What Are the Costs of Cervical Radiculopathy Prior to Surgical Treatment?

Cameron Barton, MD; Piyush Kalakoti, MD; Nicholas A. Bedard, MD; Nathan R. Hendrickson, MD; Comron Saifi, MD; Andrew J. Pugely, MD

Disclosures

Spine. 2019;44(13):937-942. 

In This Article

Discussion

Refractory cervical radiculopathy is a condition commonly treated surgically with ACDF. While the operative costs have been previously defined, little is known about the costs that occur prior to operative intervention. In this context, the current study comprehensively examined nonoperative costs including those incurred for diagnostic tests and treatment modalities in patients with cervical radiculopathy in the year prior to ACDF. Overall, we found the average diagnostic and nonoperative treatment course to be relatively inexpensive compared with surgical treatment. These expenses speak to the behavior of providers treating cervical radiculopathy, a condition with a weaker base of evidence to guide treatment. Several of these findings merit further discussion.

Approximately, two-thirds of the costs associated with cervical radiculopathy were from diagnostic modalities, with 100% of patients undergoing at least one diagnostic test. MR imaging comprised the highest relative cost of 37.0% and nearly 87% of our patient population underwent MR imaging. CT scan was utilized in 35% of patients, with a relative cost of 18.6%. Comparing these costs to CPGs, the NASS CPG gave CT and MRI a grade "B" recommendation.[1] The combined costs for MRI and CT scan comprised of over half of the total nonoperative costs (55.6%), indicating that the majority of diagnostic costs for cervical radiculopathy are supported by fair evidence in CPGs. Interestingly, only 58% of patients had radiographs taken for the diagnosis of cervical radiculopathy. This data reveals that patients undergoing ACDF have a variable diagnostic imaging work-up.

Most patients (73%) underwent at least one perscribed treatment in the year prior to ACDF. Injections held the highest relative treatment cost ($3.01 million), with approximately one-quarter patient utilization. PT was only utilized by 18% of patients, with a low relative cost of 7.9%. Bracing was utilized by 13% of patients while chiropractic services were utilized by 6% of patients. This data highlights the variable nonoperative treatment courses experienced by patients prior to ACDF. The variable treatment courses experienced by patient population may be attributed by the lack of adequate evidence supporting nonoperative treatments for cervical radiculopathy. Of the nonoperative treatments identified in this study, none received grade "A" or "B" recommendations in the NASS CPG.[1]

Medications comprised 6.0% ($862,751) of the total costs. Narcotic medications held the highest percentage of patient utilization at 41%, with a low relative cost of 3.6%. Although narcotic medications held the highest patient utilization, but limited data exist supporting use of narcotics in the patient population. The NASS CPG did not provide a recommendation for medications for cervical radiculopathy due to "no studies to adequately address the role of pharmacologic treatment."[1] The current study highlights the need for future studies to address the role of pharmacologic treatment in this patient population, particularly narcotic use. With lack of evidence-based guidelines recommending the beneficial effect of opioids in cervical radiculopathy, the high-narcotic utilization rates as demonstrated in our data serves as a red-flag, warranting efforts directed at combating or mitigating opioid use in patients presenting with cervical radiculopathy including identification of high-risk patients and supplementing with alternative pain medications to prevent potential abuse.

The true costs of ACDF have varied widely in prior studies, largely due to inherent difficulties in obtaining and reporting true costs of a procedure and associated services. Variables affecting cost differences include insurance payer, geographic location, and even patient demographics including sex and race.[8] Large differences in hospital charges versus true cost and actual reimbursement also exist. This study found the mean cost of ACDF to be $22,559, including $18,142 for the hospital stay and $4457 in professional payments. In comparison, prior studies have revealed costs or charges for ACDF ranging from $5396 to $53,893.[8–12] ACDF costs are increasing, with one study showing an increase in hospital charges for ACDF from $24,755 in 2000 to $53,893 in 2009.[8] Our results fall on the lower end of previously reported costs, likely due to our figures representing actual paid reimbursements rather than hospital charges.

Despite the obvious merit in our study, there exists several potential limitations that needs to be addressed and considered prior to interpretation of our findings. Since the study utilized data from a claims registry, limitations governing those to large administrative cohorts apply to the present study. This includes documentation and coding errors. The use of CPT codes for defining nonoperative diagnostic and treatment modalities excludes facility fees, and therefore the reported cost estimates represent an under-inflated overview for the incurred economic burden in the year prior to surgical intervention. For example, the relatively low cost of imaging techniques including MRI in this study reflects the fact that only professional charges can be obtained when querying the data source using CPT codes. Further, these cost figures may underestimate the cost of nonoperative interventions, as diagnostic modalities and nonoperative treatments may have been billed and reimbursed under a different ICD-9 code, that is, neck pain. Despite this limitation, a comprehensive breakdown of cost data for various non-diagnostic and conservative interventions are less known and since the facility charges represent only a fraction of the total incurred costs, the projected data serves as a best approximation of the economic burden in patients with cervical radiculopathy. The study design was descriptive and is confounded by the lack of functional severity or radiological parameters that may have impacted costs. Further, the reported cost estimates are based upon our pre-determined categories of diagnostic and treatment modalities based upon the presence of ICD-9 or CPT coding definitions and may not truly reflect the actual nonoperative costs, albeit a close approximation. The secondary data source limits granularity in analysis that may influence cost estimates such as the impact of average time interval between diagnosis and commencement of nonoperative treatment modalities, initiation of conservative treatment, and surgical intervention. The observational design of the study limits the scope in predicting causality including indications for specific diagnostic or nonoperative intervention over others. Despite these limitations, the longitudinal nature of the data source utilized for a comprehensive depiction of cost data for various diagnostic and conservative interventions from across diverse practice settings enables baseline generalization and provides framework for future studies investigating the impact of recent healthcare policies on the economics associated with cervical radiculopathy.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....