title: Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial.
abstract: OBJECTIVE
  We analyzed the cost-effectiveness and cost-utility of treating failed back-surgery syndrome using spinal cord stimulation (SCS) versus reoperation.
  
  
  METHODS
  A disinterested third party collected charge data for the first 42 patients in a randomized controlled crossover trial. We computed the difference in cost with regard to success (cost-effectiveness) and mean quality-adjusted life years (cost-utility). We analyzed the patient-charge data with respect to intention to treat (costs and outcomes as a randomized group), treated as intended (costs as randomized; crossover failure assigned to a randomized group), and final treatment costs and outcomes.
  
  
  RESULTS
  By mean 3.1-year follow-up, 13 of 21 patients (62%) crossed from reoperation versus 5 of 19 patients (26%) who crossed from SCS (P < 0.025) [corrected]. The mean cost per success was US $117,901 for crossovers to SCS. No crossovers to reoperation achieved success despite a mean per-patient expenditure of US $260,584. The mean per-patient costs were US $31,530 for SCS versus US $38,160 for reoperation (intention to treat), US $48,357 for SCS versus US $105,928 for reoperation (treated as intended), and US $34,371 for SCS versus US $36,341 for reoperation (final treatment). SCS was dominant (more effective and less expensive) in the incremental cost-effectiveness ratios and incremental cost-utility ratios. A bootstrapped simulation for incremental costs and quality-adjusted life years confirmed SCS's dominance, with approximately 72% of the cost results occurring below US policymakers' "maximum willingness to pay" threshold.
  
  
  CONCLUSIONS
  SCS was less expensive and more effective than reoperation in selected failed back-surgery syndrome patients, and should be the initial therapy of choice. SCS is most cost-effective when patients forego repeat operation. Should SCS fail, reoperation is unlikely to succeed.
authors.affiliation: Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland 21287, USA. RNorth@jhmi.edu
authors.forename: Richard B
authors.initials: RB
authors.lastname: North
authors.forename: David
authors.initials: D
authors.lastname: Kidd
authors.forename: Jane
authors.initials: J
authors.lastname: Shipley
authors.forename: Rod S
authors.initials: RS
authors.lastname: Taylor
mesh_terms: D000328:Adult; D000368:Aged; D001416:Back Pain / Q000191:economics / Q000601:surgery* / Q000628:therapy*; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D018592:Cross-Over Studies; D004599:Electric Stimulation Therapy / Q000191:economics*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D012086:Reoperation / Q000191:economics*; D017211:Treatment Failure