title: Explantation Rates and Healthcare Resource Utilization in Spinal Cord Stimulation.
abstract: OBJECTIVE
  Certain patients ultimately undergo explantation of their spinal cord stimulation (SCS) devices. Understanding the predictors and rates of SCS explantation has important implications for healthcare resource utilization (HCRU) and pain management. The present study identifies explant predictors and discerns differences in HCRU for at-risk populations.
  
  
  METHODS
  We designed a large, retrospective analysis using the Truven MarketScan Database. We included all adult patients who underwent a SCS trial from 2007 to 2012. Patients were grouped into cohorts that remained explant-free or underwent explantation over a three-year period, and multivariate models evaluated differences in healthcare resource utilization.
  
  
  RESULTS
  A total of 8727 unique instances of trial implants between 2007 and 2012 were identified. Overall, 805 (9.2%) patients underwent device explantation. One year prior to SCS implantation, the explant cohort had significantly higher median baseline costs ($42,140.3 explant vs. $27,821.7 in non-explant groups; p < 0.0001), total number of pain encounters (180 vs. 103 p < 0.0001), and associated costs ($15,446.9 vs. $9,227.9; p < 0.0001). The explant cohort demonstrated increased use of procedures (19.0 vs. 9.0; p < 0.0001) compared to non-explanted patients. For each month after initial SCS implantation, explanted patients had a slower decrease in total costs (4% vs. 6% in non-explant; p < 0.01). At the month of explant, explant patients were expected to have incurred 2.65 times the total cost compared to the non-explant cohort (CR 2.65, 95% CI [1.83, 3.84]; p < 0.001). Medium volume providers had lower rates of explantation at one-year and three-years compared to low volume providers (p = 0.042). Increased age and Charlson index were independent predictors of explantation during the same periods.
  
  
  CONCLUSIONS
  In this nationwide analysis, we identified that SCS device explantation is correlated with patients who have higher baseline costs, higher total cost post-SCS implantation, and increased use of procedures to control pain. The higher rates of explantation at three-years postimplant among low volume providers suggest that variations in provider experience and approach also contributes to differences in explantation rates.
authors.affiliation: Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Jing L
authors.initials: JL
authors.lastname: Han
authors.affiliation: Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Kelly R
authors.identifier: http://orcid.org/0000-0002-9220-3563
authors.initials: KR
authors.lastname: Murphy
authors.affiliation: Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Syed Mohammed Qasim
authors.identifier: http://orcid.org/0000-0002-8006-5343
authors.initials: SMQ
authors.lastname: Hussaini
authors.affiliation: Department of Biostatistics, Duke University Medical Center, Durham, NC, USA.
authors.forename: Siyun
authors.initials: S
authors.lastname: Yang
authors.affiliation: Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Beth
authors.initials: B
authors.lastname: Parente
authors.affiliation: Department of Biostatistics, Duke University Medical Center, Durham, NC, USA.
authors.forename: Jichun
authors.initials: J
authors.lastname: Xie
authors.affiliation: Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Promila
authors.initials: P
authors.lastname: Pagadala
authors.affiliation: Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Shivanand P
authors.initials: SP
authors.lastname: Lad
mesh_terms: D000328:Adult; D000368:Aged; D059350:Chronic Pain / Q000191:economics* / Q000628:therapy; D015331:Cohort Studies; D020878:Device Removal / Q000191:economics* / Q000639:trends*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D012189:Retrospective Studies; D062187:Spinal Cord Stimulation / Q000191:economics* / Q000639:trends*
keywords: Chronic pain; device explantation; explant rate; healthcare resource utilization; spinal cord stimulator