Cost-utility analysis of treatment methods in spinal diseases

MPRA Paper, 2020

Cost-Utility study for operative methods in spinal surgery AIM: The purpose of the present study is to evaluate the quality of life (QoL) of patients with spinal problems before and after surgery with the use of the EQ-5D-5L health status questionnaire. MATERIALS-METHODS: The research is based on primary data collection of 314 patients who completed the questionnaires at three different times: a) preoperatively; that is, after completion of conservative treatment which involved medication, physiotherapy, etc., b) ten days postoperatively and c) immediately after the first post-operative month. RESULTS: Out of the 314 patients, aged between 34 and 79 years (mean age 52±15,07) who participated in this study, 172 were males (54,8%) and 142 females (45,2%). 77,71% of the patients suffered from a herniated intervertebral disc and 22,29% from spondylolisthesis in the lumbar region. Total improvement of the quality of life (QoL) in our study was on average 0,59 QALYs at 10 days and 0,82 QALYs at 30 days. The total average direct cost of these surgical interventions amounted to 9341,86±4042,53 euro while the index of cost-utility for the sample population was estimated to be 15870,16 euro/ QALY at 10 days. This index decreased considerably to 11867,14 euro/ QALY at 30 days after the surgical intervention since the average benefit in QALYs increased and the QoL improved. CONCLUSIONS: The evaluation of the data of this study was highlighted the high degree of effectiveness of each surgery applied to treat the symptomatology of patients. All the statistical tests applied to the sample showed a very significant improvement of all variables used by the questionnaire for all intervals evaluated after surgery. Lastly, there has also been a very large improvement in the overall QoL of patients.

Innovative Publication, 2016

Background: Back pain has been known since the start of written history, probably the first report of back pain and sciatica can be found in an ancient text, the so-called Edwin Smith Surgical Papyrus presumably written around 1550 B.C.1 Although backache (with or without sciatica) is a benign often self -limiting condition (Macnab). 2 The cost of both time lost from work (with loss of productivity) and medical care, as well as the cost of litigation and disability claims, make back pain an industry unto itself. Purpose: The main purpose of this study was to evaluate the clinical, radiological outcome of the lumbar disc patients managed surgically and to compare the results of different surgeries performed. Methods: This study was prospective, non-randomized, cohort study it was carried out in the Department of Orthopaedics, Acharya Vinoba Bhave Rural Hospital, Wardha, between August 2013 – 2015. Patients with more than 18 years were included with persistent bothersome sciatic pain, despite conservative management for a period of 6-12 weeks. All the patients with progressive neurological involvement during a period of conservative treatment. All the patients with cauda equina syndrome or impending cauda equina syndrome. Results: Out of total 67 patients the mean age was 49.85±8.75 years ranging from 40 to 72 years. Male gender was predominantly forming 66% of the sample size whereas 34% of females. All the patients had radicular pain, 26 out of 67 patients had left sided radiculopathy and right-sided radiculopathy was observed in 21 patients whereas 20 patients had bilateral radiculopathy. After MRI 34 patients had extrusion of disc, whereas 17 patients showed sequestrated disc, protrusion of disc was observed in 12 patients, whereas disc bulge was observed in 4 patients. 42% of patients were operated by laminectomy, 33 % patients were operated by microscopic discectomy and minimum 25% of patients were operated with microendoscopic discectomy. L4-L5 level was the most common level to get involved. Mean Pre-operative VAS score for male patients was 6.64 and female patients was 6.78, which was reduced to 3.14 and 3.48 respectively after 6 months of operative management. Mean Pre-operative Oswestery score for male patients was observed to be 44.05 and female patients was 44.87, which was reduced to 24.95 and 27.83 respectively after 6 months of operative management. Complications in all three surgeries were observed. Conclusion: Minimally invasive techniques in all areas of surgery have gained momentum in recent years. Spinal surgery has been no exception. Unfortunately, minimally invasive techniques have often been equated with minimally effective procedures. We understand that the micro endoscopic discectomy and microscopic discectomy techniques are superior to the standard discectomy technique for the treatment of single level lumbar disc herniation’s with regard to pain relief, clinical outcome and functional outcome, volume of blood loss, systemic repercussions, and duration of hospital stay. However, technical expertise and learning curve of the technique could be the limitation. Minimally invasive surgeries are cost-effective treatment for lumbar herniated discs. Results and complications were comparable with those associated with standard discectomy techniques. Patient satisfaction was high, and a cost savings was realized.

Journal of Neurosurgery: Spine, 2006

Object Cost–utility analysis is currently the preferred method with which to compare the cost-effectiveness of various interventions. The authors conducted a study to establish the cost–utility results of routine neurosurgery-based spinal interventions by examining patient-derived values. Methods Two hundred seventy patients undergoing surgery for cervical or lumbar radicular pain filled in the 15-dimensional health-related quality of life (HRQOL) questionnaire before and 3 months after surgery. Quality-adjusted life years (QALYs) were calculated using the utility data and the expected remaining life years of the patients. The mean HRQOL score (scale, 0–1) increased after cervical surgery (169 patients, mean age 52 years, 40% women) from 0.81 ± 0.11 preoperatively, to 0.85 ± 0.11 at 3 months, and after lumbar surgery (101 patients, mean age 54 years, 59% women) from 0.79 ± 0.10 preoperatively, to 0.85 ± 0.12 at 3 months (p < 0.001). Of the 15 dimensions of health, improvement in ...

The Journal of Bone and Joint Surgery. British volume, 2009

We investigated the pre-operative and one-year post-operative health-related quality of life (HRQoL) outcome by using a Euroqol (EQ-5D) questionnaire in 230 patients who underwent surgery for lumbar spinal stenosis. Data were obtained from the National Swedish Registry for operations on the lumbar spine between 2001 and 2002. We analysed the pre- and postoperative quality of life data, age, gender, smoking habits, pain and walking ability. The relative differences were compared to a Swedish EQ-5D population survey. The mean age of the patients was 66 years, and there were 123 females (53%). Before the operation 62 (27%) of the patients could walk more than 500 m. One year after the operation 150 (65%) were able to walk 500 m or more. The mean EQ-5D score improved from 0.36 to 0.64, and the HRQoL improved in 184 (80%) of the patients. However, they did not reach the level reported by a matched population sample (mean difference 0.18). Women had lower pre- and post-operative EQ-5D sco...

European Spine Journal, 2005

Arquivos de Neuro-Psiquiatria

Objective: To study the impact of surgery on pain, disability, quality of life, and patient satisfaction in a sample of patients with Degenerative Lumbar Disease (DLD). Methods: Retrospective analysis of prospectively collected data. Comparison between pre and postoperative (6 – 12 months) ODI and SF-36, plus postoperative Patient Satisfaction Index. Results: From a total of 216 patients included, improvement was observed in average scores of pain (201.2%), disability (39.7%), physical quality of life (42%), and mental quality of life (37.8%). Among these patients, 57.7% reached or surpassed the minimal clinically important difference (MCID) for ODI, 57.7% for the SF-36 pain component, 59.7% for the SF-36 physical component summary, and 50.5% achieved or surpassed the MCID for the SF-36 mental component summary. Conclusions: Surgery produced a significantly positive impact on pain, disability, and quality of life of patients. Overall, 82.5% of the patients were satisfied.

The journal of bone and joint surgery, 2005

We investigated the pre-operative and one-year post-operative health-related quality of life (HRQOL) outcome by using a Euroqol (EQ-5D) questionnaire in 263 patients who had undergone surgery for herniation of a lumbar disc. Data from the National Swedish Register for lumbar spinal surgery between 2001 and 2002 were used and, in addition, a comparison between our cohort and a Swedish EQ-5D population survey was performed. We analysed the pre-and post-operative quality of life data, age, gender, smoking habits, pain and walking capacity. The mean age of the patients was 42 years (20 to 66); 155 (59%) were men and 69 (26%) smoked. Pre-operatively, 72 (17%) could walk at least 1 km compared with 200 (76%) postoperatively. The mean EQ-5D score improved from 0.29 to 0.70, and the HRQOL improved in 195 (74%) of the patients. The pre-operative score did not influence the post-operative score. In most patients, all five EQ-5D dimensions improved, but did not reach the level reported by an ageand gender-matched population sample (mean difference 0.17). Predictors for poor outcome were smoking, a short pre-operative walking distance, and a long history of back pain.

Canadian Journal of Surgery, 2015

Background: The beneficial treatment effect surgery demonstrates over conservative care for radiculopathy secondary to acute lumbar disc herniation (LDH), occurs in the first 3 to 6 months; thereafter outcomes are recognized to be similar. This is not surprising given the favourable natural history; 90% will experience gradual resolution of their symptoms within 4 months. In Canada, owing to the inherent wait time to see a surgeon and the referring physician's expectation that most patients will improve without surgery, symptomatic patients presenting to surgeons are often the 10% that have remained symptomatic longer than the expected 4 months. The purpose is to determine whether surgery is superior to conservative care in a patient population that has had persistent symptoms for more than 4 months, and therefore create a study population which is generalizable to the Canadian health care experience. Methods: This single blinded (assessor) RCT enrolled 18-to 60-year-old patients with a unilateral, single radiculopathy from a posterolateral L4-5 or L5-S1 disc herniation. Radiculopathy duration was longer than 4 months but less than 12 months. Patients on a waiting list to see surgeons at 1 academic hospital centre were randomized to early microdiscectomy or standardized nonoperative care, including medications, education, physiotherapy and steroid injections. Patients were excluded if they had previously received these conservative modalities. The primary outcome was intensity of sciatica (scale 0-10) measured at 6 months following randomization. Secondary outcome measures included back pain, Oswestry Disability Index (ODI), SF-36, work status and satisfaction. Results: This interim analysis reports on 40 nonoperative and 39 surgical patients. No difference existed between their demographic or preoperative data. At 6 months follow-up 32 of 39 surgical patients and 36 of 40 nonoperative patients had data available. Treatment effect for all outcome measures favoured surgery for the intent-to-treat, as-treat and last-value carried forward analysis (p < 0.05). To date 13 of 40 nonoperative patients have undergone microdiscectomy (performed after the primary outcome measure of 6 mo); they have had persistent inferior scores than early surgical patients (p < 0.05). Conclusion: At the interim analysis microdiscectomy is superior to nonoperative care for patients presenting with sciatica secondary to LDH. This study will continue to confirm robustness and validity of results.

European Spine Journal, 2017

Purpose In clinical decision-making, it is crucial to discuss the probability of adverse outcomes with the patient. A large proportion of the outcomes are difficult to classify as either failure or success. Consequently, cutoff values in patient-reported outcome measures (PROMs) for ''failure'' and ''worsening'' are likely to be different from those of ''non-success''. The aim of this study was to identify dichotomous cutoffs for failure and worsening, 12 months after surgical treatment for lumbar disc herniation, in a large registry cohort. Methods A total of 6840 patients with lumbar disc herniation were operated and followed for 12 months, according to the standard protocol of the Norwegian Registry for Spine Surgery (NORspine). Patients reporting to be unchanged or worse on the Global Perceived Effectiveness (GPE) scale at 12-month follow-up were classified as ''failure'', and those considering themselves ''worse'' or ''worse than ever'' after surgery were classified as ''worsening''. These two dichotomous outcomes were used as anchors in analyses of receiver operating characteristics (ROC) to define cutoffs for failure and worsening on commonly used PROMs, namely, the Oswestry Disability Index (ODI), the EuroQuol 5D (EQ-5D), and Numerical Rating Scales (NRS) for back pain and leg pain. Results ''Failure'' after 12 months for each PROM, as an insufficient improvement from baseline, was (sensitivity and specificity): ODI change \13 (0.82, 0.82), ODI% change \33% (0.86, 0.86), ODI final raw score [25 (0.89, 0.81), NRS back-pain change\1.5 (0.74, 0.86), NRS backpain % change \24 (0.85, 0.81), NRS back-pain final raw score [5.5 (0.81, 0.87), NRS leg-pain change \1.5 (0.81, 0.76), NRS leg-pain % change \39 (0.86, 0.81), NRS legpain final raw score [4.5 (0.91, 0.85), EQ-5D change \0.10 (0.76, 0.83), and EQ-5D final raw score[0.63 (0.81, 0.85). Both a final raw score [48 for the ODI and an NRS [7.5 were indicators for ''worsening'' after 12 months, with acceptable accuracy. Conclusion The criteria with the highest accuracy for defining failure and worsening after surgery for lumbar disc herniation were an ODI percentage change score\33% for failure and a 12-month ODI raw score [48. These cutoffs can facilitate shared decision-making among doctors and patients, and improve quality assessment and comparison Electronic supplementary material The online version of this article (

Health and Quality of Life Outcomes, 2007

Background: Over 500,000 spinal surgeries are performed annually in the United States. Although pain relief and improved health-related quality of life (HRQOL) are expectations following lumbar spinal surgery, there is limited research regarding this experience from the individual's perspective. In addition, no studies have examined the HRQOL of persons who have had this surgery using a comprehensive approach. The intent of this study was to address this deficiency by an assessment of both the individual and environmental factors that impact perceived HRQOL using the Wilson and Cleary Model for Health-Related Quality of Life in persons who have undergone lumbar spinal surgery.