title: Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation.
abstract: METHODS
  Cost-effectiveness analysis of a randomized plus observational cohort trial.
  
  
  OBJECTIVE
  Analyze cost-effectiveness of Spine Patient Outcomes Research Trial data over 4 years comparing surgery with nonoperative care for three common diagnoses: spinal stenosis (SPS), degenerative spondylolisthesis (DS), and intervertebral disc herniation (IDH).
  
  
  BACKGROUND
  Spine surgery rates continue to rise in the United States, but the safety and economic value of these procedures remain uncertain.
  
  
  METHODS
  Patients with image-confirmed diagnoses were followed in randomized or observational cohorts with data on resource use, productivity, and EuroQol EQ-5D health state values measured at 6 weeks, 3, 6, 12, 24, 36, and 48 months. For each diagnosis, cost per quality-adjusted life year (QALY) gained in 2004 US dollars was estimated for surgery relative to nonoperative care using a societal perspective, with costs and QALYs discounted at 3% per year.
  
  
  RESULTS
  Surgery was performed initially or during the 4-year follow-up among 414 of 634 (65.3%) SPS, 391 of 601 (65.1%) DS, and 789 of 1192 (66.2%) IDH patients. Surgery improved health, with persistent QALY differences observed through 4 years (SPS QALY gain 0.22; 95% confidence interval, CI: 0.15, 0.34; DS QALY gain 0.34, 95% CI: 0.30, 0.47; and IDH QALY gain 0.34, 95% CI: 0.31, 0.38). Costs per QALY gained decreased for SPS from $77,600 at 2 years to $59,400 (95% CI: $37,059, $125,162) at 4 years, for DS from $115,600 to $64,300 per QALY (95% CI: $32,864, $83,117), and for IDH from $34,355 to $20,600 per QALY (95% CI: $4,539, $33,088).
  
  
  CONCLUSIONS
  Comparative effectiveness evidence for clearly defined diagnostic groups from Spine Patient Outcomes Research Trial shows good value for surgery compared with nonoperative care over 4 years.
authors: The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Lebanon, NH 03756, USA. anna.tosteson@dartmouth.edu
authors: Anna N A
authors: AN
authors: Tosteson
authors: Tor D
authors: TD
authors: Tosteson
authors: Jon D
authors: JD
authors: Lurie
authors: William
authors: W
authors: Abdu
authors: Harry
authors: H
authors: Herkowitz
authors: Gunnar
authors: G
authors: Andersson
authors: Todd
authors: T
authors: Albert
authors: Keith
authors: K
authors: Bridwell
authors: Wenyan
authors: W
authors: Zhao
authors: Margaret R
authors: MR
authors: Grove
authors: Milton C
authors: MC
authors: Weinstein
authors: James N
authors: JN
authors: Weinstein
mesh_terms: D057186:Comparative Effectiveness Research; D003362:Cost-Benefit Analysis; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000191:economics / Q000601:surgery* / Q000628:therapy; D019637:Orthopedic Procedures / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic / Q000191:economics; D013130:Spinal Stenosis / Q000191:economics / Q000601:surgery* / Q000628:therapy; D013168:Spondylolisthesis / Q000191:economics / Q000601:surgery* / Q000628:therapy; D011795:Surveys and Questionnaires