From the 2019 HVPAA National Conference
Dr. Majd Marrache (Johns Hopkins Medical Institute), Mr. Andrew Harris (Johns Hopkins Medical Institute), Dr. Michael Raad (Johns Hopkins Medical Institute), Dr. Varun Puvanesarajah (Johns Hopkins Medical Institute), Dr. Amit Jain (Johns Hopkins Medical Institute)
Anterior cervical discectomy and fusion (ACDF) is commonly performed to treat symptomatic degenerative cervical spine pathologies.
With the advent of a bundled payment approach, it has become increasingly important to understand how healthcare resources are distributed in the perioperative period surrounding ACDF.
Using a private insurance claims database, we identified patients who underwent single-level, inpatient ACDF for degenerative spinal disease. Patients were selected using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Gross healthcare payments for outpatient services, drug claims, laboratory tests and inpatient admissions were determined from insurance claims spanning 6-months preoperatively to 6-months postoperatively.
In our cohort containing 33,617 patients, median perioperative spending within the year encompassing surgery totaled $37,398 (Interquartile range (IQR): $28,536 – 50,150) per patient. Index hospital admission accounted for the highest proportion of total spending (79%) with a median spending of $30,131 (IQR: $22,483 – 40,753). Preoperative spending accounted for 9.6% of total spending, $3,116 (IQR: $1,809 – 5,226) per patient. Postoperative spending accounted for 11.4% of total spending, $1,527 (IQR: $434 – 4,134). Imaging (39%), office visits (15%) and physical therapy (10%) were the highest contributors to preoperative spending. Postoperatively, unplanned hospital readmission (6%) contributed the most to postoperative spending (45%), followed by imaging (12%) and physical therapy (11%). Patients with unplanned readmissions had significantly higher spending in the postoperative period compared to those who were not readmitted ($26,456 vs $1,304, p<0.001). Most utilized services postoperatively were imaging, office visits and opioid prescription medication. Discharge to a rehabilitation facility was associated with higher postoperative spending ($22,717) compared to patients discharged home ($1,495), home with home care ($2,980) and to another facility ($5,177), p<0.001.
The majority of overall spending in the 1-year period encompassing ACDF surgery can be attributed to the surgical admission, while diagnostic testing represents the majority of preoperative spending and unplanned readmissions represent the highest percentage of postoperative spending.
Although surgery accounted for the greatest costs, other sources of cost before and after ACDF surgery are not trivial and may be potential targets for cost reduction.