Cost Benefit Analysis of Preoperative Optimization of Modifiable Health Conditions Prior to Adult Cervical Deformity Surgery

Introduction: Benefits and cost differences to optimizing comorbidities prior to surgical adult cervical deformity correction merits further study.

Methods: ACD patients with available up to 2-year data were included. Preoperative optimization for osteoporosis was assessed by treatment with an FDA approved drug prior to surgery. Patients were divided into 2 groups: those who had preoperative rehabilitation [Prehab] and those who did not [no Prehab]. Prehab consisted of cognitive behavioral therapy and physical therapy. Nutritional status assessed by ranking patients into quartiles (Q1-Q4) by baseline BMI. Q1 (low BMI) and Q4 (high BMI) were considered not optimized. Patients stratified by optimization in all three (Opt) or non-optimized. Cost analysis was based on average Medicare reimbursement while accounting for surgical approach and revision status, inflation adjusted to 2022. For QALY analysis, utility was calculated using EQ-5D as previously published. ANCOVA and logistic regression analyses assessed outcomes while accounting for surgical and demographic differences between groups.

Results: 547 (average 57.9±12.1 years, 48% female, 29.0±6.82 kg/m2) were included. Multivariate analysis confirmed Prehab patients more likely to improve in ODI (OR .055 [CI .006-.476], p=.008) at 2Y. However, Prehab and no Prehab patients exhibited similar ODI IHS recovery rates from BL to 2Y, P<.05. Total cost for Prehab patients was $59,272 compared to $72,878 for not Prehab, P<.05. Cost effectiveness was determined via cost per QALY: Prehab = $14,463 and not Prehab = $45,515, P<.05. For osteoporosis (85.4% Opt), Opt patients had lower odds of 2Y complications (OR: 0.207 [.086, .498],p <.001) and lower cost ($28,053 vs. $33,171,p=.002) compared to non-optimized patients. Optimized patients had lower cost at 2 years ($33,898.40 vs. $36,861.86, p=.009). Linear regression modeling was significant for optimized BMI predicting lower cost at 2 years with average change of $2963.45 (OR:.45 [1.02,2.89], p=.009).

Conclusion : While preoperative optimization of modifiable health conditions may present greater upfront costs, the longer-term cost savings associated with optimized adult cervical deformity patients may outweigh the initial cost.