• Amit Jain, Samrat Yeramaneni, Khaled M Kebaish, Micheal Raad, Jeffrey L Gum, Eric O Klineberg, Hamid Hassanzadeh, Michael P Kelly, Peter G Passias, Christopher P Ames, Justin S Smith, Christopher I Shaffrey, Shay Bess, Virginie Lafage, Steve Glassman, Leah Y Carreon, Richard A Hostin, and International Spine Study Group.
• Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD.
• Spine. 2020 Jul 15; 45 (14): 1009-1015.

Study DesignEconomic modeling of data from a multicenter, prospective registry.ObjectiveThe 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 DataASD surgery is expensive and presents risk of major complications. BMP is frequently used off-label to reduce the risk of pseudarthrosis.MethodsOf 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).ResultsBMP 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.ConclusionBMP 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 Evidence2.

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