Beatrice Ugiliweneza

Cancer after spinal fusion: the role of bone morphogenetic protein.

BACKGROUND Bone morphogenetic protein (BMP) is used in tens of thousands of spinal fusions each year. A trial evaluating a high-dose BMP formulation demonstrated that its use may be associated with an increased risk of cancer. OBJECTIVE To evaluate whether BMP, as commonly used today, is associated with an increased risk of cancer or benign tumors. METHODS We performed a retrospective study using the Thomson Reuter MarketScan database. We retained all patients who had no previous diagnosis of cancer or benign tumor and had at least 2 years of uninterrupted enrollment in the database before and after their operations. A propensity score--matched cohort was created to ensure greater covariate balance between treatment groups. RESULTS Within the propensity score--matched cohort (n = 4698), BMP-exposed patients had a nonsignificant increase in the rate of cancer diagnosis (9.37% vs 7.92%; P = .08). After adjustment for covariates, BMP exposure was associated with a 31% increased risk of benign tumor diagnosis (odds ratio, 1.31; 95% confidence interval, 1.02-1.68; P < .05). When the benign tumor diagnoses were stratified by organ type, BMP patients had significantly more diagnoses of benign nervous system tumors (0.81% vs 0.34%; P = .03), and within this group, benign tumors of the spinal meninges were much more common in the BMP-treated group (0.13% vs 0.02%; P = .002). CONCLUSION The results of this large, independent, propensity-matched study suggest that the use of BMP in lumbar fusions is associated with a significantly higher rate of benign neoplasms but not malignancies.

Spinal surgery: variations in health care costs and implications for episode-based bundled payments.

Study Design. Retrospective, observational. Objective. To simulate what episodes of care in spinal surgery might look like in a bundled payment system and to evaluate the associated costs and characteristics. Summary of Background Data. Episode-based payment bundling has received considerable attention as a potential method to help curb the rise in health care spending and is being investigated as a new payment model as part of the Affordable Care Act. Although earlier studies investigated bundled payments in a number of surgical settings, very few focused on spine surgery, specifically. Methods. We analyzed data from MarketScan. Patients were included in the study if they underwent cervical or lumbar spinal surgery during 2000–2009, had at least 2-year preoperative and 90-day postoperative follow-up data. Patients were grouped on the basis of their diagnosis-related group (DRG) and then tracked in simulated episodes-of-care/payment bundles that lasted for the duration of 30, 60, and 90 days after the discharge from the index-surgical hospitalization. The total cost associated with each episode-of-care duration was measured and characterized. Results. A total of 196,918 patients met our inclusion criteria. Significant variation existed between DRGs, ranging from

Long-term economic impact of coiling vs clipping for unruptured intracranial aneurysms.

11,180 (30-day bundle, DRG 491) to

Outcomes of percutaneous and paddle lead implantation for spinal cord stimulation: a comparative analysis of complications, reoperation rates, and health-care costs.

107,642 (30-day bundle, DRG 456). There were significant cost variations within each individual DRG. Postdischarge care accounted for a relatively small portion of overall bundle costs (range, 4%–8% in 90-day bundles). Total bundle costs remained relatively flat as bundle-length increased (total average cost of 30-day bundle:

Complications, Reoperation Rates, and Health-Care Cost Following Surgical Treatment of Lumbar Spondylolisthesis

33,522 vs.

Racial disparities in medicaid patients after brain tumor surgery

35,165 for 90-day bundle). Payments to hospitals accounted for the largest portion of bundle costs (76%). Conclusion. There exists significant variation in total health care costs for patients who undergo spinal surgery, even within a given DRG. Better characterization of impacts of a bundled payment system in spine surgery is important for understanding the costs of index procedure hospital, physician services, and postoperative care on potential future health care policy decision making. Level of Evidence: N/A

Racial disparities in outcomes of spinal surgery for lumbar stenosis.

BACKGROUND : Treatment of unruptured intracranial aneurysms (UIAs) involves endovascular coiling or aneurysm clipping. While many studies have compared these treatment modalities with respect to various clinical outcomes, few studies have investigated the economic costs associated with each procedure. OBJECTIVE : To determine the reoperation rate, postoperative complications, and inpatient and outpatient costs associated with surgical or endovascular treatment of patients with UIAs in the United States. METHODS : We utilized the MarketScan database to examine patients who underwent surgical clipping or endovascular coiling procedures for UIAs from 2000 to 2009, comparing reoperation rates, complications, and angiogram and healthcare resource use. Propensity score matching techniques were used to match patients. RESULTS : We identified 4,504 patients with surgically treated UIAs, with propensity score matching of 3,436 patients. Reoperation rates were significantly lower in the clipping group compared to the coiling group at 1- (P < .001), 2- (P < .001), and 5 years (P < .001) following the procedure. However, postoperative complications (immediate, 30 and 90 days) were significantly higher in those undergoing surgical clipping. Although hospital length of stay and costs were higher in the clipping group for the index procedure, the number of postoperative angiograms and outpatient services used at 1, 2, and 5 years were significantly higher in the coiling group. CONCLUSION : Though surgical clipping resulted in lower reoperation rates, it was associated with higher complication rates and initial costs. However, overall costs at 2 and 5 years were similar to endovascular coiling due to the significantly higher number of follow-up angiograms and outpatient costs in these patients. ABBREVIATIONS : SAH, subarachnoid hemorrhageUIAs, unruptured intracranial aneurysms.

Utilization of spinal cord stimulation in patients with failed back surgery syndrome.

Spinal cord stimulation (SCS) is a well‐established modality for the treatment of chronic pain, and can utilize percutaneous or paddle leads. While percutaneous leads are less invasive, they have been shown to have higher lead migration rates. In this study, we compared the long‐term outcomes and health‐care costs associated with paddle and percutaneous lead implantation.

Disparities in the outcomes of lumbar spinal stenosis surgery based on insurance status.

BACKGROUND Surgery remains the mainstay for management of lumbar spondylolisthesis and is considered an effective therapeutic modality following unsuccessful nonoperative treatment. Surgical procedures include decompression, decompression with instrumented arthrodesis, and decompression with noninstrumented arthrodesis. The purpose of this study was to examine the complications, reoperation rates, and health-care costs associated with each of these procedures. METHODS The MarketScan database was utilized to identify 16,556 patients with a primary diagnosis of lumbar spondylolisthesis who underwent surgical treatment from 2000 to 2009. Outcomes were evaluated in propensity score-matched cohorts, with complication rates analyzed with the chi-square test, reoperation rates analyzed using the Mantel-Haenszel test, and health-care resource use analyzed using the Wilcoxon signed-rank test. RESULTS Complication rates were significantly higher in patients who underwent arthrodesis compared with those who had decompression alone during the initial hospitalization (8.3% versus 4.8%; p < 0.0001) and at the time of the ninety-day follow-up (9.6% versus 5.5%; p < 0.0001). Complication rates were similar for those who received instrumented and noninstrumented arthrodesis. Patients who underwent decompression alone had higher reoperation rates at two years or more than those who received arthrodesis (15.7% versus 11.9%; p = 0.034). Patients with instrumented arthrodesis trended to have higher reoperation rates than those without instrumentation at five years or more (18.4% versus 10.6%; p = 0.063). Initial hospital costs and two-year and five-year overall costs (in 2009 U.S. dollars) were higher for patients managed with arthrodesis than for those who had decompression only (

Surgery for spinal stenosis: long-term reoperation rates, health care cost, and impact of instrumentation.

102,906 versus