Clinical Data

Cost-effectivenss of SIJF in Multi-level LF (Ackerman - CEOR 2022)

Cost-Utility Analysis of Sacroiliac Joint Fusion in High-Risk Patients Undergoing Multi-Level Lumbar Fusion to the Sacrum.

Ackerman SJ, Deol GS, Polly DW.
Clinicoecon Outcomes Res. 2022 Aug 8;14:523-535.
DOI: 10.2147/CEOR.S377132. PMID: 35966399; PMCID: PMC9374202.


Purpose: Multi-level lumbar fusion to the sacrum (MLF) can lead to increased stress and angular motion across the sacroiliac joint (SIJ), with an incidence of post-operative SIJ pain estimated at 26-32%. SIJ fusion (SIJF) can help obviate the need for revisions by reducing range of motion and screw stresses. We aimed to evaluate the cost-utility of MLF + SIJF compared to MLF alone among high-risk patients from a payer perspective, where high risk is defined as high body mass index and high pelvic incidence.

Methods: A Markov process decision-analysis model was developed to evaluate cumulative 5-year costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) of MLF + SIJF compared to MLF alone using published data; costs from Medicare claims data analyses and health state utility values (derived from EQ-5D) informed by three prospective, multicenter, clinical trials. The base case assumed a reduction in post-operative SIJ pain from 30% to 10% (relative risk reduction [RRR] of 67%). Costs and utilities were discounted 3% annually. The ICER is reported in 2020 US dollars. One-way, multi-way, and probabilistic sensitivity analyses were performed.

Results: With an assumed 30% incidence of SIJ pain after MLF alone, stabilizing with SIJF was associated with an additional 5-year cost of $2421 and a gain of 0.14 QALYs, resulting in an ICER of $17,293 per QALY gained (similar to total knee arthroplasty and more favorable than open discectomy). ICERs were most sensitive to the RRR of post-operative SIJ pain conferred by SIJF, time horizon, and probability of successful treatment with MLF alone. At a willingness-to-pay threshold of $50,000/QALY gained, MLF + SIJF has a 97.7% probability of being cost-effective in the target patient population.

Conclusions: Fusing the SIJ in high-risk patients undergoing MLF was cost-effective when the incidence of post-operative SIJ pain after MLF alone exceeds approximately 25%, providing value-based healthcare from a payer perspective.

KEYWORDS: cost-effectiveness analysis; lumbar spinal fusion surgery; sacroiliac joint pain.

Author Information

Ackerman SJ - Department of Biomedical Engineering, Johns Hopkins University, San Diego, CA, USA.

Deol GS - Wake Orthopedics, Raleigh, NC, USA.

Polly DW - Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA.

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