title: Bending the Cost Curve-Establishing Value in Spine Surgery.
abstract: As publically promoted by all stakeholders in health care reform, prospective outcomes registry platforms lie at the center of all current evidence-driven value-based models.
  
  
  
  To demonstrate the variability in outcomes and cost at population level and individual patient level for patients undergoing spine surgery for degenerative diseases.
  
  
  
  Retrospective analysis of prospective longitudinal spine registry data was conducted. Baseline and postoperative 1-year patient-reported outcomes were recorded. Previously published minimal clinically important difference for Oswestry Disability Index (14.9) was used. Back-related resource utilization and quality-adjusted life years (QALYs) were assessed. Variations in outcomes and cost were analyzed at population level and at the individual patient level.
  
  
  
  A total of 1454 patients were analyzed. There was significant improvement in patient-reported outcomes at postoperative 1 year ( P < .0001). For patients demonstrating health benefit at population level, 12.5%, n = 182 of patients experienced no gain from surgery and 38%, n = 554 failed to achieve minimal clinically important difference. Mean 1-year QALY-gained was 0.29; 18% of patients failed to report gain in QALY. For patients with 2-year follow-up, surgery resulted in 0.62 QALY-gained at average direct cost of $28 953. A wide variation in both QALY-gained and cost was observed.
  
  
  
  Spine treatments that on average are cost-effective may have wide variability in value at the individual patient level. The variability demonstrated here represents an opportunity, through registries, to identify specific care that may be less effective, and refine patient-specific care delivery and indications to drive overall group-level treatment value. Understanding value of spine care at an individualized as well as population level will allow clinicians, and eventually payers, to better target resources for improving care for nonresponders, ultimately driving up the average health for the whole population.
authors.affiliation: Department of Orthopedics Surgery and Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Scott L
authors.initials: SL
authors.lastname: Parker
authors.affiliation: Department of Orthopedics Surgery and Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Silky
authors.initials: S
authors.lastname: Chotai
authors.affiliation: Department of Orthopedics Surgery and Neurological surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Clinton J
authors.initials: CJ
authors.lastname: Devin
authors.affiliation: Spinal Cord Injury Clinical Research Unit, Krembil Neuroscience Centre, University Health Network, Toronto, Canada.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Tetreault
authors.affiliation: Center for Spine Health, Department of Neurosurgery and Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Mroz
authors.affiliation: Department of Orthopedics, University of Utah School of Medicine, Salt Lake City, Utah.
authors.forename: Darrel S
authors.initials: DS
authors.lastname: Brodke
authors.affiliation: Division of Neurosurgery, University of Toronto, Toronto, Canada.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Fehlings
authors.affiliation: Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: McGirt
mesh_terms: D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D000071066:Patient Reported Outcome Measures; D019057:Quality-Adjusted Life Years; D012042:Registries; D012189:Retrospective Studies; D013122:Spinal Diseases / Q000601:surgery*; D013997:Time Factors
keywords: Cost; Cost-effectiveness; Patient-reported outcomes; QOD; Spine; Spine registry; Surgery; Value