Benefits of intra-operative neuromonitoring might not outweigh the costs

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Researchers announced interesting findings during the 81st American Association of Neurological Surgeons (AANS) Annual Scientific Meeting (27 April–1 May 2013, New Orleans, USA) regarding the value of intra-operative neuromonitoring when comparing its use in influencing patient outcomes compared to the added cost it incurs. 

In the study entitled “Comparative effectiveness, cost utility and cost benefit analysis of intra-operative neuromonitoring in cervical spine surgery: Where is the value?”, presenting author Scott Parker and colleagues found that in a real world comparative effectiveness study of patients undergoing cervical spine surgery for degenerative spondylosis, intra-operative neuromonitoring was associated with significant added cost without a corresponding benefit in safety or patient outcomes.

“This [study] highlights where you have to look deeper into the details to understand the type of treatment being conducted,” said study co author Matthew McGirt. “Different treatments can be of high value in some situations, and lack value in other situations. This is a lesson on how important it is to have clinical expertise and a focused look at value.”

In the study, all patients undergoing cervical spine surgery for degenerative spondylosis were enrolled into a prospective registry. Data collected included demographics, treatment variables and 90-day surgical morbidity. Patient-reported outcomes, return to work and medical resource utilization were prospectively recorded at baseline and three months.

CPT codes 95920 [baseline electrophysiologic testing (per hour)], 95295/95926 [SSEP], 95928/95929 [MEP] and 95937 [neuromuscular junction testing] were used to calculate the cost of intra-operative neuromonitoring from a payer perspective. The cost of intra-operative neuromonitoring per reduction in surgical morbidity (cost-benefit), and the difference in mean total cost per QALY-gained with intra-operative neuromonitoring via incremental cost-effectiveness ratio [ICER] (cost-utility), were assessed.

A total of 180 patients underwent cervical surgery (102 with intra-operative neuromonitoring, 78 without), and baseline characteristics were similar between the two groups. Intra-operative neuromonitoring changes were only noted in four patients, and surgical strategy was only modified in one patient. There was no difference in 90-day morbidity and patient-reported outcomes improvement at three months between the two groups.

The average added cost of intra-operative neuromonitoring per patient was US$1,208 (Medicare) and US$2,053 (private payer) with no reduction in morbidity. The ICER for intra-operative neuromonitoring vs. not was US$358,205/QALY.

The researchers concluded that, for certain low-risk cervical procedures with specific patient populations, intra-operative neuromonitoring appears to be an area where cost can be saved without sacrificing surgical quality or patient safety. “Cost-effectiveness and value are going to be ever-more important as we go forward,” noted McGirt. “As physicians, we owe it to everybody, including our patients, to provide care in a sustainable way. We need to take a critical look at how we do that. intra-operative neuromonitoring, we felt up front has a lot of value and a lot of importance, that allows us to do safe spinal surgery. Intra-operative neuromonitoring is a critical adjunct for a lot of different cases. And it’s important to note that these conclusions should not be extrapolated to high-risk spine surgeries such as spine tumours, trauma or deformity. But we looked at the lowest-risk population, at one specific subset of disease states, and did a traditional value analysis. We asked what the costs were that we put into the system, and based on evidence, our results showed this particular patient subset might allow us to cost-cut in a patient-centered way. It isn’t always about doing more — sometimes it’s about learning to do less.”