Spine

Predictors of the Charges for Lumbar Fusion Surgery in Florida Hospitals

Anna Ialynytchev, PhD, Alan M. Sear, PhD, Arthur R. Williams, PhD, Barbara Langland-Orban, PhD, Nanhua Zhang, PhD Disclosures

Abstract and Introduction

Abstract

Study Design A mixed-effects model was used to evaluate the effects specific surgical procedure by International Classification of Diseases, Ninth Revision, Clinical Modification, procedure code, patient age, sex, ethnic group, payers for the inpatient hospital stay, and number of additional diagnoses beyond the principal diagnosis that led to the procedure (as a proxy for severity of illness) on the charges for lumbar fusion surgery.

Objective The present research examined the charges and the predictors of the charges for lumbar fusion surgery in Florida hospitals in 2010.

Summary of Background Data The number of spinal fusion surgical procedures in the United States has grown exponentially in recent years despite the procedure’s high costs and questionable efficacy for many of the principal diagnoses associated with it.

Methods All records with any of the 5 International Classification of Diseases, Ninth Revision, Clinical Modification, principal procedure codes for lumbar fusion were extracted (cases) from the Florida Agency for Health Care Administration (AHCA) hospital discharge data for the year 2010. A control group was obtained by taking all patients who had the same principal diagnoses as the cases, but who did not have fusion surgery. This produced 16,236 cases and 21,856 controls.

Results The total hospital charges for lumbar fusion surgery in Florida in 2010 were $2,095,413,584. Despite having the same principal diagnoses and a similar number of additional diagnoses, patients who underwent a fusion surgery had 3 times the charges as those incurred by the controls. The number of additional diagnoses, sex, age, payer, and principal procedure, were all found to be statistically significant predictors of charges. Ethnicity was not significant. Of all the predictors, the number of additional diagnoses was the most significant in the model (F = 2577, P < 0.0001).

Conclusion The high incidence and charges for fusion surgical procedures shown in this study emphasize the need for a better understanding of when these surgical procedures are justified and for which patients.

Level of Evidence N/A

Introduction

Medical care costs for lower back pain in the United States, including spinal fusion surgery, exceed $20 billion dollars per year.[1] In recent decades, rates of spinal fusion surgery in the United States have grown exponentially. Furthermore, lumbar fusion surgical procedures continue to be performed at increasing rates despite a lack of scientific evidence and consensus that they are cost-effective and produce better clinical outcomes than less radical treatments.[2]

In addition to using screws, rods, cages, or plates to hold the vertebrae in place, in many cases expensive bone morphogenetic protein is also inserted into the fusion site.[3,4] Tens of thousands of dollars of instrumentation and bone graft can be used in a single fusion surgery and in some cases this accounts for up to 87% of the cost of the procedure.[5]

Moreover, many surgeons are not knowledgeable about the costs of the instrumentation used in fusion surgical procedures and thus, are unable to make informed decisions about the true costs of the instrumentation they employ. In fact, surgeons tend to underestimate the cost of expensive spinal implants and overestimate the cost of inexpensive ones. Because, these devices can vary substantially in cost, using less expensive instrumentation could be 1 method of containing the costs of fusion surgery.[6]

Consequently, large amounts of health care dollars continue to be invested in these costly procedures. This research is a population-based study and examines some predictors of the charges for lumbar fusion surgical procedures in Florida hospitals including principal diagnoses (and number of additional diagnoses), principal procedure, patient age, ethnic group, sex, and a full range of payers. The purpose of this study is to examine the charges for lumbar fusion surgery in Florida hospitals in 2010 to understand the predictors of these charges.

Although the database used in this study does not allow us to calculate outcome measures such as quality-adjusted life years, or economic measures such as the cost-effectiveness of the surgical procedures performed; the data do provide a valid picture of the charges by the hospitals, the payers for the procedures, and the characteristics of the patients (including the full range of ages) who presented with lumbar symptoms and then did or did not receive lumbar fusion surgery (and the type of fusion surgery, if present).

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Josh Sandberg

Josh Sandberg is the President of Ortho Sales Partners and Partner for The De Angelis Group. He also serves as Co-Founder and Editor of OrthoSpineNews.

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