1576. Five-Year Non-Operative Treatment Costs in Patients with Symptomatic Lumbar Stenosis or Spondylolisthesis Ultimately Requiring Surgery

Authors: Owoicho Adogwa, MD, MPH; Mark Davison, BS; Victoria Vuong; Daniel Lilly, BA; Shyam Desai, BA; Jessica Moreno; Joseph Cheng; Carlos Bagley (St Louis, MO)

Introduction: The costs and utilization of long-term maximal non-operative therapy (MNT) can be substantial; in the current era of bundled payments, the duration of conservative therapy trials should be reassessed. The purpose of this study is to characterize the utilization and costs of MNTs prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. Methods: A insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. Only patients with lumbar stenosis or spondylolisthesis and those continuously active within the insurance system for at least 5 years prior to the index operation were eligible. Results: A total of 4,133 out of 497,822 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion. 20.8% of patients were smokers, 44.5% had type II DM, and 38.2% were obese (BMI > 30 kg/m 2 ). Patient maximal non-operative therapy (MNT) utilization was as follows: 66.7% used NSAIDs, 84.4% used opioids, 58.6% used muscle relaxants, 65.5% received LESI, 66.6% had physical therapy, 21.1% presented to the ED, and 24.9% received chiropractor treatments. The total direct cost associated with all MNT prior to index spinal fusion was $9,000,968 ; LESI comprised the largest portion of the total cost of MNT ($4,094,646, 45.5%), followed by NSAIDS ($1,624,217, 18.0%) and opioid costs ($1,279,219, 14.2%). At the patient level, an average of $4,010 per patient utilizing therapy was spent on MNT prior to index lumbar surgery. Conclusion: Assuming minimal improvement in pain and functional disability after maximum non-operative therapies, the incremental cost effectiveness ratio (ICER) for MNT could be highly unfavorable. More effort is needed to identify patients earlier in the course of treatment that might benefit from surgery.