Browsing by Author "Hassanzadeh, Hamid"

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    Cost-utility analysis of cervical deformity surgeries using 1-year outcome.
    (The spine journal : official journal of the North American Spine Society, 2018-09) Poorman, Gregory W; Passias, Peter G; Qureshi, Rabia; Hassanzadeh, Hamid; Horn, Samantha; Bortz, Cole; Segreto, Frank; Jain, Amit; Kelly, Michael; Hostin, Richard; Ames, Christopher; Smith, Justin; LaFage, Virginie; Burton, Douglas; Bess, Shay; Shaffrey, Chris; Schwab, Frank; Gupta, Munish

    Background context

    Cost-utility analysis, a special case of cost-effectiveness analysis, estimates the ratio between the cost of an intervention to the benefit it produces in number of quality-adjusted life years. Cervical deformity correction has not been evaluated in terms of cost-utility and in the context of value-based health care. Our objective, therefore, was to determine the cost-utility ratio of cervical deformity correction.

    Study design

    This is a retrospective review of a prospective, multicenter cervical deformity database. Patients with 1-year follow-up after surgical correction for cervical deformity were included. Cervical deformity was defined as the presence of at least one of the following: kyphosis (C2-C7 Cobb angle >10°), cervical scoliosis (coronal Cobb angle >10°), positive cervical sagittal malalignment (C2-C7 sagittal vertical axis >4 cm or T1-C6 >10°), or horizontal gaze impairment (chin-brow vertical angle >25°). Quality-adjusted life years were calculated by both EuroQol 5D (EQ5D) quality of life and Neck Disability Index (NDI) mapped to short form six dimensions (SF6D) index. Costs were assigned using Medicare 1-year average reimbursement for: 9+ level posterior fusions (PF), 4-8 level PF, 4-8 level PF with anterior fusion (AF), 2-3 level PF with AF, 4-8 level AF, and 4-8 level posterior refusion. Reoperations and deaths were added to cost and subtracted from utility, respectively. Quality-adjusted life year per dollar spent was calculated using standardized methodology at 1-year time point and subsequent time points relying on maintenance of 1-year utility.

    Results

    Eighty-four patients (average age: 61.2 years, 60% female, body mass index [BMI]: 30.1) were analyzed after cervical deformity correction (average levels fused: 7.2, osteotomy used: 50%). Costs associated with index procedures were 9+ level PF ($76,617), 4-8 level PF ($40,596), 4-8 level PF with AF ($67,098), 4-8 level AF ($31,392), and 4-8 level posterior refusion ($35,371). Average 1-year reimbursement of surgery was $55,097 at 1 year with eight revisions and three deaths accounted for. Cost per quality-adjusted life year (QALY) gained to 1-year follow-up was $646,958 by EQ5D and $477,316 by NDI SF6D. If 1-year benefit is sustained, upper threshold of cost-effectiveness is reached 3-4.5 years after intervention.

    Conclusions

    Medicare 1-year average reimbursement compared with 1-year QALYdescribed $646,958 by EQ5D and $477,316 by NDI SF6D. Cervical deformity surgeries reach accepted cost-effectiveness thresholds when benefit is sustained 3-4.5 years. Longer follow-up is needed for a more definitive cost-analysis, but these data are an important first step in justifying cost-utility ratio for cervical deformity correction.
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    Cost-Utility Analysis of rhBMP-2 Use in Adult Spinal Deformity Surgery.
    (Spine, 2020-07) Jain, Amit; Yeramaneni, Samrat; Kebaish, Khaled M; Raad, Micheal; Gum, Jeffrey L; Klineberg, Eric O; Hassanzadeh, Hamid; Kelly, Michael P; Passias, Peter G; Ames, Christopher P; Smith, Justin S; Shaffrey, Christopher I; Bess, Shay; Lafage, Virginie; Glassman, Steve; Carreon, Leah Y; Hostin, Richard A; International Spine Study Group

    Study design

    Economic modeling of data from a multicenter, prospective registry.

    Objective

    The aim of this study was to analyze the cost utility of recombinant human bone morphogenetic protein-2 (BMP) in adult spinal deformity (ASD) surgery.

    Summary of background data

    ASD surgery is expensive and presents risk of major complications. BMP is frequently used off-label to reduce the risk of pseudarthrosis.

    Methods

    Of 522 ASD patients with fusion of five or more spinal levels, 367 (70%) had at least 2-year follow-up. Total direct cost was calculated by adding direct costs of the index surgery and any subsequent reoperations or readmissions. Cumulative quality-adjusted life years (QALYs) gained were calculated from the change in preoperative to final follow-up SF-6D health utility score. A decision-analysis model comparing BMP versus no-BMP was developed with pseudarthrosis as the primary outcome. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates (Alpha = 0.05).

    Results

    BMP was used in the index surgery for 267 patients (73%). The mean (±standard deviation) direct cost of BMP for the index surgery was $14,000 ± $6400. Forty patients (11%) underwent revision surgery for symptomatic pseudarthrosis (BMP group, 8.6%; no-BMP group, 17%; P = 0.022). The mean 2-year direct cost was significantly higher for patients with pseudarthrosis ($138,000 ± $17,000) than for patients without pseudarthrosis ($61,000 ± $25,000) (P < 0.001). Simulation analysis revealed that BMP was associated with positive incremental utility in 67% of patients and considered favorable at a willingness-to-pay threshold of $150,000/QALY in >52% of patients.

    Conclusion

    BMP use was associated with reduction in revisions for symptomatic pseudarthrosis in ASD surgery. Cost-utility analysis suggests that BMP use may be favored in ASD surgery; however, this determination requires further research.

    Level of evidence

    2.
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    Early Patient-Reported Outcomes Predict 3-Year Outcomes in Operatively Treated Patients with Adult Spinal Deformity.
    (World neurosurgery, 2017-06) Jain, Amit; Kebaish, Khaled M; Sciubba, Daniel M; Hassanzadeh, Hamid; Scheer, Justin K; Neuman, Brian J; Lafage, Virginie; Bess, Shay; Protopsaltis, Themistocles S; Burton, Douglas C; Smith, Justin S; Shaffrey, Christopher I; Hostin, Richard A; Ames, Christopher P; International Spine Study Group

    Background

    For patients with adult spinal deformity (ASD), surgical treatment may improve their health-related quality of life. This study investigates when the greatest improvement in outcomes occurs and whether incremental improvements in patient-reported outcomes during the first postoperative year predict outcomes at 3 years.

    Methods

    Using a multicenter registry, we identified 84 adults with ASD treated surgically from 2008 to 2012 with complete 3-year follow-up. Pairwise t tests and multivariate regression were used for analysis. Significance was set at P < 0.01.

    Results

    Mean Oswestry Disability Index (ODI) and Scoliosis Research Society-22r total (SRS-22r) scores improved by 13 and 0.8 points, respectively, from preoperatively to 3 years (both P < 0.001). From preoperatively to 6 weeks postoperatively, ODI scores worsened by 5 points (P = 0.049) and SRS-22r scores improved by 0.3 points (P < 0.001). Between 6 weeks and 1 year, ODI and SRS-22r scores improved by 19 and 0.5 points, respectively (both P < 0.001). Incremental improvements during the first postoperative year predicted 3-year outcomes in ODI and SRS-22r scores (adjusted R2 = 0.52 and 0.42, respectively). There were no significant differences in the measured or predicted 3-year ODI (P = 0.991) or SRS-22r scores (P = 0.986).

    Conclusions

    In surgically treated patients with ASD, the greatest improvements in outcomes occurred between 6 weeks and 1 year postoperatively. A model with incremental improvements from baseline to 6 weeks and from 6 weeks to 1 year can be used to predict ODI and SRS-22r scores at 3 years.
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    Incidence of perioperative medical complications and mortality among elderly patients undergoing surgery for spinal deformity: analysis of 3519 patients.
    (Journal of neurosurgery. Spine, 2017-11) Jain, Amit; Hassanzadeh, Hamid; Puvanesarajah, Varun; Klineberg, Eric O; Sciubba, Daniel M; Kelly, Michael P; Hamilton, D Kojo; Lafage, Virginie; Buckland, Aaron J; Passias, Peter G; Protopsaltis, Themistocles S; Lafage, Renaud; Smith, Justin S; Shaffrey, Christopher I; Kebaish, Khaled M; International Spine Study Group
    OBJECTIVE Using 2 complication-reporting methods, the authors investigated the incidence of major medical complications and mortality in elderly patients after surgery for adult spinal deformity (ASD) during a 2-year follow-up period. METHODS The authors queried a multicenter, prospective, surgeon-maintained database (SMD) to identify patients 65 years or older who underwent surgical correction of ASD from 2008 through 2014 and had a minimum 2 years of follow-up (n = 153). They also queried a Centers for Medicare & Medicaid Services claims database (MCD) for patients 65 years or older who underwent fusion of 8 or more vertebral levels from 2005 through 2012 (n = 3366). They calculated cumulative rates of the following complications during the first 6 weeks after surgery: cerebrovascular accident, congestive heart failure, deep venous thrombosis, myocardial infarction, pneumonia, and pulmonary embolism. Significance was set at p < 0.05. RESULTS During the perioperative period, rates of major medical complications were 5.9% for pneumonia, 4.1% for deep venous thrombosis, 3.2% for pulmonary embolism, 2.1% for cerebrovascular accident, 1.8% for myocardial infarction, and 1.0% for congestive heart failure. Mortality rates were 0.9% at 6 weeks and 1.8% at 2 years. When comparing the SMD with the MCD, there were no significant differences in the perioperative rates of major medical complications except pneumonia. Furthermore, there were no significant intergroup differences in the mortality rates at 6 weeks or 2 years. The SMD provided greater detail with respect to deformity characteristics and surgical variables than the MCD. CONCLUSIONS The incidence of most major medical complications in the elderly after surgery for ASD was similar between the SMD and the MCD and ranged from 1% for congestive heart failure to 5.9% for pneumonia. These complications data can be valuable for preoperative patient counseling and informed consent.
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    Increasing Cost Efficiency in Adult Spinal Deformity Surgery: Identifying Predictors of Lower Total Costs.
    (Spine, 2022-01) Passias, Peter G; Brown, Avery E; Bortz, Cole; Alas, Haddy; Pierce, Katherine; Ahmad, Waleed; Naessig, Sara; Lafage, Renaud; Lafage, Virginie; Hassanzadeh, Hamid; Labaran, Lawal A; Ames, Christopher; Burton, Douglas C; Gum, Jeffrey; Hart, Robert; Hostin, Richard; Kebaish, Khaled M; Neuman, Brian J; Bess, Shay; Line, Breton; Shaffrey, Christopher; Smith, Justin; Schwab, Frank; Klineberg, Eric; International Spine Study Group

    Study design

    Retrospective study of a prospective multicenter database.

    Objective

    The purpose of this study was to identify predictors of lower total surgery costs at 3 years for adult spinal deformity (ASD) patients.

    Summary of background data

    ASD surgery involves complex deformity correction.

    Methods

    Inclusion criteria: surgical ASD (scoliosis ≥20°, sagittal vertical axis [SVA] ≥5 cm, pelvic tilt ≥25°, or thoracic kyphosis ≥60°) patients >18 years. Total costs for surgery were calculated using the PearlDiver database. Cost per quality-adjusted life year was assessed. A Conditional Variable Importance Table used nonreplacement sampling set of 20,000 Conditional Inference trees to identify top factors associated with lower cost surgery for low (LSVA), moderate (MSVA), and high (HSVA) SRS Schwab SVA grades.

    Results

    Three hundred sixtee of 322 ASD patients met inclusion criteria. At 3-year follow up, the potential cost of ASD surgery ranged from $57,606.88 to $116,312.54. The average costs of surgery at 3 years was found to be $72,947.87, with no significant difference in costs between deformity groups (P > 0.05). There were 152 LSVA patients, 53 MSVA patients, and 111 HSVA patients. For all patients, the top predictors of lower costs were frailty scores <0.19, baseline (BL) SRS Activity >1.5, BL Oswestry Disability Index <50 (all P < 0.05). For LSVA patients, no history of osteoporosis, SRS Activity scores >1.5, age <64, were the top predictors of lower costs (all P < 0.05). Among MSVA patients, ASD invasiveness scores <94.16, no past history of cancer, and frailty scores <0.3 trended toward lower total costs (P = 0.071, P = 0.210). For HSVA, no history of smoking and body mass index <27.8 trended toward lower costs (both P = 0.060).

    Conclusion

    ASD surgery has the potential for improved cost efficiency, as costs ranged from $57,606.88 to $116,312.54. Predictors of lower costs included higher BL SRS activity, decreased frailty, and not having depression. Additionally, predictors of lower costs were identified for different BL deformity profiles, allowing for the optimization of cost efficiency for all patients.Level of Evidence: 3.
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    Poor Nutrition Status and Lumbar Spine Fusion Surgery in the Elderly: Readmissions, Complications, and Mortality.
    (Spine, 2017-07) Puvanesarajah, Varun; Jain, Amit; Kebaish, Khaled; Shaffrey, Christopher I; Sciubba, Daniel M; De la Garza-Ramos, Rafael; Khanna, Akhil Jay; Hassanzadeh, Hamid

    Study design

    Retrospective database review.

    Objective

    To quantify the medical and surgical risks associated with elective lumbar spine fusion surgery in patients with poor preoperative nutritional status and to assess how nutritional status alters length of stay and readmission rates.

    Summary of background data

    There has been recent interest in quantifying the increased risk of complications caused by frailty, an important consideration in elderly patients that is directly related to comorbidity burden. Preoperative nutritional status is an important contributor to both sarcopenia and frailty and is poorly studied in the elderly spine surgery population.

    Methods

    The full 100% sample of Medicare data from 2005 to 2012 were utilized to select all patients 65 to 84 years old who underwent elective 1 to 2 level posterior lumbar fusion for degenerative pathology. Patients with diagnoses of poor nutritional status within the 3 months preceding surgery were selected and compared with a control cohort. Outcomes that were assessed included major medical complications, infection, wound dehiscence, and mortality. In addition, readmission rates and length of stay were evaluated.

    Results

    When adjusting for demographics and comorbidities, malnutrition was determined to result in significantly increased odds of both 90-day major medical complications (adjusted odds ratio, OR: 4.24) and 1-year mortality (adjusted OR: 6.16). Multivariate analysis also demonstrated that malnutrition was a significant predictor of increased infection (adjusted OR: 2.27) and wound dehiscence (adjusted OR: 2.52) risk. Length of stay was higher in malnourished patients, though 30-day readmission rates were similar to controls.

    Conclusion

    Malnutrition significantly increases complication and mortality rates, whereas also significantly increasing length of stay. Nutritional supplementation before surgery should be considered to optimize postoperative outcomes in malnourished individuals.

    Level of evidence

    3.
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    Validity, Reliability, and Responsiveness of SRS-7 as an Outcomes Assessment Instrument for Operatively Treated Patients With Adult Spinal Deformity.
    (Spine, 2016-09) Jain, Amit; Lafage, Virginie; Kelly, Michael P; Hassanzadeh, Hamid; Neuman, Brian J; Sciubba, Daniel M; Bess, Shay; Shaffrey, Christopher I; Ames, Christopher P; Scheer, Justin K; Burton, Douglas; Gupta, Munish C; Hart, Robert; Hostin, Richard A; Kebaish, Khaled M; International Spine Study Group

    Study design

    A retrospective analysis.

    Objective

    The aim of our study was to compare the normality, concurrent validity, internal consistency, responsiveness, and dimensionality of an item response theory-derived seven-question instrument (SRS-7), against the Scoliosis Research Society-22r (SRS-22r) questionnaire in operatively treated patients with adult spinal deformity (ASD).

    Summary of background data

    Compared with SRS-22r, SRS-7 (which has been validated in operatively treated patients with adolescent idiopathic scoliosis) has advantages of being short, unidimensional, and linear.

    Methods

    A prospective database of ASD patients was queried for patients 18 years or older who were operatively treated, and who answered pre- and postoperative (at 2-year follow-up) SRS-22r questions (n = 276). Corresponding SRS-7 scores were calculated using answers to SRS-22r items 1, 4, 6, 10, 18, 19, and 20. Significance was set at a P value less than 0.01.

    Results

    SRS-7 and SRS-22r were normally distributed preoperatively but not postoperatively. SRS-7 and SRS-22r scores had high correlation both preoperatively (r = 0.76, P < 0.01) and postoperatively (r = 0.83, P < 0.01). The internal consistency reliability Cronbach α values were 0.61 (SRS-7) and 0.83 (SRS-22r) preoperatively and 0.91 (SRS-7) and 0.95 (SRS-22r) postoperatively. SRS-7 was found to be more responsive than SRS-22r with measures of effect size: Cohen d = 1.21 versus 1.13, Hedge g = 1.21 versus 1.13, and effect size correlation r = 0.52 versus 0.49. Iterative principal factor analysis of pre- and postoperative scores showed the presence of one dominant latent factor in SRS-7 (unidimensionality) and four latent factors in SRS-22r (multidimensionality).

    Conclusion

    SRS-7 is a valid, reliable, responsive, and unidimensional instrument, which can be used as a short-form alternative to the SRS-22r for assessing global changes in patient-reported outcomes over time in patients with ASD.

    Level of evidence

    3.