169 - Comparison of Patient Functional Outcome and System Reimbursement for...

#169 Comparison of Patient Functional Outcome and System Reimbursement for Lumbar Decompression via Standard Open versus Less Invasive Techniques

General Session: Advocacy of MIS

Presented by: R. Knight


R.Q. Knight (1)
C. Goldberg (1)
C. Spivak (1)
P. Jenkins (1)
M. Scribani (1)
N. Krupa (1)

(1) Bassett Healthcare Network, Department of Surgery, Cooperstown, NY, USA


Background Context: Degenerative lumbar conditions refractory to non-operative measures are traditionally treated via open direct decompression, a “gold standard”. Less invasive techniques assisted by tubular retractors and or endoscopic visualization continue to grow in popularity amongst surgeons and patients.

Purpose: Compare patient functional outcome measures and health system economic impact associated with open versus tube or endoscopically assisted direct decompression of the lumbar spine.

Study Design/Setting: Single center prospective non-randomized registry and chart review of patients requiring elective lumbar decompression.

Patient Sample: A consecutive cohort of 278 patients with refractory symptoms of lumbar spinal stenosis collected from January 2010 through July 2012.

Outcome Measures: Visual analog scale (back and leg pain), Oswestry Disability Index and Net revenue generated in subset of Medicare patients.

Methods: A prospective non-randomized registry was established for all operative spine care within our system. Functional outcome data, chart review for perioperative demographics, and hospital cost data was compiled on 278 consecutive elective lumbar degenerative cases and subset of 86 Medicare patients. Patients requiring spinal fusion or adjunctive procedures are excluded. Cases categorizes are open, tube-assisted, or endoscope-assisted. Surgeons chose procedures based on standard practice patterns. Data is collected by an independent clinical coordinator preoperatively, at one, four, and ten months postoperatively. Patients not returning to clinic are mailed outcome data forms. Perioperative demographics: length of hospital stay (days), intraoperative estimated blood loss (cc's), operative time (minutes), fluoroscopy time (seconds), occurrence of intraoperative or postoperative complications, and discharge to skilled nursing facilities. Hospital finance data year-to-date, January 2012 through July 2012, generated a Med/Surgery patient cost per day of hospital stay and cost per minute of operating room time. Medicare DRG 490 and APC data related to CPT 63047 was used to assess economic impact related to procedure type and location of service. Statistical analysis using SAS for ANOVA and Student´s t-test. Research was IRB approved.

Results: Case types were 125 open, 77 endoscope-assisted, and 76 tube-assisted. Demographic means: age 56.7 years, OR time 123.4 minutes, levels decompressed 1.3, estimated blood loss 69.6 ccs, fluoroscopy time 33.3 seconds, hospital stay 1.1 days. 12 intraoperative and 13 postoperative complications occurred. 8 patients required discharge to a skilled nursing facility. Significant functional outcome improvement on the basis of ODI, VASB, and VASL was experienced in each case type regardless of time interval (Group: Preop - ODI 49, VASB 64, VASL 66; 10 month - ODI 28, VASB 40, VASL 33). There was no significant difference between cohorts over time. Medicare revenue generated is net positive regardless of case type or location (Average 66% net inpatient revenue). Economic impact in this Medicare subset is heavily weight towards inpatient services.

Conclusions: Functional improvement following treatment of degenerative lumbar conditions via direct decompression should be anticipated regardless of case type: open, tube or endoscope-assisted. Each hospital system generates a system specific cost structure. Under present reimbursement scenarios overnight stay is a significant revenue generator. Reductions in operating room time and collaboration within hospital systems can improve the economics of direct lumbar decompression regardless of procedure type and location of service.