-choice surgical treatment for skeletally immature patients (age > 10 years) with moderate to severe IS, who have failed nonoperative management, from a US integrated healthcare delivery system perspective.Patients and Methods: The CUA uses a Markov state transition model, capturing a 15-year period following index surgery. Transition probabilities, including revision risk and subsequent fusion, were based on published surgical outcomes and an ongoing VBT observational study (NCT02897453). Patients were assigned utilities derived from published patient-reported outcomes (PROs; SRS-22r mapped to EQ-5D) following fusion and the above VBT study. Index and revision procedure costs were included. Probabilistic (PSA) and deterministic sensitivity analyses (DSA) were performed.Results: VBT was associated with higher costs but also higher quality-adjusted life years (QALYs) than fusion (incremental costs: $45,546; QALYs gained: 0.54). The subsequent incremental cost-effectiveness ratio for VBT vs fusion was $84,391/QALY gained. Mean PSA results were similar to the base case, indicating that results were generally robust to uncertainty. The DSA indicated that results were most sensitive to variations in utility values.Conclusion: This is the first CUA comparing VBT with fusion in pediatric patients with IS and suggests that VBT may be a cost-effective alternative to fusion in the US, given recommended willingness-to-pay thresholds ($100,000–$150,000). The results rely on HRQoL benefits for VBT compared with fusion. For improved model accuracy, further analyses with longer-term PROs for VBT, and comparative effectiveness studies, would be needed.Keywords: idiopathic scoliosis, cost-effective analysis, spinal fusion, vertebral body tethering, pediatric