Purpose:Evaluate the prevalence and economic burden of adult spinal deformity (ASD) in a large, United States (US) commercial payer population. Patients and Methods:Patients aged 21-64 having an encounter with an ASD diagnosis from the MerativeTM Marketscan® Commercial Databases 2016-2022 were included to calculate prevalence. The economic burden cohort included those with an outpatient ASD encounter and no spine surgery within the prior year. Continuous health plan enrollment was required for tracking. Expenditures are tabulated from the payer and societal perspectives (2023 US$) and rates of utilization and expenditures are reported overall and by service category. Results:Annual ASD prevalence was 0.50%. 169,855 patients (46±13 years, 67.7% female) had an outpatient ASD encounter and were included in the economic burden cohort. Total spine-related payer expenditures averaged $7,619 (95% CI; $7,438, $7,800) per patient within 1 year - a payer burden of $3.8 million per 100,000 commercially-insured beneficiaries. Spine-related societal expenditures were $8,759 ($8,570, $8,947) per patient within 1 year - a societal burden of $6.2 billion among the US commercially-insured population. Nonoperative costs comprised 44% of the 1-year payer burden and 48% of the societal burden. While surgical treatment rates were low (3.5% fusions and 2.9% decompressions within 1 year), the associated economic burden was high (55% of payer burden, 51% of societal burden). The 2-year cumulative payer burden totaled $5.4 million per 100,000 commercially-insured beneficiaries, and the US commercially-insured societal burden totaled $8.9 billion. Conclusion:The burden of both operative and nonoperative care for ASD is large. Considerable opportunity exists for development of improved nonoperative treatment modalities to increase the value of ASD care by reducing the need for continued nonoperative interventions of limited benefit and reducing the use of costly surgical interventions.

BACKGROUND CONTEXT Data on nonoperative treatment of ASD is limited. Quantifying the associated economic burden of ASD will better inform payers and policymakers on strategies for improving value of care. PURPOSE The purpose is to: 1) determine the prevalence of ASD in a large, national commercial payer population, 2) quantify the associated economic burden from the payer and societal perspectives, and 3) better understand the breakdown of expenditures by health care service category. STUDY DESIGN/SETTING Retrospective National Claims Cohort. PATIENT SAMPLE Patients aged 21-64 with an encounter including a diagnosis of ASD (scoliosis, lordosis, and/or flatback) from the MerativeTM Marketscan® Commercial Databases 2016-2022 were included. For the outpatient ASD cohort, patients were required to have continuous medical and pharmacy enrollment 1 year pre and 1 year post the index encounter for longitudinal tracking. Those with spine surgery within the prior year, on plans not providing financial and/or outpatient pharmacy data, or with neoplasms, infection, or trauma were excluded. OUTCOME MEASURES Annual prevalence of ASD among the enrolled Marketscan population. Total spine-related net (payer only) and gross (payer + patient) costs (2023 US $) per patient overall and by health care resource utilization (HCRU) category. Proportion of patients using each HCRU category. Commercial payer economic burden per 100,000 beneficiaries at 1 and 2 years. United States societal burden at 1 and 2 years. METHODS Spine-related payments were identified as payments for any health care encounter with a spine-related diagnosis, and gross and net payments were summed overall and by HCRU category (physical therapy, injections, radiology, office visits, etc.). Negative and zero payments were excluded from the calculations. The commercial payer burden per 100,000 beneficiaries was calculated as the total net payments per patient times ASD prevalence times 100,000. The total societal burden was calculated as the total gross payments per patient times ASD prevalence times the size of the US commercially-insured population aged 21-64. RESULTS A total of 426,673 patients with ASD were identified, putting the annual prevalence of ASD within the enrolled Marketscan commercial population aged 21-64 at 0.50%. In the 140,435 patients presenting with ASD at an outpatient encounter and meeting the inclusion and exclusion criteria, payer expenditures per patient totaled $5,327 (5,223, 5,431) in the first year and $8,438 (8,252, 8,623) within 2 years. Total gross costs per ASD patient totaled $5,810 (5,712, 5,909) in the 1st year and $9,443 (9,259, 9,627) within 2 years. These costs translated to total payer expenditures per 100,000 commercially-insured beneficiaries of $2.66 (2.61, 2.72) million in the 1st year and $4.22 (4.13, 4.31) million within 2 years; spinal fusion patients (3.7%) accounted for 62.6% of 1-year payer expenditures. US societal burden totaled $4.13 (4.06, 4.20) billion at 1 year and $6.72 (6.59, 6.85) within 2 years. CONCLUSIONS The disease burden and the economic burden to payers and society from ASD is large. The top 25 payers have an average of roughly 500,000 adult beneficiaries. For a plan this size, payers can expect $13.3 million in spine-related expenditures from patients receiving an ASD diagnosis within the 1st year, alone, and $21.1 million within 2 years. These results provide a better understanding regarding the value of care for ASD and pave the way for comparing the value of different management strategies. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs.

Background Adult spinal deformity (ASD) is a prevalent condition estimated at 38%. Symptomatic ASD is associated with substantial health care costs. The role of nonoperative interventions in the management of ASD remains elusive. The National Scoliosis Clinic’s (NSC) scoliosis realignment therapy (SRT) is a personalized digital health exercise program for the nonoperative management of ASD. Objective This exploratory study had two objectives: (1) to evaluate the effect of the SRT program on users’ intention of having spinal fusion; and (2) from a US payer perspective, to estimate the annual cost savings per 100,000 beneficiaries by averting spinal surgery. Methods Individuals were enrolled in the SRT study from October 1, 2023 to September 1, 2024. Participants completed a web-based, cross-sectional survey about their history of prior scoliosis surgery and intent of having surgery before and after use of SRT (on a 4-point Likert scale, where 1 = “No Intent for Surgery” and 4 = “High Intent for Surgery”). Intent for surgery before and after participation in SRT was compared using a nonparametric Wilcoxon signed-rank test for paired data. Annual cost savings per 100,000 beneficiaries by averting spinal fusions were estimated separately for commercial payers and Medicare using published literature and public data sources. Payer expenditures were inflation-adjusted to 2024 US dollars using the Hospital Services component of the Consumer Price Index. Results A total of 62 NSC members (38.8%) responded to the survey and were enrolled in the SRT program for an average (SD) of 17 (12) weeks. The mean (SD) age was 65.3 (13.5) years, and the majority were female (47/48, 98%) and White (45/46, 98%). Among the SRT users who did not have prior scoliosis surgery (n=56), 14% (8/56) reported a decrease in intent for surgery (that is, a lower Likert score) with the use of SRT. The mean (SD) intent for surgery scores before compared to after SRT were 1.29 (0.53) and 1.14 (0.35), respectively (mean difference 0.15 [P=.006]). Participants with “No Intent for Surgery” pre- versus postuse of SRT (42/56 versus 48/56, respectively) corresponded to an absolute risk reduction of 11% and a number needed to treat of 9 to avert one spinal fusion. Among the 6 participants who transitioned to “No Intent” for spinal surgery with the use of SRT, 3 were aged <65 years and 3 were ≥65 years of age. The annual cost savings from averted spinal surgeries were estimated at US $415,000 per 100,000 commercially-insured beneficiaries and US $617,000 per 100,000 Medicare beneficiaries. Conclusions SRT is a personalized, scoliosis-specific digital health exercise program with the potential for averting 1 spinal surgery for every 9 participants, resulting in a substantial reduction in payer expenditures while improving the quality of care for commercial payers and Medicare beneficiaries.

Adult scoliosis (AS) is a prevalent condition estimated at 38%. Symptomatic AS is associated with substantial healthcare costs. The role of nonoperative interventions in the management of AS remains elusive. The National Scoliosis Clinic’s (NSC) Scoliosis Realignment Therapy (SRT) is a personalized digital health exercise program for the nonoperative management of AS. The purpose of this study was two-fold: (1) To evaluate the effect of the SRT program on users’ intention of having spinal fusion; and (2) From a US payer perspective, to estimate the annual cost savings per 100,000 beneficiaries by averting spinal surgery. Individuals were enrolled in the SRT study from October 1, 2023 to September 1, 2024. Participants completed an online survey about history of prior scoliosis surgery and intent of having surgery before and after use of SRT (on a 4-point Likert scale, where 1 = “No Intent for Surgery” and 4 = “High Intent for Surgery”). Intent for surgery before and after participation in SRT was compared using a non-parametric Wilcoxon signed-rank test for paired data. Annual cost savings per 100,000 beneficiaries by averting spinal fusions were estimated separately for commercial payers and Medicare using published literature and public data sources. Payer expenditures were inflation-adjusted to 2024 US dollars using the Hospital Services component of the Consumer Price Index. In total, 62 NSC members were enrolled in the SRT study for an average of 17 weeks (SD 12). The mean age was 65.3 (SD 13.5) years and the majority were female (98%) and white (98%). Among the SRT users who did not have prior scoliosis surgery (N=56), 14% (8/56) reported a decrease in intent for surgery (that is, a lower Likert score) with use of SRT. The mean intent for surgery scores before compared to after SRT were 1.29 (SD 0.53) and 1.14 (SD 0.35), respectively (mean difference 0.15 [P=.006]). Participants with “No Intent for Surgery” pre- versus post-use of SRT (42/56 versus 48/56, respectively) corresponds to an absolute risk reduction (ARR) of 11% and a number needed to treat (NNT) of 9 to avert one spinal fusion. Among the six participants who transitioned to “No Intent” for spinal surgery with use of SRT, three were <65 and three were ≥65 years of age. Annual cost savings from averted spinal surgeries were estimated at US $415,000 per 100,000 commercially-insured beneficiaries and US $617,000 per 100,000 Medicare beneficiaries. SRT is a personalized, scoliosis-specific digital health exercise program with the potential for averting 1 spinal surgery for every 9 participants, resulting in a substantial reduction in payer expenditures while improving quality of care for commercial payer and Medicare beneficiaries.

Purpose:In the United States (US), total hip arthroplasty (THA) is the most common hospital inpatient operation among Medicare beneficiaries and is ranked fourth when considering all payers. Spinopelvic pathology (SPP) is associated with an increased risk of THA revision (rTHA) due to dislocation. Several strategies have been proposed to mitigate the risk of instability in this population, including use of dual-mobility implants, anterior-based surgical approaches, and technology-assistance (digital 2D/3D pre-surgical planning, computer navigation, and robotic assistance). For primary THA (pTHA) patients with SPP who subsequently undergo rTHA due to dislocation, we aimed to estimate (1) target population size; (2) economic burden; and (3) 10-year projected savings to the US payer of lowering the risk of rTHA due to dislocation among pTHA patients with SPP.Methods:A budget impact analysis from the US payer perspective was undertaken using published literature; American Academy of Orthopaedic Surgeons American Joint Replacement Registry 2021 Annual Report; Centers for Medicare & Medicaid Services MEDPAR 2019; and National (Nationwide) Inpatient Sample (NIS) 2019. Expenditures were inflation-adjusted to 2021 US dollars using the Medical Care component of the Consumer Price Index. Sensitivity analyses were performed.Results:The target population size in 2021 was estimated at 5040 (range, 4830-6309) for Medicare (fee-for-service plus Medicare Advantage) and 8003 (range, 7669-10,018) for all-payer. Annual rTHA episode-of-care (through 90 days) expenditures for Medicare and all-payer were $185 million and $314 million, respectively. Using a 4.14% compound annual growth rate from NIS, the estimated number of applicable rTHA procedures that will be performed from 2022-2031 was 63,419 Medicare and 100,697 all-payer. With each 10% reduction in relative risk of rTHA due to dislocation, Medicare and all-payer could save $233 million and $395 million, respectively, over a 10-year period.Conclusion:Among pTHA patients with spinopelvic pathology, a modest reduction in the risk of rTHA due to dislocation could achieve substantial cumulative savings to payers while improving healthcare quality.

Purpose: Multi-level lumbar fusion to the sacrum (MLF) can lead to increased stress and angular motion across the sacroiliac joint (SIJ), with an incidence of post-operative SIJ pain estimated at 26-32%. SIJ fusion (SIJF) can help obviate the need for revisions by reducing range of motion and screw stresses. We aimed to evaluate the cost-utility of MLF + SIJF compared to MLF alone among high-risk patients from a payer perspective, where high risk is defined as high body mass index and high pelvic incidence.Methods: A Markov process decision-analysis model was developed to evaluate cumulative 5-year costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) of MLF + SIJF compared to MLF alone using published data; costs from Medicare claims data analyses and health state utility values (derived from EQ-5D) informed by three prospective, multicenter, clinical trials. The base case assumed a reduction in post-operative SIJ pain from 30% to 10% (relative risk reduction [RRR] of 67%). Costs and utilities were discounted 3% annually. The ICER is reported in 2020 US dollars. One-way, multi-way, and probabilistic sensitivity analyses were performed.Results: With an assumed 30% incidence of SIJ pain after MLF alone, stabilizing with SIJF was associated with an additional 5-year cost of $2421 and a gain of 0.14 QALYs, resulting in an ICER of $17,293 per QALY gained (similar to total knee arthroplasty and more favorable than open discectomy). ICERs were most sensitive to the RRR of post-operative SIJ pain conferred by SIJF, time horizon, and probability of successful treatment with MLF alone. At a willingness-to-pay threshold of $50,000/QALY gained, MLF + SIJF has a 97.7% probability of being cost-effective in the target patient population.Conclusion: Fusing the SIJ in high-risk patients undergoing MLF was cost-effective when the incidence of post-operative SIJ pain after MLF alone exceeds approximately 25%, providing value-based healthcare from a payer perspective.

Background: Vulvovaginitis (VV) is a common reason women seek medical attention in the USA. Both the non-specific clinical presentation and risk of preterm labor or delivery necessitate accurate identification of the causative agents to guide appropriate therapy. The diagnostic accuracy of amplified molecular probe testing (AMP) has been shown to exceed that of non-amplified molecular probe (NAMP) by 20%-25%. Objective: To evaluate the impact of diagnosis with AMP testing on health care utilization, direct costs, and health outcomes, compared with NAMP, for symptomatic patients with suspected VV from a commercial payer perspective. Methods: Symptomatic women (aged 18-64 years) who underwent VV testing with AMP or NAMP from January 1, 2012-December 31, 2016 were identified using the Truven Health Analytics MarketScan Database; those with continuous medical and pharmacy benefit enrollment 6 months pre/post AMP or NAMP testing were included. Patients were propensity score (PS) matched and 6-month all-cause health care resource utilization, all-cause direct costs (2017 USD), risk of all-cause hospitalization, and risk of preterm labor or delivery were compared between cohorts. Results: After PS match (N=46,810 per group, mean age 34.2 years), AMP had significantly (all P<0.0001) fewer mean hospital outpatient visits (AMP 0.9 vs NAMP 1.0), primary care physician office visits (AMP 1.1 vs NAMP 1.2), and prescription medications (AMP 7.3 vs NAMP 8.0), and a 21% reduction in risk of hospitalization (risk ratio [RR]=0.79, 95% CI=0.75-0.83, P<0.0001). Total medical expenditures per patient were lower for AMP than NAMP (mean AMP $3,287 vs NAMP $3,555, P<0.0001). Among pregnant women (N=2,175 per group), AMP had a 12% reduction in risk of preterm labor or delivery (RR =0.88, 95% CI=0.77-0.99, P=0.041). Conclusion: This real-world study offers evidence on the clinical utility for symptomatic patients with suspected VV diagnosed with AMP compared to NAMP - demonstrating an opportunity to improve the patient journey while delivering value-based care.

Purpose Treating early-onset scoliosis (EOS) with traditional growing rods (TGR) is effective but requires periodic surgical lengthening, risking complications. Alternatives include magnetically controlled growing rods (MCGR) that lengthen noninvasively and the growth guidance system (GGS), which obviate the need for active, distractive lengthenings. Previous studies have reported promising clinical effectiveness for GGS; however the direct medical costs of GGS compared to TGR and MCGR have not yet been explored. Methods To estimate the cost of GGS compared with MCGR and TGR for EOS an economic model was developed from the perspective of a US integrated health care delivery system. Using dual-rod constructs, the model estimated the cumulative costs associated with initial implantation, rod lengthenings (TGR, MCGR), revisions due to device failure, surgical-site infections, device exchange, and final spinal fusion over a 6-year episode of care. Model parameters were from peer-reviewed, published literature. Medicare payments were used as a proxy for provider costs. Costs (2016 US$) were discounted 3% annually. Results Over a 6-year episode of care, GGS was associated with fewer invasive surgeries per patient than TGR (GGS: 3.4; TGR: 14.4) and lower cumulative costs than MCGR and TGR, saving $25,226 vs TGR. Sensitivity analyses showed that results were sensitive to changes in construct costs, rod breakage rates, months between lengthenings, and TGR lengthening setting of care. Conclusion Within the model, GGS resulted in fewer invasive surgeries and deep surgical site infections than TGR, and lower cumulative costs per patient than both MCGR and TGR, over a 6-year episode of care. The analysis did not account for family disruption, pain, psychological distress, or compromised health-related quality of life associated with invasive TGR lengthenings, nor for potential patient anxiety surrounding the frequent MCGR lengthenings. Further analyses focusing strictly on current generation technologies should be considered for future research.

Aims: To compare (1) complication and (2) conversion rates to open surgery (OS) from laparoscopic surgery (LS) and robotic-assisted surgery (RA) for rectal cancer patients who underwent rectal resection. (3) To identify patient, physician, and hospital predictors of conversion. Materials and methods: A US-based database study was conducted utilizing the 2012-2014 Premier Healthcare Data, including rectal cancer patients 18 with rectal resection. ICD-9-CM diagnosis and procedural codes were utilized to identify surgical approaches, conversions to OS, and surgical complications. Propensity score matching on patient, surgeon, and hospital level characteristics was used to create comparable groups of RA\LS patients (n = 533 per group). Predictors of conversion from LS and RA to OS were identified with stepwise logistic regression in the unmatched sample. Results: Post-match results suggested comparable perioperative complication rates (RA 29% vs LS 29%; p = .7784); whereas conversion rates to OS were 12% for RA vs 29% for LS (p<.0001). Colorectal surgeons (RA 9% vs LS 23%), general surgeons (RA 13% vs LS 35%), and smaller bed-size hospitals (RA 14% vs LS 33%) have reduced conversion rates for RA vs LS (p<.0001). Statistically significant predictors of conversion included LS, non-colorectal surgeon, and smaller bed-size hospitals. Limitations: Retrospective observational study limitations apply. Analysis of the hospital administrative database was subject to the data captured in the database and the accuracy of coding. Propensity score matching limitations apply. RA and LS groups were balanced with respect to measured patient, surgeon, and hospital characteristics. Conclusions: Compared to LS, RA offers a higher probability of completing a successful minimally invasive surgery for rectal cancer patients undergoing rectal resection without exacerbating complications. Male, obese, or moderately-to-severely ill patients had higher conversion rates. While colorectal surgeons had lower conversion rates from RA than LS, the reduction was magnified for general surgeons and smaller bed-size hospitals.

OBJECTIVE There is substantial heterogeneity in the number of screws used per level fused in adolescent idiopathic scoliosis (AIS) surgery. Assuming equivalent clinical outcomes, the potential cost savings of using fewer pedicle screws were estimated using a medical decision model with sensitivity analysis.METHODS Descriptive analyses explored the annual costs for 5710 AIS inpatient stays using discharge data from the 2009 Kids' Inpatient Database (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality), which is a national all-payer inpatient database. Patients between 10 and 17 years of age were identified using the ICD-9-CM code for idiopathic scoliosis (737.30). All inpatient stays were assumed to represent 10-level fusions with pedicle screws for AIS. High screw density was defined at 1.8 screws per level fused, and the standard screw density was defined as 1.48 screws per level fused. The surgical return for screw malposition was set at $23,762. A sensitivity analysis was performed by varying the cost per screw ($600 $1000) and the rate of surgical revisions for screw malposition (0.117%-0.483% of screws; 0.8%-4.3% of patients). The reported outcomes include estimated prevented malpositioned screws (set at 5.1%), averted revision surgeries, and annual cost savings in 2009 US dollars, assuming similar clinical outcomes (rates of complications, revision) using a standard-versus high-density pattern.RESULTS The total annual costs for 5710 AIS hospital stays was $278 million ($48,900 per patient). Substituting a high for a standard screw density yields 3.2 fewer screws implanted per patient, with 932 malpositioned screws prevented and 21 to 88 revision surgeries for implant malposition averted, and a potential annual cost savings of $11 million to $20 million (4%-7% reduction in the total cost of AIS hospitalizations).CONCLUSIONS Reducing the number of screws used in scoliosis surgery could potentially decrease national AIS hospitalization costs by up to 7%, which may improve the safety and efficiency of care. However, such a screw construct must first be proven safe and effective.

Purpose: Traditional growing rod (TGR) for early-onset scoliosis (EOS) is effective but requires repeated invasive surgical lengthenings under general anesthesia. Magnetically controlled growing rod (MCGR) is lengthened noninvasively using a hand-held magnetic external remote controller in a physician office; however, the MCGR implant is expensive, and the cumulative cost savings have not been well studied. We compared direct medical costs of MCGR and TGR for EOS from the US integrated health care delivery system perspective. We hypothesized that over time, the MCGR implant cost will be offset by eliminating repeated TGR surgical lengthenings.Methods: For both TGR and MCGR, the economic model estimated the cumulative costs for initial implantation, lengthenings, revisions due to device failure, surgical-site infections, device exchanges (at 3.8 years), and final fusion, over a 6-year episode of care. Model parameters were estimated from published literature, a multicenter EOS database of US institutions, and interviews. Costs were discounted at 3.0% annually and represent 2015 US dollars.Results: Of 1,000 simulated patients over 6 years, MCGR was associated with an estimated 270 fewer deep surgical-site infections and 197 fewer revisions due to device failure compared with TGR. MCGR was projected to cost an additional $61 per patient over the 6-year episode of care compared with TGR. Sensitivity analyses indicated that the results were sensitive to changes in the percentage of MCGR dual rod use, months between TGR lengthenings, percentage of hospital inpatient (vs outpatient) TGR lengthenings, and MCGR implant cost.Conclusion: Cost neutrality of MCGR to TGR was achieved over the 6-year episode of care by eliminating repeated TGR surgical lengthenings. To our knowledge, this is the first cost analysis comparing MCGR to TGR - from the US provider perspective - which demonstrates the efficient provision of care with MCGR.

Introduction: Low back pain is common and originates in the sacroiliac (SI) joint in 15%-30% of cases. Traditional SI joint disruption/degenerative sacroiliitis treatments include nonoperative care or open SI joint fusion. To evaluate the usefulness of newly developed minimally-invasive technologies, the costs of traditional treatments must be better understood. We assessed the costs of nonoperative care for SI joint disruption to commercial payers in the United States (US).Methods: A retrospective study of claim-level medical resource use and associated costs used the MarketScan (R) Commercial Claims and Encounters as well as Medicare Supplemental Databases of Truven Healthcare. Patients with a primary ICD-9-CM diagnosis code for SI joint disruption (720.2, 724.6, 739.4, 846.9, or 847.3), an initial date of diagnosis from January 1, 2005 to December 31, 2007 (index date), and continuous enrollment for $1 year before and 3 years after the index date were included. Claims attributable to SI joint disruption with a primary or secondary ICD-9-CM diagnosis code of 71x.xx, 72x.xx, 73x.xx, or 84x.xx were identified; the 3-year medical resource use-associated reimbursement and outpatient pain medication costs (measured in 2011 US dollars) were tabulated across practice settings. A subgroup analysis was performed among patients with lumbar spinal fusion.Results: The mean 3-year direct, attributable medical costs were $16,196 (standard deviation [SD] $28,592) per privately-insured patient (N=78,533). Among patients with lumbar spinal fusion (N=434), attributable 3-year mean costs were $91,720 (SD $75,502) per patient compared to $ 15,776 (SD $27,542) per patient among patients without lumbar spinal fusion (N=78,099). Overall, inpatient hospitalizations (19.4%), hospital outpatient visits and procedures (14.0%), and outpatient pain medications (9.6%) accounted for the largest proportion of costs. The estimated 3-year insurance payments attributable to SI joint disruption were $1.6 billion per 100,000 commercial payer beneficiaries.Conclusion: The economic burden of SI joint disruption among privately-insured patients in the US is substantial, highlighting the need for more cost-effective therapies.

The sacroiliac (SI) joint has been reported as the pain generator in 15% to 22% of patients with low back pain. The SI joint as a source of low back pain is often overlooked or misdiagnosed as discogenic or radicular low back pain, possibly due to a lack of awareness and also because there is no gold standard for SI joint pain diagnosis. It is uncertain how often lumbar spinal fusion is being performed on patients who really have SI pathology, but one report estimates at least 5% of the time.

Perioperative blood loss during total hip arthroplasty (THA) increases patient morbidity, length of stay (LOS), medical resource use (MRU), and costs. Minimizing blood loss may reduce postoperative anemia, the need for blood transfusions, and the increased risk of infections and longer hospital stays associated with blood transfusions. Pharmacologic agents and bipolar sealer devices can minimize perioperative bleeding. A retrospective, comparative cohort study in the US hospital setting was conducted to assess MRU and associated costs and the incidence of transfusion and complications among patients undergoing THA with or without the use of a bipolar sealer. Using a nationwide all-payer hospital administrative database, THA procedures from January 1, 2008, to March 31, 2011, were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 81.51. The bipolar sealer cohort (n=2683) and matched control cohort (n=2683) had a mean age of 65 years from 38 hospitals. The 2 groups had similar incidences of pre-operative anemia and medical comorbidities. Patients in the bipolar sealer group required significantly fewer blood transfusions (21.3% vs 23.8%; P=.0286) and had significantly lower incidence of hematomas (0.2% vs 0.9%; P=.0015) and significantly shorter LOS (2.90 vs 3.31 days; P<.0001) overall. The bipolar sealer group had higher supply costs, which were offset by reduced hospital inpatient room and board and operating room costs; there was no significant difference in total hospital costs between the 2 groups ($18,937 vs $18,734; P=.56). A bipolar sealer decreases postoperative blood transfusions and LOS during primary THA without increasing total hospital costs.

OBJECT Low-back pain (LBP) is highly prevalent among older adults, and the cost to treat the US Medicare population is substantial. Recent US health care reform legislation focuses on improving quality of care and reducing costs. The sacroiliac (SI) joint is a recognized generator of LBP, but treatments traditionally have included either nonoperative medical management or open SI joint fusion, which has a high rate of complications. New minimally invasive technologies have been developed to treat SI joint disruption and degenerative sacroiliitis, so it is important to understand the current cost impact of nonoperative care to the Medicare program. The objective of this study was to evaluate the medical resource use and associated Medicare reimbursement for patients managed with nonoperative care for degenerative sacroiliitis/SI joint disruption. METHODS A retrospective study was conducted using claim-level data from the Medicare 5% Standard Analytical Files (SAFs) for the years 2005-2010. Included were patients with a primary ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code for degenerative sacroiliitis/SI joint disruption (ICD-9-CM diagnosis codes 720.2, 724.6, 739.4, 846.9, or 847.3) with continuous enrollment for at least 1 year before and 5 years after diagnosis. Claims attributable to degenerative sacroiliitis/SI joint disruption were identified using ICD-9-CM diagnosis codes (claims with a primary or secondary ICD-9-CM diagnosis code of 71x.xx, 72x.xx, 73x.xx, or 84x.xx), and the 5-year medical resource use and Medicare reimbursement (in 2012 US dollars) were tabulated across practice settings. A subgroup analysis was performed among patients who underwent lumbar spinal fusion. RESULTS Among all Medicare patients with degenerative sacroiliitis or SI joint disruption (n = 14,552), the mean cumulative 5-year direct medical costs attributable to degenerative sacroiliitis/SI joint disruption was $18,527 ± $28,285 (± SD) per patient. The cumulative 5-year cost was $63,913 ± $46,870 per patient among the subgroup of patients who underwent lumbar spinal fusion (n = 538 [3.7%]) and $16,769 ± $25,753 per patient among the subgroup of patients who had not undergone lumbar spinal fusion (n = 14,014 [96.3%]). For the total population, the largest proportion of cumulative 5-year costs was due to inpatient hospitalization (42.1%), outpatient physician office (20.6%), and hospital outpatient costs (14.9%). The estimated cumulative 5-year Medicare reimbursement across practice settings attributable to SI joint disruption or degenerative sacroiliitis is approximately $270 million among these 14,552 Medicare beneficiaries ($18,527 per patient). CONCLUSIONS In patients who suffer from LBP due to SI joint disruption or degenerative sacroiliitis, this retrospective Medicare claims data analysis demonstrates that nonoperative care is associated with substantial costs and medical resource utilization. The economic burden of SI joint disruption and degenerative sacroiliitis among Medicare beneficiaries in the US is substantial and highlights the need for more cost-effective therapies to treat this condition and reduce health care expenditures.

INTRODUCTION:The economic burden associated with the treatment of low back pain (LBP) in the United States is significant. LBP caused by sacroiliac (SI) joint disruption/degenerative sacroiliitis is most commonly treated with nonoperative care and/or open SI joint surgery. New and effective minimally invasive surgery (MIS) options may offer potential cost savings to Medicare. METHODS:An economic model was developed to compare the costs of MIS treatment to nonoperative care for the treatment of SI joint disruption in the hospital inpatient setting in the US Medicare population. Lifetime cost savings (2012 US dollars) were estimated from the published literature and claims data. Costs included treatment, follow-up, diagnostic testing, and retail pharmacy pain medication. Costs of SI joint disruption patients managed with nonoperative care were estimated from the 2005-2010 Medicare 5% Standard Analytic Files using primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes 720.2, 724.6, 739.4, 846.9, or 847.3. MIS fusion hospitalization cost was based on Diagnosis Related Group (DRG) payments of $46,700 (with major complications - DRG 459) and $27,800 (without major complications - DRG 460), weighted assuming 3.8% of patients have complications. MIS fusion professional fee was determined from the 2012 Medicare payment for Current Procedural Terminology code 27280, with an 82% fusion success rate and 1.8% revision rate. Outcomes were discounted by 3.0% per annum. RESULTS:The extrapolated lifetime cost of treating Medicare patients with MIS fusion was $48,185/patient compared to $51,543/patient for nonoperative care, resulting in a $660 million savings to Medicare (196,452 beneficiaries at $3,358 in savings/patient). Including those with ICD-9-CM code 721.3 (lumbosacral spondylosis) increased lifetime cost estimates (up to 478,764 beneficiaries at $8,692 in savings/patient). CONCLUSION:Treating Medicare beneficiaries with MIS fusion in the hospital inpatient setting could save Medicare $660 million over patients' lifetimes.

The American Recovery and Reinvestment Act of 2009 includes an estimated $27 billion over 10 years to support adoption of electronic health records (EHRs). This includes the Health Information Technology (HIT) for Economic and Clinical Health Act of 2009, which promotes meaningful use of HIT through Medicare and Medicaid EHR Incentive Programs. In November 2011, the United States (US) Department of Health and Human Services released a report showing adoption of HIT doubled in two years. The objective of this review was to examine the impact of EHR and computerized physician order entry (CPOE) on health care efficiency. A review of published original research in the United States was conducted in PubMed for years 2007 through 2011. The number of studies reporting efficiencies and inefficiencies, setting of care, and areas of efficiency and inefficiency were examined. A total of 18 studies were reviewed: 13 EHR or EHR/CPOE and 5 CPOE only. Settings of care included the hospital inpatient (n=6), outpatient clinic/practice (n=6), emergency department (n=3), surgical center (n=2), and assisted-living facility (n=1). All but one study reported efficiencies in at least one area. Efficiencies from EHR or EHR/CPOE were reported in decreased physician/staff time (n=6), increased patient volume (n=3), decreased length of stay (n=3), increased provider productivity (n=2), decreased tests/procedures ordered (n=1), and decreased time to diagnosis (n=1). Efficiencies from CPOE were observed in decreased order processing/verification time (n=3), decreased physician/staff time (n=1), and decreased time to medication administration (n=1). Inefficiencies from one CPOE study were reported in increased prescribing time. Three of the EHR or EHR/CPOE studies also reported inefficiencies. Some factors that contributed to inefficiencies included complex/acute cases and the level of EHR implementation. EHR implementation has the potential to improve efficiencies in various practice settings. Further investigation is warranted to examine factors contributing to inefficiencies.

BACKGROUND: Chronic pain is a prevalent condition in the United States. Musculoskeletal pain, including joint and back pain, is the most common type of chronic pain, and many patients with back pain have a neuropathic component. Pain has direct economic consequences. While oxycodone controlled-release (CR) is one of the most widely used oral long-acting opioids for pain, including pain with a neuropathic component, it is often associated with bothersome side effects, resulting in additional medical resource use (MRU) and costs.OBJECTIVE: To examine the impact on MRU and costs to payers of side effects in patients taking oxycodone CR alone or in combination with other pain medications for noncancer pain (including those with neuropathic pain symptoms).METHODS: A nationwide convenience sample of adults in the United States, who participated in a survey research panel and reported current use of oxycodone CR for noncancer pain, completed an online survey between November 2, 2010, and December 13, 2010. Respondents were excluded if they reported current use of other extended-release or long-acting opioid prescription medications. The survey consisted of questions on demo-graphics, clinical characteristics, pain characteristics, experience with pain medication, and MRU associated with side effects. Payer costs were calculated based on the MRU reported by the respondents multiplied by Medicare reimbursement rates for hospitalizations and outpatient visits and average wholesale price (AWP) minus 20% for medications. A subgroup of patients who reported neuropathic pain symptoms also was examined.RESULTS: After applying the exclusion criteria, 432 respondents completed the survey. Approximately half of the respondents (n=219; 50.7%) reported neuropathic pain symptoms. The majority of respondents were Caucasian (88.4%) and female (63.7%) with an average age of 41.8 years (14.89). Respondents most frequently reported low back pain (41.2%), followed by osteoarthritis/rheumatoid arthritis (20.4%), neuropathic pain (10.6%), and fibromyalgia (9.0%). Respondents reported having their pain condition for an average of 5.4 (7.42) years. On days when taken, respondents reported a mean oxycodone CR daily dose of 83.3 mg (126.93) taken in an average of 2 doses. Most respondents (82.4%) reported experiencing at least 1 side effect with 77.5% being bothered by at least 1 side effect. The most frequently reported side effects (>25%) were drowsiness (41.4%), constipation (37.0%), fatigue or daytime sleepiness (36.6%), and dizziness (27.1%). Among respondents who reported being bothered by one or more side effects in the previous month, MRU associated with side effects was reported by 39.1% of respondents and significantly increased as the level of side-effect bother increased from 19.8% among those "A little bit bothered" to 38.4% among those "Bothered" to 61.0% among those "Extremely bothered" (P<0.001). Additionally, total average payer costs (in 2010 dollars) per respondent in the previous month associated with side effects were $238 ($1,159) and also significantly increased as the level of side-effect bother increased from $61 ($512) among those "A little bit bothered" to $238 ($1,160) among those "Bothered" to $425 ($1,561) among those "Extremely bothered" (P < 0.001). Results reported in the neuropathic pain subgroup were similar to results reported in the total study sample.CONCLUSIONS: Among adults taking oxycodone CR for chronic noncancer pain (with or without a neuropathic pain component), over three-fourths reported being bothered by side effects. Respondents who reported higher levels of side-effect bother also reported greater MRU, resulting in increased payer costs. The results of this study provide further support of the economic burden to payers associated with opioid-related side effects in patients with chronic noncancer pain, with and without neuropathic pain. J Manag Care Pharm. 2012;18(8):615-26 Copyright (C) 2012, Academy of Managed Care Pharmacy. All rights reserved.