The spine journal : official journal of the North American Spine Society | 2019
Creating Value in Spine Surgery: Using Patient Reported Outcomes to Compare the Short-term Impact of Different Orthopaedic Surgical Procedures.
Abstract
BACKGROUND CONTEXT\nSociety increasingly asks Medicine to create value for patients. As healthcare costs rise, this question will become more important. Debate exists regarding the relative value of many surgical procedures, including spinal surgery. Comparison of the relative value that patients experience after different orthopaedic procedures is theoretical, but informs the ongoing debate.\n\n\nMETHODS\nThe Patient Reported Outcome Measurement Information System (PROMIS) assessments for Physical Function, Pain Interference, and Depression are routinely collected in our orthopaedic clinics. Patients who underwent lumbar discectomy (DSC) or arthroscopic anterior cruciate ligament reconstruction (ACLR) were retrospectively identified. Data relating to PROMIS domains, patient demographics, and other relevant encounter details were extracted. The primary outcomes were (i) pre-operative PROMIS domain scores and (ii) scores at a minimum of 40 days post-operatively for DSC patients and 133 days post-operatively for ACLR patients, and (iii) the change in scores with surgery. Propensity score matching identified age-, sex-, race-, and comorbidity-matched groups from each cohort. Chi-square tests and non-parametric Kruskal-Wallis tests compared the distribution of outcomes and characteristics. Multivariate linear regression models with interactions between the matched cohort and operative phase estimated the change in the outcomes scores between the two cohorts and controlled for the baseline differences between them.\n\n\nRESULTS\nBefore surgery, the DSC cohort had lower physical function, higher pain interference and higher depression scores as compared to the ACLR cohort. This pattern remained post-operatively, indicating less desirable outcomes for DSC patients. However, after controlling for their baseline scores, DSC patients experienced significantly greater improvements after surgery of 3.84 (95% CI: 1.08 to 6.60; p=0.01), -4.87 (95% CI: -7.52 to -2.23; p<0.001), and -2.95 (95% CI: -5.70 to -0.21; p=0.04) points in their physical function, pain interference, and depression scores, respectively, as compared to ACLR patients.\n\n\nCONCLUSIONS\nBased upon PROMIS assessments at short-term follow-up, DSC patients receive a larger benefit from surgery than ACLR despite the overall less desirable post-operative PROMIS scores in the DSC cohort. This result, while theoretical, informs the debate regarding the comparative value of DSC to patients.