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Cost-effectiveness of Operative versus Nonoperative Treatment of Adult Symptomatic Lumbar Scoliosis an Intent-to-treat Analysis at 5-year Follow-up

Carreon, Leah Y. MD, MSc; Glassman, Steven D. MD∗,†; Lurie, Jon MD, MS; Shaffrey, Christopher I. MD§; Kelly, Michael P. MD, MSc; Baldus, Christine R. RN, MHA; Bratcher, Kelly R. RN; Crawford, Charles H. III∗,†; Yanik, Elizabeth L. PhD; Bridwell, Keith H. MD

doi: 10.1097/BRS.0000000000003118

Study Design. Secondary analysis using data from the NIH-sponsored study on adult symptomatic lumbar scoliosis (ASLS) that included randomized and observational arms.

Objective. The aim of this study was to perform an intent-to-treat cost-effectiveness study comparing operative (Op) versus nonoperative (NonOp) care for ASLS.

Summary of Background Data. The appropriate treatment approach for ASLS continues to be ill-defined. NonOp care has not been shown to improve outcomes. Surgical treatment has been shown to improve outcomes, but is costly with high revision rates.

Methods. Patients with at least 5-year follow-up data were included. Data collected every 3 months included use of NonOp modalities, medications, and employment status. Costs for index and revision surgeries and NonOp modalities were determined using Medicare Allowable rates. Medication costs were determined using the RedBook and indirect costs were calculated based on reported employment status and income. Qualityadjusted life year (QALY) was determined using the SF6D.

Results. There were 81 of 95 cases in the Op and 81 of 95 in the NonOp group with complete 5-year follow-up data. Not all patients were eligible 5-year follow-up at the time of the analysis. All patients in the Op and 24 (30%) in the NonOp group had surgery by 5 years. At 5 years, the cumulative cost for Op was $96,000 with a QALY gain of 2.44 and for NonOp the cumulative cost was $49,546 with a QALY gain of 0.75 with an incremental cost-effectiveness ratio (ICER) of $27,480 per QALY gain.

Conclusion. In an intent-to-treat analysis, neither treatment was dominant, as the greater gains in QALY in the surgery group come at a greater cost. The ICER for Op compared to NonOp treatment was above the threshold generally considered cost-effective in the first 3 years of the study but improved over time and was highly cost-effective at 4 and 5 years.

Level of Evidence: 2

This is an intent-to-treat cost-effectiveness study, in which neither nonsurgical nor surgical treatment was dominant for adult lumbar scoliosis, as greater quality-adjusted life years gains in the surgery group come at a greater cost.

Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY

University of Louisville School of Medicine Department of Orthopaedic Surgery, 550 S. Jackson St., 1st Floor ACB Louisville, KY

Department of Medicine, Geisel School of Medicine at Dartmouth, One Medical Center Dr., Lebanon, NH

§Department of Orthopaedic Surgery Spine Division, Duke University School of Medicine, Durham, NC

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO.

Address correspondence and reprint requests to Leah Y. Carreon MD, MSc, Norton Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202; E-mail:

Received 15 January, 2019

Revised 21 February, 2019

Accepted 8 May, 2019

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

National Institute of Arthritis and Musculoskeletal and Skin Diseases (5R01AR055176-03) funds were received in support of this work.

Relevant financial activities outside the submitted work: board membership, consultancy, grants, royalties, patents, employment, travel/accommodations/meeting expenses.

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