Economic and Outcomes Analysis of Recalcitrant Cervical Radiculopathy

Is Nonsurgical Management or Surgery More Cost-Effective?

Jeffrey A. Rihn, MD; Suneel Bhat, MD; Jonathan Grauer, MD; James Harrop, MD; Zoher Ghogawala, MD; Alexander R. Vaccaro, MD, PhD; Alan S. Hilibrand, MD

Disclosures

J Am Acad Orthop Surg. 2019;27(14):533-540. 

In This Article

Results

Utilities/Cost-effectiveness

The average lifetime per patient direct cost associated with a strategy of ACDF was $24,027 (Table 5). The average lifetime per patient direct cost with a strategy of cervical epidural injections ranged from $28,724 to $13,426 based on the success of the injections. The average incremental lifetime QALY increase against the base state of radiculopathy associated with surgery was 3.55, and the incremental lifetime QALY increase associated with a strategy of initial epidural injections ranged from 3.18 to 3.32. The average total number of lifetime surgeries associated with initial surgical management was 1.28, and the number associated with the initial management of cervical epidural injections ranged from 1.14 to 0.3 depending on the success of the injections. The average incremental cost-effectiveness ratio (ICER) associated with ACDF was $6,768 per QALY over the lifetime of the patient, whereas the ICER associated with cervical injections ranged from $9,033 to $4,044 per QALY based on the success rate of cervical injections. With lower ICERs representing a more dominant cost-effective strategy, this suggests that ACDF remains the dominant strategy for long-term durable success rates of epidural injections below 50% (Figure 1).

Figure 1.

Break-even ICER threshold of cervical epidural injections versus ACDF. ACDF = anterior cervical diskectomy and fusion, ICER = incremental cost effectiveness ratio

Sensitivities

The PSA varying all probabilities, outcomes, discounts, and costs ±10% demonstrated consistency with the results of our analysis. Trial runs that managed initially with ACDF and without cervical injections tended to yield higher incremental QALYs with a tendency to slightly higher associated reimbursements. Trial runs that managed initially with cervical injections tended to yield relatively lower incremental QALYs gained with a tendency toward slightly lower associated reimbursements. The clustering of results and the tendencies demonstrated by the PSA were driven by the rate of success of cervical epidural injections in each simulation scenario (Figure 2).

Figure 2.

Probabilistic sensitivity analysis. ACDF = anterior cervical diskectomy and fusion

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