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Cost-Utility Analysis of Operative Versus Nonoperative Treatment of Thoracic Adolescent Idiopathic Scoliosis

Jain, Amit, MD; Marks, Michelle C., MS; Kelly, Michael P., MD; Lenke, Lawrence G., MD§; Errico, Thomas J., MD; Lonner, Baron S., MD||; Newton, Peter O., MD∗∗; Sponseller, Paul D., MD; the Harms Study Group

doi: 10.1097/BRS.0000000000002936

Study Design. Cost-utility analysis

Objective. To compare the cost utility of operative versus nonoperative treatment of adolescent idiopathic scoliosis (AIS) and identity factors that influence cost-utility estimates.

Summary of Background Data. AIS affects 1% to 3% of children aged 10 to 16 years. When the major coronal curve reaches 50°, operative treatment may be considered. The cost utility of operative treatment of AIS is unknown.

Methods. A decision-analysis model comparing operative versus nonoperative treatment was developed for a hypothetical 15-year-old skeletally mature girl with a 55° right thoracic (Lenke 1) curve. The AIS literature was reviewed to estimate the probability, health utility, and quality-adjusted life years (QALYs) for each event. For the conservative model, we assumed that operative treatment did not result directly in any QALYs gained, and the health utility in AIS patients was the same as the age-matched US population mean. Costs were inflation-adjusted at 3.22% per year to 2015 US dollars. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates.

Results. Operative treatment was favored in 98.5% of simulations, with a median ICUR of $20,600/QALY (95% confidence interval, $20,500–$21,900) below the societal willingness-to-pay threshold (WTPT) of $50,000/QALY. The median incremental net monetary benefit associated with operative treatment was $15,100 (95% confidence interval, $14,800–$15,700). Operative treatment produced net monetary benefit across various WTPTs. Factors that most affected the ICUR were net costs associated with uncomplicated operative treatment, undergoing surgery during adulthood, and development of pulmonary complications.

Conclusion. Cost-utility analysis suggests that operative treatment of AIS is favored over nonoperative treatment and falls below the $50,000/QALY WTPT for patients with Lenke 1 curves.

Level of Evidence: 2

Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, MD

Setting Scoliosis Straight Foundation, San Diego, CA

Department of Orthopedic Surgery, Washington University, St. Louis, MO

§Department of Orthopedic Surgery, Columbia University, New York, NY

Department of Orthopedic Surgery, New York University, New York, NY

||Department of Orthopedic Surgery, Mount Sinai University, New York, NY

∗∗Department of Orthopedic Surgery, University of California San Diego, San Diego, CA.

Address correspondence and reprint requests to Paul D. Sponseller, MD, Johns Hopkins Children's Center, 1800 Orleans St, 7359A, Baltimore, MD 21287; E-mail:

Received 8 February, 2018

Revised 19 July, 2018

Accepted 20 July, 2018

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, grants, royalties, expert testimony, payment for lecture, travel/accommodations/meeting expenses.

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