Elsevier

World Neurosurgery

Volume 109, January 2018, Pages e389-e397
World Neurosurgery

Original Article
Surgery and Radiotherapy for Symptomatic Spinal Metastases Is More Cost Effective Than Radiotherapy Alone: A Cost Utility Analysis in a U.K. Spinal Center

https://doi.org/10.1016/j.wneu.2017.09.189Get rights and content

Background

Surgery for symptomatic spinal metastases is effective at prolonging ambulation and life, but it can appear costly at first glance. We have studied the difference between the cost of surgery and reimbursement received, and the cost-effectiveness of surgery in a U.K. tertiary referral spinal center.

Methods

A cost-versus-reimbursement and cost–utility analysis was performed in a prospective cohort of patients admitted for surgical treatment of spinal metastases. Outcome measures were health-related quality of life using the EuroQol EQ-5D-3L, Frankel score, quality-adjusted life years (QALYs), and treatment and reimbursement costs.

Results

One hundred thirty consecutive patients were prospectively recruited, of whom 92 had information available for cost and reimbursement comparison, and 100 had information to complete cost–utility analysis. Median cost of hospital treatment per patient was £20,752; median reimbursement received was £18,291, with a median shortfall of £1,967. Surgery in addition to radiotherapy over a lifetime horizon was both more effective and less costly than radiotherapy alone, and therefore was found to be cost-effective.

Conclusions

Our results demonstrate that reimbursement to hospitals for surgical management of symptomatic spinal metastases in the United Kingdom is broadly in line with costs, and that there was an overall saving as a result of community care costs being mitigated by patients walking for longer, which is within the expected National Health Service threshold. Surgery for metastatic spinal tumors is effective and a good value for the money.

Introduction

Spinal metastases occur in up to 75% of the most common cancers, including breast, prostate, and lung cancer,1, 2 of which 26% may develop into skeletal related events, including pathologic fracture and metastatic spinal cord compression (MSCC).3 In the United Kingdom, the National Institute for Health and Care Excellence (NICE) have produced guidelines that promote surgical management in approximately 70% of patients with symptoms of MSCC.4, 5 These guidelines are supported by Patchell et al.,6 who demonstrated a higher percentage of people able to mobilize, greater longevity of ambulation, and better survival following surgical management in conjunction with radiotherapy compared with radiotherapy alone as primary treatment.6 Despite surgery, MSCC has a significant influence on quality of life and survival,7 and in tandem there are significant hospital costs associated with the surgical management of symptomatic spinal metastases, which we have previously reported as averaging £16,885 per patient,8 and when combined with out of hospital costs may be as high as €87,814.9 Providing good-value healthcare, which is both high quality and affordable is vital to the sustainability of the National Health Service (NHS) and other publicly funded healthcare systems.10 In today's tough economic climate, there is an emerging body of literature analyzing the cost-effectiveness of medical interventions to inform process changes that promote efficiency.11 Clinicians are in the optimal position to develop and deliver changes to practice, maintaining the focus on high quality patient care.

Different financial metrics are available to assist with analysis. We have previously reported the average in-hospital cost of surgically treating symptomatic spinal metastases in one U.K. center.8 The difference between this and the reimbursement rate that the hospital receives from the NHS is important at local and national levels; this has not yet been determined in patients with symptomatic spinal metastases. In other conditions, including hip and knee revision surgery, there is a possible shortfall in reimbursement of £861–4,566 per patient,12, 13 which was suggested to be largely associated with a more complex patient case mix than the NHS average in the hospitals studied, with patients requiring more expensive or longer treatment despite receiving the same, nationally averaged, reimbursement tariff for that patient group. This shortfall requires the departments in question to implement more efficient pathways, or negotiate local variations to the tariff. As an additional incentive for some departments, several tariffs are now reimbursed on the basis of cost of evidence-based, efficient, patient pathways, rather than national average cost, and future tariffs may be split between healthcare and social care systems.14

At a national level, recommendations for healthcare service provision are based on cost–utility analysis, balancing cost of treatment with quality and length of life gained following treatment, measured in quality-adjusted life years (QALYs).15 Recommendations by NICE have implied an upper limit of £30,000/QALY for NHS-funded treatments,15, 16 although there is considerable debate about the appropriateness of this threshold,16, 17 and a suggestion that populations may be willing to pay more for end-of-life management than short-term health problems.18 In patients with symptomatic spinal metastases, cost of surgical management over a lifetime horizon has been found to be both more expensive, and more effective than nonsurgical management19, 20; the incremental cost per QALY gained for surgery compared with radiotherapy alone has been estimated at $250,307 by Furlan et al.,19 which is significantly higher than the $50,000 commonly used threshold in the United States,21 whereas Miyazaki et al.22 estimated it at $42,003.22 There is a paucity of data in this area,23 and methodologies differ significantly, giving rise to significant variations in cost effectiveness. The former study looked at medical costs combined with estimated community palliative care costs; these high-input homecare costs can be reduced by successful surgical intervention, improving cost effectiveness.

We have studied the cost effectiveness of the surgical treatment of MSCC at one London center. We aimed to determine whether reimbursement was broadly in line with cost, and the cost effectiveness of surgical treatment of metastatic spine disease.

Section snippets

Subjects

Consecutive patients were prospectively recruited at a single NHS spinal tertiary referral center in London if they required surgery for symptomatic spinal metastases from any known or unknown primary cancer, verified by intraoperative histology. Patients were recruited between 2009 and 2015. Patients were included in the analysis if they were confirmed as having died, or if they had at least 12 months of follow-up data and were confirmed alive in July 2015 following a search of records of

Results

During the study period, 130 consecutive patients were recruited, of whom 92 had information available to complete cost and reimbursement comparison, and 100 had information available to complete the cost–utility analysis.

Principle Findings

Symptomatic spinal metastases represent a significant clinical and economic burden. To our knowledge, this study is the first to investigate the cost utility of surgical management of symptomatic spinal metastases using prospectively collected health utility data, and the first health utility study for MSCC in the United Kingdom. There is a perception among surgeons that hospitals in the United Kingdom are under-reimbursed for the work they perform under the current system. We found a

Conclusion

Our results demonstrate that reimbursement to a tertiary referral hospital for surgical management of symptomatic spinal metastases in the United Kingdom is broadly in line with costs, and that because of community care costs being mitigated by a greater percentage of ambulatory patients with better quality of life, surgery for MSCC is both effective and a good value for the money.

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  • Cited by (0)

    This work was performed at University College London Hospital, which receives funding from the National Institute for Health Research Biomedical Research Centre. David Choi receives research funding from DePuy Synthes and for other projects from DePuy Synthes, Icotec, and the Wellcome Trust. The researchers work in an independent capacity to the funders.

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