Costs of Surgery in Adult Spinal Deformity

Study Design.This was a retrospective study.To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4 degrees), and pelvic tilt (HC: 25.3 vs. LC: 22.4 degrees). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P=0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P=0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P=0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.3.Enthusiasm for adult spinal deformity (ASD) surgery has grown over the last two decades.1 At the same time, these procedures are resource-intensive, expensive and carry a high complication profile.2 The potential for complications also extends well beyond the initial postoperative period, and mechanical failure and consequent need for revision frequently occur several years following the index intervention. From a health policy perspective, the high cost associated with ASD surgery has been a target of increased scrutiny. General projections of health expenditures estimate that health care will reach 19.7% of the US gross domestic product by 2028, with Medicare experiencing the fastest growth in spending of major payers.3 Given that the prevalence of ASD has been estimated as high as 68% for those over age 60, it is unsurprising that costly interventions occurring more often in elderly patients are of significant interest to policymakers.4 Although more invasive surgical interventions may be more expensive at baseline, they may also obviate the need for more expensive care in the years following the index surgery. At present, it remains unclear whether more aggressive and expensive procedures have the capacity to pay longer term dividends in terms of superior patient outcomes and lower likelihood of adverse events and revisions. Comparisons are frequently inhibited by a lack of sufficient follow-up, as well as confounding due to selection and indication bias. In an effort to address these questions in a more comprehensive fashion, we used a large, prospectively collected, spine surgical registry with extensive follow-up to evaluate differences in outcomes between higher cost and lower cost deformity procedures. This surgical registry has been utilized previously to address health policy questions in the setting of ASD surgery. We used propensity score matching (PSM) as a causal inference test to address issues of confounding by indication at baseline. We hypothesized that following matched analysis, higher cost ASD surgeries would outperform lower cost interventions in terms of both patient-reported outcomes and deformity correction.Study Design.This was a retrospective study.To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4 degrees), and pelvic tilt (HC: 25.3 vs. LC: 22.4 degrees). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P=0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P=0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P=0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.3.Enthusiasm for adult spinal deformity (ASD) surgery has grown over the last two decades.1 At the same time, these procedures are resource-intensive, expensive and carry a high complication profile. 2 The potential for complications also extends well beyond the initial postoperative period, and mechanical failure and consequent need for revision frequently occur several years following the index intervention. From a health policy perspective, the high cost associated with ASD surgery has been a target of increased scrutiny. General projections of health expenditures estimate that health care will reach 19.7% of the US gross domestic product by 2028, with Medicare experiencing the fastest growth in spending of major payers.3 Given that the prevalence of ASD has been estimated as high as 68% for those over age 60, it is unsurprising that costly interventions occurring more often in elderly patients are of significant interest to policymakers.4 Although more invasive surgical interventions may be more expensive at baseline, they may also obviate the need for more expensive care in the years following the index surgery.At present, it remains unclear whether more aggressive and expensive procedures have the capacity to pay longer term dividends in terms of superior patient outcomes and lower likelihood of adverse events and revisions. Comparisons are frequently inhibited by a lack of sufficient follow-up, as well as confounding due to selection and indication bias. In an effort to address these questions in a more comprehensive fashion, we used a large, prospectively collected, spine surgical registry with extensive follow-up to evaluate differences in outcomes between higher cost and lower cost deformity procedures. This surgical registry has been utilized previously to address health policy questions in the setting of ASD surgery. We used propensity score matching (PSM) as a causal inference test to address issues of confounding by indication at baseline. We hypothesized that following matched analysis, higher cost ASD surgeries would outperform lower cost interventions in terms of both patient-reported outcomes and deformity correction.Study Design.This was a retrospective study.To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4 degrees), and pelvic tilt (HC: 25.3 vs. LC: 22.4 degrees). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P=0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P=0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P=0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.3.Enthusiasm for adult spinal deformity (ASD) surgery has grown over the last two decades.1 At the same time, these procedures are resource-intensive, expensive and carry a high complication profile.2 The potential for complications also extends well beyond the initial postoperative period, and mechanical failure and consequent need for revision frequently occur several years following the index intervention. From a health policy perspective, the high cost associated with ASD surgery has been a target of increased scrutiny. General projections of health expenditures estimate that health care will reach 19.7% of the US gross domestic product by 2028, with Medicare experiencing the fastest growth in spending of major payers.3 Given that the prevalence of ASD has been estimated as high as 68% for those over age 60, it is unsurprising that costly interventions occurring more often in elderly patients are of significant interest to policymakers.4 Although more invasive surgical interventions may be more expensive at baseline, they may also obviate the need for more expensive care in the years following the index surgery.At present, it remains unclear whether more aggressive and expensive procedures have the capacity to pay longer term dividends in terms of superior patient outcomes and lower likelihood of adverse events and revisions. Comparisons are frequently inhibited by a lack of sufficient follow-up, as well as confounding due to selection and indication bias. In an effort to address these questions in a more comprehensive fashion, we used a large, prospectively collected, spine surgical registry with extensive follow-up to evaluate differences in outcomes between higher cost and lower cost deformity procedures. This surgical registry has been utilized previously to address health policy questions in the setting of ASD surgery. We used propensity score matching (PSM) as a causal inference test to address issues of confounding by indication at baseline. We hypothesized that following matched analysis, higher cost ASD surgeries would outperform lower cost interventions in terms of both patient-reported outcomes and deformity correction.Study Design.This was a retrospective study.To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4 degrees), and pelvic tilt (HC: 25.3 vs. LC: 22.4 degrees). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P=0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P=0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P=0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.3.Enthusiasm for adult spinal deformity (ASD) surgery has grown over the last two decades.1 At the same time, these procedures are resource-intensive, expensive and carry a high complication profile.2 The potential for complications also extends well beyond the initial postoperative period, and mechanical failure and consequent need for revision frequently occur several years following the index intervention. From a health policy perspective, the high cost associated with ASD surgery has been a target of increased scrutiny. General projections of health expenditures estimate that health care will reach 19.7% of the US gross domestic product by 2028, with Medicare experiencing the fastest growth in spending of major payers.3 Given that the prevalence of ASD has been estimated as high as 68% for those over age 60, it is unsurprising that costly interventions occurring more often in elderly patients are of significant interest to policymakers.4 Although more invasive surgical interventions may be more expensive at baseline, they may also obviate the need for more expensive care in the years following the index surgery.At present, it remains unclear whether more aggressive and expensive procedures have the capacity to pay longer term dividends in terms of superior patient outcomes and lower likelihood of adverse events and revisions. Comparisons are frequently inhibited by a lack of sufficient follow-up, as well as confounding due to selection and indication bias. In an effort to address these questions in a more comprehensive fashion, we used a large, prospectively collected, spine surgical registry with extensive follow-up to evaluate differences in outcomes between higher cost and lower cost deformity procedures. This surgical registry has been utilized previously to address health policy questions in the setting of ASD surgery. We used propensity score matching (PSM) as a causal inference test to address issues of confounding by indication at baseline. We hypothesized that following matched analysis, higher cost ASD surgeries would outperform lower cost interventions in terms of both patient-reported outcomes and deformity correction.Study Design.This was a retrospective study.To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4 degrees), and pelvic tilt (HC: 25.3 vs. LC: 22.4 degrees). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P=0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P=0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P=0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.3.Enthusiasm for adult spinal deformity (ASD) surgery has grown over the last two decades.1 At the same time, these procedures are resource-intensive, expensive and carry a high complication profile.2 The potential for complications also extends well beyond the initial postoperative period, and mechanical failure and consequent need for revision frequently occur several years following the index intervention. From a health policy perspective, the high cost associated with ASD surgery has been a target of increased scrutiny. General projections of health expenditures estimate that health care will reach 19.7% of the US gross domestic product by 2028, with Medicare experiencing the fastest growth in spending of major payers.3 Given that the prevalence of ASD has been estimated as high as 68% for those over age 60, it is unsurprising that costly interventions occurring more often in elderly patients are of significant interest to policymakers. 4 Although more invasive surgical interventions may be more expensive at baseline, they may also obviate the need for more expensive care in the years following the index surgery.At present, it remains unclear whether more aggressive and expensive procedures have the capacity to pay longer term dividends in terms of superior patient outcomes and lower likelihood of adverse events and revisions. Comparisons are frequently inhibited by a lack of sufficient follow-up, as well as confounding due to selection and indication bias. In an effort to address these questions in a more comprehensive fashion, we used a large, prospectively collected, spine surgical registry with extensive follow-up to evaluate differences in outcomes between higher cost and lower cost deformity procedures. This surgical registry has been utilized previously to address health policy questions in the setting of ASD surgery. We used propensity score matching (PSM) as a causal inference test to address issues of confounding by indication at baseline. We hypothesized that following matched analysis, higher cost ASD surgeries would outperform lower cost interventions in terms of both patient-reported outcomes and deformity correction.Study Design.This was a retrospective study.To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4 degrees), and pelvic tilt (HC: 25.3 vs. LC: 22.4 degrees). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P=0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P=0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P=0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.3.Enthusiasm for adult spinal deformity (ASD) surgery has grown over the last two decades. 1 At the same time, these procedures are resource-intensive, expensive and carry a high complication profile.2 The potential for complications also extends well beyond the initial postoperative period, and mechanical failure and consequent need for revision frequently occur several years following the index intervention. From a health policy perspective, the high cost associated with ASD surgery has been a target of increased scrutiny. General projections of health expenditures estimate that health care will reach 19.7% of the US gross domestic product by 2028, with Medicare experiencing the fastest growth in spending of major payers.3 Given that the prevalence of ASD has been estimated as high as 68% for those over age 60, it is unsurprising that costly interventions occurring more often in elderly patients are of significant interest to policymakers.4 Although more invasive surgical interventions may be more expensive at baseline, they may also obviate the need for more expensive care in the years following the index surgery.At present, it remains unclear whether more aggressive and expensive procedures have the capacity to pay longer term dividends in terms of superior patient outcomes and lower likelihood of adverse events and revisions. Comparisons are frequently inhibited by a lack of sufficient follow-up, as well as confounding due to selection and indication bias. In an effort to address these questions in a more comprehensive fashion, we used a large, prospectively collected, spine surgical registry with extensive follow-up to evaluate differences in outcomes between higher cost and lower cost deformity procedures. This surgical registry has been utilized previously to address health policy questions in the setting of ASD surgery. We used propensity score matching (PSM) as a causal inference test to address issues of confounding by indication at baseline. We hypothesized that following matched analysis, higher cost ASD surgeries would outperform lower cost interventions in terms of both patient-reported outcomes and deformity correction.Study Design.This was a retrospective study.To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4 degrees), and pelvic tilt (HC: 25.3 vs. LC: 22.4 degrees). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P=0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P=0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P=0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.3.Enthusiasm for adult spinal deformity (ASD) surgery has grown over the last two decades.1 At the same time, these procedures are resource-intensive, expensive and carry a high complication profile.2 The potential for complications also extends well beyond the initial postoperative period, and mechanical failure and consequent need for revision frequently occur several years following the index intervention. From a health policy perspective, the high cost associated with ASD surgery has been a target of increased scrutiny. General projections of health expenditures estimate that health care will reach 19.7% of the US gross domestic product by 2028, with Medicare experiencing the fastest growth in spending of major payers.3 Given that the prevalence of ASD has been estimated as high as 68% for those over age 60, it is unsurprising that costly interventions occurring more often in elderly patients are of significant interest to policymakers.4 Although more invasive surgical interventions may be more expensive at baseline, they may also obviate the need for more expensive care in the years following the index surgery.At present, it remains unclear whether more aggressive and expensive procedures have the capacity to pay longer term dividends in terms of superior patient outcomes and lower likelihood of adverse events and revisions. Comparisons are frequently inhibited by a lack of sufficient follow-up, as well as confounding due to selection and indication bias. In an effort to address these questions in a more comprehensive fashion, we used a large, prospectively collected, spine surgical registry with extensive follow-up to evaluate differences in outcomes between higher cost and lower cost deformity procedures. This surgical registry has been utilized previously to address health policy questions in the setting of ASD surgery. We used propensity score matching (PSM) as a causal inference test to address issues of confounding by indication at baseline. We hypothesized that following matched analysis, higher cost ASD surgeries would outperform lower cost interventions in terms of both patient-reported outcomes and deformity correction.Study Design.This was a retrospective study.To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4 degrees), and pelvic tilt (HC: 25.3 vs. LC: 22.4 degrees). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P=0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P=0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P=0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.3.Enthusiasm for adult spinal deformity (ASD) surgery has grown over the last two decades.1 At the same time, these procedures are resource-intensive, expensive and carry a high complication profile.2 The potential for complications also extends well beyond the initial postoperative period, and mechanical failure and consequent need for revision frequently occur several years following the index intervention. From a health policy perspective, the high cost associated with ASD surgery has been a target of increased scrutiny. General projections of health expenditures estimate that health care will reach 19.7% of the US gross domestic product by 2028, with Medicare experiencing the fastest growth in spending of major payers.3 Given that the prevalence of ASD has been estimated as high as 68% for those over age 60, it is unsurprising that costly interventions occurring more often in elderly patients are of significant interest to policymakers.4 Although more invasive surgical interventions may be more expensive at baseline, they may also obviate the need for more expensive care in the years following the index surgery.At present, it remains unclear whether more aggressive and expensive procedures have the capacity to pay longer term dividends in terms of superior patient outcomes and lower likelihood of adverse events and revisions. Comparisons are frequently inhibited by a lack of sufficient follow-up, as well as confounding due to selection and indication bias. In an effort to address these questions in a more comprehensive fashion, we used a large, prospectively collected, spine surgical registry with extensive follow-up to evaluate differences in outcomes between higher cost and lower cost deformity procedures. This surgical registry has been utilized previously to address health policy questions in the setting of ASD surgery. We used propensity score matching (PSM) as a causal inference test to address issues of confounding by indication at baseline. We hypothesized that following matched analysis, higher cost ASD surgeries would outperform lower cost interventions in terms of both patient-reported outcomes and deformity correction.Study Design.This was a retrospective study.To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4 degrees), and pelvic tilt (HC: 25.3 vs. LC: 22.4 degrees). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P=0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P=0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P=0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.3.Enthusiasm for adult spinal deformity (ASD) surgery has grown over the last two decades.1 At the same time, these procedures are resource-intensive, expensive and carry a high complication profile.2 The potential for complications also extends well beyond the initial postoperative period, and mechanical failure and consequent need for revision frequently occur several years following the index intervention. From a health policy perspective, the high cost associated with ASD surgery has been a target of increased scrutiny. General projections of health expenditures estimate that health care will reach 19.7% of the US gross domestic product by 2028, with Medicare experiencing the fastest growth in spending of major payers.3 Given that the prevalence of ASD has been estimated as high as 68% for those over age 60, it is unsurprising that costly interventions occurring more often in elderly patients are of significant interest to policymakers. 4 Although more invasive surgical interventions may be more expensive at baseline, they may also obviate the need for more expensive care in the years following the index surgery.At present, it remains unclear whether more aggressive and expensive procedures have the capacity to pay longer term dividends in terms of superior patient outcomes and lower likelihood of adverse events and revisions. Comparisons are frequently inhibited by a lack of sufficient follow-up, as well as confounding due to selection and indication bias. In an effort to address these questions in a more comprehensive fashion, we used a large, prospectively collected, spine surgical registry with extensive follow-up to evaluate differences in outcomes between higher cost and lower cost deformity procedures. This surgical registry has been utilized previously to address health policy questions in the setting of ASD surgery. We used propensity score matching (PSM) as a causal inference test to address issues of confounding by indication at baseline. We hypothesized that following matched analysis, higher cost ASD surgeries would outperform lower cost interventions in terms of both patient-reported outcomes and deformity correction.